The View from Above: Emphasizing Performance in Practice Potential Implications of ICF for Occupational Therapy & Physical Therapy Potential Implications of ICF for Occupational Therapy & Physical Therapy

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) PERFORMANCE is influenced by CONTEXTS e.g. home, school, culture, timeAREAS e.g. self-care, work, educational, play, & social activitiesCOMPONENTS 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 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)

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

Forrest Gump TOP-DOWN vs. BOTTOM-UP oFictional, Exaggerated, and Humorous but also a Telling Example oThe view from below: Maybe misses the possibilities for success in his life with focus on mental retardation and weaknesses oThe 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 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 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... How does the WHO definition of disability mesh with occupational therapy and physical therapy practice in the school environment? Is our view of disability focused on impairment without adequate consideration of activity limitations and participation restrictions? For Discussion... How does the WHO definition of disability mesh with occupational therapy and physical therapy practice in the school environment? Is our view of disability focused on impairment without adequate consideration of activity limitations and participation restrictions?

CONSIDER 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 environmentCONSIDER 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 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  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  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, Disability and Health (ICF) oThe ICF is WHO's framework for measuring health and disability oAcknowledges that every human being can experience a decrement in health and thereby experience some degree of disability othus, ICF 'mainstreams' the experience of disability and recognizes it as a universal human experience oShifts the focus from cause to impact, placing all health conditions on an equal footing allowing them to be compared using a common metric - the ruler of health and disability oTakes into account the social aspects of disability and does not see disability only as 'medical' or 'biological' dysfunction oRecords the impact of the environment on the person's functioning by including Contextual Factors oThe ICF is WHO's framework for measuring health and disability oAcknowledges that every human being can experience a decrement in health and thereby experience some degree of disability othus, ICF 'mainstreams' the experience of disability and recognizes it as a universal human experience oShifts the focus from cause to impact, placing all health conditions on an equal footing allowing them to be compared using a common metric - the ruler of health and disability oTakes into account the social aspects of disability and does not see disability only as 'medical' or 'biological' dysfunction oRecords the impact of the environment on the person's functioning by including Contextual Factors

ICF: Interaction of Concepts Environmental Factors Personal Factors Health Condition ( disorder/disease ) Body structure & function (Impairment) Activities(Limitation)Participation(Restriction)

What does this mean? oBody 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 oEnvironmental factors are a significant determinant oShifts the focus from underlying cause(s) to impact oThe RULER oHealth = Successful Performance of and Participation in Life Activities oDisability = Activity limitations and Participation Restrictions oBody 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 oEnvironmental factors are a significant determinant oShifts the focus from underlying cause(s) to impact oThe RULER oHealth = Successful Performance of and Participation in Life Activities oDisability = Activity limitations and Participation Restrictions

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 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: Olympic Gold-Medalist ACTIVITY: Basketball CONTEXT: Pro League ACTIVITY: Wrestling CONTEXT: College & Olympics

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: “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? 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)

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?  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  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  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)

DISCUSSION