Course:

BSC (Hons) Applied Rehabilitation (Physiotherapy)

Module:
Principles of Applied Rehabilitation

Module Code:
PHY3055-N

Module Leader / Tutor:

Dave Grover / Karen Johnson

Student Name:
Nur Suraya binti Yusoff

Student ID:
P1083586

Assignment Title:
Assessment Component 2

Date of submission:
5th May 2023

Word Count
3055 words

1
This essay will explain about analysis, application, and evaluation of models and
concepts of health and disability, a client-centred team approach, the clinical
reasoning process, goals setting, and outcomes. As well as critical reflection on the
professional role of the physiotherapist and contribution to collaborative client-
centred rehabilitation in my preferred case scenario two which is an 83-year-old
gentleman diagnosed with Parkinson's disease 10 years ago and having a disability.

Parkinson's disease (PD) is a chronic neurodegenerative disease with

complex motor and non-motor symptoms and often leads to a significant burden to
the caregiver. People with PD might present with falling, loss of confidence and
independence, and reduced quality of life (Iansek and Morris, 2013). Other than
pharmacological and surgical treatment, rehabilitation is considered an adjuvant
treatment for PD to optimize functional ability and minimize secondary complications
(Abbruzzese et al., 2016). World Health Organisation (WHO) (2023) defined
rehabilitation as "a set of interventions designed to optimize functioning and reduce
disability in individuals with health conditions in interaction with their environment".

Rehabilitation covers attention to the medical, psychological, and social

aspects of illness and recovery (Palmer and Wegener, 2003). Garg and Dhamija
(2020) highlighted that rehabilitation strategies are a vital component in the
management of PD, and should be offered to patients as soon as possible to
promote an active lifestyle and to improve their quality of life. The symptom of PD
inevitable to progress and gradually result in disability in the performance of daily
activities (Shulman, 2010). Disability is a result of the relations between persons with
a health condition, personal and environmental factors including negative attitudes,
inaccessible transportation, and inadequate social support (WHO, 2023). Disability is
unique within bigotry, everyone has the possibility of becoming disabled at any point
in their life, and disabilities come in many forms, so it is quite difficult to ensure that
they are treated fairly (Bunbury, 2019). While Rattan (2013) defined health as a state
of satisfactory physical and mental independence in activities of daily living (ADL).

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 There are many models and concepts of health and disability in healthcare
such as the medical model, social model, biopsychosocial model, and holistic
models. Each model addressed the perceived causes of disability, appropriate
response, and deeper meaning. The medical model is a part of the general
biomedical approach. This model is a disease as bodily biological dysfunction, and
its ethical imperative is to cure the disease and fix the dysfunction (Fuller, 2017) by
rehabilitating the patient, but if it failed, he is considered a person with limited ability
to participate in society (Bunbury, 2019). Moreover, the medical model presumes
that a disabled person's autonomy is limited due to the impairment (Payne,2006).
While Hogan (2019) stated that the social model would require political engagement
and a more focus on societal including environmental and economic, rather than
individual problems and it is a community approach to prevent disease and illness.

However, Owens (2015) clarified that it has been used successfully for
political activism but simultaneously created debate in disability study, sociology, and
sociology of the body and has been considered an outdated ideology in need of
additional development (Owens, 2015). Integration of medical and social models will
provide maximum benefit to the patient. It is a better model which acknowledges
psychological and social factors in health and illness alongside biological factors is
the biopsychosocial (BPS) model (Hunt, 2021). The BPS model is an example of a
holistic model. The International Classification of Functioning, Disability and Health
(ICF) is a classification of human functioning and disability developed by WHO which
provides a standard language and frameworks to describe health and health-related
states (WHO, 2002). ICF is based on this model, a combination of medical and
social models, it provides by the synthesis, a rational view of different perspectives of
health, involving biological, social, and individual (WHO, 2002).

I choose the BPS model to address the issues regarding my chosen scenario.
Physiotherapy's aim in patients with PD is to keep them moving safely and
independently with the body in as good working condition as possible. In addition,
physical-motor rehabilitation appears to also have a positive influence on cognitive
and psychological functions in a patient (Monaco et al., 2022). Within the ICF
framework as Appendix 2, a person’s health condition covers a spectrum of body
function and structure, activity and participation, environmental factors, and personal
factors (Huang et al., 2022). ICF framework helps in setting goals and treatment

3
plans for the selected scenario. For example, if the medical model was chosen, the
medicine was given to treat the symptoms of Parkinson's disease and other body
structures involved and he will be taught with exercises to strengthen the muscle and
proper transfer technique to make him easier to move. However, the issue is still not
resolved with the structural problem in his residential area where he needs ramps to
facilitate outdoor movement by using a wheelchair. Here, the social model can help
by accommodating the physical environment (WHO, 2002) by building ramps then
his wife can minimally assist him to manage the wheelchair outside the house since
his wife also faced some health problems. Neither model is suitable, they both are
partially reasonable. The BPS model is the most suitable as it not only covers body
function and social aspects, but it encourages a patient-centred and personalized
approach to care, including cognitive, behavioural, family-based, peer support, and
positive psychology model (Palmer and Wegener, 2003).

As physiotherapists, we are healthcare professionals that recommend patient's self-

management which combines the BPS perspective by combining functional training
for the body and coaching (Higgs, Refshauge, and Ellis, 2001). Peek et al. (2016)
suggested that self-management approaches form an important part of
physiotherapy management plans because patients will spend more time away from
physiotherapists than receiving hospital-based or clinic care. Effective self-
management is usually determined by the collaboration between the patient and the
physiotherapist (Peek et al., (2016).

An approach to practice established through the formation and fostering of a

therapeutic relationship between all care providers, patients, and others significant to
them in their lives is also known as patient-centred care (Sanerma et al., 2020). It is
promoted by values of respect for persons, individual right to self-determination,
mutual respect, and understanding (McCormack, and McCance, 2017). Håkansson
et al. (2019) stated that this approach is to plan, deliver, and evaluate health care
that depends on mutually beneficial cooperation, is well-organized and implemented,
and is evaluated in interprofessional collaboration where the client has the latest
care and service plan.

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 There are four key principles to providing person-centred care by NICE
guidelines (2012) which are the person is treated with dignity, compassion, and
respect, offering personalized and coordinated care, and enabling them. Client-
centred care is concentrating on care needs, participation, autonomy, and respect.

As for the case scenario, patient-centred care is the most suitable approach.
Care is coordinated and personalized. It goes beyond physical well-being to also
include the psychological and social aspects of the patient's situation. He will
probably express everything that is hidden in his heart about all the problems and
stress he had faced that may not have told his wife and daughter for fear that it will
trouble them. It can improve patient satisfaction by listening, and empathy during
history taking, providing a clear explanation of certain issues, answering patient
questions properly, and providing education on how to self-manage and the different
options.

For other problems beyond the expertise of physiotherapy, I would refer him
to the related department. For example, if he has a stress problem, I will refer him to
a psychologist, and so on. Then, I can make decisions based on patient problems
and collaborate to set goals based on patient preferences. A review by Bhidayasiri et
al., (2020) highlighted the importance of patient education and patient-centred care
to improve patient experience and engagement in individualized therapy. Greig et al.
(2015) highlighted that patient satisfaction with physiotherapy care is greatly
influenced by therapist interaction and the process of care.

Salles et al. (2022) explained that optimal patient care requires a thorough
exploration of the information provided by the patient and a structural and functional
assessment to guide the appropriate treatment plan. This process is also known as
diagnostic thinking or clinical reasoning (CR) (Jones, 1997). CR refers to
professional reasoning, judgement, and decision-making in which the clinician
engaged during a clinical session (Higgs, 2008). Higg's and Jones (2000) defined
CR as a process of interaction between therapist and patient including carers, that
helps the patient to structure the goals and treatment based on the assessment,
patient choices, professional judgement, and knowledge.

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 Clinical decision-making is greatly influenced by medical science in
physiotherapy, where the formation of diagnosis is central. The combination of
diagnostic reasoning and hypothetico-deductive reasoning is based on a biomedical
perspective which remains dominant in physiotherapy practice and education
(Thomson, Petty, and Moore, 2014). However, it has been argued that physiotherapy
management based on a biomedical perspective cannot engage with the complexity
of patient problems and disabilities that patient experience (Wellens, 2010).
Chowdury and Bjorbækmo (2017) highlighted that good physiotherapy practice
needs sensitivity, tactfulness, and the desire to build a cooperative patient-therapist
relationship.

A qualitative study conducted by Cruz, Caeiro and Pereira (2014) found that
narrative reasoning promotes patient-centred care by having the capability to
understand patients' experiences and necessity is a must to be able to create a goal
based on patient-centred goals. As related to the case scenario, I would prefer to
use narrative reasoning as the model of clinical reasoning. Edwards et al. (2004)
defined narrative reasoning as a reasoning approach where the clinician is engaged
in understanding and appreciating the unique living experience of an individual. The
narrative approach includes communication in a clinical setting, as well as how
individual experiences are formed, which can contribute to ensuring that the clinical
reasoning and decision-making process are consistent with the individual patient’s
needs (Ahlsen and Solbrække, 2018).

Thus, I need to understand the current problems that he faces in everyday life
and the goal he expects. During the subjective assessment, I will collect the
information from the patient, perform a physical assessment and makes the decision
on the treatment then explain the details to the patient. This is important to ensure
that the patient understands the problem medically and works together in setting the
goals based on the patient’s needs with caregivers and a multidisciplinary team to
achieve optimal levels of functioning and independence.

Goal setting is defined as a process through which an individual established

objectives or aims for their action (Bird, Swann, and Jackman, 2023). Goal setting is
important in rehabilitation to motivate the patient for rehabilitation, increase
behavioural changes and enhance patient adherence (Wade, 2009). I chose the

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‘SMART’ (specific, measurable, achievable, realistic, and time-framed) goal principle
developed by Locke and Latham (2002) to plan better management for the case
scenario. An exploratory study conducted by Fisher et al., (2018) highlighted that the
use of SMART goal setting gave better feedback and improvement by actively
engaging the patient in the goal-setting process. The goal should be meaningful in
the patient's environment, contrary to what the physiotherapist considers to be the
best for the patient.

On the other side, the physiotherapist feared of the patient may ask for
unrealistic goals or that the patient would have different desires and ideas (Melin et
al., 2021). As related to the case scenario, by setting SMART goals for the short and
long term, I can clarify the patient's ideas, make sure that the patient can focus on
his effort, use his time and resources productively, and increase the chances of
achieving his goal in life.

The short-term goal (STG), the first one is to enable him to get out of bed
independently within three weeks. The second STG is to enable him to do the sit-to-
stand with minimal assistance within six weeks. As he can sit-to-stand, so the long-
term goal (LTG) is to ensure that he can get in and out of his daughters' car with
minimal assistance since his wife is unable to support him too much with her medical
condition. Day by day, he will be more confident to go outside slowly and manage to
do some outdoor social activities with minimal support from his wife.

There are many outcome measures to determine the baseline function of the
patient at the beginning of treatment and to assess the effectiveness of treatments
that have been given to patients. Carter, Lubinsky and Domholdt (2011) clarified that
an outcome measure is a standardized measurement tool to document the change
of one or two values over time, and should be reliable, valid, and responsive to
change. The use of valid and reliable outcomes measures for the evaluation of
physiotherapy treatment is increased in demand due to evidence-based practice
(EBP) (Hanna et al., 2007) and has been shown to improve both the process of care,
outcomes of care and patient-clinician communication (Snyder et al., 2012).

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 There are outcome measures related to Parkinson's disease such as 39-Item
Parkinson Disease Questionnaire (PDQ-39), Unified Parkinson Disease Rating
Scale (UPDRS), the Timed Up and Go (TUG) test, and so on. Patient-reported
outcome measures (PROM) are increasingly used by physiotherapists. It may allow
the physiotherapist to effectively track the effectiveness of treatment and help
develop optimal management strategies to empower patients, support clinical
decision-making processes, and improve quality of care (Kyte, et al., 2015).

However, I do not use PROM in this case scenario because there are too
many questions and it takes long time (Philpot et al., 2017) which can cause the
patient to become tired and bored since my patient is already 83-years old and I am
worried if he is unable to concentrate to complete the questionnaire. I chose to use
the Five Times Sit to Stand Test (FTSST) as an outcome measure for the case
scenario. FTSST is simple and broadly used for the assessment of lower limb
functional strength, balance, and risk of falls in various populations.

A study conducted by Duncan, Leddy, and Earhart (2011) concluded that

FTSST is a valid and reliable measure in people with PD. Since the patient has
difficulty with transfer, FTSST is the most suitable outcome measure for him for the
time being. Sit to stand is the most important movement in functional activity. It
requires lower limb muscles to generate forces to lift the body against gravity pull.
He also can do sit-to-stand as an exercise at home with minimal supervision from his
wife. FTSST has been used in a study conducted by Siega et al., (2021) where it
shows an improvement for the patient with PD during performing functional mobility
and motor function.

PD is a complex heterogeneous disorder from early to advanced stages with

a wide range of motor and non-motor symptoms from rigidity, bradykinesia to sleep
disturbance, dysautonomia, and cognitive impairment (Fereshtehnejad et al., 2019).
It needs the involvement of healthcare professionals from different fields for an
optimal management plan (Fereshtehnejad et al., 2021). Clinical guidelines
recommend patients with PD should have access to a wide range of medical and
allied health professionals for individualized, integrative, and multidisciplinary team
(MDT) care (Radders et al. 2020).

8
 A review conducted by Qamar et al. (2017) found that physiotherapist,
speech, and language-therapist involvement in MDT for PD management is
important for a patient’s recovery and effective management. Lidstone et al. (2020)
synthesized in their review that a variety of interventions of allied health
professionals in MDT give positive feedback to patient-centred care. Short-term
improvement in UPDRS motor score for outpatient PD in MDT care programmes
was found in a study conducted by Carne et al. (2005).

Another study by Carne et al. (2005b) reported that a multidisciplinary team

approach is a key to success for long-term improvement in motor function. Aye et al.
(2020) mentioned that currently, MDT is the most established model for PD. As for
the case scenario, the neurologist, specialist nurse, and I as a physiotherapist form
the MDT for this patient. He came for physiotherapy and went through assessment
for transfer, balance, and gait then received treatment.

The specialist nurse did an assessment that includes measurement of body

weight, and blood pressure, and enquire about other functions such as swallowing,
sleep, sexual function, speech, and so on. The MDT will be having a team meeting
to discuss patient problems and improvement to develop a consistent approach and
ensure the team is working towards shared goals for the patient. From here, the
neurologist can review the patient with any additional intervention that can be added
if necessary.

Besides that, the meeting boosts the growth and continuation of rapport
between team members and makes us more informed of the roles and potentials of
other disciplines. However, the most important thing in this rehabilitation is the
involvement of the patient. The patient should be actively involved to ensure the
effectiveness of the treatment and achieve the goals that have been set
collaboratively. All the effort are in vain if the patient is non-compliance and only
choose to receive the intervention instead of actively participating and adhering to
the treatment given. Yip and Schoeb (2020) stated that active patient involvement is
vital for effective physiotherapy intervention.

9
 Teamwork and collaboration between patients and rehabilitation professionals
are essential during decision-making, goal-setting, and therapy sessions to ensure
that the interventions provided are patient-centred (Lexell, Lexell and Larson, 2016).
O'Brien, Clemson, and Canning (2016) qualitative study concluded that active
involvement in exercise after suffering from Parkinson's disease as a self-motivation
to return active even though the goal has been adjusted.

In conclusion, physiotherapy plays an important role in the rehabilitation of

patients with Parkinson's disease in the MDT approach which is to maintain and
improve the level of function and independence to improve the person's quality of
life. As for the case scenario, I chose and implemented a biopsychosocial model of
health and disability to identify the underlying issues, and narrative reasoning used in
the clinical reasoning process to understand the patient problems to collaboratively
set goals based on patient-centred care. FTSST is used as an evidence-based
outcome measure to assess the patient's status and determine the effectiveness of
the treatment. As well as patient-centred care throughout the entire care process.
However, there are several barriers to implementing patient-centred care at the
workplace such as time constraints and lack of motivation when there is a shortage
of staff with a lot of work to do (Dunn, 2003). Even so, I must apply it since it gives
more positive than negative effects on patients with rehabilitation.

10
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 Appendices

Appendix 1 – The ICF framework (2002).

Health condition
(Disorder or disease)

Body Function and Structure Activity Participation

Environmental Factors Personal Factors

Contextual Factors

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Appendix 2- Completed ICF Framework for the case scenario.

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