Metodología o autor utilizado para la construcción del guión

FIGURE 1.4 Limited ability to reach overhead (functional limitation) as the result of impaired shoulder mobility may lead to difficulty performing person- al grooming or household tasks independently (disability).

BOX 1.3 Common Functional Limitations Related to Physical Tasks

Limitation of

•Reaching and grasping

•Lifting and carrying

•Pushing and pulling

•Bending and stooping

•Turning and twisting

•Throwing and catching

•Rolling

•Standing

•Squatting and kneeling

•Standing up and sitting down

•Getting in and out of bed

•Crawling, walking, running

•Ascending and descending stairs

•Hopping and jumping

involve interactions with others and participation in activi- ties that are a part of who each of us is. These roles are specific to age, gender, sex, and cultural background. N O T E : In the ICF model of functioning, disability, and health, the term “participation restriction” is used to denote the problems a person may have fulfilling personal or socie- tal obligations52,131-133_{(see Table 1.1).}

Because disability is such a complex process, the extent to which each component of the disablement process affects one’s perceived level of disability is not clearly understood. An assumption is made that when impairments and functional limitations are so severe or of such long duration that they cannot be overcome to a degree acceptable to an individual, a family, or society, the perception of “being disabled” occurs.2,103_{The per-}

ception of disability is highly dependent on a person’s or society’s expectations of how or by whom certain roles or tasks should be performed.

Prevention

Understanding the relationships among pathology, impair- ments, functional limitations, and perceived disability is fundamental to the prevention or reduction of disabili- ty.14,39,60_{The presence of functional limitations may or may}

not lead to loss of independence and result in disability. Take, for example, a relatively inactive person with long- standing osteoarthritis of the knees. The inability to get up from the floor or from a low seat (functional limitation) because of limited flexion of the knees and reduced strength of the quadriceps (impairments) could indeed lead to disability in several areas of everyday function. Disabil- ity could be expressed by problems in self-care (inability to get in and out of a tub or stand up from a standard height toilet seat), home management (inability to perform selected housekeeping, gardening, or yard maintenance tasks), or community mobility (inability to get into or out of a car or van independently). The perception of disability can be minimized if the patient’s functional ROM and strength can be improved with an exercise program and the increased ROM and strength are incorporated into progres- sively more challenging functional activities or if the phys- ical environment can be altered sufficiently with the use of adaptive equipment and assistive devices.

tations in this way highlights the importance of identifying abnormal or absent component motions of motor skills through task analysis during the physical therapy examina- tion and later integrating task-specific functional motions into a therapeutic exercise program.

N O T E : Not all sources in the literature define functional limitations in this way. For example, some sources44,45,92

classify all aspects of individual functioning, including basic ADL (personal hygiene and grooming, feeding transfers, locomotion) as functional limitations.

When a person is unable or has only limited ability to perform any of the whole body component motions identi- fied in Box 1.3, decreased independence in ADL and IADL may occur, quality of life may become compro- mised, and hence, disability may ensue. The following is an example of this relationship between functional limita- tions and potential disability. To perform a basic home maintenance task (IADL), such as painting a room, a per- son must be able to grasp a paint brush or roller, climb a ladder, reach overhead, kneel, or stoop down to the floor. If any one of these functional movements is limited, it may not be possible to perform the overall task of painting the room. An essential element of a physical therapy examina- tion and evaluation is the analysis of motor tasks to identi- fy the components of tasks that are difficult for a patient to perform. This analysis helps the therapist determine why a patient is unable to perform specific daily living tasks. This information coupled with identification and measurement of the impairments that are the source of the altered or absent component movement patterns, in turn, is used for treatment planning and selection of interventions to restore function and prevent potential disability.

Disability

The final category of the disablement continuum is disabili- ty, as shown in Figure 1.2. There is a growing body of knowledge suggesting that physical impairments and func- tional limitations directly contribute to disability.58,61_Con-

sequently, an approach to patient management that focuses on restoring or improving function may prevent or reduce disability and may have a positive impact on quality of life.

A disability is the inability to perform or participate in activities or tasks related to one’s self, the home, work, recreation, or the community in a manner or to the extent that the individual or the community as a whole (e.g., fam- ily, friends, coworkers) perceive as “normal.”2_{This is a}

broad definition of disability and encompasses individual

functioning in the context of the environment that includes

basic ADL and more complex daily living skills as well as societal functioning. These functions, or roles, fall into several categories summarized in Box 1.4.

However, some sources in the literature44,45,92_classify

only difficulty with societal functioning as a disability. Despite the inconsistencies of definitions of disability in the literature, a person’s roles or functions in life must be placed in the context of the physical environment as well

as societal expectations.40,41_{Social expectations or roles}

BOX 1.4 General Categories of Activities Relevant to Disability

•Self-care

•Mobility in the community

•Occupational tasks

•School-related tasks

•Home management (indoor and outdoor)

•Caring for dependents

•Recreational and leisure activities

Adjusting expected roles or tasks within the family may also have a positive impact on the prevention or reduction of disability. Factors within the individual also can have an impact on the prevention, reduction, or pro- gression of disablement. Those factors include level of motivation or willingness to make lifestyle changes and accommodations as well as the ability to understand and cope with an adjusted lifestyle.143_{This example highlights}

that inherent in any discussion of disability is the assump- tion that it can be prevented or remediated.14

Prevention falls into three categories.2

Primary prevention: Activities such as health promo-

tion designed to prevent disease in an at-risk population

Secondary prevention: Early diagnosis and reduction of

the severity or duration of existing disease and sequelae

Tertiary prevention: Use of rehabilitation to reduce the

degree or limit the progression of existing disability and improve multiple aspects of function in persons with chronic, irreversible disease

Therapeutic exercise, the most frequently implemented physical therapy intervention, has value at all three levels of prevention. For example, the use of resistance exercises and aerobic conditioning exercises in weight-bearing pos- tures is often advocated for the primary and secondary prevention of age-related osteoporosis.10,20,48,69_However,

therapists who work with patients with chronic muscu- loskeletal or neuromuscular diseases or disorders rou- tinely are involved with tertiary prevention of disability.

Risk Factors

As shown in Figure 1.2, modifying risk factors through an intervention such as therapeutic exercise is an important tool for reducing or preventing the major components of the disablement process. Risk factors related to disable- ment are influences or characteristics that predispose a person to the process of disablement. As such, they exist prior to the onset of the pathology, impairments, functio- nal limitations, or disability.14,60,143_{Some factors that}

increase the risk of disability are biological characteris- tics, lifestyle behaviors, psychological characteristics, and the impact of the physical and social environments. Examples of each of these types of risk factor are sum- marized in Box 1.5.

Some of the risk factors, in particular lifestyle charac- teristics and behaviors and their impact on the potential for disease or injury, have become reasonably well known because of public service announcements and distribution of educational materials in conjunction with health pro- motion campaigns, such as Healthy People 2000101_and

Healthy People 2010.141_{Information on the adverse influ-}

ences of health-related risk factors, such as a sedentary lifestyle, obesity, and smoking, has been widely dissemi- nated by these public health initiatives. Although the benefits of a healthy lifestyle, which includes regular exercise and physical activity, are well founded and widely documented,1,101,141_{initial outcomes of the pre-}

vious national campaign, Healthy People 2000, suggest

that an increased awareness of risk factors has not translated effectively into dramatic changes in lifestyle behaviors to reduce the risk of disease or injury.30_This

demonstrates that increased knowledge does not nece- ssarily change behavior.

When active pathology exists, the reduction of risk factors by means of buffers (interventions aimed at reduc- ing the progression of pathology, impairments, functional limitations, or disability) is appropriate.60_{This focus of}

intervention is categorized as secondary or tertiary preven- tion of disability. Initiating a regular exercise program and increasing the level of physical activity on a daily basis or altering the physical environment by removing architectural barriers or using assistive devices for ADL are examples of buffers that can reduce the risk of disability. (Refer to Chapter 2 of this text for in-depth information on prevention, reduction of risk factors, and wellness.)

This summary of the process of disablement has focused on key elements of this complex process. A basic understanding of the process and the various models and classification systems that have been deve- loped over the past four decades provides a conceptual framework for practice and research, establishes a foun- dation for sound clinical decision making and effective communication, and sets the stage for delivery of effec- tive, efficient, meaningful physical therapy care and services for patients.