Common Frames of Reference Used in the Evaluation and Treatment of Adult Clients Assumptions Examples of Evaluations and Assessments Frame of reference objectives All frames of reference aim to increase (restore), adapt, maintain, prevent or enhance (promote) occupational performance so that health, well-being, and participation are the outcome. Although the process objectives in the final column of this table are mainly stated at a body function or structure level, it is implicit that the practitioner’s therapy goals would be functional and focused on a client’s performance skills and engagement in his/her daily occupations. Biomechanical Frame of Reference Clients’ condition, diagnosis, or impairment is musculoskeletal disorders e.g., fracture, amputations, rheumatoid arthritis, hand injuries, or back pain. Applies knowledge from anatomy, physiology, kinesiology, and physics to restoring function. Occupation-based Assessments Barthel Index Borg Rate of Perceived Exertion (RPE Scale Engagement in occupation requires movement via for endurance) body structures and functions. Disability of Arm, Shoulder and Hand (DASH) Functional Independence Measure (FIM) Client Factor Assessments Hand Strength using a dynamometer and pinch meter Manual Muscle Test Pain Scale (visual analog and numerical rating scale) ROM measured using a goniometer Volumeter for edema To enhance occupational performance by: Increasing strength, endurance or range of motion. Compensating for musculoskeletal pathology. Reducing pain, swelling, or scarring. Preventing deformity or contractures Maintaining joint ROM or muscle strength Rehabilitative Frame of Reference Clients’ condition or disabilities are usually associated with neuro-motor, sensorimotor, or neurodevelopmental disorders such as multiple sclerosis, spinal cord injury, cerebral vascular accidents, or those that include cognitive, psychosocial or visual-perceptual disorders such as an acquired brain injury, that creates performance difficulties associated with the chronicity of a disorder. Engagement in occupation requires adaptive techniques/ compensatory strategies to environment, and/or occupation. To maximize performance in occupations through Occupation-based Assessments Canadian Occupational Performance Measure adaptation of the environment or activity (Client factors, performance skills and patterns, (COPM) may not be able to be restored in a timely manner) Functional Independence Measure (FIM) Klein-Bell Activities of Daily Living Scale Kohlman Evaluation of Living Scale (KELS) Client Factor Assessments Bells Test Mini Mental State Exam (MMSE) ROM using goniometer Semmes-Weinstein for sensation Frames of Reference for cognition, perception, and motor planning problems focus on the ability to perceive and participate in one’s environment to perform occupations. Multicontext Treatment Approach:(Toglia)25,26 This approach is used with clients who have neurological disorders that involves cognition, psychosocial and/or perceptual dysfunction. Addresses the dynamic nature of cognitive (i.e. memory, sequencing, motor planning, problemsolving, visual processing, attention, selfawareness, and how participation in occupation is influenced by personal factors, the activity/occupation being performed and the environment in which it takes place. Occupation-based/focused Assessments Assessment of Motor and Process Skills (AMPS) Cognitive Performance Test (CPT) Executive Function Performance Test (EFPT) Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE) Client Factor Assessments Cognitive Assessment of Minnesota (CAM) Aims for clients to generalize strategies learned in Lowenstein Occupational Therapy Cognitive therapy to transfer these techniques across new Assessment (LOTCA) situations. Motor Free Visual Perceptual Test (MVPT) To restore cognitive and/or perceptual abilities to engage in occupational activity. To adapt the activity or environment to allow the client to participate in meaningful occupations. To facilitate transfer of learning across a variety of contexts To develop self-awareness to utilize strategies to promote function and decrease barriers. Test of Everyday Attention (TEA) Emphasizes the practice of skills in context. Quadraphonic Approach: (Abreu and Peloquin)27 Cognitive deficits following a brain injury Continuous analysis of occupational performance is required for effective rehabilitation. See assessments above Emphasizes a “micro” focus on body function( e.g., attention, sequencing, problem-solving, motor planning) and postural control, and a “macro” focus on occupational performance areas, such as ADL’s and Work, and understanding the client’s priorities, motivation and well-being. 26,28 To remediate or compensate for abilities in body function (cognitive, perceptual and motor abilities) to be able to participate in occupations. To promote client-centered strategies based on age, health and personal characteristics to promote engagement in functional activity The narrative process of story- telling and story making is integral to the rehab process. Neurofunctional Approach:(Giles)29 Used with clients who have severe cognitive deficits following a brain injury28 “Intervention emphasizes the use of task-specific training or rote repetition of a task/routine in natural contexts to develop habits or functional behavioral routines.” (p.746) 26,29 See assessments above To retrain the lost skill/s through compensatory techniques and repetitive practice using the same task and within the same environment Frames of References for sensorimotor disorders, motor learning or motor control disorders. These are clients with impairments due to injuries, trauma or disorders of the central nervous system. These frames of references are designed to assist clients to learn and acquire appropriate developmental movement patterns and utilization of sensory input to engage in functional actions in a controlled way that allows an individual to respond to their environment and occupations.30 Motor learning/Motor Control Approach: (Carr and Shepherd) 20 Musculoskeletal, neuromotor, sensorimotor, neurodevelopmental conditions, and cognitive/perceptual disorders Usually associated with assisting clients to learn and acquire appropriate developmental movement patterns utilizing sensory input to engage in functional actions in a controlled way that allows an individual to respond to their environment and occupations.30 Motor control is the result of motor learning. 30 Emphasizes the practice of learning motor movement and control of movement to enhance participation in occupational activity (e.g., intrinsic and extrinsic feedback). Emphasizes a heterarchic dynamic process of client factors, context, environment and occupations. (Phipps) Occupation-based Assessments AMPS (Assessment of Motor and Process Skills) FIM (Functional Independence Measure) AMAT (Arm Motor Ability Test) COPM (Canadian Occupational Performance Measure) Wolf Motor Function Test (WMFT) Client Factor Assessments Fugl-Meyer Assessment (FMA) Modified Ashworth Scale Motor Assessment Scale (MAS) Reflex Testing Observe the quality of volitional movement patterns Observe reflex patterns, such as equilibrium and righting reactions. To learn and practice strategies to enhance the quality and effectiveness of movement in functional activity (i.e., the goal is to increase motor control). Utilizes both facilitation and inhibitory techniques. To gain voluntary, motor control to participate in occupations in a variety of contexts. Sensorimotor Approach: ( Rood ) Neuromotor, sensori-motor, and neurodevelopmental conditions that utilizes a neurophysiological approach to treatment Emphasizes the use of facilitation and inhibitory sensory stimulation techniques to normalize muscle tone in order to initiate a volitional motor response for functional performance skills31 See assessments above To normalize muscle tone through the use of facilitory or inhibitory techniques to initiate controlled developmental movement. Utilized primarily as a preparatory precursor to engage in occupations.31 Emphasizes both a reflexive and hierarchic model of motor control.31 Movement Approach: (Brunnstrom) Approach is specific to people who have suffered from a cerebral vascular accident (CVA) and is a neurophysiological approach to treatment. This approach addresses the reflexive and abnormal patterns in the UE and encourages synergic (flexor or extensor) activation of muscles to promote the development of purposeful, voluntary movement. The approach identifies six sequential stages of motor recovery after a stroke-induced hemiplegia. Emphasizes both a reflexive and hierarchic model of motor control.31 See asessments above The Brunnstrom Approach has influenced the development of a standardized assessment to evaluate a person recovering such as the FuglMeyer Assessment of Physical Performance (FMA). To improve movement from a reflexive pattern to voluntary control31 Proprioceptive Neuromuscular Function- PNF: ( Kabot, Knott and Voss) Focus on Central Nervous System Disorders and is a neurophysiological approach.32 Emphasizes the use of diagonal patterns (use of agonist and antagonist muscles) combined with sensory stimulation to promote voluntary, functional movement31 See assessments above Emphasizes developmental sequencing of motor movement31 To produce a controlled diagonal movement pattern of the limbs and trunk (during functional activity) that incorporates sensory input and strengthens both the agonist and antagonist muscles. _______ Emphasizes both a reflexive and hierarchic model of motor control.31 Neurodevelopmental Treatment Approach- NDT:( Bobath and Bobath)33 Central Nervous System Disorders and is a neurophysiological approach. Utilizes the facilitation of functional volitional movement patterns through manual facilitation techniques. Guides “normal’ movement patterns through the use of “handling” at key points of control (i.e., the head, shoulders, and pelvis) to engage in function activity31 See assessments above Important to emphasize normal and quality movement patterns in functional activity with manual facilitation To gain proximal stability to produce distal mobility To restore quality movement and postural control to engage in occupations31 Reinforces developmental motor milestones and integration of reflexes to promote volitional movement patterns required for performance skills Compiled with information from Cole (2012)35, Pendleton (2013)36, Radomski &Trombly (2008)37, Crepeau (2009)14