Achieving Functional Independence

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Chapter 26 Achieving Functional Independence

Ellen Guess, Debra Paul, Alison E. Lane

Functional independence is the ability to perform daily living tasks without help. The achievement of functional independence ensures that individuals can participate fully in life situations that are meaningful and purposeful. Whether experiencing a physical disability or not, participation in activities of daily living or life occupations is essential to health and well-being.3 Anthropologists have noted that involvement in the daily routines of self-maintenance, production, and leisure enables humans to express themselves, establish relationships, and build self-identity.5 The World Health Organization has recognized the importance of participation in life situations to health by reframing the International Classification of Impairments, Disabilities, and Handicaps31 as the International Classification of Functioning, Disability and Health.30 In doing this, understandings of health have shifted significantly from definitions relating to the absence of disease or impairment. This embraces the notion of an individual engaging with and functioning in her or his world even with the presence of a disability and physical challenges. Supporting this shift is emerging evidence of the powerful therapeutic benefit of participation in meaningful daily occupations.5 Individuals who are able to achieve meaningful participation in life situations are more likely to experience and report increased personal satisfaction and quality of life, increased levels of energy, fewer physical ailments, reduced pain, and improved physical functioning.17 Ultimately, this impact can decrease the costs of health associated with burden of care, the treatment of physical symptomatology, and poor emotional health.

The goal of medical rehabilitation programs for persons experiencing physical disability as a result of injury, illness, or a developmental condition is to maximize functional independence over time.7 All members of the rehabilitation team are focused on restoring or enhancing functional capacity such that individuals can engage optimally in daily life tasks that are meaningful and purposeful. Because of the subjective nature of what constitutes “meaningful” and “purposeful,” it is important to adopt a family- or client-centered frame of reference for care. This frame of reference defines a set of philosophies, attitudes, and approaches to care for persons with special needs and their families.8 It refers to a relationship between the person, family, and health care professional that builds on the person’s and family’s priorities and that responds to their mutual goals.4 Some key elements in family- or client-centered care include recognizing family strengths, respecting different methods of coping, facilitating family and professional collaboration at all levels of health care, and sharing complete and unbiased information with families on a continuing basis and in a supportive manner. By adopting this frame of reference in practice, the rehabilitation team will be able to plan an evaluation and treatment process that matches the individual’s life goals and priorities. Rehabilitation programs that focus their interventions in this way are more likely to achieve the desired outcomes of enhancing productive living, promoting efficient recovery, and reducing the burden of care for individuals with physical disabilities over the long term.10,16,26

The aim of this chapter is to provide an overview of the current evaluation and treatment principles used by the rehabilitation team to assist an individual experiencing physical disability to achieve functional independence.

Evaluation

Using a family- or client-centered approach, evaluation of an individual’s functional independence necessarily begins with the determination of that person’s life goals, premorbid roles and activities, priorities for recovery, and contextual or cultural influences. From here, a more specific assessment can be conducted that evaluates the individual’s actual performance abilities and limitations in key areas of function. It also measures components of functional skill, including strength, range of motion, tone, sensation, balance, coordination, visual perception, and cognition. This type of evaluation process is referred to as the top-down approach and is considered “the best fit for the emerging system of health-care delivery.”14 The top-down approach has the advantage of focusing clearly on the roles and activities that are meaningful for patients, which increases motivation for participation in the rehabilitation process and increases the understanding of the relevance of rehabilitation to daily life. The top-down evaluation approach also allows for documentation of outcomes of rehabilitation in terms that are most likely to receive maximum reimbursement. Payers specifically seek outcomes of therapy that allow the patient to function most efficiently and effectively in daily contexts.14 Top-down evaluation results in the medical team addressing rehabilitation goals that are directly related to the individual’s performance in life roles.

Evaluating Meaningful Life Roles and Activities

Assessment of a person’s life goals, valued functional roles and activities, and priorities for recovery is a complex one. Because of the subjective nature of the content, there are few evaluation tools that provide the rehabilitation team with succinct, quantifiable data relating to this issue. Information about the person’s priorities and premorbid activity is usually gained through discussion and interview with the person and/or caregivers. It is important that those team members charged with the responsibility of gathering this information are skilled in techniques of interviewing and counseling to ensure that the individual is able to clearly communicate personal needs and wants.

Within the field of occupational therapy, an evaluation tool has been developed specifically for the purpose of assisting occupational therapists to establish occupational performance (functional performance) goals and priorities with their clients. The Canadian Occupational Performance Measure (COPM)18 was developed using a client-centered frame of reference and consists of a semistructured interview approach for gathering patients’ perspectives on their needs and wants in areas of self-care, productive living, and leisure. The evaluation process encourages patients to rate their perceptions of their current levels of performance and satisfaction with participation in key functional tasks. These are then reevaluated and rerated at the end of the rehabilitative process to provide outcome data relating to the patient’s perspective on recovery. Evaluation tools such as the COPM provide broad, descriptive information about the person’s functional independence needs, which allows the rehabilitation team to target specific areas requiring further evaluation and focus in treatment.

Evaluating Specific Performance Abilities

Once the patient’s valued life roles and activities have been identified and goals for rehabilitation determined, more specific evaluations are then completed to establish what performance limitations and abilities exist. A variety of methods can be used to assess functional skills. In many cases, therapists use guided observation and task analysis to determine the level of functional independence demonstrated by the patient. A number of formal measures have been developed for the purpose of measuring functional capacity. The most commonly used tool in this area is the functional independence measure (FIM).2 The FIM consists of 18 items examining the functional areas of self-care, sphincter control, transfers, locomotion, communication, and social cognition. Scores on the FIM provide an indicator of level of disability within motor and cognitive domains based on the level of assistance a patient requires to perform key functional tasks.21 A pediatric version of the FIM, the WeeFIM,1 has been developed for children aged 6 months to 7 years. It uses a similar structure to the FIM but modifies the items to account for developmental differences in social cognition and communication domains. Data from the FIM and the WeeFIM are being compiled in the Uniform Data System for Medical Rehabilitation to provide a repository of information regarding the functional independence of adults and children experiencing physical disability. Other tools used in rehabilitation settings to measure the functional abilities of patients include the following:

• The Barthel Index: This index measures activity of daily living skills, including feeding, transfers, personal hygiene, toileting, bathing, ambulation, stair climbing, dressing, and bowel and bladder control.19
• The Assessment of Motor and Process Skills (AMPS): This observational tool allows for the evaluation of motor skills with a concurrent evaluation of process skills necessary to complete a task.9 The therapist chooses two or three activities of daily living tasks based on their relevance to the patient. Motor skills observed include stabilization, alignment, positioning, walking, reaching, bending, coordination, manipulation, endurance, and grip. Process skills observed include pacing, attention, choice making, initiation, adjustment, sequencing, organization, navigation, and accommodation.
• The Pediatric Evaluation of Disability Inventory (PEDI): This measure assesses functional performance in children aged 6 months to 7.5 years in the areas of self-care, mobility, and social function.13 Scoring includes a rating of functional skill, level of caregiver assistance required, and use of modifications or adaptive equipment.
• The Functional Rehabilitation Evaluation of Sensori-Neurologic Outcomes (FRESNO): This tool assesses functional performance in 0- to 18-year-olds across self-care, motor, communication, cognition, and socialization domains involving 196 items and including a rating of caregiver assistance and adaptive equipment required.25

Evaluation tools such as those discussed above provide the rehabilitation team with an overview of the functional skill competence of the patient and can provide a basis on which to measure the overall effectiveness of the rehabilitation program. These tools can provide information about a patient’s functional limitations, but they do not allow the members of the rehabilitation team to determine the specific components of functional performance that might require remediation.

Evaluation of Components of Performance

The final step in the top-down evaluation process involves the detailed assessment of the component skills that are necessary for functional independence. Depending on the identified priorities for rehabilitation of the patient and the results of the functional independence measures, all or only some of these component skills might be assessed. Information gathered from this stage of the evaluation will assist the team in determining the most appropriate course for treatment. The following component skills are typically included in an evaluation:

• Joint measurement: Passive and active range of motion is evaluated in joints required for the performance of functional skills. The evaluation seeks to determine any limitations in range of motion in upper and lower limbs that might impact patient function and require the need for remediation or adaptive equipment.
• Muscle strength: Muscle strength is often affected in disorders of the lower motor neuron system or the muscles themselves. Muscle weakness can significantly limit functional performance. Good to normal muscle strength is generally considered necessary for the independent performance of functional tasks.22
• Muscle tone, reflexes and reactions, and coordination: Normal muscle tone is essential for the stabilization of joints, movement against gravity, and the ability to shift from stable to dynamic postures. These movement components are necessary for independent performance of functional tasks. Evaluation of the degree of hypotonicity or hypertonicity, the presence or absence of incoordinated movements (such as tremor, ataxia, or athetosis), and the presence or absence of immature reflexes and reactions allow the therapist to determine what measures might be necessary to promote independent function.
• Sensation and perception: Intact sensation and perception are essential to the safe and accurate performance of daily living tasks. Elements of sensation commonly assessed include pain, light touch, pressure, thermal sensitivity, discrimination, olfaction, and gustatory sensation.15,28 Evaluation of perception, including proprioception, stereognosis, body scheme, unilateral neglect, visual form, space perception, and praxis, is necessary to determine the impact on functional performance. A combination of both clinical observation and standardized testing can be used to assess these components.
• Cognition: Cognitive skills such as memory, sequencing, problem solving, judgment and decision making, abstract thinking, and calculation impact the capacity of a person to participate in many productive activities. These can include home management, paid employment, schooling, and volunteer work. Standardized testing is available to measure cognitive skill level. Observations of processing skills during the performance of routine tasks can also reveal cognitive impairments.
• Oral–motor and swallow function: Intact oral–motor skills, oral sensory skills, and swallowing function are essential for safe and independent eating and drinking. Evaluations in this area are generally carried out by specialized occupational and speech therapists. Oral muscle tone, oral sensation, and coordination are assessed to determine whether food can be effectively and efficiently managed in the mouth. Observation of gagging, choking, or coughing while eating can indicate swallowing dysfunction. For diagnosis of swallowing disorders, a videofluroscopic study, such as an upright modified barium swallow study, should be carried out (see Chapter 27).

Using a top-down approach to evaluation, the rehabilitation team can quickly formulate a plan for intervention that involves patients and their families in key decision making that is likely to result in the most effective approach to treatment.

Treatment

A number of treatment approaches can be used to assist an individual experiencing physical disability to achieve functional independence. The treatment approach chosen by the therapist and team depends on the specific goals set by the individual, the degree of functional limitation experienced, and the type and severity of the component skill impairments noted. Multiple treatment approaches can be used simultaneously with an individual to address different goals. Treatment approaches can generally be understood to fall into two main categories: restorative or compensatory.14 The goal of a restorative or facilitatory treatment approach is to restore the person’s capacity to perform functional skills by restoring the impaired component skills. The aim of this approach is to retrain the individual to perform functional tasks in the same way as was done premorbidly. It is an appropriate treatment strategy when complete or close to complete recovery is expected and few environmental or contextual barriers to functional independence exist. A number of frames of reference for intervention can be adopted depending on the impairments experienced by the individual. The most common frames of reference used in physical rehabilitation are as follows:

• Developmental: This frame of reference assumes that recovery occurs following a hierarchic, sequential approach where simpler skills form the building blocks for complex ones. Therapy facilitates this progression by assisting in the attainment of developmentally easier skills before embarking on more complex routines. Examples of treatment techniques that use a developmental frame of reference include sensory integration, neurodevelopmental therapy (Bobath), proprioceptive neuromotor facilitation, Brunnstrom’s movement therapy, and Rood’s sensorimotor approaches.11
• Biomechanical: This frame of reference assumes that remediation of the specific component skills that are impaired will result in a return to functional independence. Treatment techniques using this frame of reference prescribe specific interventions such as exercises and graded activities to restore range of motion, strength, endurance, and normalization of tone. One example of this approach includes using botulinum toxin type A to weaken hypertonic muscles that impair function. Another approach might include serial casting to increase the length and number of muscle fibers in a hypertonic muscle to reduce tone and increase function.
• Psychosocial: Increasingly in physical medicine and rehabilitation a psychosocial frame of reference is used alongside more traditional physical rehabilitative approaches. This is in recognition of the importance of addressing issues surrounding adjustment to illness or injury, social support, and the increased likelihood of chronic emotional disturbance in individuals with significant and life-limiting disabilities. Treatment techniques using this frame of reference can include individual counseling, family therapy, social skills training, and education to patients and significant others about disease or condition processes. These techniques aim to restore the emotional well-being of the individual and, by doing so, to enhance participation in the rehabilitative plan and prevent secondary illnesses.

The goal of a compensatory or adaptive approach in rehabilitation is to facilitate functional independence through the adaptation or modification of a routine or task, or use of adaptive equipment that aids in compensation for functional skill limitations. Compensatory or adaptive approaches are useful when full recovery is not expected or significant permanent disability is likely. This approach can involve a variety of therapeutic strategies for functional difficulties, including the following:

• Changing the method by which a task is completed (e.g., using the tenodesis action to allow gross grasp and release with someone with a spinal cord injury, or teaching a one-handed dressing technique)
• Adapting objects needed for a task or prescribing an assistive device (e.g., building up the handles on eating utensils, or using a long-handled reacher to retrieve objects out of reach)
• Modifying the environment (e.g., redesigning an entire home environment or workplace to allow access for someone in a wheelchair, or removing mats and rugs to prevent falling and allow more independent mobility)12,14

With the enormous progress made in recent years in technology, individuals with physical disabilities are now able to achieve much higher levels of functional independence than was previously possible through the use of technologic aids. The area of assistive technology is a dedicated field within rehabilitation that specializes in fitting individuals with physical and cognitive disabilities with both low- and high-tech solutions to enhance mobility, communication, community access, and learning. The application of assistive technology in physical disability is discussed in Chapters 17 and 23 of this text.

The remainder of this chapter reviews treatment principles and goals in key areas of functional performance, and outlines commonly used adaptive equipment relevant to each area.

Self-Maintenance

Feeding

Feeding is a primary task of daily living essential for maintaining adequate nutrition and for participation in significant social and cultural routines. Mealtime management is generally identified by patients, families, and the rehabilitation team as a priority for intervention. Within the area of feeding, treatment might focus on developing:

• Underlying oral–motor and oral–pharyngeal coordination necessary for safe oral intake and swallowing
• Required physical skills for independent self-feeding
• Routines and strategies essential to manage the social and behavioral aspects of mealtimes

Treatment techniques incorporate both restorative and compensatory approaches. Where significant behavioral concerns exist, counseling, parent education, behavior management, and group therapy might also be indicated. Adaptive equipment commonly used to facilitate independence in feeding might include the following:

• Nonslip matting: This is useful to stabilize dishes when bilateral coordination or strength is compromised.
• Scoop dishes or plate guards: These allow food to be stabilized against the raised side, facilitating independence for individuals with functional use of just one hand (Figure 26-1).
• Weighted utensils and cups, and swivel utensils: These assist in compensating for limited hand control, ataxia, or movement disorders.
• Rocker knife: This is useful when bilateral upper limb functional skills are impaired, as seen with involvement in the patient with hemiplegia or with a spinal cord injury. A rocker knife is used by pushing the knife down into food and rocking the knife until the food is cut. This avoids the traditional sliding method, while stabilizing the food with a fork in the opposite hand (Figure 26-2).
• Adapted and built-up utensils, utensil cuffs, and splints with utensil slots: This equipment assists individuals with weak or absent grasp (see Figures 26-2 and 26-3).
• Mobile arm supports or suspension slings: These systems support the forearm while assisting and maximizing motions such as shoulder flexion and extension, horizontal abduction and adduction, external and internal rotation, and elbow flexion and extension. For individuals with limited range of motion for hand to mouth activity, these devices may support independence (see Figure 26-3).
• Sippy cups, cutout cups, spouted cups, and various bottle systems: A variety of bottles and cups are available to assist children without adequate oral–motor or oral pharyngeal skills such as sucking and lip closure (Figure 26-4).
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FIGURE 26-1 A scoop dish and a plate with plate guard are used by pushing food against the rim to scoop; it also helps as a guide.

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FIGURE 26-2 Adapted utensils: custom-made handle (A), rocker knife (B), spoon with plastic shallow bowl (C), and weighted utensil (D).

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FIGURE 26-3

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