A clinical problem-solving approach is used because it is logical and adaptable, and it has been recommended by many professionals during the past 40 years.1–7 The concept of clinical decision making based in problem-solving theory has been stressed throughout the literature over the past decades and has guided the therapist toward an evidence-based approach to patient management. This approach clearly identifies the therapist’s responsibility to examine, evaluate, analyze, draw conclusions, and make decisions regarding prognosis and treatment alternatives.^8–24

This book is divided into three sections.

Section I lays the foundation of knowledge necessary to understand and implement a problem-solving approach to clinical care across the span of human life. The basic knowledge of the function of the human body in disease and repair is constantly expanding and often changing in content, theory, and clinical focus. This section reflects that change in both philosophy and scientific research.

Roles that therapists are currently playing and will be asked to play in the future are changing.25–27 Therapists are experts in normal human movement across the life span (see Chapter 3) and how that movement is changed after life events, and with disease or pathological conditions. Therapists realize that health and wellness play a critical role in movement function as a client enters the health care system with a neurological disease or condition (see Chapter 2). In many U.S. states, clients are now able to use direct access for therapy services. In this environment, therapists must medically screen for disease and pathology to determine conditions that are outside of the defined scope of practice, and make appropriate referrals to other medical professionals (see Chapter 7). They must also make a differential diagnosis regarding movement dysfunctions within that therapist’s respective scope of practice (see Chapter 8). Section I has been designed to weave together the issues of evaluation and intervention with components of central nervous system (CNS) function to consider a holistic approach to each client’s needs (see Chapters 4, 5, 6, and 9). This section delineates the conceptual areas that permit the reader to synthesize all aspects of the problem-solving process in the care of a client. Basic to the outcomes of care is accurate documentation of the patient management process, as well as the administration and reimbursement for that process (see Chapter 10).

Section II is composed of chapters that deal with specific clinical problems, beginning with pediatric conditions, progressing through neurological problems common in adults, and ending with aging with dignity and chronic impairments. In Section II each author follows the same problem-solving format to enable the reader either to focus more easily on one specific neurological problem or to address the problem from a broader perspective that includes life impact. The multiple authors of this book use various cognitive strategies and methods of addressing specific neurological deficits. A range of strategies for examining clinical problems is presented to facilitate the reader’s ability to identify variations in problem-solving methods. Many of the strategies used by one author may apply to situations presented by other authors. Just as clinicians tend to adapt learning methods to solve specific problems for their clients, readers are encouraged to use flexibility in selecting treatments with which they feel comfortable and to be creative when implementing any therapeutic plan.¹⁶ Although the framework of this text has always focused on evidence-based practice and improvement of quality of life of the patient, the terminology used by professionals has shifted from focusing on impairments and disabilities of an individual after a neurological insult (the International Classification of Impairments, Disability and Health [ICIDH]) to a classification system that considers functioning and health at the forefront: the International Classification of Functioning, Disability and Health (ICF).²⁸ The ICF considers all health conditions, both pathological and non–disease related; provides a framework for examining the status of body structures and functions for the purpose of identifying impairments; includes activities and limitations in the functional performance of mobility skills; and considers participation in societal and family roles that contribute to quality of life of an individual. The personal characteristics of the individual and the environmental factors to which he or she is exposed and in which he or she must function are included as contextural factors that influence health, pathology, and recovery of function.²⁹ The ICF provides a common language for worldwide discussion and classification of health-related patterns in human populations. The language of the ICF has been adopted by the American Physical Therapy Association (APTA), and the revised version of the Guide to Physical Therapist Practice reflects this change.³⁰ Each chapter in this book strives to present and use the ICF model, use the language of the ICF, and present a comprehensive, patient-oriented structure for the process of examination, evaluation, diagnosis, prognosis, and intervention for common neurological conditions and resultant functional problems. Consideration of the patient/client as a whole and his or her interactions with the therapist and the learning environment is paramount to this process.

Chapters in Section II also include methods of examination and evaluation for various neurological clinical problems using reliable and valid outcome measures. The psychometric properties of standard outcome measures are continually being established through research methodology. The choice of objective measurement tools that focus on identifying impairments in body structures and functions, activity-based functional limitations, and factors that create restrictions in participation and affect health quality of life and patient empowerment is a critical aspect of each clinical chapter’s diagnostic process. Change is inevitable, and the problem-solving philosophy used by each author reflects those changes.

Section III of the text focuses on clinical topics that can be applied to any one of the clinical problems discussed in Section II. Chapters have been added to reflect changes in the focus of therapy as it continues to evolve as an emerging flexible paradigm within a multiple systems approach. A specific body system such as the cardiopulmonary system (see Chapter 30) or complementary approaches used with interactive systems (see Chapter 39) are also presented as part of Section III. These incorporate not only changes in the interactions of professional disciplines within the Western medical allopathic model of health care delivery, but also present additional delivery approaches that emphasize the importance of cultural and ethnic belief systems, family structure, and quality-of-life issues. Two additional chapters have been added to Section III. Chapter 37 on imaging emphasizes the role of doctoring professions’ need to analyze how medical imaging matches and mismatches movement function of patients. Chapter 38 reflects changes in the role of PTs and OTs as they integrate more complex technologies into clinical practice.

Examination tools presented throughout the text should help the reader identify many objective measures. The reader is reminded that although a tool may be discussed in one chapter, its use may have application to many other clinical problems. Chapter 8 summarizes the majority of neurological tools available to therapists today, and the authors of each clinical chapter may discuss specific tools used to evaluate specific clinical problems and diagnostic groups. The same concept is true with regard to general treatment suggestions and problem-solving strategies used to analyze motor control impairments as presented in Chapter 9; authors of clinical chapters will focus on evidence-based treatments identified for specific patient populations.

The changing world of health care

To understand how and why disablement, enablement, and health classification models have become the accepted models used by PTs and OTs when evaluating, diagnosing, prognosing, and treating clients with body system impairments, activity limitations, and participation restrictions resulting from neurological problems, it is important for the reader to review the evolution of health care within our culture. This review begins with the allopathic medical model because this model has been the dominant model of health care in Western society and forms the conceptual basis for health care in industrialized countries.³¹ The allopathic model assumes that illness has an organic base that can be traced to discrete molecular elements. The origin of disease is found at the molecular level of the individual’s tissue. The first step toward alleviating the disease is to identify the pathogen that has invaded the tissue and, after proper identification, apply appropriate treatment techniques including surgery, drugs (see Chapter 36), and other proven methods.

It is implicit in the model that specialists who are professionally competent have the sole responsibility for the identification of the cause of the illness and for the judgment as to what constitutes appropriate treatment. The medical knowledge required for these judgments is thought to be the domain of the professional medical specialists and therefore inaccessible to the public. PTs and OTs have never been responsible for the diagnosis or treatment of diseases or pathological conditions of a specific client. Instead, we have always focused on the body system impairments resulting in activity limitations and inability to participate in life that have been caused by the specific disease or pathological condition. Therapists are also responsible for analyzing the interactions of all other systems and how they compensate for or are affected by the original medical problem. As our roles within Western health care delivery have expanded and are becoming clearer, so has the role of the consumer. In today’s health care environment, the responsibility of both the therapist and the patient begins with health and wellness and proceeds to regaining optimal health, wellness, and functioning after neurological insult.

Levin ³² points out that there is a lot that consumers can do for themselves. Most people can assume responsibility to care for minor health problems. The use of nonpharmaceutical methods (e.g., hypnosis, biofeedback, meditation, and acupuncture) to control pain is becoming common practice. The recognition and value of a holistic approach to illness are receiving increasing attention in society. Treatment designed to improve both the emotional and physical needs of clients during illness has been recognized and advocated as a way to help individuals regain some control over their lives (see Chapters 5 and 6).

A holistic model (holos, from the Greek, meaning “whole”) of health care seeks to involve the patient in the process and take the mystery out of health care for the consumer. It acknowledges that multiple factors are operating in disease, trauma, and aging and that there are many interactions among those factors. Social, emotional, environmental, political, economic, psychological, and cultural factors are all acknowledged as influences on the individual’s potential to maintain health, to regain health after insult, or to maintain a quality of health in spite of existing disease or illness. Measures of success in health care delivery have shifted from the traditional standard of whether the person lives or dies to the assessment of the extent of the person’s quality of life and ability to participate in life after some neurological insult. Moreover, “quality of life” or living implies more than physical health. It implies that the individual is mentally and emotionally healthy as well. It takes all dimensions of a person’s being into consideration regarding health. From the beginning, even Hippocrates emphasized treatment of the person as a whole, and the influence of society and of the environment on health.

An approach that takes this holistic perspective centers its philosophy on the patient as an individual.³³ The individual with this orientation is less likely to have the physician look only for the chemical basis of his or her difficulty and ignore the psychological factors that may be present. Similarly, the importance of focusing on an individual’s strengths while helping to eliminate body system impairments and functional limitations in spite of existing disease or pathological conditions plays a critical role in this model. This influences the roles PT and OT will play in the future of health care delivery and will continue to inspire expanded practice in these professions.

The health care delivery system in Western society is designed to serve all of its citizens. Given the variety of economic, political, cultural, and religious forces at work in American society, education of the people with regard to their health care is probably the only method that can work in the long run. With limitations placed on delivery of medical care, the client’s responsibility for health and healing is constantly increasing. The task of PTs and OTs today is to cultivate people’s sense of responsibility toward their own health and the health and well-being of the community. The consumer has to accept and play a critical role in the decision-making process within the entire health care delivery model to more thoroughly guarantee compliance with prescribed treatments and optimal outcomes.34–40 PTs and many OTs today are entering their professional careers at a doctoral level and beginning to assume the role of primary care providers. A requisite of this new responsibility is the performance of a more diligent examination and evaluation process that includes a comprehensive medical screening of each patient/client.⁴¹^,⁴² Patient education will continue to be an effective and vital approach to client management and has the greatest potential to move health care delivery toward a concept of preventive care. The high cost of health care is a factor that will continue to drive patients and their families to increase their participation in and take responsibility for their own care.⁴³ Reducing the cost of health care will require providers to empower patients to become active participants in preventing and reducing impairments and practicing methods to regain safe, functional, pain-free control of movement patterns for optimal quality of life.

In-depth analysis of the holistic model

Carlson ⁴⁴ thinks that pressure to change to holistic thinking in medicine continues as a result of a societal change in its perspective of the rights of individuals. A concern to keep the individual central in the care process will continue to grow in response to continued technological growth that threatens to dehumanize care even more. The holistic model takes into account each person’s unique psychosocial, political, economic, environmental, and spiritual needs as they affect the individual’s health.

The nation faces significant social change in the area of health care. The coming years will change access to health care for our citizens, the benefits, the reimbursement process for providers, and the delivery system. Health care providers have a major role in the success of the final product. The Pew Health Professions Commission ⁴⁵ identified issues that must be addressed as any new system is developed and implemented. Most, if not all, of the issues involve close interactions between the provider and client. These issues include (1) the need of the provider to stay in step with client needs; (2) the need for flexible educational structures to address a system that reassigns certain responsibilities to other personnel; (3) the need to redirect national funding priorities away from narrow, pure research access to include broader concepts of health care; (4) the licensing of health care providers; (5) the need to address the issues of minority groups; (6) the need to emphasize general care and at the same time educate specialists; (7) the issue of promoting teamwork; and (8) the need to emphasize the community as the focus of health care. There are other important issues, but the last to be included here is mentioned in more detail because of its relevance to the consumer. Without the consumer’s understanding during development of a new system, the system could omit several opportunities for enrichment of design. Without the understanding of the consumer during implementation of a new system, the consumer might block delivery systems because of lack of knowledge. Thus, the delivery of service must be client centered and client and family driven, and the focus of intervention needs to be in alignment with client objectives and desired outcomes.^33–36^,⁴⁶^,⁴⁷ Today, as stated earlier,⁴³ this need may be driven more by financial necessity than by ethical and best practice philosophy, but the end result should lead to a higher quality of life for the consumer.

Providers are more willing to include the client by designing individualized plans of care, educating, addressing issues of minority groups, and becoming proactive team caregivers.37–40 The influence of these methods extends to the community and leads to greater patient/client satisfaction. The research as of 2011 demonstrates the importance of patient participation, and this body of work is expected to grow.

The potential for OTs and PTs to become primary providers of health care in the twenty-first century is becoming a greater reality within the military system as well as in some large health maintenance organizations (HMOs).48–53 The role a therapist in the future will play as that primary provider will depend on that clinician’s ability to screen for disease and pathological conditions, examine and evaluate clinical signs that will lead to diagnoses and prognoses that fall inside and outside of the scope of practice, and select appropriate interventions that will lead to the most efficacious, cost-effective treatment.

The role of therapists in the area of neurological rehabilitation will first be in the area of health and wellness. Medical screening and early detection of neurological problems should facilitate early referral of the consumer to a medical practitioner. This may occur in a wellness center or in physical and occupational therapy clinics where the patient is being seen for some other problem such as back pain. Similarly, patients may reenter physical or occupational therapy after a neurological insult as someone who has a chronic movement dysfunction or degenerative condition that may be getting worse and who needs some instruction to regain motor function.

Neurological rehabilitation is taking place and will continue to take place in a changing health care environment and ever-evolving delivery system. The balance between visionary and pragmatist must be maintained by the practitioner. By the end of the twenty-first century, neurological rehabilitation will have evolved into a new shape and form, will take place within a very different health system, and will involve the client as the center of the dynamic exchange among wellness, disease, function, and empowerment.

Therapeutic model of neurological rehabilitation within the health care system

Traditional therapeutic models

Keen observation of human movement and how impairments in the neuromusculoskeletal system alter motor behavior and functional mobility led several remarkable therapists to develop unique models of therapeutic interventions. These models include those of Ayers (sensory integration), Bobath (NeuroDevelopmental Treatment [NDT]), Brunnstrom (movement therapy approach), Feldenkrais (Functional Integration and Awareness Through Movement), Klein-Vogelbach (Functional Kinetics), Knott and Voss (Proprioceptive Neuromuscular Facilitation [PNF]), and Rood (Rood approach to neuromuscular dysfunction). These were the first behaviorally based models introduced within the health care delivery system, and they have been used by practitioners within the professions of physical and occupational therapy since the middle of the twentieth century. These individuals, as master clinicians, tried to explain what they were doing and why their respective approaches worked using the science of the time. From their teachings, various philosophical models evolved. These models were isolated models of therapeutic intervention that were based on successful treatment procedures as identified through observation and described and demonstrated by the teachers of those approaches. The general model of health care under which these approaches were used was the allopathic model of Western medicine, which begins with disease and pathology. Today, our models must begin with health and wellness, with an understanding of variables that lead a client into the health care delivery system, and an understanding of how the nervous system works and repairs itself.

During the past decades, both short-term and full-semester courses, as well as literature related to treatment of clients with CNS dysfunction, have been divided into units labeled according to these techniques. Often, interrelation and integration among techniques were not explored. Clinicians bound to one specific treatment approach without considering the theoretical understanding of its step-by-step process may have lacked the basis for a change of direction of intervention when a treatment was ineffective. It was difficult, therefore, to adapt alternative treatment techniques to meet the individual needs of clients. As a result, clinical problem solving was impeded, if not stopped, when one approach failed, because little integration of theories and methods of other approaches was never stressed in the learning process. Similarly, because a specific treatment has a potential effect on multiple body systems and interactions with the unique characteristics of each client’s clinical problem, establishing efficacy for interventions using a Western research reductionist model became extremely difficult. This does not negate the potential usefulness of any treatment intervention, but it does create a dilemma regarding efficacy of practice. Similarly, the rationale often used to explain these therapeutic models was based on an understanding of the nervous system as described in the 1940s, 1950s, and 1960s. That understanding has dramatically changed. With the basic neurophysiological rationale for explaining these approaches under fire for validity and the inability to demonstrate efficacy of these approaches using traditional research methods, many of these treatment approaches are no longer introduced to the student during academic training. However, if these master clinicians were much more effective than their clinical counterparts, then the hands-on therapeutic nature of their interventions may still be valid in certain clinical situations, but the neurophysiological explanation for the intervention may be very different. To make statements today saying that these masters did not use theories of motor learning or motor control is obvious because those theories and the studies supporting them had not yet been formulated. Yet patients treated by these master clinicians demonstrated improvements for which, it would seem according to our present-day theories, that concepts of motor learning must have been reinforced and repetitive practice encouraged. Although the verbal understanding of behavior sequences used to promote motor learning did not exist, these behavior sequences were often demonstrated by the client, and thus the success of the treatments and the skill of these master clinicians cannot be denied.

Physical and occupational therapy practice models

Disablement models have been used by clinicians since the 1960s. These models are the foundation for clinical outcomes assessment and create a common language for health care professionals worldwide. The first disablement model was presented in 1965 by Saad Nagi, a sociologist.⁵⁴^,⁵⁵ The Nagi model was accepted by APTA and applied in the first Guide to Physical Therapist Practice, which was introduced in 2001.³⁰ In 1980 the ICIDH was published by the World Health Organization (WHO).⁵⁶ This model helped expand on the International Classification of Diseases (ICD), which has a narrow focus based on categorizing diseases. The ICIDH was developed to help measure the consequences of health conditions on the individual. The focus of both the Nagi and the ICIDH models was on disablement related to impaired body structures and functions, functional activities, and handicaps in society (Figure 1-1). The WHO ICF model²⁸ evolved from a linear disablement model (Nagi, ICIDH) to a nonlinear, progressive model (ICF) that encompasses more than disease, impairments, and disablement. It includes personal and environmental factors that contribute to the health condition and well-being of individuals. The ICF model is considered an enablement model as it not only considers dysfunctions, but helps practitioners and researchers understand and use an individual’s strengths in the clinical presentation. Each of these models provides an international standard to measure health and disability, with the ICF emphasizing the social aspects of disability. The ICF recognizes disability not only as a medical or biological dysfunction, but as a result of multiple overlapping factors including the impact of the environment on the functioning of individuals and populations. The ICF model is presented in Table 1-1 and discussed in greater depth in Chapters 4, 5, and 8.

Figure 1-1 Behavioral model for evaluation and treatment based on the International Classification of Functioning, Disability and Health (ICF) enablement schema. *ROM,* Range of motion.

It is easy to integrate the ICF model into behavioral models for the examination, evaluation, diagnosis, prognosis, and intervention of individuals with neurological system pathologies (see Figure 1-1). Whether an individual’s activity limitations, impairments, and strengths lead to a restriction in the ability to participate in life activities, the perception of poor health, or restriction in the ability to adapt and adjust to the new health condition will determine the eventual quality of life of the person and the amount of empowerment or control he or she will have over daily life. The importance of the unique qualities of each person and the influence of the inherent environment helped to drive changes to world health models. The ICF is widely accepted and used by therapists throughout the world and is now the model for health in professional organizations such as APTA in the United States.³⁰

As world health care continues to evolve, so will the WHO models. The sequential evolution of the three models is illustrated in Table 1-1. This evolution has created an alignment with what many therapists and master clinicians have long believed and practiced—focus on the patient, not the disease. The shift from disablement to enablement models of health care is a reflection of this change in perspective.

TABLE 1-1

ENABLEMENT AND DISABLEMENT MODELS WIDELY ACCEPTED THROUGHOUT THE WORLD OVER THE LAST 50 YEARS *

ICF model, WHO 2001³⁰	Health condition	Body function and structure (impairments)	Activity (limitations)	Participation (restrictions)
ICIDH model, WHO 1980⁵⁶	Disease or pathology	Organ systems (impairments)	Disabilities	Handicaps
Nagi model, 1965⁵⁵	Disease or pathology	Organ systems (impairments)	Functional limitations	Disabilities

ICF, International Classification of Functioning, Disability and Health; ICIDH, International Classification of Impairments, Disabilities, and Handicaps; WHO, World Health Organization.

^*Placed in table form to show similarities in concepts across the models. Please note that the ICF is a nonlinear, progressive model of enablement and includes contextual factors (personal and environmental) that contribute to the well-being of the individual. Also refer to Chapter 8 for a more detailed discussion of the ICF model.

The need for students to develop problem-solving strategies is accepted by faculty across the country and by the respective accrediting agencies of health professionals. Unfortunately, we may not be educating students to the level of critical thinking that we hope.⁵⁹^,⁶⁰ The need for this cognitive skill development in clinicians may be emergent as both physical and occupational therapy professions have moved or plan to move to a doctoring professions.⁴⁹ All health-related professions must evolve as patient care demands increase, delineation of professional boundaries become less clear, and collaboration becomes a more integral factor in providing high-quality health care.

All previously presented models (statistical, medical, behavioral, or belief) can stand alone as acceptable models for health care delivery (see Figure 1-2, A) or can interact or interconnect (Figure 1-2, B). These interconnections should validate the accuracy of the data derived from each model. The concept of an integrated problem-solving model for neurological rehabilitation must also identify the functional components within the CNS (Figure 1-2, C).

A model that identifies the three general neurological systems (cognitive, emotional, motor) found within the human nervous system can be incorporated into each of the other models separately or when they are interconnected (Figure 1-2, D). A systems or behavioral model that focuses on the neurological systems is much more than just the motor systems and their components, or cognition with its multiple cortical facets, or the affective or emotion limbic system with all its aspects. The complexity of a neurological systems model (Figure 1-3), whether used for statistics, for medical diagnosis, for behavioral or functional diagnosis, or for documentation or billing, cannot be oversimplified. As the knowledge bank regarding central and peripheral system function increases, as well as knowledge about their interactions with other functions within and outside the body, the complexity of a systems model also enlarges.⁶¹ The reader must remember that each component within the nervous system has many interlocking subcomponents and that each of those components may or may not affect movement. Therapists use these movement problems as guidelines to establish problem lists and intervention sequences. These components, considered impairments or reasons why someone has difficulty moving, are critical to therapists but are of little concern within a general statistics model and may have little bearing on the medical diagnosis made by the physician.

Figure 1-3 Systems model. Dynamic interactive subcomponents: whole to part to whole. F²ARV, Fear and frustration, anger, rage, violence; *GAS,* general adaptation syndrome; *L.T.,* long term; *S.T.,* short term.

In addition to the Western health care delivery paradigms are the interlocking roles identified within an evolving transdisciplinary model (Figure 1-4). Within this model, the environments experienced by the client both within the Western health care delivery system and those environments external to that system are interlocking and forming additional system components; they influence one another and affect the ultimate outcome demonstrated by the client. Because all these once-separate worlds encroach on or overlay one another and ultimately affect the client, practitioners are now operating in a holistic environment and must become open to alternative ways of practice. Some of those alternatives will fit neatly and comfortably with Western medical philosophy and be seen as complementary. Evidence-based practice, which used linear research to establish its reliability and validity, has provided therapists with many effective tools both for assessment and treatment, but we still are unable to do similar analyses while simultaneously measuring multiple subsystem components. We can measure tools and interventions across multiple sites but are a long way from truly understanding the future of best practice. Other evaluation and treatment tools may sharply contrast with Western research practice, having too many variables or variables that cannot be measured; therefore arriving at evidence-based conclusions seems an insurmountable problem. In time many of these other assessment tools and intervention strategies may be accepted, once research methods have been developed to show evidence of efficacy, or they may be discarded for the same reason. Until these approaches have gone beyond belief in their effects, therapists will always need to expend additional focus measuring quantitative outcomes and analyzing accurately functional responses. Because the research is not available does not mean the approach has no efficacy (see Chapter 39). Thus the clinician needs to learn to be totally honest with outcomes, and quality of care and quality of life remain the primary objective for patient management. Today, models that incorporate health and wellness have been added to these disablement and enablement models to delineate the complexity of the problem-solving process used by therapists⁶²^,⁶³ (see Chapter 2). This delineation should reflect accurate behavioral diagnoses based on functional limitations and strengths, preexisting system strengths and accommodations, and environmental-social-ethnic variables unique to the client. Similarly, it includes the family, caregiver, financial security, or health care delivery support systems. All these variables guide the direction of intervention⁶⁴ (Figure 1-5). These variables will affect behavioral outcomes and need to be identified through the examination and evaluation process. Many of these variables may not relate to the CNS disease or pathological condition medical diagnosis to which the patient has been assigned.