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The View from Above: Emphasizing Performance
in Practice
The View from Above: Emphasizing Performance
in Practice
Potential Implications of ICF Potential Implications of ICF
for Occupational Therapy & Physical Therapyfor Occupational Therapy & Physical Therapy
Potential Implications of ICF Potential Implications of ICF
for Occupational Therapy & Physical Therapyfor Occupational Therapy & Physical Therapy
Ask Yourself . . .Ask Yourself . . . What is the emphasis of our practice and focus of our
assessment? Do we take a ‘bottom-up’ approach (i.e. looking first
at component skills before performance of relevant activities)?
If how a person performs given activities is our concern, then is our current focus of practice and assessment too narrow?
What is the emphasis of our practice and focus of our assessment?
Do we take a ‘bottom-up’ approach (i.e. looking first
at component skills before performance of relevant activities)?
If how a person performs given activities is our concern, then is our current focus of practice and assessment too narrow?
Sample Framework(based upon former AOTA Guidelines)
Sample Framework(based upon former AOTA Guidelines)
PERFORMANCEPERFORMANCEis influenced byis influenced by
CONTEXTSCONTEXTS
e.g. home, school, culture, time
AREASAREAS
e.g. self-care, work, educational, play, &
social activities
COMPONENTSCOMPONENTS
e.g. e.g. dexterity, strength, balance, intelligence
QUESTION: According to this framework, is our practice emphasis and primary focus of assessment on the components of performance
rather than performance of activities in different environments?
CASE STUDY: IEP for Forrest GumpCASE STUDY: IEP for Forrest Gump
Eligibility: Mental Retardation (IQ < 80)
Areas of Strength: Speed (“magic legs”), eye-hand coordination, loyalty, perserverance
Areas of Weakness: Cognitive, speech (tone), social skills
Impact of Disability: Tormented by peers, referred to as “the local idiot”
Supports: A caring Momma, some clever sayings, Lieutenant Dan (1-to-1)
Eligibility: Mental Retardation (IQ < 80)
Areas of Strength: Speed (“magic legs”), eye-hand coordination, loyalty, perserverance
Areas of Weakness: Cognitive, speech (tone), social skills
Impact of Disability: Tormented by peers, referred to as “the local idiot”
Supports: A caring Momma, some clever sayings, Lieutenant Dan (1-to-1)
Forrest Gump: ACTIVITIES & CONTEXT
Forrest Gump: ACTIVITIES & CONTEXT
Graduated University of Alabama “after 5 years of playing football”
In army, medal of honor winner and ping-pong champion
Shrimpin’ boat captain and owner of Bubba-Gump shrimp company (following hurricane)
Best friend of Bubba, Husband of Jenny, Father of little Forrest
Graduated University of Alabama “after 5 years of playing football”
In army, medal of honor winner and ping-pong champion
Shrimpin’ boat captain and owner of Bubba-Gump shrimp company (following hurricane)
Best friend of Bubba, Husband of Jenny, Father of little Forrest
Forrest GumpTOP-DOWN vs. BOTTOM-UP
Forrest GumpTOP-DOWN vs. BOTTOM-UP
o Fictional, Exaggerated, and Humorous but also a Telling Example
o The view from below:
Maybe misses the possibilities for success in his life with focus on mental retardation and weaknesses
o The view from above:
Shows the successes possible given his activities of choice and the contexts (including luck & timing) that supported his performance
o Fictional, Exaggerated, and Humorous but also a Telling Example
o The view from below:
Maybe misses the possibilities for success in his life with focus on mental retardation and weaknesses
o The view from above:
Shows the successes possible given his activities of choice and the contexts (including luck & timing) that supported his performance
The WHO and ICFThe WHO and ICF
The World Health Organization – WHO – has proposed and revised definitions of disability to
emphasize performance (activities and participation) and environment as key determinants
of health and disability
Disability – an umbrella term, covering impairments, activity limitations,
and participation restrictions
The World Health Organization – WHO – has proposed and revised definitions of disability to
emphasize performance (activities and participation) and environment as key determinants
of health and disability
Disability – an umbrella term, covering impairments, activity limitations,
and participation restrictions
Defining DisabilityDefining Disability Impairment - a problem in body function or structure Activity limitation - a difficulty encountered by an
individual in executing a task or action Participation restriction - a problem experienced by
an individual in involvement in life situations
Thus disability is a complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives.
Impairment - a problem in body function or structure Activity limitation - a difficulty encountered by an
individual in executing a task or action Participation restriction - a problem experienced by
an individual in involvement in life situations
Thus disability is a complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives.
For Discussion . . .For Discussion . . .
How does the WHO definition of disability mesh with How does the WHO definition of disability mesh with occupational therapy and physical therapy practice in occupational therapy and physical therapy practice in the school environment? the school environment?
Is our view of disability focused on impairment without Is our view of disability focused on impairment without adequate consideration of activity limitations and adequate consideration of activity limitations and participation restrictions?participation restrictions?
For Discussion . . .For Discussion . . .
How does the WHO definition of disability mesh with How does the WHO definition of disability mesh with occupational therapy and physical therapy practice in occupational therapy and physical therapy practice in the school environment? the school environment?
Is our view of disability focused on impairment without Is our view of disability focused on impairment without adequate consideration of activity limitations and adequate consideration of activity limitations and participation restrictions?participation restrictions?
CONSIDERCONSIDER Emphasis in IEPs and assessments appears to be on impairment
(e.g. eligibility, areas of strength, and areas of weakness) or the component parts of performance
‘Impact of Disability’ statement is now required, which describes the affect of impairment on performance of activities and participation limitations; but should activity and participation be considered in terms of areas of strengths and weaknesses rather than just what is impacted?
‘Access’ is a term we use - e.g. “student can access her educational program” - which would seem to reflect the interface or interaction between a person’s body and the environment, but how much do we consider the environment or contextual side of this interaction
Focus on impairment alone de-contextualizes the student both from the educational activity and the educational environment
CONSIDERCONSIDER Emphasis in IEPs and assessments appears to be on impairment
(e.g. eligibility, areas of strength, and areas of weakness) or the component parts of performance
‘Impact of Disability’ statement is now required, which describes the affect of impairment on performance of activities and participation limitations; but should activity and participation be considered in terms of areas of strengths and weaknesses rather than just what is impacted?
‘Access’ is a term we use - e.g. “student can access her educational program” - which would seem to reflect the interface or interaction between a person’s body and the environment, but how much do we consider the environment or contextual side of this interaction
Focus on impairment alone de-contextualizes the student both from the educational activity and the educational environment
CASE STUDY: IEP for Stephen HawkingCASE STUDY: IEP for Stephen Hawking
Eligibility: Orthopedic Impairment (ALS / Lou Gehrig’s Disease)
Areas of Strength: Cognitive
Areas of Weakness: All physical and motor abilities, speech
Impact of Disability: Complete dependence for all ADLs and physical activities
Supports: 24 hour nursing care and sophisticated assistive technology
Eligibility: Orthopedic Impairment (ALS / Lou Gehrig’s Disease)
Areas of Strength: Cognitive
Areas of Weakness: All physical and motor abilities, speech
Impact of Disability: Complete dependence for all ADLs and physical activities
Supports: 24 hour nursing care and sophisticated assistive technology
Stephen Hawking: ACTIVITIES & CONTEXT
Stephen Hawking: ACTIVITIES & CONTEXT
In academia, where ideas are valued, he develops ground-breaking theories and is a brilliant scientist
He communicates with friends and colleagues and lectures to packed auditoriums on topics beyond most people’s comprehension
In his personal life, he maintains relationships including marriage
In academia, where ideas are valued, he develops ground-breaking theories and is a brilliant scientist
He communicates with friends and colleagues and lectures to packed auditoriums on topics beyond most people’s comprehension
In his personal life, he maintains relationships including marriage
Stephen Hawking: IMPAIRMENT vs. PERFORMANCE
Stephen Hawking: IMPAIRMENT vs. PERFORMANCE
Impairment - in terms of body structure and function, he could not be more impaired with regard to motor abilities
Activity Performance - he is perhaps unparalleled in his theory development and scientific endeavor
Contextual Factors - performance in academic realm where it is a culture of ideas; lives in an historical context in which technology enables him to participate in chosen life activities fully when otherwise he might not have had a voice
Impairment - in terms of body structure and function, he could not be more impaired with regard to motor abilities
Activity Performance - he is perhaps unparalleled in his theory development and scientific endeavor
Contextual Factors - performance in academic realm where it is a culture of ideas; lives in an historical context in which technology enables him to participate in chosen life activities fully when otherwise he might not have had a voice
International Classification of Functioning, International Classification of Functioning, Disability and Health (ICF)Disability and Health (ICF)
International Classification of Functioning, International Classification of Functioning, Disability and Health (ICF)Disability and Health (ICF)
o The ICF is WHO's framework for measuring health and disabilityThe ICF is WHO's framework for measuring health and disabilityo Acknowledges that every human being can experience a decrement in Acknowledges that every human being can experience a decrement in
health and thereby experience some degree of disabilityhealth and thereby experience some degree of disability o thus, ICF 'mainstreams' the experience of disability and thus, ICF 'mainstreams' the experience of disability and
recognizes it as a universal human experiencerecognizes it as a universal human experienceo Shifts the focus from cause to impact, placing all health conditions on Shifts the focus from cause to impact, placing all health conditions on
an equal footing allowing them to be compared using a common an equal footing allowing them to be compared using a common metric - the ruler of health and disabilitymetric - the ruler of health and disability
o Takes into account the social aspects of disability and does not see Takes into account the social aspects of disability and does not see disability only as 'medical' or 'biological' dysfunctiondisability only as 'medical' or 'biological' dysfunction
o Records the impact of the environment on the person's functioning by Records the impact of the environment on the person's functioning by including Contextual Factorsincluding Contextual Factors
o The ICF is WHO's framework for measuring health and disabilityThe ICF is WHO's framework for measuring health and disabilityo Acknowledges that every human being can experience a decrement in Acknowledges that every human being can experience a decrement in
health and thereby experience some degree of disabilityhealth and thereby experience some degree of disability o thus, ICF 'mainstreams' the experience of disability and thus, ICF 'mainstreams' the experience of disability and
recognizes it as a universal human experiencerecognizes it as a universal human experienceo Shifts the focus from cause to impact, placing all health conditions on Shifts the focus from cause to impact, placing all health conditions on
an equal footing allowing them to be compared using a common an equal footing allowing them to be compared using a common metric - the ruler of health and disabilitymetric - the ruler of health and disability
o Takes into account the social aspects of disability and does not see Takes into account the social aspects of disability and does not see disability only as 'medical' or 'biological' dysfunctiondisability only as 'medical' or 'biological' dysfunction
o Records the impact of the environment on the person's functioning by Records the impact of the environment on the person's functioning by including Contextual Factorsincluding Contextual Factors
ICF: Interaction of ConceptsICF: Interaction of Concepts
Environmental Environmental FactorsFactors
Personal Personal FactorsFactors
Health Condition Health Condition ((disorder/diseasedisorder/disease))
Body structure & Body structure & function function
(Impairment)(Impairment)
ActivitiesActivities(Limitation)(Limitation)
ParticipationParticipation(Restriction)(Restriction)
What does this mean?What does this mean?o Body structure and function are one of a number of
factors in health & disability on equal footing with activities and participation, not the sole or primary concern
o Environmental factors are a significant determinant
o Shifts the focus from underlying cause(s) to impact o The RULER
o Health = Successful Performance of and Participation in Life Activities
o Disability = Activity limitations and Participation Restrictions
o Body structure and function are one of a number of factors in health & disability on equal footing with activities and participation, not the sole or primary concern
o Environmental factors are a significant determinant
o Shifts the focus from underlying cause(s) to impact o The RULER
o Health = Successful Performance of and Participation in Life Activities
o Disability = Activity limitations and Participation Restrictions
CASE STUDY: Body Structure & Function in Sports
CASE STUDY: Body Structure & Function in Sports
7 feet
225 lbs.
Long, rangy
Jumps High
Fast
6 feet
185 lbs.
Fit and lean
Good balance
Strong
Which one is the more successful athlete?
Sports: ACTIVITY & CONTEXT
Sports: ACTIVITY & CONTEXT
Kevin Garnett (KG)
Prep to Pro
NBA All Star
$100+ million contract
No championships
Cael Sanderson
Amateur
Only 4-time NCAA Champion
W/L Record: 159-0
Olympic Gold-Medalist
ACTIVITY: Basketball ACTIVITY: Basketball CONTEXT: Pro LeagueCONTEXT: Pro League
ACTIVITY: Wrestling ACTIVITY: Wrestling CONTEXT: College & OlympicsCONTEXT: College & Olympics
Sports:Defining DISABILITY
Sports:Defining DISABILITY
Focusing on Body Structure and Function alone would likely lead to the conclusion that KG is the superior athlete compared to Cael Sanderson based upon their measurables
However, given their chosen activities and contexts, they are both successful athletes with perhaps Cael Sanderson being more successful (question of money vs. winning and historical measure)
Reversing roles, either one would be significantly ‘disabled’ in the other’s sport relative to their current successes and ‘health’ in their own sport
Focusing on Body Structure and Function alone would likely lead to the conclusion that KG is the superior athlete compared to Cael Sanderson based upon their measurables
However, given their chosen activities and contexts, they are both successful athletes with perhaps Cael Sanderson being more successful (question of money vs. winning and historical measure)
Reversing roles, either one would be significantly ‘disabled’ in the other’s sport relative to their current successes and ‘health’ in their own sport
Consider the element of the ICF that: Consider the element of the ICF that:
“Every human being can experience a decrement in health and thereby
experience some degree of disability . . . thus, ICF 'mainstreams'
the experience of disability and recognizes it as a universal human
experience.”
“Every human being can experience a decrement in health and thereby
experience some degree of disability . . . thus, ICF 'mainstreams'
the experience of disability and recognizes it as a universal human
experience.”
CASE STUDY: Yourself
HOW AM I DISABLED?CASE STUDY: Yourself
HOW AM I DISABLED?
Some Possibilities (in case you have trouble seeing past your own perfection)
Some Possibilities (in case you have trouble seeing past your own perfection)
Technology - sometimes the ON button eludes you
Shopping - the case for most guys Cooking - your food doesn’t look
or taste like on the food network Sports - goofy, awkward, and/or
clumsy and just don’t see the point of it all (or of sweating)
Driving - on the cell phone or not Dating - goofy, awkward, and/or
clumsy and just don’t see the point of it all (or of sweating about it)
Technology - sometimes the ON button eludes you
Shopping - the case for most guys Cooking - your food doesn’t look
or taste like on the food network Sports - goofy, awkward, and/or
clumsy and just don’t see the point of it all (or of sweating)
Driving - on the cell phone or not Dating - goofy, awkward, and/or
clumsy and just don’t see the point of it all (or of sweating about it)
CASE STUDY: Yourself
WHY AM I DISABLED?CASE STUDY: Yourself
WHY AM I DISABLED? According to the ICF definition, we all
experience disability at some time It becomes a question of what the source of
the disability might be Likely, it is a function of an activity
limitation and/or participation restriction as well as context as much, if not more so, than a function of an impairment to our body structure of function
According to the ICF definition, we all experience disability at some time
It becomes a question of what the source of the disability might be
Likely, it is a function of an activity limitation and/or participation restriction as well as context as much, if not more so, than a function of an impairment to our body structure of function
CASE STUDY: Yourself
HOW DO I ADDRESS MY DISABILITY?
CASE STUDY: Yourself
HOW DO I ADDRESS MY DISABILITY? Changing your body structure and function
through practice, skill development, some form of rehabilitation or medical approach
Changing the activity and/or context, by EITHER not engaging in the activity and removing oneself from the context that demands it OR simplifying the activity and altering the environment
Likely some degree of both approaches, with the former likely being a longer process and the latter having a more immediate impact
Changing your body structure and function through practice, skill development, some form of rehabilitation or medical approach
Changing the activity and/or context, by EITHER not engaging in the activity and removing oneself from the context that demands it OR simplifying the activity and altering the environment
Likely some degree of both approaches, with the former likely being a longer process and the latter having a more immediate impact
Embracing the ICF in the educational environment and potential effects on assessment and practice
Embracing the ICF in the educational environment and potential effects on assessment and practice
Top-down approach - team discussion starts with activity limitations and participation restrictions
Assessment - progresses from this starting point to determine sources of disability - nature of activity, body structure and function, environmental and contextual factors
Practice - treatment and service provision consist of longer term approaches such as skill development and remediation as well as short term approaches and strategies to change the activity or context
Top-down approach - team discussion starts with activity limitations and participation restrictions
Assessment - progresses from this starting point to determine sources of disability - nature of activity, body structure and function, environmental and contextual factors
Practice - treatment and service provision consist of longer term approaches such as skill development and remediation as well as short term approaches and strategies to change the activity or context
Benefits of the ICF in the educational environment for occupational therapy and physical therapy
Benefits of the ICF in the educational environment for occupational therapy and physical therapy
Focus on Performance of Activities (e.g. navigating a campus, writing notes, playground games), a more tangible and measurable outcome, than Underlying Skills (e.g. sensory processing, visual perception) which can be less clear
(Thus,) More opportunity for evidence-based practice Areas of weakness, in terms of skills, that do not impact
performance need not be addressed if there is not a corresponding activity limitation
More opportunity for team approaches with focus on performance of activities rather than skills which can be divisive (e.g. psycho-educational skills testing by psychologist and sensory-motor skills by OT and PT)
Focus on Performance of Activities (e.g. navigating a campus, writing notes, playground games), a more tangible and measurable outcome, than Underlying Skills (e.g. sensory processing, visual perception) which can be less clear
(Thus,) More opportunity for evidence-based practice Areas of weakness, in terms of skills, that do not impact
performance need not be addressed if there is not a corresponding activity limitation
More opportunity for team approaches with focus on performance of activities rather than skills which can be divisive (e.g. psycho-educational skills testing by psychologist and sensory-motor skills by OT and PT)
DISCUSSIONDISCUSSION
