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  • ??? Models of Disability

    Hello everyone,

    Anyone using models of disability such as Nagi's or ICF for patient treatment and assessment here? If so, do you use the mobility assessments?

    Any comments, thoughts or criticisms about the models and on mobility assessments. I am working on a paper on mobility and how it is measured in older adults.

    Thank you!
    Anoop
    Anoop Balachandran
    EXERCISE BIOLOGY - The Science of Exercise & Nutrition

  • #2
    The Nagi and ICF are discussed and taught in schools. That's where I left them. I use some of the language in documentation to keep people happy (payor, auditors, other mindless zombies...)

    From a physical therapy perspective, I felt they were something created by a bunch of people that had schedules not filled with patients and had a need to model everything.
    It seems to me the people pushing this stuff are trying to create "rules" by which we label/speak and/or treat humans.

    For "formal mobility" tests:
    I used the SPPB, 5x sit to stand, 30 seconds sit to stand, Timed up and go, 6 minute walk test, etc

    Basic observation:
    Walk to treatment room, sit down, stand up, supine/bed mobility, floor object retrieval
    "The views expressed here are my own and do not reflect the views of my employer."

    Comment


    • #3
      Thank you so much

      So you have some assessments where you look at lower body and upper body functioning right?

      And is one of your treatment goal to improve the person in these tests? or the tests just give you a baseline and pain is the major concern.

      Also do you use any self reported measures, like LLFDI (Late Life Disability Instrument) to assess how they do in their environment? I am guessing they are coming in because they cannot do some activities at home or work or something.
      Last edited by anoopbal; 28-06-2018, 04:13 AM.
      Anoop Balachandran
      EXERCISE BIOLOGY - The Science of Exercise & Nutrition

      Comment


      • #4
        anoop,

        Typically the patients are unable to complete community activities (grocery shopping, retail shopping), stairs to enter/exit the home or basement, get off the floor or toilet, or perform their recreational activities (golfing, walking around neighborhood, etc.).

        From an outcome perspective, I don't (guilty as charged) use much in the way of self-report for many of these patients. I prefer to use more objective measures like I listed above. The self-report I may use for this population will likely be a PSFS, GROC, LEFS. For these folks, pain is typically not too limiting or they are coping well enough and function is their primary concern.

        The goal for me is to improve what they want, not what the measures ask. That said, the measures can be used as a proxy for how they perform outside the clinic. When a 6 MWT or TUG improve, the patient typically reports their activities outside the clinic are improving. Whether its true physiological change or self-efficacy, that's another story I suppose.

        I put more stock in the objective measures, above what the self-report give me...at least from a function perspective. From a psycho-social perspective the self reports are nice.
        "The views expressed here are my own and do not reflect the views of my employer."

        Comment


        • #5
          Hi John,

          Thank you! That makes sense. The patients are coming in because they cannot perform a certain role in their life.

          From what I have read and understood, disability can only be truly measured through self reports since only self reports take into account both the environment and personal factors. For example, even if a person can walk faster when you test their 400m walk between two cones, this may not change their walking outside because of the terrain, weather, fear of tripping and falling, crossing the road, they not being watched and so forth. So from a patient perspective, they still cannot walk outside or we didn't change anything. And the ultimate goal for the patient is to improve their functioning in the society and not walking 400 m. So our measures should reflect that I feel. Of course, the measures are more objective, but meaningless from a patient perspective. Performance measures measures the capacity whereas self-reports measure the actual performance . The measures are correlated, but I think the magnitude of correlation might be small or moderate. I will have to look at the studies to check how well they are related.

          We use 400m walk at out center to measure mobility disability. If they cannot complete 400m walk in 15 min, they are classified as 'disabled'. Since this an objective measure, it is considered more valid and sensitive. Mind you, these studies are worth millions of dollars. The more and more I read about the models, the more I feel these measures are not right. One of the major reasons ICF developed is to use a neutral language and not classify people as disabled or handicapped. Hence worded as activities and participation in ICF. Also, the biggest change in our thinking was that disability is inextricably linked with the environment and personal factors than just an intrinsic concept. So our measures should reflect that change. Objective measures or performance measures measure function, but leave out the environment and the personal factors from the equation.

          What is your opinion? I am just thinking out loud than replying to specifically.
          Anoop Balachandran
          EXERCISE BIOLOGY - The Science of Exercise & Nutrition

          Comment


          • #6
            Hi John,

            Thank you! That makes sense. The patients are coming in because they cannot perform a certain role in their life.

            From what I have read and understood, disability can only be truly measured through self reports since only self reports take into account both the environment and personal factors. For example, even if a person can walk faster when you test their 400m walk between two cones, this may not change their walking outside because of the terrain, weather, fear of tripping and falling, crossing the road, they not being watched and so forth. So from a patient perspective, they still cannot walk outside or we didn't change anything. And the ultimate goal for the patient is to improve their functioning in the society and not walking 400 m. So our measures should reflect that I feel. Of course, the measures are more objective, but meaningless from a patient perspective. Performance measures measures the capacity whereas self-reports measure the actual performance . The measures are correlated, but I think the magnitude of correlation might be small or moderate. I will have to look at the studies to check how well they are related.

            We use 400m walk at out center to measure mobility disability. If they cannot complete 400m walk in 15 min, they are classified as 'disabled'. Since this an objective measure, it is considered more valid and sensitive. Mind you, these studies are worth millions of dollars. The more and more I read about the models, the more I feel these measures are not right. One of the major reasons ICF developed is to use a neutral language and not classify people as disabled or handicapped. Hence worded as activities and participation in ICF. Also, the biggest change in our thinking was that disability is inextricably linked with the environment and personal factors than just an intrinsic concept. So our measures should reflect that change. Objective measures or performance measures measure function, but leave out the environment and the personal factors from the equation.

            What is your opinion? I am just thinking out loud than replying to specifically.
            Anoop Balachandran
            EXERCISE BIOLOGY - The Science of Exercise & Nutrition

            Comment


            • #7
              Hi John,

              Thank you! That makes sense. The patients are coming in because they cannot perform a certain role in their life.

              From what I have read and understood, disability can only be truly measured through self reports since only self reports take into account both the environment and personal factors. For example, even if a person can walk faster when you test their 400m walk between two cones, this may not change their walking outside because of the terrain, weather, fear of tripping and falling, crossing the road, they not being watched and so forth. So from a patient perspective, they still cannot walk outside or we didn't change anything. And the ultimate goal for the patient is to improve their functioning in the society and not walking 400 m. So our measures should reflect that I feel. Of course, the measures are more objective, but meaningless from a patient perspective. Performance measures measures the capacity whereas self-reports measure the actual performance . The measures are correlated, but I think the magnitude of correlation might be small or moderate. I will have to look at the studies to check how well they are related.

              We use 400m walk at out center to measure mobility disability. If they cannot complete 400m walk in 15 min, they are classified as 'disabled'. Since this an objective measure, it is considered more valid and sensitive. Mind you, these studies are worth millions of dollars. The more and more I read about the models, the more I feel these measures are not right. One of the major reasons ICF developed is to use a neutral language and not classify people as disabled or handicapped. Hence worded as activities and participation in ICF. Also, the biggest change in our thinking was that disability is inextricably linked with the environment and personal factors than just an intrinsic concept. So our measures should reflect that change. Objective measures or performance measures measure function, but leave out the environment and the personal factors from the equation.

              What is your opinion? I am just thinking out loud than replying to specifically.
              Anoop Balachandran
              EXERCISE BIOLOGY - The Science of Exercise & Nutrition

              Comment


              • #8
                Originally posted by Johnny_Nada View Post
                anoop,

                Typically the patients are unable to complete community activities (grocery shopping, retail shopping), stairs to enter/exit the home or basement, get off the floor or toilet, or perform their recreational activities (golfing, walking around neighborhood, etc.).

                From an outcome perspective, I don't (guilty as charged) use much in the way of self-report for many of these patients. I prefer to use more objective measures like I listed above. The self-report I may use for this population will likely be a PSFS, GROC, LEFS. For these folks, pain is typically not too limiting or they are coping well enough and function is their primary concern.

                The goal for me is to improve what they want, not what the measures ask. That said, the measures can be used as a proxy for how they perform outside the clinic. When a 6 MWT or TUG improve, the patient typically reports their activities outside the clinic are improving. Whether its true physiological change or self-efficacy, that's another story I suppose.

                I put more stock in the objective measures, above what the self-report give me...at least from a function perspective. From a psycho-social perspective the self reports are nice.
                Hi John,

                Thank you! That makes sense. The patients are coming in because they cannot perform a certain role in their life.

                From what I have read and understood, disability can only be truly measured through self reports since only self reports take into account both the environment and personal factors. For example, even if a person can walk faster when you test their 400m walk between two cones, this may not change their walking outside because of the terrain, weather, fear of tripping and falling, crossing the road, they not being watched and so forth. So from a patient perspective, they still cannot walk outside or we didn't change anything. And the ultimate goal for the patient is to improve their functioning in the society and not walking 400 m. So our measures should reflect that I feel. Of course, the measures are more objective, but meaningless from a patient perspective. Performance measures measures the capacity whereas self-reports measure the actual performance . The measures are correlated, but I think the magnitude of correlation might be small or moderate. I will have to look at the studies to check how well they are related.

                We use 400m walk at out center to measure mobility disability. If they cannot complete 400m walk in 15 min, they are classified as 'disabled'. Since this an objective measure, it is considered more valid and sensitive. Mind you, these studies are worth millions of dollars. The more and more I read about the models, the more I feel these measures are not right. One of the major reasons ICF developed is to use a neutral language and not classify people as disabled or handicapped. Hence worded as activities and participation in ICF. Also, the biggest change in our thinking was that disability is inextricably linked with the environment and personal factors than just an intrinsic concept. So our measures should reflect that change. Objective measures or performance measures measure function, but leave out the environment and the personal factors from the equation.

                What is your opinion? I am just thinking out loud than replying to specifically.
                Anoop Balachandran
                EXERCISE BIOLOGY - The Science of Exercise & Nutrition

                Comment


                • #9
                  I won't disagree with a word you've said. It's my understanding you are a PhD or currently pursuing one, therefore I respect your interest and reliance on metrics, data, measurements, etc.

                  An experienced and up to date clinician can get away without self reports if they are interactive with the patient. A thorough subjective can cover what self reports ask. Those factors you listed above:

                  "walking outside because of the terrain, weather, fear of tripping and falling, crossing the road, they not being watched and so forth"

                  can be easily asked and discussed with the patient.....and should be for anyone coming into a clinic for pain or disability.

                  Thats where clinicians and researchers diverge I guess. Clinician's use self reports because payors require them. If the clinician is interactive and an effective communicator (verbal and non-verbal) they can glean the same information as a PRO. In many cases better than a self report. Many PROM ask about information a patient doesn't care about (turning while running fast on level ground for example).

                  Just yesterday I performed a 6MWT and TUG on a patient with PD. They completed them well in my flat, predictable, reliable, safe environment. Does that correlate to the environment where they have fallen or struggle (yard, home, outdoors, grocery store etc)? Probably not, but, and I could be way off here, some improvement in these functional scores suggests the potential to improve in other settings. I am not suggesting an improved 6MWT or TUG in my clinic will decrease falls in the yard, but they help me suggest the use of a device, improved strength, endurance, mobility that is beneficial in similar settings. More often than not these test a nice to suggest a device. The addition of a device in many cases reduces disability, improves safety and participation in society.

                  Look forward to your thoughts.
                  "The views expressed here are my own and do not reflect the views of my employer."

                  Comment


                  • #10
                    Hi Anoop! You have successfully lured me out of SomaSimple seclusion. I already sent you the summary of the Pain and Disability Drivers Management model validation study, which incorporates the ICF language and concepts into a predictive model to target care for patients with pain and disability due to low back pain. So, it's neither a performance or self-report measure but a predictive tool to presumably better target care for patients. However, I seen no reason why a change score couldn't be calculated pre- and post-treatment to determine if targeted care improved the patient's "score" on the PDDM.

                    I practice pretty much like Johnny using a variety of performance measures like the TUG, 6MWT, and also the Functional Gait Assessment. Some of these tools have pretty good predictive ability for falls. However, I also use self-report measures mostly because, as Johnny stated, payors require them.

                    The challenge of course is to develop tools that clinicians can use that accurately reflect what the patient is able to do or at risk of injury if they do it. A tool that is so idiosyncratic that it only applies to a tiny subset of patients is not very useful. It's like that tool you needed once to fix the dryer 10 years ago, and you spent $25 for a tool that you'll never use again in your lifetime.
                    John Ware, PT
                    Fellow of the American Academy of Orthopedic Manual Physical Therapists
                    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                    Comment


                    • #11
                      Anoop,

                      In the past I was in charge of outcomes using FOTO for my employer. Like John suggested, FOTO is also a nice predictive outcome tool that allows for targeting care to the patient. It also had the capability to add other outcomes as the clinician felt they needed.

                      If it wasn't for payors, I don't think you'd see clinicians using PRO outside of "what do you think" "do you feel better" "are you doing better?" You might see the GROC here and there if you were lucky.

                      John W,

                      Welcome back. This place has been pretty desolate lately. Not sure what the issue is: facebook, people joining other groups (paincloud, modernpainscience) teaching, recent site changes, life, etc? Either way, good to know you're still out their fighting the good fight.
                      "The views expressed here are my own and do not reflect the views of my employer."

                      Comment


                      • #12
                        Thank you Jon for coming back! Facebook is not at all good for having discussions. I am not sure how people are so involved in forums are moving to facebook. The threads and posts get lost, no good way to edit and quote text, cannot write long posts and so forth. I am in a few discussions forum, but just hate it.

                        I think the vantage point we are looking at is a bit different. Almost all your clients you see have a predictable source of the problem: Injury/pain leading to change in body functions which leads to mobility limitations that in turn affects participation. And this is true of most of the rehabilitation areas like cognitive impairment, spinal chord injury, cerebral palsy and so forth.

                        In aging, however, the problems are much more broader and very gradual in nature, the restrictions they experience could be due to a variety of reasons, such as pain, strength loss, fatigue, joint mobility, cognitive issues, lack of motivation, habits, lack of transportation, financial and so forth. I don't think even the person knows what is the cause of their restriction could be. So even if there is an improvement in physical performance tests, there is no guarantee that this will show up as a better participation. I know there is some controversy regarding the definition of participation, but the ultimate goal for any rehab or aging intervention should lead to the person improving in social roles or life situations. From reading both of your posts, you are measuring participation through your questions to the patient which is similar to using self-reports. And that is the right way to go, I think.

                        My main concern is that most of the tests we use in aging, including me, are still based on the medical models/disease models of disability where the disability is seen more as a personal problem and less as an interaction of the environment and personal factors. And out major tests are just reflecting our thinking. For example, the LIFE studycost 92 million, the Engrize study is 10 million. The primary outcome in both these studies is a 400m walk in 15 minutes which they call "mobility disability". Here is the disability is still framed without the context of the environment or personal factors which I think is wrong and misguided. If we look at disability from the ICF, our interventions will be more holistic , comprehensive, individualized and less based on just exercise to improve mobility.

                        Thoughts?
                        Anoop Balachandran
                        EXERCISE BIOLOGY - The Science of Exercise & Nutrition

                        Comment


                        • #13
                          Trying to study how a human interacts with the environment (home, social, community, occupation, leisure, etc) is a large task if you want to do it well. As a PT with some humility I recognize our role is relevant but incomplete for the patient.

                          My overarching goal is returning the aging population to their participation in life. I also work with aging patients referred for "physical deconditioning" or "generalized weakness." In these cases pain is not an impediment. They've simply lost their ability to function and participate (sedentary, aging, illness, etc). Many have lost their transportation to and from their social groups, amongst other things.

                          I would agree, given participation's complex nature a more thorough self report (many self reports???) may be warranted and important. If looking at the societal impact on a grander scale, I'm in full agreement with you. We will need much more thorough data than a simple 400m/6MWT. If we are to look at disability from the ICF vantage point, things have now become multifactorial which makes things even more challenging from a research perspective.
                          "The views expressed here are my own and do not reflect the views of my employer."

                          Comment


                          • #14
                            Hey John

                            I forgot to add. I am doing a Postdoctorate at the Institute on Aging. Still learning

                            I think from your perspective, the patient has a clear goal and communicates it you and your questions/treatment are focused on that goal. And I guess that goal is related to participation. From a research perspective, the researcher decides the goal(s). I am sure some of the participants in our studies might be wondering what good came out in his/her life by walking 400m in 15 min. Probably nothing.

                            Some of the self-reports which looks at all the participation areas are the LLFDI and the WHODAS 2.0 (WHO's). We use LLFDI. They are based on the ICF model. The definition of participation is not without criticisms though. It is not really clear when activity becomes participation. ICF lumps them together.I feel like we emphasize patient-reports, which is good, but the questions seem to be made by researchers/clinicians. Any thoughts on the definition of participation and problems it may have?

                            I think just like 'precision medicine where we try to individualize the treatment, we need to individualize the rehabilitation looking at both environment, biology and contextual factors.

                            Just thinking out loud. Thank you for the discussions.
                            Anoop Balachandran
                            EXERCISE BIOLOGY - The Science of Exercise & Nutrition

                            Comment


                            • #15
                              "Any thoughts on the definition of participation and problems it may have?"

                              That's why I dislike these models. People are trying to use models to describe a human's perspective or experience. Trying to model someone's complex inner workings is pretty short sighted in my opinion.

                              Participation: what do you value; what gives you meaning, what do you want to do.

                              That might be crocheting, sewing, reading, walking, occupation, going to the movies. It might be social, it might not. It could be anything.

                              Or

                              They may be participating in everything already, but it's not as pleasant as before (pain).

                              "The views expressed here are my own and do not reflect the views of my employer."

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