REHABILITATIVE
FRAME
OF
REFERENCE
Presented By,
N. Preethi
WHAT IS REHABILITATION?
Rehabilitation focuses on the existing
capacities of the handicapped person , and
brings him to the optimum level of his or her
functional ability by the combined and
coordinated use of medical, social,
educational and vocational measures.
The rehabilitative approach includes the
concepts of adaptation, compensation, and
environmental modifications.
It may be used in conjunction with other
approaches or in isolation.
This approach places an emphasis on the
client’s strengths as opposed to their
limitations.
The ultimate goal is to maximize independence
despite the presence of persistent impairments.
This approach may be most appropriate for
client’s who are living with impairments that
are permanent, including both static and
progressive impairments.
This approach may also be useful when an
underlying impairment is potentially
amenable to remediation but the client is
not motivated to participate in the
sometimes long and difficult process of
remediation.
Contextual factors such as limited therapy
visits may also lead therapists to adopt this
approach because some may argue that
functional independence is achieved
quicker.
Clients living with the following diagnoses
may be candidates for the rehabilitative
approach in isolation or in conjunction with
the other approaches discussed:
Multiple sclerosis,
Amyotrophic lateral sclerosis, Severe stroke,
Advanced arthritis, Advancing Parkinson’s
disease, Spinal cord injuries, etc..
The Rehabilitative approach is used for
various impairments beyond motor deficits.
THE REHABILITATION FRAME OF REFERENCE HAS
FIVE ASSUMPTIONS:
The 1st assumption states that a person can
regain independence through compensation.
The 2nd assumption states that motivation for
independence cannot be separated from the
volitional and habituation subsystems. Motivation
for independence is influenced by lifelong values,
future roles, and a renewed sense of purpose.
The 3rd assumption states that motivation for
independence cannot be separated from
environmental context. The demands of the
discharge setting, the patient’s financial status,
and the family’s emotional resources are
examples of environmental influences on
motivation for independence.
The 4th assumption is that a minimum of emotional
and cognitive prerequisite skills are needed to make
independence possible.
The 5th assumption is the belief that clinical
reasoning should take a top-down approach.
The 5 steps in this top-down hierarchy are
identifying
1. Environmental demands of the discharge
setting such as a second floor bathroom.
2. Current functional capability such as
dependence in toileting.
3. Task demands the patient cannot perform
such as standing balance.
4. Type of rehabilitation method such as
adaptive devices.
5. Specific modalities such as long-handled
FUNCTION – DYSFUNCTION CONTINUA
The three function – dysfunction continua that
are the domains of concern for the rehabilitation
frame of reference are activities of daily
living (ADL), work , and leisure tasks.
ADL are further divided into self- care and
homecare activities.
Self-care encompasses a wide range of skills
including eating, dressing, bathing and toileting.
Homecare includes homemaking, childcare and
home maintenance tasks such as simple home
repair.
Leisure and work tasks are highly varied and
constantly changing.
BEHAVIOURS INDICATIVE OF FUNCTION-DYSFUNCTION :
A patient’s behavior can be replaced on these three
continua by behaviors indicative of change found by
using evaluation tools. Test scores indicate the levels
of assistance needed. Assistance formerly referred to
the levels of physical assistance such as minimum,
moderate, and maximal assistance.
Today, Medicare guidelines for levels of assistance
have added levels of supervision needed. This
documents the needs of cognitively impaired patients
who can place a significant burden on caretakers.
Momentum has been growing for all hospitals to
adopt one standardized self-care evaluation to
provide uniform classification. Several standardized
tests have been developed, but they exhibit little
consensus.
The skills they test vary considerably, with bed
mobility, bowel and bladder control, skin care,
communication and environmental hardware
such as doorknobs, most frequently omitted.
Their scoring system also varies from a 2-point
scale to a 7-point scale.
Tests that evaluate leisure skills are limited to
interest checklists for adults and play
evaluations for children. Work evaluations are
available to assess work behaviors like
punctuality, general work traits like grip
strength, work tolerance, that is, the ability to
sustain effort, and specific work skills like
welding. Specific work skills can be evaluated
using actual job samples or simulated work
samples.
Postulates regarding change identify links
between presenting problems and functional
outcomes in a specific format.
for example:
The patient has suffered a
CVA resulting in a flaccid left hemiplegia.
General deficit is dependence in toileting.
Stage specific cause is flaccid left
hemiplegia, hemianopsia, hemianesthesia,
and shoulder pain.
Functional outcome is toileting with
minimum physical assistance and
intermittent verbal cuing by the patient’s
wife at home.
It is essential to identify the stage-specific
cause of the dysfunction. If you omit this
link in your thought process, you don’t know
whether you should use positioning devices
that inhibit spasticity or compensate for
lack of structural stability during the flaccid
stage of recovery.
The cause also identifies deficits such as
pain, hemianesthesia, and hemianopsia,
which will not respond to compensatory
one-handed techniques.
GENERAL METHOD RATIONALE SPECIFIC ACTIVITY
ADAPTIVE DEVICES COMPENSATE FOR ZIPPER PULL
LACK OF A
ADAPTED STABILIZING HAND PROPER W/C USING
PROCEDURE SUBSTITUTE FOR SOUND ARM AND LEG
LOSS OF LOWER DETACHABLE
W/C MODIFICATION EXTREMITY ROM LEGRESTS
FACILITATES W/C
TRANSFERS ARM TROUGH FOR
FACILITATES W/C LEFT UPPER
ENVIRONMENTAL PROPER POSITIONING EXTREMITY
MODIFICATION FACILITATES SAFETY GRAB BARS IN
SAFETY EDUCATION PRIVATE BATHROOM
COMPENSATES FOR USE VERBAL CUES
HEMIANOPSIA TO ATTEND TO LEFT
COMPENSATES FOR SIDE
SENSORY LOSS OF TURN ON COLD
LIMBS WATER BEFORE HOT
POSTULATES REGARDING CHANGE AND
INTERVENTION:
Postulates regarding intervention create
links between functional outcomes, specific
adaptive devices, modifications, and
procedures in a specific format
There are 7 general rehabilitation methods:
1. Adaptive devices,
2. Upper extremity orthotics,
3. Environmental modifications,
4. Wheelchair modifications,
5. Ambulatory devices,
6. Adapted procedures, and
7. Safety education.
The rationales for these methods identify the
task demands that each method compensates
for. some method rationales are well established,
such as the rationale for using a long-handled
reachers which is lack of sufficient reach.
Some rationales need to be updated. For
example, environmental modifications to
improve safety have gone beyond grab bars and
other strategies for the physically impaired. They
now address safety issues on the joints like low
back and repetitive motion injuries.
Some method rationales need to be identified.
For example, Wheelchair modifications are
usually discussed by grouping wheelchair parts
into categories such as armrests.
Wheelchair equipment should be ordered
because it facilitates transfers and proper
positioning, overcomes architectural barriers,
and permits self-propulsion and transportation of
needed objects.
After you have used rationales to select the
rehabilitation method that meets your patient’s
need, you still need to critique the advantages
and disadvantages of each method. For example,
adapted procedures like one- handed techniques
have the advantage of relatively low cost.
The therapists time to have adaptive procedures
costs less than some wheelchairs and
environmental modifications. Adapted
procedures also have the advantage of low
visibility.
These procedures are not highly noticeable
unless someone is really scrutinizing how a task
is performed. People are likely to stare at a
person who is using a rocker knife in a
restaurant.
Adapted procedures have the disadvantage of
not providing external prompts to remind the
cognitively impaired patient to perform
activities a new way, however.
Adapted procedures can also elicit strong
negative emotions. Many feel resentment when
their personal habits are scrutinized. Instead of
the halo effect associated with technologic
solutions like electric wheelchairs, adapted
procedures often elicit comments like “I’ve done
it my way for 40 years.”
Postulates regarding intervention in the
rehabilitation frame of reference are the
culmination of a complex interaction of therapist,
patient, and current knowledge.
REFERENCES :
• A frame of reference for occupational therapy in
physical dysfunction-Pedretti
• Occupational therapy practice skills for physical
dysfunction 3rd edition-Pedretti
• Activities of daily living-Pedretti
• Willard and spackmans 12th edition
THE
END…
