Advances in
Disability Research
Disability Reconsidered: The Paradox
of Physical Therapy
Susan E. Roush, Nancy Sharby
The purposes of this perspective article are: (1) to explore models of disability from
the perspective of the academic discipline of disability studies (DS), (2) to consider
the paradox of improving functional capacities while valuing disability as diversity,
(3) to identify how physical therapy’s use of the International Classification of
Functioning, Disability and Health (ICF) disablement model intersects with various
disability models, and (4) to apply this broader understanding of disability to physical
therapist practice, education, and research. The DS literature has been critical of
rehabilitation professionals, particularly targeting the medical model of disability. In
contrast, advocates for a social model of disability recognize disability as diversity.
It is paradoxical for physical therapy to simultaneously work to ameliorate disability
while celebrating it as diversity. The ICF biopsychosocial disablement model offers a
mechanism to practice within this paradox and suggests that it is no longer sufficient
to conceptualize disability as a purely individual matter that requires attention in
isolation from the impact of the larger society.
S.E. Roush, PT, PhD, Department
of Physical Therapy, University of
Rhode Island, Kingston, RI 02881
(USA). Address all correspondence
to Dr Roush at: roush@uri.edu.
N. Sharby, PT, DPT, Department
of Physical Therapy, Northeastern
University, Boston, Massachusetts.
[Roush SE, Sharby N. Disability
reconsidered: the paradox of
physical therapy. Phys Ther.
2011;91:1715–1727.]
© 2011 American Physical Therapy
Association
Published Ahead of Print: October
14, 2011
Accepted: June 24, 2011
Submitted: November 15, 2010
Post a Rapid Response to
this article at:
ptjournal.apta.org
December 2011
Volume 91
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Disability and the Paradox of Physical Therapy
P
hysical therapists know disability. We spend years learning to
recognize subtle departures
from normal so we can apply
evidence-based treatments to ameliorate impairments and increase function. In addition to direct care, we
conduct research to expand or refine
the evidence base of our work and
support fund-raising to find new
treatments and cures. We also strive
to educate the public on prevention
so disability can be avoided whenever possible. Our value to individuals and society is apparent, and we
rightly enjoy our role in our clients’
success.
The call for contributions to this special issue asked for “important breakthroughs and advances in the conceptualization,
definition,
and
measurement of disability”1(p325) An
abundance of scholarship has been
produced in the last 25 years that
reconsiders the definition and conceptualization of disability. Surprisingly, much of that literature has
been critical of health care providers
in general and rehabilitation professionals in particular.2
This criticism comes from an alternative conceptualization of disability
that focuses on social, political, environmental, and attitudinal features
that hinder people with disabilities
from full participation in society. It
rejects the notion that disability
needs to be cured or changed. This
understanding of disability can per-
Available With
This Article at
ptjournal.apta.org
• Audio Podcast: “RCTs on
Disability Intervention in Physical
Therapy and Rehabilitation:
Unique Challenges and
Opportunities” symposium
recorded at PT 2011, National
Harbor, Maryland.
1716
f
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Volume 91
haps best be explored through the
scholarship of disability studies (DS).
This discipline has emerged as the
academic outgrowth of the disability
rights movement3 that began in the
1960s.4 It has become a critical,
interdisciplinary field that “promotes
the study of disability in social, cultural, and political contexts” and
considers it “a key aspect of human
experience . . . that . . . has important . . . implications for society as a
whole.”5 A major tenet of DS is that
oppression of people with disabilities comes about through historical
notions of disability that result in
well-intended practices, social structures and norms, laws, and unchallenged assumptions.”6(p737) This perspective and associated implications
for practice have not been considered in physical therapy. The purposes of this perspective article,
therefore, are: (1) to explore alternative models of disability, (2) to consider the paradox of improving functional capacities while valuing
disability as diversity, (3) to identify
how physical therapy’s use of the
World
Health
Organization’s
(WHO’s) International Classification of Functioning, Disability and
Health (ICF) disablement model7
intersects with alternative disability
models, and (4) to apply this broader
understanding to physical therapist
practice, education, and research.
Models of Disability
One way to explore DS is to consider
the multiple models that have been
used to describe and understand disabilities. These models attempt to
explain disability as a cultural phenomenon that defines the context in
which individuals experience disability.8 They help explain how people with disabilities are perceived
and treated by society. They may
apply equally to how some individuals with disabilities feel about themselves, particularly those with
acquired
disabilities.
Although
numerous disability models have
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been presented in the literature,9,10
there is consistent contrast between
medical (or biomedical) and social
paradigms.11 Olkin12 offered a particularly meaningful discussion of 3
prominent disability models: moral,
medical, and social. She also offered
a concise summary, presented in
Table 1, that contrasts these models
on multiple dimensions.
Moral Model
The moral perspective equates disability with sin, loss of faith, or a test
of faith.13 Although religion and spirituality can be positive resources for
many, they also contribute to feelings of shame and reinforce the
belief that disability is punishment
for bad behavior.13 A dual characterization (ie, both positive and negative perceptions of disabilities) is
seen in many religions, including
Judaism, Christianity, Islam, Buddhism, and Hinduism.14 Although
the moral model may seem dated, it
remains a part of our culture. As
Oklin12 stated, well-intentioned comments such as “God only gives us
what we can bear” or “She didn’t
deserve this” also reflect the moral
model, as do characterizations of
physical therapy as “doing God’s
work.”
Medical Model
The next model is broadly known as
the medical or biomedical model. In
contrast to the moral model, this
conceptualization places the cause
of disability in anatomical or physiological departures from “normal”
that need to be “fixed” or cured.15–18
A key feature of this model is the
reliance on specialized professionals
to diagnose and treat these conditions. Physical therapy is most
closely aligned with this model of
disability as our practice is fully
embedded in the desire to “fix”
impairments, with the belief that
these fixes provide the best path to
function and independence. Patients
who do not share the desire to “be
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Disability and the Paradox of Physical Therapy
Table 1.
Comparison of the Moral, Medical and Social Models of Disabilitya
Measure
Moral Model
Medical Model
Social Models
Meaning of disability
Disability is a defect caused by
moral lapse or sins, failure of
faith, evil, or test of faith.
A defect in or a failure of a
bodily system that is
inherently abnormal and
pathological.
Disability is a social construct.
Problems reside in the
environment that fails to
accommodate people with
disabilities.
Moral implications
Disability brings shame to the
person with the disability
and his or her family.
Medical abnormality due to
genetics, bad health
habits, or person’s
behavior.
Society has failed a segment of
its citizens and oppresses them.
Sample ideas
“God gives us only what we
can bear” or “There is a
reason I was chosen to have
this disability.”
Clinical descriptions of
“patients” in medical
terminology. Isolation of
body parts.
“Nothing about us without us”
or “Civil rights, not charity.”
Origins
Oldest model and still most
prevalent worldwide.
Mid-19th century. Most
common model in the
United States. Entrenched
in most rehabilitation
clinics and journals.
In 1975, with the demonstrations
by people with disabilities in
support of the yet-unsigned
Rehabilitation Act.
Goals of interventions
Spiritual or divine acceptance.
“Cure” or amelioration of
the disability to the
greatest extent possible.
Political, economic, social, and
policy systems; increased
access and inclusion.
Benefits of model
An acceptance of being
selected, a special
relationship with God, a
sense of greater purpose to
the disability.
A lessened sense of shame
and stigma. Faith in
medical intervention.
Spurs medical and
technological advances.
Promotes integration of the
disability into the self. A sense
of community and pride.
Depathologizing of disability.
Negative effects
Shame, ostracism, need to
conceal the disability or the
person with the disability.
Paternalistic, promotes
benevolence and charity.
Services for, not by,
people with disabilities.
Powerlessness in the face of
broad social and political
changes needed. Challenges to
prevailing ideas.
View of nonadherence to
medical treatmentb
Personal failure of the text of
faith, patient undeserving of
care.
Blame patient for failing to
follow through with what
is known to be good for
him or her.
Understandable selection from
multiple resources that meet
individual goals.
a
Reprinted with permission of the American Psychological Association from: Olkin R. Could you hold the door for me: including disability in diversity. Cultur
Divers Ethnic Minor Psychol. 2002;8:130 –137.
b
“View of nonadherence to medical treatment” was not in the original Olkin table, but was added by the present authors.
fixed” may be labeled nonadherent
or unmotivated.
to health disparities between people
with and without disabilities.24
Research has shown that health care
professionals’ views of having an
impairment are typically consistent
with views held by the general population19 –22 and often are more negative than self-reports of people with
disabilities.23 Another concern is that
these unstated and unrecognized
negative attitudes toward people
with disabilities “can influence their
response to treatment and to the
development or maintenance of selfacceptance”22(p2562) Negative attitudes also are believed to contribute
The medical model of disability can
be linked to charity.11 If a disability
cannot be eliminated, or significantly
ameliorated, people with disabilities
often are viewed as pitiful or helpless. This portrayal is frequently seen
with disability-related fund-raising. It
is a very effective fund-raising technique, but comes at an enormous
cost to the dignity of those being
helped. Advocates of DS not only ask
“Is the price too high for the good
that can be done with the donations?”,
they
condemn
such
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approaches as patronizing and
demeaning.18 When people are portrayed stereotypically as helpless,
dependent, and needing care, it can
lead to exclusion from participation
in many life experiences, including
employment and independent living.
Social Models
Both the moral and medical models
conceptualize disability as residing
in the individual. In contrast, social
models of disability shift the perspective from the individual to the environment and its role in defining,
amplifying, and ameliorating the
effects of impairments. There are
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Disability and the Paradox of Physical Therapy
multiple disability models that fall
under the broad category of social
models, including social justice,
minority group, environmental, and
sociopolitical. They all place the
problem of disability in society and
its lack of ability or unwillingness to
accommodate differences. The conceptualization of accommodation in
the social models goes well beyond
physical space and recognizes prejudice and discrimination as powerful
features of the disability experience.
At the core of the social models is
the decreased value people living
with impairments experience and
the attitudes of a society that considers them to be “less than” their peers
who are nondisabled.19,21 Goffman’s
classic 1963 work Stigma: Notes on
the Management of Spoiled Identity25 described this negative perception of people with disabilities and
others with devaluing characteristics. Yoshino26 built on Goffman’s
work and included disability in his
discussion of the eroding civil rights
of individuals in multiple minority
groups. Specific to disability,
Wright27 called this perspective the
fundamental negative bias. She
contended service providers may
unknowingly have this bias, which
has been termed “ableism.”28
Ableism is defined as “a pervasive
system of discrimination and exclusion that oppresses people who have
mental, emotional, and physical
disabilities”28(p198) or, alternatively,
“discrimination in favor of the
able-bodied.”29(p32)
Advocates of the social models of
disability argue that disability is part
of the human condition that affects
most people, if not all people, at
some point. They further argue that
disability is a form of diversity that
offers a unique perspective that
should be valued and even celebrated.30,31 Disability allies,9 but
notably not rehabilitation providers,
have been identified as important
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sources of support for this perspective and for people who define their
lives in this way. Interactions with
service providers are typically
grounded in the medical model of
fixing impairments or deficits. Disability allies, however, “advocate for
disability awareness and changes in
policy and practice to ensure that
individuals with impairments are
treated equitably.”9(p77) Using different language, Silverstein32 recognized
the importance of rehabilitation professionals becoming disability allies
when he implored us to become disability policy change agents.
Federal disability legislation is
grounded in the social models of disability. For example, the Rehabilitation Act of 197333 and its amendments and the Americans With
Disabilities Act34 and its amendments are based on the Civil Rights
Act of 1964 and the principles of
social justice. The goal of this legislation was not only to improve physical access but also to change attitudes and facilitate full participation
in all desired life activities for everyone. Unfortunately, these laws have
not yet achieved their intended
goals,35 which is easily seen, for
example, in the continued lack of
accessible transportation for people
with disabilities.
Advocates of DS further argue that
rehabilitation has a skewed conceptualization of disability, with diagnosis and treatment not necessarily
objective, but rather culturally
defined.36,37 Although some cultures
continue to explain disability primarily through a moral model,38 – 44 EuroAmerican cultures typically place
disability in the individual and define
it in a fundamentally negative
way.19,21,25–29 The attitudes and
behaviors of health care professionals are particularly critical in the lives
of people with disabilities because
they strategically control access to
services and influence public pol-
Number 12
icy.23 However, when service providers are “focusing on the client’s
impairment as the problem rather
than treating environmental (physical, social, political, and economic)
barriers as the true problem, rehabilitation can reinforce the perception
that disability is an individual matter
requiring private solutions rather
than a matter of socially produced
barriers requiring public, political
solutions.”45(p490)
Although there has been movement
toward more egalitarian service provision in health care, paternalism is
still a powerful influence in the relationship between service providers
and service recipients. As noted in
Table 1, this paternalism may be
well-intentioned, and it often is
grounded in the ethical principle of
beneficence, but it can lead to ableist
care that assumes every patient
wants to eliminate his or her impairment to the fullest extent possible. It
may be difficult for physical therapists to understand clients and consumers who do not endorse a cure at
all costs, labeling them as nonadherent or unmotivated. This idea may be
uncomfortable for us and at odds
with how physical therapists view
themselves. Research and personal
narratives of people with disabilities,
however, tell us that it frequently
happens.2,15,18,46 Thus, we have the
paradox of physical therapy— how
do we practice in the medical model
and intervene to minimize the
effects of a disability while recognizing and celebrating disability as
diversity? From a traditional physical
therapy perspective, it is inherently
contradictory.
Physical therapy, however, seems to
be on the threshold of considering
this paradox. In 1986, Roush47 suggested that health care professionals
may be perpetrators of negative attitudes toward people with disabilities. She emphasized the negative
perceptions that health care profesDecember 2011
Disability and the Paradox of Physical Therapy
sionals can have of people with disabilities, linking them to the lack of
balanced power in helper-helpee
relationships. Further consideration
of these ideas in physical therapy
has been limited, although recently
Lundstrom,48 a physical therapist in
Sweden, also recognized this paradoxical conflict in physical therapist
practice. Fortunately, we can look to
the work of our colleagues in occupational therapy4,45,49 –53 and nursing6,30,54 –56 who have taken steps to
integrate a DS philosophy into rehabilitation practice. These professions
have traditionally been more focused
than physical therapy on the environmental context in which clients
and consumers live their lives. In
addition to being familiar with how
other health care professions operationalize DS concepts in their practice, understanding their perspectives can bring about closer
collaborations and access to important tools that can lead to more positive and meaningful lives for clients
and consumers, as well as greater job
satisfaction for ourselves.
The ICF Meets Disability
Studies
The WHO’s ICF7,57,58 offers a complex conceptualization of disability
that supplants the basic framework
of the medical model. The Figure
illustrates the basic components of
the ICF model that was created as a
framework for measuring health and
disability at both individual and population levels. In 2001, the United
Nations approved the model, and in
2008 it was officially adopted as the
preferred disablement model by the
American Physical Therapy Association (APTA).59 The ICF uses “disability” as an umbrella term that considers the consequences of health
conditions, including impairments of
body structures or functions, activity
limitations, and restrictions in participation. Furthermore, the ICF
“provides health care professionals
with a powerful tool to communiDecember 2011
Figure.
Basic elements of the World Health Organization’s International Classification of Function, Disability and Health (ICF).
cate specific nuances of function,
document outcomes, and conduct
research.”60(p928) What is most striking about the ICF is that it not only
measures biological changes in body
function or structure but also places
equal emphasis on the contextual
domains of personal and environmental factors. The ICF’s expanded
understanding of disability can guide
physical therapists to move beyond
our core understanding of disability
as being based mainly on changes in
bodily functions and structures and
activity limitations.
As physical therapists seek to practice in the paradox created at the
intersection of the medical and
social models of disability, it
becomes apparent that neither
model fully explains participation
and functional outcomes of people
with impairments. Although social
values and environmental barriers
can significantly assist or constrain
successful entry into the community,
they cannot account for the full
degree of disablement. Similarly, the
medical model cannot do so by using
only changes in bodily functions and
structures. Clearly, neither model
alone is sufficient, although both are
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partially valid. Disability, as envisioned by the ICF, intersects these
models and envisions that impairment, the individual, and the social
environment all play equally key
roles in the disablement process.
Thus, it proposes a more useful
model of disability that can be called
the biopsychosocial model.57 In fact,
this has become the preferred contemporary
disablement
framework.61 Furthermore, Scott Ward,
current APTA president, identifies
the ICF as a construct for physical
therapists and other health care professionals that can be used to more
accurately identify and address the
multiple factors that affect and contribute to a client’s recovery.62
It is interesting to note that in 2005,
Jette supported the ICF for providing
a framework that embraces a biopsychosocial aspect of health care
that is “familiar to physical
therapists.”63(p118) We would argue
that while the concept of a biopsychosocial model may be familiar, it is
still not widely embraced. We are
more comfortable with older models
of disability that are based mainly on
the impact of deficits or impairments
on the ability to perform socially
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Disability and the Paradox of Physical Therapy
Table 2.
Examples of Contextual Factors That Are Considered in the Determination of
Disability Through the International Classification of Functioning, Disability and Health
(ICF)
Personal Factors
Environmental Factors
1. Age
1. Physical environment
2. Sex
2. Access to transportation
3. Race/ethnicity
3. Access to services
4. Comorbid conditions
4. Access to medical services
5. Sexual orientation
5. Adapted equipment
6. Education
6. Social attitudes
7. Work history
7. Stigma
8. Income
8. Community resources
9. Motivation
9. Government policies
10. Attitudes of health professionals
11. Health of the economy
12. Availability of caring family
defined roles. Verbrugge and Jette64
were ahead of their time when they
wrote that ICF precursors could be
used to describe a disablement process that also includes personal and
environmental impacts on outcomes. At the time, there was no
language in these models that explicitly supported these concepts.
We propose that it is time to make a
transition to more fully embrace a
biopsychosocial model that considers the contexts identified by the
ICF. The explicit addition of these
elements is essential to assist physical therapists to move beyond the
medical model and assume a broader
conceptualization of disability.
There are many resources that
describe application of the ICF.65,66
Several fundamental elements, however, specifically relate to this discussion. First, a key addition to the ICF
from previous disablement models
was the explicit inclusion of contextual factors to the determination of
disability. These contexts can be
either internal (personal) or external
(environmental). Examples of each
are given in Table 2. These contexts
will have a unique impact on the
individual’s experiences and out1720
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comes; in other words, the model is
primarily client centered. It is important to note that performance and
participation will vary widely in different environments and are not
influenced solely by impairments,
lack of motivation, or the need to
“try harder.” Most significantly, the
ICF “gives permission” to address
people’s self-determined goals very
broadly.67(p5) It empowers clients
and consumers by placing an emphasis on goals and activities that are
most meaningful to each individual.67 An example would be to
achieve independent mobility in the
community rather than to ambulate
in the community.67 Furthermore,
the client is included as an “evaluator” of the impact of various factors
on the level of participation. Perhaps
the most striking feature of the ICF
is that it is not linear, but ecological.
Every aspect of the model affects
every other aspect. Although changes
in bodily function or structure may
affect participation in important
life activities, participation in these
activities, in turn, affects bodily
structures and impairments.53
These are not new ideas, but perhaps it is time to revisit them, given
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the tremendous changes that have
occurred in the physical therapy profession over the last several decades.
In 2001, Rothstein68 reminded us of
the importance of client and consumer input in physical therapist
practice. In a moving Physical Therapy editorial, he asked: “Do impairments always produce disability?”
Unfortunately, we may too often
believe the answer is “yes.” The editorial and accompanying article69
argued that this does not have to be
so. Furthermore, Rothstein reminded
us to remember patients’ humanity
and to place their needs first. He
wondered if “[a]s our profession
grew and we focused on attaining
credibility, did we too often align
ourselves with those who ignore this
premise?”68(p887) We feel this question is as valid today as it was 10
years ago.
In summary, both personal and environmental factors affect the participation of people with disabilities in
activities that are important and
meaningful for them. At least in
some situations, the environment,
specifically stereotypes and stigma,
may be the most recalcitrant barrier.
The greatest obstacles to participation often are attitudinal ones.70 This
situation leads us to consider that
with a different focus and intent,
physical therapists could have a
greater impact on many environmental and personal factors that facilitate
performance and participation.53
Biopsychosocial Model
Applications in Practice
Three applications of the biopsychosocial model in practice will be considered. The first relates the biopsychosocial model to the physical
therapy profession’s Code of Ethics.71 The next application comes
from recently published physical
therapy scholarship, and the third
considers new ways to relate these
concepts to clinical practice.
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Disability and the Paradox of Physical Therapy
The APTA Code of Ethics71,72 establishes the foundational principles for
professionalism and provides a
vision for our expanded role in providing high-quality health care services as a doctoring profession.
These principles also provide important linkages between current practice and fully embracing the biopsychosocial model of care envisioned
by the ICF. Additionally, the Code of
Ethics has a clear social justice
agenda that can be easily aligned
with the social models. We will
briefly discuss the relevant principles and their application to our
expanded vision of physical therapist practice.
Principle IA of the Code of Ethics
states: “Physical therapists shall act
in a respectful manner toward each
person regardless of age, gender,
race, nationality, religion, ethnicity,
social or economic status, sexual orientation, health condition, or disability.”71 This, of course, has always
been an essential feature of our practice. However, perhaps we need to
consider and expand our appreciation of the word “respectful.” Traditionally, we may have assumed that
this word meant polite, courteous,
and welcoming. However, some definitions include being deferential.73
It may be difficult to be truly welcoming and deferential to those
whose daily lives are different than
ours in ways we do not comprehend
or appreciate. For example, what do
we feel when a client is consistently
late or misses appointments? Do we
feel annoyed and perhaps a little
angry over this disruption in our
carefully orchestrated schedules, or
do we appreciate and respect that a
major cause of no-shows and tardiness
is lack of reliable transportation?
According to the ICF, it is not
enough to know whether a client or
consumer can pass a driving assessment or walk inside of your facility.
The ICF also would ask, is the indiDecember 2011
vidual unemployed due to his or her
disability and unable to afford a car?
Do you know what the parking lots
look like at your facility? Perhaps
they are “accessible” in name only
and do not accommodate actual
needs. Are parking lots and sidewalks cleared of snow in the winter?
Are sidewalks well-maintained and
barrier-free? For individuals who do
not drive, is public transportation
available, affordable, and accessible?
The ICF guides us to look at capacity,
which is the highest level of function
under ideal circumstances, and at
performance, which is the highest
level of function in actual circumstances. A more careful examination
of environmental factors affecting
client or consumer performance will
perhaps deepen our ability to
respect their full impact.
Another possible issue is how we
feel about, or respect, clients and
consumers who are “nonadherent.”
For example, what happens when a
carefully developed home exercise
program has not been followed? Perhaps the client or consumer places
limited, or no, value on the program.
We might want to reconsider the
personal context of disability and
question whether the client or consumer may have goals that are very
different from those we have developed and may be choosing to not
adhere to our plan of care due to
these differences. Clients and consumers also may be rejecting a medical model approach and do not like
the service providers’ attitude that
they need to be “fixed.” Perhaps
learning how to hire, train, and fire a
personal care attendant is more
important to the client or consumer
than learning how to bathe or dress.4
Principle 1B of the Code of Ethics
requires that “physical therapists
shall recognize their personal biases
and shall not discriminate against
others in physical therapist practice,
consultation, education, research,
Volume 91
and administration.”71 Although
overt discrimination is not common,
unintentional biases may exist when
we are not aware of our personal
attitudes and beliefs. Therapists do
not always choose the values they
bring to the clinical setting, many of
which are the result of living in a
culture with an ableist orientation.
We should carefully evaluate any
biases that may interfere with our
full collaboration with a client or
consumer to meet his or her participation goals.
Understanding personal beliefs and
biases is the first order of cultural
competence and requires significant,
intentional self-reflection and guidance.74 Good intentions and the
desire to be culturally competent are
insufficient to create meaningful
change. Individuals who have contact with people with disabilities
generally have a higher regard for
those with impairments than those
who do not have contact. The most
positive beliefs are held by those
who have personal friends, peers in
the workplace, or a family member
with a disability and share social
experiences with them.22 Interacting with people who are different
from ourselves and reflecting on our
feelings and responses have been
identified as important steps in
changing cultural values.74 We must
find mechanisms to explore and discuss the personal beliefs that affect
our practice in order to change
them.
Personal bias and beliefs about people with disabilities and ableism may
contribute to the lack of acceptance
of health care professionals who
have disabilities. Nurses with disabilities employed in hospital settings
report contending with disabilityrelated hostile work environments,55
a finding echoed in Kontosh and colleagues’ work.56 How welcoming is
physical therapy to practitioners
who have disabilities? Surprisingly,
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Disability and the Paradox of Physical Therapy
researchers asked this question more
than 20 years ago,75,76 although
there is a dearth of recent data.
Although we know that making
disability-related accommodations
for physical therapist students has
been increasing,77,78 it is unclear
how these students are transitioning
into practice. It seems that attitudinal barriers are the most difficult for
physical therapists with disabilities
to overcome. Anecdotally, physical
therapists and physical therapist
assistants with disabilities face “challenges, such as misunderstanding
among other therapists about how
they could function as therapists,
although many do” (Elizabeth Kay,
Laurie Rappl; personal communication; April 11, 2011).
Principle 2D of the Code of Ethics
requires physical therapists to collaborate with clients and consumers to
empower them in decisions about
their health care.71 This principle
brings us directly in line with the ICF
and a biopsychosocial model.
Although we have well-honed skills
in both assessment and intervention
for impairments, how fully are we
able to welcome and include the
ideas of clients whose goals are not
compatible with ours? We may
encounter those whose goals are
beyond what we consider achievable and label them unrealistic or “in
denial.” Often, there are ways we
have not explored or considered to
achieve these goals, or resources
that can be accessed to find alternatives. At other times, we may push
our clients to become independent
in a functional skill that can be performed by an aide or assistant. In this
scenario, we may label the client
unmotivated or nonadherent rather
than granting him or her the dignity
to choose. Changing the focus from
our goals to their goals, may leave
the client free to pursue activities
that are most meaningful.
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Physical therapists are beginning to
integrate the ICF model of disablement into their practices. Two
recent examples from the physical
therapy literature illustrate the
strengths of the ICF model and
demonstrate that physical therapists’
understanding of its broader aspects
is not fully developed. Rauch et al79
developed an ICF-based documentation tool that can be applied in a
multidisciplinary clinical setting. The
case that is reported in this article
involves a young adult with a cervical spinal cord injury who wants to
return to his previous level of participation in all areas of his life,
including independence in activities
of daily living, employment, and
sports. The assessment tool that was
developed provides a comprehensive and coordinated model that
identifies short-term and long-term
goals that are meaningful to the client and guides the rehabilitation
team to focus on interventions that
will achieve these goals. The authors
are to be praised for this elegant
model that incorporates traditional
assessment and documentation
within the ICF framework.
Although Rauch and colleagues’ ICFbased documentation tool is patient
focused, it still falls short of fully
embracing the biopsychosocial
model. For example, there are only 2
items listed under “personal factors.”
One is motivation, the other is
acceptance of disease, and each is
graded “yes” or “no.” Although this
might appear to be sufficient for this
particular client, it does not allow a
full appraisal of other factors that
may affect goal achievement such as
level of education, prior employment, race, or age. Additionally, the
binary assessment grossly understates what are complex, nuanced,
and evolving characteristics—for
example, motivated to do what, how
is acceptance of disease assessed,
and what are the issues outside of
the individual (eg, social, attitudinal,
Number 12
economic, or political considerations) that DS reminds us are essential to consider?
A further concern about Rauch and
colleagues’ ICF-based documentation tool is that the environmental
assessment component for this
patient asks only whether products
or technology to support independent movement need to be
addressed. This item, however, specifically examined only the “inspection of wheelchair fit.” The physical
accessibility of his home, work environment, and community, as well as
the attitude of others (eg, his
employer, family, and friends) were
not addressed.
The ICF identifies 5 environmental
areas for consideration, which are
presented in Appendix 1. In order to
fully embrace the ICF, physical therapists need to consider a broader
perspective that values contexts as
much as impairments.80 It may not
be possible for us to identify and
fully assess each of these areas, but
we can and should become disability
allies and work with other professionals to address common trouble
spots such as wheelchair accessibility of buildings and stores. A well-fit
wheelchair will not enable a client to
enter an inaccessible building. We
also must become aware of attitudes
and biases that are prevalent in our
clients’ and consumers’ community,
their families, and their places of
employment. A well-fit wheelchair
can enter a fully accessible building,
but the user may not be able to gain
employment in such a building
because of ableist attitudes of some
employers.
Another example from a recent article in Physical Therapy looked at
the barriers to exercise for people
with multiple sclerosis.81 This study
investigated the physical activity levels of people living with multiple
sclerosis. They found that fatigue
December 2011
Disability and the Paradox of Physical Therapy
was the most significant obstacle to
exercise and that it was probably
both a primary effect and a secondary effect of the condition. In accordance with the ICF model, multiple
personal and environmental factors
were assessed to determine the best
predictors of exercise participation.
Not surprisingly, the best predictors
of low activity levels were disease
severity, reliance on a disability pension (ie, being unable to work), and
having children to care for. There
appeared to be a clear connection
among the individual’s performance,
familial demands, and exercise
behavior. Although severity of illness
and having children are not modifiable factors, making accommodations to employment can be supported at various levels by physical
therapists. For example, adapting
equipment, modifying work environments, and attending to energy
demands are all tasks that we currently perform. Perhaps we can add
to this list advocacy for full inclusion
in all aspects of the community. This
advocacy
will
require
using
evidence-based interventions to
improve capacity while allying with
others to improve participation by
effecting changes in contextual
factors.
Another concern with this article is
the authors’ advice, provided in the
Bottom Line box.81(p1003) Patients are
instructed to change their own circumstances to delay the progression
of their disease, stay active, stay
involved at work, and find support in
caring for children. Although this
advice is all well intended, it in fact
puts the entire burden of participation on the person and does not shift
any responsibility to the environment. The biopsychosocial model
requires adjustments in all spheres.
Applications in Education
Although we may believe that we
engage in a biopsychosocial model
of care, physical therapist practice is
December 2011
still deeply embedded in the medical
model. Changing our practices to
better reflect a biopsychosocial orientation requires changes not only in
ourselves but also in how we educate and socialize students.
We suggest that the disability experience be included under the cultural competence umbrella in the
Doctor of Physical Therapy curriculum. Doing so would provide a conceptual framework of disability in
the context of human diversity, illness, the life span, and the constructed social and cultural environments. Including disability as a
diversity topic also would facilitate
understanding of patient-centered
care and quality of life from our clients’ and consumers’ perspectives.80
The Commission on Accreditation in
Physical Therapy Education82 is cognizant of the need to educate physical therapist students in the art of
understanding the impact of disability on the person who is disabled.
Courses in this content area are to be
found in virtually every professional
(entry-level) physical therapy curriculum. How effectively do we achieve
this goal, and what tools do we use
to achieve it? Evidence indicates that
the lived experiences, or narratives,
of individuals with disabilities are
powerful educational tools.51 We
need to teach students how to listen
attentively to clients’ and consumers’ voices and interpret their meanings to understand their importance.
It is a tenet of the disability rights
movement that there is “Nothing
about us without us,”35,51 and learning how to elicit and appreciate
these stories is essential to this end.
Another key strategy in changing
attitudes of rehabilitation professionals in training is to provide opportunities for social interactions with
people with disabilities. Many institutions use service learning pedagogy, but we know that interacting
Volume 91
with them as peers rather than “clients” or “patients” is the most powerful component of these interactions.21,83 Critical analysis of service
learning activities should ask: Is the
client an equal partner in these
events, or the passive recipient of
services designed by “others”? and
Are the interactions more closely
allied with the medical model and
providing charity or with one of the
social models? Careful consideration
needs to be taken to ensure the full
inclusion of the desires of the clients
and consumers. Another strategy
that has proven helpful is for students to visit people with disabilities
in their home or work environments,
ideally several times.21
Finally, DS would discourage using
“disabled for a day” activities
because they are a grossly limited
imitation of a complex personal and
social phenomenon. This perspective can be better understood when
people with disabilities are compared with other minority groups.
We would never imitate the skin
color of an African American by
using blackface in the hopes of better understanding the perspective
of this minority group. Some would
see that it is equally inappropriate
to pretend to use a wheelchair for
mobility.
Applications in Research
Adopting the biopsychosocial model
will necessarily occur in increments.
One foundational question is: What
is the best evidence for how to efficiently and effectively elicit the clients’ and consumers’ points of view,
which should be included in the
plan of care? The biopsychosocial
model goes well beyond taking a typical history. Questions that need to
be explored include: How can we
best listen to fully understand the
context of our clients’ and consumers’ lives? and What skills are most
important to acquiring this information? A second important area of
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Disability and the Paradox of Physical Therapy
research will explore the best way
for physical therapists to identify and
understand their own biases about
people living with permanent
impairments and identify how those
biases and beliefs are related to client
or consumer care. Of paramount
importance will be understanding
how our attitudes, biases and perceptions change as we incorporate
principles of these new frameworks
into our work. Other research questions are listed in Appendix 2.
Conclusions
Physical therapists know disabilities.
This perspective article, however,
invites us to consider alternative
views of disability. Whether you are
evaluating or treating, conducting
research, or fund-raising or educating to prevent disability, we invite
you to humbly appreciate and
embrace the paradox of physical
therapy, using each encounter as an
opportunity to explore how best to
provide each person the services
needed to meet goals that are important to that individual in the context
of his or her life while offering our
considerable knowledge and skill.
Principle 8 of the Code of Ethics71
implores us to embrace the full
import of the biopsychosocial
model, which requires us to consider that social, political, and economic factors need our attention to
support clients and consumers to
achieve optimal levels of independence according to their needs and
desires. It is no longer sufficient to
conceptualize disability as a purely
individual matter that requires attention in isolation from the impact of
the larger society. Indeed, it is no
longer sufficient for physical therapists to be solely service providers;
we need to develop ourselves as disability allies, too.
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Both authors provided concept/idea/project
design and writing. Dr Roush provided project management.
DOI: 10.2522/ptj.20100389
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Appendix 1.
Selected International Classification of Function, Disability and Health (ICF) Environmental Contextsa
e1. Products and Technology
e110 For personal consumption (food, medicines)
e115 For personal use in daily living
e120 For personal indoor and outdoor mobility and transportation
e125 Products for communication
e150 Design, construction and building products and technology of buildings for public use
e155 Design, construction and building products and technology of buildings for private use
e2. Natural Environment and Human-Made Changes to Environment
e225 Climate
e240 Light
e250 Sound
e3. Support and Relationships
e310 Immediate family
e320 Friends
e325 Acquaintances, peers, colleagues, neighbors and community members
e330 People in position of authority
e340 Personal care providers and personal assistants
e355 Health professionals
e360 Health-related professionals
e4. Attitudes
e410 Individual attitudes of immediate family members
e420 Individual attitudes of friends
e440 Individual attitudes of personal care providers and personal assistants
e450 Individual attitudes of health professionals
e455 Individual attitudes of health-related professionals
e460 Societal attitudes
e465 Social norms, practices and ideologies
E5. Services, Systems and Policies
e525 Housing services, systems and policies
e535 Communication services, systems and policies
e540 Transportation services, systems and policies
e550 Legal services, systems and policies
e570 Social security, services, systems and policies
e575 General social support services, systems and policies
e580 Health services, systems and policies
e585 Education and training services, systems and policies
e590 Labour and employment services, systems and policies
Any Other Environmental Factors
a
International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland; World Health Organization; 2001.
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Appendix 2.
Topics for Future Research
1. Does a biopsychosocial model such as the International Classification of Function, Disability and Health (ICF)
contribute to patient empowerment, sense of control, and self-efficacy?
2. Is it more or less expensive to have patients and clients making decisions about how much rehabilitation they
desire and what outcomes they would choose for themselves? Will length of stay, total health care costs, return
to work, and community living change under a biopsychosocial model?
3. Would patients and clients choose more or less care than physical therapists would suggest? Will it take more or
less time to reach rehabilitation goals? Will spending time listening to and partnering with patients and clients
result in greater use of physical therapists’ time?
4. How will a biopsychosocial approach affect patient or client adherence and participation in a rehabilitation
program? What effect will it have on patient or client satisfaction? What effect will it have on physical therapists’
job satisfaction?
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