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.

Levin³² 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.

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.

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.

Conceptual frameworks for client/provider interactions

Three conceptual frameworks for client-provider interactions are commonly used in the current health care delivery system. Each framework serves a different purpose and is used according to the goals of the desired outcome and the group interpreting the results (Figure 1-2). The four primary conceptual frameworks include (1) the statistical model, (2) the medical diagnostic model, (3) the behavioral or enablement model, and (4) the philosophical or belief model.

Statistical model

The statistical model framework considers some predetermined set of mathematical values as the main driver for patient/client management decisions. For example, in today’s health care arena there is often a disconnect between the extent of a patient’s clinical problems and the number of approved, predetermined treatment visits needed to remediate these problems. In this situation the clinician must make certain clinical decisions before deciding service and must determine how best to meet the needs of the patient given this limitation. Another illustration of this model involves the use of “numbers” or “grades” obtained from some outcome measure to make a determination on either the extent of functional limitation or the efficacy of a particular intervention. For example, if a patient scores 14 out of 24 points one week and 17 out of 24 points the next, and the payer knows that a score of 19 means the individual’s risk of falling is reduced, then the payer often permits additional therapy visits. Those payers generally have little interest in the reasons why the client moved from a score of 14 to 17, only that the person is improving. If clinicians do not provide these types of quantitative measurements, payment for services often is denied. To be able to optimize care under this model, today’s therapists need to be flexible critical thinkers who are able to skillfully document and communicate progress to individuals who need numbers, as well to provide this information to patients and their families, who are in emotional crisis because of problems associated with the neurological dysfunction, in a manner that they can understand.

Because efficacy of any intervention may be questioned by anyone, including the client, family, physician, third-party payer, or a lawyer, outcome tools that clearly measure problems in all domains must be carefully selected. Before an evaluation tool is chosen, the specific purpose for the request for examination and the model by which to interpret the meaning of the data must be identified.

Medical diagnostic model

Physicians are educated to use a medical disease or pathological condition diagnostic model for setting expectations of improvement or lack thereof. In patients with neurological dysfunction, physicians generally formulate their medical diagnosis on the basis of results from complex, highly technical examinations such as magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), computerized axial tomography (CAT or CT scan), positron emission tomography (PET scan), evoked potentials, and laboratory studies (see Chapter 37). When abnormal test results are correlated with gross clinical signs and patient history such as high blood pressure, diabetes, or head trauma, a medical diagnosis is made along with an anticipated course of recovery or disease progression. This medical diagnostic model is based on an anatomical and physiological belief of how the brain functions and may or may not correlate with the behavioral and enablement models used by therapists.

Behavioral or enablement model

The behavioral or enablement model evaluates motor performance on the basis of two types of measurement scales. One type of scale measures functional activities, which range from simple movement patterns such as rolling to complex patterns such as dressing, playing tennis, or using a word processor. These tools identify functional activities or aspects of life performance that the person has been or is able to do and serve as the “strengths” when remediating from activity limitations or participation restrictions. The second scale looks at bodily systems and subsystems and whether they are affecting functional movement. These measurement tools must look at specific components of various systems and measure impairments within those respective areas or bodily systems. For example, if the system to be assessed is biomechanical, a simple tool such as a goniometer that measures joint range of motion might be used, whereas a complex motion analysis tool might be used to look at interactions of all joints during a specific movement. These types of measurements specifically look at movement and can be analyzed from both an impairment and an ability perspective. Chapter 8 has been designed to help the reader clearly differentiate these two types of measurement tools and how they might be used in the diagnosis, prognosis, and selection of intervention strategies when analyzing movement.

Philosophical or belief model

A fourth model or framework for client-provider interaction that may still be found in clinical use is a philosophical or belief model such as those described by master clinicians from the past, including Rood, Knott, Bobath, and Ayers, or homeopathic models such as acupuncture or Chinese medicine. These philosophical models, when applied to functional outcomes, would be included with today’s behavioral models and encompass a systems approach. The gap between philosophy and practice is narrowing as evidence is slowly showing that many of these approaches positively affect patient outcomes. Research has also identified approaches that have no efficacy. The link is outcome measures and whether a patient changes in participating in and has a quality of life. Thus the change is seen in the patient. Research today has created an alignment with what many therapists and master clinicians have long believed and practiced—focus on the patient, not the disease.

Therapists appreciate a statistical model through research and acceptance of evidence-based practice. A third-party payer also uses numbers to justify payment for services or to set limits on what will be paid and for specific number of visits that will be covered. Therapists also appreciate physicians’ knowledge and perspective of disease and pathology because of the effect of disease and pathology on functional behavior and the ability to engage and participate in life. On the other hand, third-party payers and physicians may not be aware of the models used by OTs and PTs. It is therefore critical that therapists make the bridge to physicians and third-party payers because research has shown that interdisciplinary interactions help reduce conflict between professionals and provide better consistency for the patient.^57,58

It is a medical shift in practice to recognize that patient participation plays a critical role in the delivery of health care. The importance of the patient and what each individual brings to the therapeutic environment has been recognized and incorporated into patient care by rehabilitation professionals.37–40 This integration and acceptance will guide health care practice well into the next decade.

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.

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 therapists^62,63 (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.

The client brings to this environment life experiences. Many of these life events may have just been a life experience; others may have caused slight adjustments to behavior (e.g., running into a tree while skiing out of patrolled downhill ski areas and then never doing it again), some may have caused limitations (e.g., after running into the tree, the left knee needed a brace to support the instability of that knee during any strenuous exercising), or caused adjustments in motor behavior and emotional safety before that individual entered the heath care delivery system after CNS problems occurred. The accommodations or adjustments can dramatically affect both positively and negatively the course of intervention. To quickly accumulate this type of information regarding a client, the therapist must become open to the needs of the client and family. This openness is not just sensory, using eyes and ears, but holistic and includes a bond that needs to and should develop during therapy (see Chapters 5 and 6).

Efficacy

Efficacy has been defined as the “ability of an intervention to produce the desired beneficial effect in expert hands and under ideal circumstances.”⁶⁵ When any model of health care delivery is considered, the question the therapist must ask is “Which model will provide the most efficacious care?” Therapists may not diagnose a pathological disease or its process, but they are in a position of responsibility to examine body systems for existing impairments and to analyze normal movement to determine appropriate interventions for activity-based functional problems. Some differences in this responsibility may exist between practice settings. Therapists in private practice act independently to select both examination tools and intervention approaches that are efficacious and prove beneficial to the patient. Within a hospital-based system, therapists may be expected to use specific tools that are considered a standard of care for that facility, regardless of the therapy diagnosis and treatment rendered. In some hospitals and rehabilitation settings a clinical pathway may be employed that defines the roles and responsibilities of each person on a multidisciplinary team of medical professionals. Regardless of which clinical setting or role the therapist plays, it is always the responsibility of the therapist to be sure that the plan of care is appropriate, is consistent with the medical and therapy diagnoses, meets the needs of the patient, and renders successful outcomes. If the needs of the particular client do not match the progression of the pathway, it is the therapist’s responsibility to recommend a change in the client’s plan of care. Efficacy does not come because one is taught that an examination tool or intervention procedure is efficacious, it comes from the judicious use of tools to establish impairments, activity limitations, and participation restrictions, identify movement diagnoses, create functional improvements, and improve quality of life in those individuals who have come to us for therapy.

Today’s health care climate demands that the therapeutic care model be efficient, be cost-effective, and result in measurable outcomes.⁶⁶ The message being given today might be considered to reflect the idea that “the end justifies the means.” This premise has come to fruition through the linear thought process of established scientific research. Yet when a holistic model is accepted into practice it becomes apparent that outcome tools are not yet available to simultaneously measure the interactions of all body systems that make up the patient, making it difficult to apply models that purport to balance quality and cost of care. Thus we must guard against the reductionist research of today, which has the potential to restrain our evolution and choice of therapeutic interventions. Sometimes the individuals making decisions about what to include and what to eliminate with regard to patient services are not health care providers. They are individuals who are trained to use evidence gained from numbers or statistics to make their decision and do not have knowledge of the patient, his or her situation, or the effect of the neurological condition on function. Therapists should always be able to defend their choice and use of intervention approaches. This becomes even more relevant as the cost of health care rises.

Evidence-based practice is basic to the care process.^30,67,68 Clinicians need to identify which of their therapeutic interventions have demonstrated positive outcomes for particular clinical problems or patient populations and which have not.⁶⁹ Those that remain in question may still be judged as useful. The basis for that judgment may be a client satisfaction variable that has become a critical variable for many areas in health care delivery.^70,71 But there is still limited information on patient satisfaction with PT and OT services, although within the last few years more information has become available.^72–76 Although patient satisfaction is a critical variable within the ICF model, there are always problems with satisfaction and outcomes versus identification of specific measurable variables within the CNS that are affecting outcomes. One reason for the problem of integrating patient satisfaction with PT and OT services within a neurorehabilitation environment is the large discrepancy between the variables we can measure and the variables within the environment that are affecting performance. For example, when a neurosurgeon once asked the question to one of the editors, “Do you know how to prove the theories of intervention you are teaching?” The answer was, “Yes, all I need are two dynamic PET units that can be worn on both the client’s and the therapist’s heads while performing therapeutic interventions. I also need a computer that will simultaneously correlate all synaptic interactions between the therapist and the client to prove the therapeutic effect.” The physician said, “We don’t have those tools!” The response was, “You did not ask me if the research tools were available, only if I know how to obtain an efficacious result.” Thus, the creativity of the therapist will always bring the professions to new visions of reality. That reality, when proven to be efficacious, assists in validating the accepted interventions used by the professional. The therapist today has a responsibility to provide evidence-based practice to the scientific community…but more important, also to the client. Therapeutic discovery usually precedes validation through scientific research. This discovery leads the way to, first, effective interventions, followed by efficacious care. If research and efficacious care always have to come before the application of therapeutic procedures, nothing new will evolve because discovery of care is most often, if not always, found in the clinic during interaction with a client. Thus the range of therapeutic applications will become severely limited and the evolution of neurological care stopped if that discovery is ignored because there is no efficacy as defined by today’s research models. However, performing interventions because the approaches “have been typically done in the past” could be wasteful and irresponsible.

Diagnosis: A process used by all professionals when drawing conclusions

Diagnosis is a conclusion drawn regarding specific diseases and pathological processes within the human body; when made by a physician it is considered a medical diagnosis. Diagnosis made by a PT or an OT is a conclusion drawn regarding the status of body systems, activity and participation, and their interactions considering the patient’s personal factors and the environment. Specific activity-based functional limitations and the impairments within the body systems that affect the client’s ability to control quiet postures or dynamic movement in any activity become a focus in the diagnostic process. The functional loss itself may or may not reflect specific diseases or pathological conditions within the CNS but does reflect specific impairments within that client’s body. PTs and OTs, by use of functional behavioral models, are becoming comfortable with the diagnosis of body system problems (impairments), activity restrictions (functional limitations), and participation and the conceptual understanding that the diagnosis made by a PT or an OT is very different from that made by a physician.

Once the interpretation has been made, a therapist must draw conclusions regarding those results and their interactions. That interpretation leads to a therapy diagnosis. The interpretation of the evaluation results and their interaction with therapist’s and client’s desired outcomes, available resources, and client’s potential lead to the prognosis. Selection of the best and most efficient resources to achieve the desired outcome will lead to establishment of the treatment intervention plan or “road map.”

The diagnostic process used by therapists is complex and is clearly divided into two specific phases of differential diagnosis (Figure 1-6). This is further explained in Chapters 7 and 8.

Prognosis: how long will it take to get from point A to point B?

If a client has a variety of impairments, activity limitations, and participation restrictions, then a variety of appropriate prognoses may be formulated. These prognoses could be used to speculate the amount of time or number of treatments it will take to get from the existing activity limitations and participation restrictions (point A) to the desired outcomes (point B). The outcomes will state whether the intervention will (1) eliminate functional limitations through changes, adaptations, and learning within the client as an organism or (2) improve function through compensation and modification of the external environment. Once the therapy diagnosis has been established, a clinician must consider many factors when making a prognosis. Some factors are related to the internal environment of the client, such as number and extent of impairments, level of physical conditioning or deconditioning of the client, the ability and motivation to learn, participate, and change, and the neurological disease or condition that led to the existing problems. The client’s support systems have a dramatic impact on prognosis. Cultural and ethnic pressures, financial support to promote independence, availability of appropriate skilled professional services, prescribed medications, and the interaction of all of these factors need to be considered. Specific environmental factors such as belief in health care and agreement about who has the responsibility for healing can create tremendous conflict among current health care delivery systems; the client; the family; and you, the clinician.^79,82,83 All of these variables affect prognosis. The last aspect of determining prognosis relates to empowerment of the client. Who sets the goals? Who determines function? Who identifies when a therapeutic modality should be used versus a meaningful life activity? If consensus to these questions cannot be found by the therapist and the client, then conflict between anticipated and actual outcome will result and a definitive prognosis will not be achieved.

Once a prognosis has been established, the therapist’s next step is to identify the intervention strategies that will guide the client to the desired outcome within the time frame identified. (Refer to Chapter 9 and all chapters in Section II.)

Documentation

Documentation of the examination, evaluation, goals, plan, and daily interventions has always been integral to the therapeutic process. However, there is added emphasis in today’s health care environment, as well as a renewed respect for the importance of the issue. Documentation must produce a clear framework from which to record and follow client progress. Documentation communicates the process of care and the product or outcome of that process. The outcome is the realistic reflection of the effectiveness of care. The goals should be stated in measurable functional terms and prioritized in order of importance to the client. The number of goals developed by the therapist takes into account the realistic probability of effectiveness of interventions, the environment in which the interventions will likely occur, and support systems available to the client. As the process goes forward, the therapist may add, delete, or change a functional goal, and so states that on the client’s record. Refer to Chapter 10 for further information about this process.

Intervention

Clients with neurological diseases or conditions can interact with the medical community for either short or long periods. They possess neurological problems of all types that range from sudden to insidious in onset and presentation. All aspects of human function are represented in the variety of problems. If individual beliefs and values energize and motivate physical behavior, think of the possibilities for stimulating wellness. Return to wellness might be considered return to previous function, maintenance of function, slowing progression of functional loss, habilitation of function never achieved, and striving for excellence in performance. Refer to Chapter 9 for additional discussion.

The established plan of care determines the interventions and the method, or road map, toward the achievement of the agreed-on outcome goals. The therapist, in collaboration with the client, can choose from restrictive and nonrestrictive treatment environments and interventions to best achieve identified goals. The available choices of interventions will depend on the therapist’s skill, the level of function and ability of the client to control his or her own neuromuscular system, and treatment tools and strategies that are available in the clinic. Yet freedom within that established environment must exist if learning by the client is to occur. Another way to consider intervention is to refer to it as a clinical road map (Figure 1-7). Within the map, a therapist, through professional education, efficacy of preexisting clinical pathways, and clinical experience can generally identify the most expedient way to guide a client toward the desired outcome. When the specific client enters into this interaction, slight variations off the existing pathway may lead to quicker outcomes. If the client diverges away from the desired end product, it is the therapist’s responsibility to guide that individual back into the clinical map. For example, if a therapist and client are working on coming to standing patterns and the client begins to fall, the therapist would need to guide the client back into the desired movement patterns and not allow the fall. In that way the client is working on the identified outcome. Falling as a functional activity should be taught as a different intervention and would be considered part of a different clinical map. The degree to which the therapist needs to control the response of the client will determine the extent to which the intervention would be considered contrived. Contrived interventions can, in time, lead to functional independence of the client, but as long as the therapist needs to control the environment, functional independence has not been achieved. There are many ways to get to a desired outcome. Involving the client in the goal setting and intervention planning process will lead to the best result These interactions require trust of the therapist as a guide and teacher. Refer to Chapter 9 and all chapters in Section II for a more thorough discussion of intervention strategies.

Most treatment interventions used for clients with CNS pathology incorporate principles of neuroplasticity, adaptation, motor control, and motor learning in various environmental contexts. Thus, the consideration of the basic science of central and peripheral nervous system function (see Chapter 4) and a behavioral analysis of movement (see Chapter 3) must be included in any conceptual model used as a foundation for the entire diagnostic process.

Also of considerable significance is the client-therapist interaction, which is labeled the learning environment. This may be the critical factor in the success or failure of therapeutic interventions. The concept of human movement as a range of observable behaviors, the complexity of the CNS as a control center, and the interactions between the client and therapist within closed and open learning environments form an abstract conceptual triad. Each part of this triad has unique characteristics that have the ability to influence performance and progress in the clinical setting. Together they allow for the client to be viewed as a total human being, allowing the therapist to consider multiple constructs at once so that a client’s responses and movement patterns may all be considered and developed simultaneously. In this way, key signs such as movement in body parts distant to the area being treated, pain, or a response of the autonomic nervous system will not be missed. Attention to these responses may be the answer to attaining goals and successful client-therapist rapport.

Concept of the learning environment

The concept of the learning environment is the most abstract and complex of the three concepts in the clinical triad model. For that reason it is by far the most difficult to present in concrete terms. Components of the therapist, the patient, and the clinical environment formulate and maintain this environment.

To comprehend the dynamics of the learning environment and function with optimal success, the clinician must do the following:

 Understand the learning process and provide an environment that promotes learning.

 Investigate the use of sensory input and motor output systems, feed-forward and feedback mechanisms, and cognitive processing as means for higher-order learning.

 Use the principles and theories of motor control, motor learning, and neuroplasticity to facilitate learning and carryover of treatment into real-life environments.

 Obtain knowledge of both the client’s and the provider’s learning styles. If these learning styles are not compatible, then the clinician is obligated to teach using the client’s preferred style.

 Attend to the sensory-motor, cognitive, and affective aspects of each client, regardless of the clinical emphasis at any given time.

At all times there are four distinct components of the learning environment in operation: the internal and external environments of the client, and the internal and external environments of the clinician (Figure 1-8). All four represent interactive components of the learning environment.

The client

A critical component of the ability to learn is the client’s internal environment. When a lesion occurs within a body system it affects the entire internal environment of the client both directly and indirectly. If the lesion occurs before initial learning, then habilitation must take place. These clients may possess a genetic predisposition for a specific learning style, even though one has not yet been established. The therapist should test the inexperienced CNS by creating experiences in various contexts that require a variety of types of higher-order processing to discover optimal methods of learning that best suit the CNS of the client. Then the therapist can employ the most effective strategies in treatment. If previous learning has occurred and preferential modes of operating have been established, then the therapist needs to know what those are and whether they have been affected by the neurological insult so that proper rehabilitation can be instituted.⁸⁴ The use of preferential sensory input modes such as visual compared with verbal or kinesthetic does not mean that other modes are ineffective, nor do all modes function optimally in any given situation.

One way to determine preferential learning styles is by taking a thorough history. Leisure activities and job choices often give clues to learning styles. For example, a client who loved to take car engines apart or build model ships demonstrates a preference for the visual-kinesthetic learning style, whereas a client whose preference for pure enjoyment was sitting in a chair with a novel demonstrates a probable preference toward verbal learning. Again, this does not mean that the clients in the examples mentioned could not selectively use all methods, but it does illustrate the issue of preference. Both the position of the lesion and the preferential learning style can play key roles in matching the learner with a particular treatment environment and identifying potential for recovery of function. For example, if a client has had a massive insult to the left temporal lobe and before the trauma showed poor ability in using the right parieto-occipital lobe, then spatial or verbal strategies may be ineffective in the relearning process. However, a client with the same lesion who had high-level right parieto-occipital function before the insult will probably learn at a much faster rate if visual-kinesthetic strategies are used to promote learning.

The client’s external environment is the second critical component.⁸⁵ All external stimuli, including noise, lighting, temperature, touch, humidity, and smell, modulate the client’s responses. External inputs can invoke either negative or positive influences on internal mechanisms and alter the client’s ability to manipulate the world. A therapist should make every effort to be aware of what externally is influencing the client.^86–89 It is important to know what is happening to the client both within and outside of the hospital or clinic experience. Any behavioral change displayed by the client, such as a change in mood or attitude, or a change in muscle tone could serve as an indicator to the therapist that an environmental effect may have occurred. A follow-up determination of what may have happened can help the therapist understand the situation, help the client deal with the environmental influences, and allow the therapist to obtain additional professional assistance if needed.

The third critical component is the internal environment of the clinician.⁹⁰ The clinician should be aware of personal internal factors that can influence patient responses. Everyone has preferential styles of teaching and learning; yet many of us may be unaware of what they are and how they affect our outlook on life and interactions with other people. A common example of a mismatch of styles is what happens when two people are arguing opposing sides of a political issue. Although both individuals may process the same data, they may have different learning strategies and come up with very different conclusions.

The interplay of learning styles occurs continually in an academic setting. A student who is asked the question “What do you want out of this course?” would probably say, “A good grade.” Getting a good grade requires doing well on course requirements, including tests. High-grade test performance usually depends on not only a knowledgeable demonstration of a subject but also the way in which the teacher formulates the question and the teacher’s expectation for a response. In a clinical setting, it is important that the clinician be aware of the client’s response to the practitioner’s request.

This external-internal environmental interaction concept brings up another important clinical consideration.⁹¹ As students, most of us probably “clashed” with one or two teachers with whose learning styles we could never identify. As learners we cannot or will not adapt to all learning styles. For that reason there may be some clients who do not respond to our teaching. When that seems evident, a shift of therapists is appropriate for the rehabilitation process to succeed.

The fourth component of the learning environment is the clinician’s external environment. It is generally expected that personal life should never affect professional work. To accept this assumption, however, may be to deny that emotions affect behavioral patterns (see Chapters 5 and 6 ). Response patterns can vary without cognitive awareness when an individual is emotionally upset or under stress. For example, suppose that Mr. Smith, who has a hypertonic condition because of a stroke, comes down early for therapy each morning, has a cup of coffee, and chats while you write notes. If one day you are under extreme stress and do not feel like interacting as Mr. Smith rolls his wheelchair into your office, you might say, “Mr. Smith, I’ll be with you in a few minutes. Go over to the mat, lock your brakes, pick up the pedals, and we’ll transfer when I get there.” Mr. Smith will quickly sense a change in your behavior. Society has taught him that you are a professional and that your personal life does not affect your job. Thus he may draw a logical conclusion that he must have done something to change your behavior. When you go to transfer him you notice he is more hypertonic than usual and ask, “Is something bothering you? You’re tighter than usual,” and so goes the interaction. Your external environment altered your internal state and, thus, normal response patterns. In turn, you altered Mr. Smith’s external environment, changing his internal balance, and created a change of emotional tone that resulted in increased hypertonicity.^92,93 If instead of interacting with Mr. Smith as if nothing were wrong, you had informed him you were upset over something unrelated to him, you might have avoided creating a negative environment. Mr. Smith’s responses may have been different if you had shared with him the fact that there are days that you are upset and have mood changes. As he accepts your changes as normal, you may have created an opportunity for him to also exhibit a range of behavioral moods. You have also given him an opportunity to offer his assistance to comfort or help you if he so desires. Such behavior encourages interdependence and social interaction and facilitates long-term goals for all rehabilitation clients.

Each client is unique. Therefore it is difficult to analyze the specifics related to each individual’s learning environment. However, six basic learning principles have been established that are relevant to both the client and the clinician in any learning environment.94–96 These six principles of the learning experience are as follows:

1. Individuals need to be able to solve problems and practice those solutions as motor programs if independence in daily living is desired. This requires the use of intrinsic feedback systems to modulate feed-forward motor plans as well as correct existing plans.

2. The possibility of success must exist in all functional tasks, regardless of the level of challenge to the client.

3. An individual will revert to safer or more familiar motor programs or ways to solve problems and succeed at functional tasks when task demands are new, difficult, or unfamiliar.

4. The learning effect occurs in multiple areas of the CNS simultaneously when teaching and learning are focused within one area of the CNS.

5. Motivation is necessary to drive the individual to try to experience what would be considered unknown. Simultaneously, success at the activity is critical to keep the individual motivated to continue to practice.

6. Clinicians need to be able to analyze an activity as a whole, determine its component parts, and use problem-solving strategies to design effective individualized treatment programs. At the same time, if independence in living skills is an objective, the therapist needs to teach the client those problem-solving strategies rather than teaching the solution to the problem.

Although all six learning principles seem simple, their application within the clinical setting is not always as obvious. Principles 1 and 2 are intricately linked with the appropriateness and difficulty of tasks presented to clients. If a client is asked to perform a task such as standing, rolling, relaxing, dressing, or maneuvering a wheelchair, a problem has been presented that requires a sequence of acts leading to a solution. To succeed, the client must be able to plan the entire task and modulate all motor control during the sequence of the entire activity. If steps are not mastered, if sequencing is inappropriate or absent, or if motor control systems are not modulated accurately, dependence on the clinician to solve the problem is reinforced. If the clinician can differentiate missing components (impairments) from functioning systems, creating an environment that encourages and allows the CNS to adapt and learn ways to regain that control, it will lead to optimal self-empowerment of the client and will help eliminate disabilities. Error in the ability to intrinsically self-correct during practice is critical for motor learning. Error that always leads to failure does not help the client learn avenues of adaptation. Linked intricately with success is the challenge of the task. The greater the task difficulty or complexity, the greater the challenge and consequently the greater the satisfaction of success.

There is a subtle interplay among degree of difficulty, challenge, and success. Selecting tasks that are age appropriate, clinically relevant, and goal related is a challenge to the therapist. For the patient to be successful, the therapist must be a creative problem solver and knowledgeable about the client’s needs, abilities, and goals. If the tasks are too simple or if the client considers them unimportant, boredom will ensue and progress may diminish. If the tasks are too difficult, the client may feel defeated and may turn away from them. In such cases a child tends to withdraw physically, whereas an adult usually avoids the problem. Being late to therapy, having to leave early, needing to go to the bathroom, and scheduling conflicting sessions are all avoidance behaviors that may be linked to inappropriate tasks.

The third learning principle describes a behavior inherent in all people: reversal. When confronted by a problem, individuals revert to patterns that produce feelings of comfort and competence when solving the problem. In Figure 1-9, a 2-year-old child is confronted with just such a conflict. The bridge he wants to cross is unstable. The task goal is to cross the bridge; how that is accomplished is not as relevant as the task specificity. Therefore the child chooses a 6-month-old behavior and thus scoots. On gaining confidence, the child sequences from scooting to four-point bunny hopping, then creeping, on to cruising, and finally to reciprocal walking. The child’s reversal lasted approximately 2 minutes. Although reverting to more familiar or comfortable ways of solving problems is normal, it creates constant frustration in the clinic if it is prolonged. For example, if a client with residual hemiplegia has spent a week modifying and controlling a hypertonic upper-extremity pattern during a simple task and is now confronted with a more difficult problem, the hypertonia within the limb will most likely return with the added complexity of the task. If another client has successfully worked to obtain the standing position and then is asked to walk, the strong synergistic patterns that had been controlled may return. The pattern or plan for standing is different from that for walking, and the emotional implications of walking are very high. The clinician should anticipate the possibility of the patient returning to a more stereotypical pattern. This possibility must also be explained to the patient. Anticipating that less efficient patterns will usually return as the tasks demanded increase in complexity, the clinician can attempt to modify the unwanted responses and let the patient know that the response is actually normal given the CNS dysfunction, but that movement can be changed and normalized with practice. The key to comprehension of this concept is not the behavior itself; instead, it is the attitude of a therapist toward a new task presented to the client. If the clinician expects the client to be successful, the client will also expect success. If failure occurs, both parties will be disappointed and a potentially negative clinical situation will be created; however, if the client succeeds, both will have expected the result and their attitude will be neither excited nor depressed. On the other hand, a clinician who expects the client to revert to an old behavior can prepare the client. If the client reverts, neither party will be disappointed; but if no reversion occurs, both will be excited, pleased, and encouraged by the higher functional skill. By understanding the concept, the clinician can maintain a very positive clinical environment without the constant negative interference of perceived failure when a client does revert.

The fourth learning principle deals with the totality of the client. Whether the area of emphasis is motor performance, emotional balance, or perceptual integration, all areas are affected. Therefore understanding and respect for all areas are important if optimal client function is a primary objective. This does not suggest that therapists should address each aspect of personality; however, integration of the client’s physical, mental, and spiritual areas should be a responsibility of the staff. Awareness of possible adverse effects of one learned behavior on other CNS functions can help avoid potential problems. For example, if working on lower extremity patterns creates extreme upper extremity hypertonicity through associated patterns, the clinician is not dealing with the client as a whole.

The unknown creates fear and curiosity for most individuals, and the fifth learning principle points out that for most clients the unknown is all encompassing, whatever the degree of prior learning. For a client whose only difficulty is a flaccid upper extremity, functional activities such as toileting, dressing, or eating will be troublesome and unfamiliar. Motivation is a critical factor for success. Maintaining motivation to try while ensuring a high degree of success is an important teaching strategy that tends to encourage present and future learning.

An additional comment regarding clients who lack motivation should be made. If a client chooses to be totally dependent and has no need to become independent, then a therapist will probably fail at whatever task is presented. For example, Mr. Brown, a 63-year-old bank president with a wife, four children, and 10 grandchildren, survives an operable brain tumor with residual right hemiparesis and minimal cognitive-affective deficits. The client’s work history indicates that he was highly success oriented. Unknown to most persons is that for 63 years Mr. Brown desired to be a passive-dependent person, but circumstances never allowed him to manifest those behaviors. With the neurological insult, he is in a position to actualize his needs. Until the client desires to improve, therapy will probably be ineffective; thus, motivating the client becomes critical. This might be accomplished in a variety of ways. Knowing that Mr. Brown values privacy, especially with respect to hygiene, that he thoroughly enjoys dancing and birdwatching in the forest, and that he ascribes importance to being accepted in social situations, such as cocktail parties, helps the therapist create a learning environment that motivates this client toward independence. Being independent in hygiene requires certain combinations of motor actions, including sitting, balance, and transfer skills. Being able to birdwatch deep in an unpopulated forest requires ambulation skills, tolerance of the upright position for extended periods of time, and endurance. Being socially accepted depends to a large extent not only on grooming but on normal movement patterns, especially in the upper extremity and trunk. Creating a therapeutic environment that stresses independence in the three goals identified by the client will simultaneously create further independence in other areas. Whether the client decides to return to banking and other activities in conflict with his personality will need to be addressed later. Another way to motivate Mr. Brown is to place him in an environment in which he is not satisfied, such as a nursing home or his own home with an assistant rather than his wife to help him with his needs. Dissatisfaction with the current external environment will generally motivate an individual to change. Obviously, creating a positive environment for change versus a negative one would be the method of choice.

The sixth learning principle has been discussed in earlier sections. To be a successful teacher of motor skills and to assist the client in recovery of function, the clinician should be able to break more complex motor plans and functional tasks into smaller component parts. These parts can then be taught successfully and then integrated back into the whole activity for optimal learning to occur. The therapist should always strive to allow each client to solve movement problems and develop strategies for reaching the outcome goals, rather than producing the desired outcome for or with the patient.

Many additional learning principles from the fields of education, development, and psychology can be used to explain the behavioral responses seen in our clients. It is not expected that all therapists will intuitively or automatically know how to create an environment conducive to helping the patient achieve optimal potential. Yet all can become better at creating a beneficial learning environment by understanding how people learn. The critical importance of being honest and accurate with prognosis and how that will ultimately affect function outcomes, participation in life, and quality of life cannot be overemphasized.⁹⁷

The principles presented in this chapter deliver a strong message: individuals need to solve problems and most want to solve the problem given a chance that the solution will be successful. Unless the task fits the individual’s current capability, adaptation using whatever is available will become the consensus that drives the motor performance through the CNS. Learning is taking place in all aspects of life, and the client must ultimately take responsibility for the means to solve the problem.⁹⁸

Active participation in life and in relationships promotes learning. Rogers⁹⁹ defines significant learning as learning that makes a difference and affects all parts of a person. We have spoken of a relationship centered on an individual’s health. One of the individuals involved in the relationship (the therapist) has knowledge that is to be imparted to or skills to be practiced by the other. The relationship “works” if the learning environment facilitates exchange between the participants. The concept of equal partners is crucial. The issue and practice of informed consent is not just political or ethical; it is central to client care. Voluntarism has to be practiced by both practitioner and client. Each has a moral obligation to facilitate the process of health care within the moment. Although the Western world of medicine has steadily climbed a path toward excellence in medical technology and clarification of medical diagnosis as seen in WHO’s ICD-10,¹⁰⁰ it has not as easily recognized the client’s need to assume an equal role in the decision making or for the practitioner to seek the client’s help. Consumers are now seeking to play a more active role in their health care. This role has developed out of our scientific understanding of motor learning (see Chapter 4) and the fiscal necessity of decreasing the number of therapeutic visits.

Consumers of health care are becoming aware of the affect of medicine’s control over their lives. This awareness has been fueled by the price they are paying for that health care. A recent Surgeon General’s report confirms that expenditures for health are increasing. In addition, preventive care assumes major importance in view of the fact that seven out of 10 deaths in the United States today are the result of degenerative diseases, such as heart disease, stroke, and cancer.¹⁰¹ Like other major causes of death, trauma (cited as the most frequent cause of death in persons younger than age 40 years¹⁰²) is increasingly linked to lifestyles.

During their training, individuals in the health care professions internalize values that reinforce the traditional professional attitude alluded to earlier. Many of these values do not support a partnership relationship with the client. Society is beginning to question the traditional role of the health care professional as the knowledge expert; however, professional educational institutions and organizations resist the pressure to change the image. The professions still hold the image of great authority given to them by the public and fostered through increased political activity. This is true for both those professionals dealing with disease and pathology (physicians, nurses, pharmacists) and those dealing with functional movement problems limiting participation in life (OTs, PTs, Speech Language Pathologists).

The major purpose of the patient’s relationship with the health care professional is to exchange information useful to both regarding the health care of the client. McNerney³¹ calls health education of the client the missing link in health care delivery. As the gap grows between technology and the users of that technology, client health education becomes more important than ever.¹⁰³ McNerney³¹ notes that although health care providers are now making efforts to educate their clients, they are doing so with little consistency, enthusiasm, theoretical base, or imagination and often with little coordination with other services. The health care professional continues to receive training and embrace professional organizational membership that places a premium on control of information and control of the decision making. There is and should be a special effort to introduce health education concepts into the basic educational programs of health care professionals. McNerney identified many of the problems three decades ago, and many still exist today.

When patients are given more information about their illnesses and retain the information, they express more satisfaction with their caregivers. A study by Bertakis¹⁰⁴ tested the hypothesis that patients with greater understanding and retention of the information given by the physician would be more satisfied with the physician-patient relationship. The experimental group received feedback and retained 83.5% of the information given to them by the physician. The control group received no feedback and retained 60.5% of the information. Not surprisingly, the experimental group was more satisfied with the physician-patient relationship.

If the client is to be informed and included in the treatment process, client health education will have to go beyond the current styles of information giving. If the client is to assume some of the responsibility for his or her therapy, the therapist will have to facilitate that involvement. The attitude of the therapist toward educating clients about their health could affect his or her ability to facilitate client involvement in the care process.

The more the professional sees himself or herself as the expert, the less likely he or she will be to see the client as capable of responsibility or expertise in the care process. If communication skills and health education were an integral part of medical school and health care professional school curricula, perhaps the health care professionals would temper their assumption of the “expert” professional role. Payton¹⁰⁵ points out that it is the client alone who can ultimately decide whether a goal is worth working for. Careful planning can be influential in helping all providers include the client in the process.

The health care delivery system in the United States has to serve all citizens.¹⁰⁶ That is no easy task. The United States is a society of great pluralism. It is a free society. It is a society that is used to being governed by persuasion, not coercion. 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. The future task of health education will be to “cultivate people’s sense of responsibility toward their own health and that of the community.” Health education is an effective approach with perhaps the most potential to move us toward a concept of preventive care.

Becker and Maiman¹⁰⁷ discussed Rosenstock’s Health Belief model as a framework to account for the individual’s decision to use preventive services or engage in preventive health behavior. Action taken by the individual, according to the model, depends on the individual’s perceived susceptibility to the illness, his or her perception of the severity of the illness, the benefits to be gained from taking action, and a “cue” of some sort that triggers action. The cue could be advice from a friend, reading an article about the illness, a television commercial, and so on. In some way, the person is motivated to do something.

Mass media has promoted individuals’ education, which may correctly guide or misguide consumers’ decision making.^108,109 This concept was put forward as early as 1976.¹¹⁰ Today the consumer thus has a heightened expectation of the quality of care he or she will receive. Similarly, consumers come to receive medical care because of media education, whereas in the past that level of education was not available.^111,112 As of today, the media are just beginning to be used by OT and PT professions, in the hope that this media use will educate the public regarding when, where, and how to decide on whether to seek our services. It will be a few years before research can be done to determine if this use of media will assist in educating the public.

Many aspects of today’s lifestyles do not reinforce wellness. The obesity seen throughout the industrialized world proves that point.113–115 Yet whether the client takes some responsibility for his or her functional problems and recovery depends a great deal on whether the health care provider gives some to him or her. Today’s literature certainly reinforces the need for patient responsibility and active participation in one’s own functional recovery.^116–124 This change in responsibility may be caused by third-party payers and the lack of funding versus promotion of a new health care model in which the patient is an active participant, but as long as the change occurs, the world will be better served.

Fink¹²⁵ in 1980, over three decades ago, recognized the importance of the provider-patient relationship. The state of what is referred to as health varies for each client and includes both the simple and complex variables of that client’s life, from the last nutritional meal to the totality of the client’s life event history (see Figure 1-5). The relationship of the therapist and the client can lead to better use of the health care system by giving responsibility to the consumer.^126,127 The therapist has an advantage over most other health care practitioners, who see the patient at infrequent intervals and who seldom touch the patient as a PT or an OT does.

The illness or trauma of the client that represents a disintegrating force in his or her life may represent an opportunity for the therapist to grow professionally. The client and the therapist may have different psychological backgrounds, and, although the client’s presence is usually related to a medical crisis, the therapist’s presence may support the purposes of personal growth, financial gain, prestige, and unconscious gratification in influencing the lives of others through professional skill.¹²⁸

As the consumer becomes more involved, so should the family.¹²⁹ Patients in therapy have always been happier with the family involved.¹³⁰ The therapist must be willing to facilitate the involvement of the family members and help them learn to take responsibility for some of the care and decision making. Most health care professionals are not conditioned to allowing patients and family members to assume responsibility for their own care; however, better outcomes can be achieved if this is permitted and accepted.

Therapists are caught up in the same problems of the health care system as other health care professionals. Inflation has often caused profit to become a more important motive than human care considerations for setting priorities in our clinics. Research is heavily focused on technical procedures, yet the relationship with patients in the care process is vital. Singleton¹³¹ labeled this phenomenon a paradox in therapy. Despite the commitment to humanistic service on which the profession was founded, the service rendered is often mechanistic.

The educational programs should emphasize whole-patient treatment, increased communication skills, interdisciplinary awareness, and patient-centered care.44–46^,132 The change in roles described previously requires a professional who demonstrates a potential for the assumption of many roles, responsibilities, and choices along the care pathway. The therapist working with the client with neurological problems must always be ready to respond to triggers anywhere along the pathway from early intervention, midway during a crisis, or later during long-term care, because these triggers signal a need for change. Of equal importance, the path must be well documented to empower the therapist to reflect on current and prognosticated treatment intervention.

Conclusion

In this sixth edition of the textbook, we hope to bring the reader into the clinical practice of the twenty-first century. As the professions continue to evolve in depth and breadth, the future will encapsulate the knowledge, skill, and lessons of the past and the needs and problems of current and immediate health delivery systems while maintaining unique scopes and parameters of practice in an ever-changing environment. The professions must adapt and grow as they embrace change without losing the integrity and philosophical reasons they came into existence. The only concept that is guaranteed in the future is change. Both physical and occupational therapy are dynamic professions with the ability to adapt and evolve to provide the health care service expected and deserved by the consumer. The future is up to every practitioner. The consumer of our services is dependent on our willingness to learn, adapt, and provide a high quality of care at an appropriate cost for the best outcomes. We have done that in the past, are doing it in the present, and will continue doing it in the future.