Occupational Therapy Evidence in Practice for Physical Rehabilitation

A reflective challenge ᭿ 241 British Pharmaceutical Industry, 1999), as there were fears of service users emerg- ing from the programme with a ‘sheaf of printouts from the internet, demanding a particular treatment that is unproved, manifestly unsuitable, astronomically expensive, or all three’ (Shaw, 2004). The fact that this programme refers to the expert patient rather than service user is also interesting, as once again this infers a power position placing those who need help subject to those who are in a position to offer it. The grammatical term ‘patient’ refers to an entity upon whom an action is carried out. For example, in the sentence ‘Jack kicked the ball’, ‘the ball’ is the patient. Applied in a health context, ‘the patient is the participant of a situation upon whom an action is carried out’ (Wickipedia on-line, 2006). In literal terms the word patient comes from the Latin verb ‘patior’ meaning to ‘suffer’, both in the sense of pain and forbearance (Medicinenet.com, accessed 2006); both of these definitions hardly denote a term which promotes a shift in power from service user to provider. The notion of user involvement is more complex than merely providing individuals with the opportunity to express their views or concerns. Braye and Preston-Shoot (1995) point out the distinction between giving users the right to ‘exist’ (to choose one service instead of another) and ‘voice’, whereby they can express their view after receiving a service, in comparison to users having a sense of participation in the planning and delivery of services. There is an argument that ‘voice’ and ‘exist’ are merely a form of window-dressing, as users typically lack the time, motivation and knowledge to impact on service providers. Giving service users a participatory role actually ensures that they contribute to the pro- cesses and systems which shape service provision. One has to also bear in mind the distinction between the service user (individually) and service users (collec- tively). One has also got to give careful consideration to service users who do not have the experience, confidence or intellectual capability to participate in such processes. There is sometimes an assumption that simply giving service users the forum and opportunity to contribute their views, experiences and opinions is sufficient to realise meaningful participation. However this is somewhat naïve; service users frequently lack the confidence, skills, knowledge and motivation that are intrinsic to enable meaningful involvement (Bray and Preston-Shoot, 1995). Giarchi (1998) terms the phrase ‘information deprivation’ to reflect the lack of knowledge many individuals hold in relation to public service provision. The concept of ‘cultural capital’ reflects the lack of skills and confidence which many social groups experience in relation to articulating aspirations and expectations. Being in need of human services means that individuals are also vulnerable, concerned and physically or psychologically weak. This could be argued to make it even more difficult for active participation to take place. There- fore empowering service users is not merely presenting them with an opportu- nity, but rather a process which provides them with the insights, experiences and skills over a period of time which enables individuals to realise and use such opportunities.

242 ᭿ Occupational Therapy Evidence in Practice for Physical Rehabilitation Modern professional–user relations The notion of being a ‘professional’ and a ‘service user’ has been significantly challenged over the last two decades as alluded to above. The professional’s role has been challenged, critiqued and opposed by the development of a post-modern era, in which absolute truth and authority have been rejected and public confi- dence in professionals somewhat displaced. The incorporation of market princi- ples into welfare provision has, to some extent, allowed (some) service users to exercise a degree of choice and to articulate concerns and complaints. The ques- tion as to the long-term impact of such changes has already been debated; sug- gestions include the notion that professionals are a dying entity, with service users gradually acquiring the role of active consumer, to the idea that the role of the professional will be transformed to that of a source of technical expertise who will advise and empower the service user (Jones et al., 1998). Professional practice, power relations and ethics will, however, certainly become more fluid, less certain and more open to scrutiny. Challenge to the reader Select any of the case studies from one of the previous chapters. Thinking about your potential role as a health and social care professional take some time to think through the Government’s recently stated objective of promoting a greater sense of user involvement, with individual clients being given the opportunity to not merely give feedback, but to exercise choice and some degree of control. Reflect upon the following questions: ᭿ How might your sense of authority and expertise as a professional help to shape the relationship you develop with the client? ᭿ To what extent do you think the client might be willing and able to make demands and exercise choice? ᭿ What ethical and practical issues might potentially impact on the choices and opportunities you might be able to allow the client to realise? Disability and the caring professionals Disability is frequently linked to the notions of normality and difference (Saraga, 1998). There is also a belief that the category ‘disabled’ is somehow fixed, universal and innate. Because such difference is linked to the biological, a process of essen- tialism takes place whereby it could and will be argued that social–cultural aspects of difference assume powerful positions because they are constructed around the biological (Corker and Shakespeare, 2002). Therefore intervention by professionals would not only be seen to be appropriate, but inevitable and legiti- mate (Drake, 1999). The disabled person is constructed as being needy, vulnerable

A reflective challenge ᭿ 243 and helpless rather than being socially marginalised and excluded. Such argu- ments provide a useful and highly appropriate focus when exploring the interven- tion of occupational therapists seeking to meet human need. This focus is particularly interesting as the professional has come under criticism by a number of disabled writers who have accused it of being disempowering and disabling (Apperby, 1995; Finklestein, 1999). There is a need to understand the nature of the argument posed by members of the disability movement, even if one does not fully accept them, so as to reflect critically on our clinical practice. Disability is not a natural category of difference but a product of modernity, or modern industrial society (Barnes et al., 1999). Industrialisation, with the develop- ment of formalised, standardised and bureaucratic working practices, margin- alised people with certain impairments. It is important to recognise that impairment, or biological faults and limitations are common to all humanity and not confined to a small proportion of the population (Priestley, 2001). With indus- trialisation came the development of a scientific, ‘rational’ approach to life, and, more particularly, the development of medical science. The body and the person became separated as medical intervention developed an ethos of objectivity and authority in relation to involvement; health intervention became equated with biological repair and restoration. Such an approach constructed normality around the myth of biological purity and perfection, with intervention being capable of assessing and treating any deviation from this norm, in theory at least. Together, the dependency created by economic capitalism and classification and interven- tion by modern medicine created the illocution of a clearly definable group (the ‘disabled’) with needs that could only be met by scientific and ‘objective’ interven- tion. The categories of ‘impairment’ and ‘disability’ became interlinked, seem- ingly fixed, universal and clearly definable. Intervention within the context of scientific and objective modernity was all about making the disabled individual ‘fit’ as well as possible into mainstream society; the rehabilitation model of intervention was based upon the need to restore a degree of normality, to the greatest extent possible (Priestley, 2001). The notion of ‘special’ became equated with difference, inferiority and need. The role of the professional within scientific medicine took on the authority, power and social status experienced by priests in pre-industrial, pre-modern society (Drake, 1999). The relationship between special provision and difference has been debated; whilst the theory of special or additional help is to empower or enable, it has been argued that, in reality, such provision actually highlights and compounds hierar- chical difference (Drake, 1999). The social model of disability developed from groups of disabled people who formed in the US and Britain in the 1970s and 1980s who challenged the tradi- tional ethos and philosophy of health and social care intervention. Alongside this movement, a number of disabled academics developed a theoretical model which underpinned the approach adopted by disabled activists. Central to the social model of disability was the argument that disability was socially/culturally con- tracted rather than being the product of biological impairment. Oliver (quoted in Barnes et al., 1999) suggests that disability is a product of:

244 ᭿ Occupational Therapy Evidence in Practice for Physical Rehabilitation The disadvantage or restriction caused by contemporary social organisation which takes little or no account of the needs of people with impairments and this excludes them from main- stream social activities. Disability is, therefore, the product of the social processes which ignore, reject, marginalise and exclude people with impairments. Marks (1999) remarks that ‘impairment only becomes disabling because of social structures and organisations’. The social model of disability adopts a position shared by the women’s and race equal- ity movements, by arguing that society’s unwillingness to incorporate needs and aspirations into everyday life results in second class citizenship. The social model and the activists in the disability movement were particularly articulate and critical about the relationship between disability and medicine. In essence it was argued that the link of biological impairment with disability ren- dered disabled people powerless, vulnerable and requiring expert help. Not only were disabled people to be treated, modified and equipped to be as ‘normal’ as possible, but they were to be paternally ‘looked after’ and even controlled! Dis- ability was constructed as a personal tragedy which was reflected in individual helplessness and dependency (Marks, 1999). Albrecht (1992) articulates a thesis based on the notion of ‘The Disability Business’, whereby it is argued a range of health and social care professionals have a vested interest in disabled peoples’ dependency and need; basically it creates jobs for them. It is also provides meaning, status and authority to those who join the ranks of the professions. Intrinsic to this argument is the inherent power imbalance within the professional–disabled person relationship; the power to control disabled peoples’ bodies, their access to a whole range of social opportunities (work, housing, social security) and, of course, to engage in processes whereby certain individuals are labelled as being different, needy and helpless (Marks, 1999). It has been argued that the notion of ‘independence’ and ‘dependency’ is a myth (Barnes et al., 1999). In reality we are all inter-dependent in modern society, reliant on complex food chains, highly devel- oped transportation systems and technology-based communication. Therefore, one has to answer the question as to why a selected and arbitrary collection of human abilities are used to define the notion of ‘independence’? The labelling of disabled people as ‘being in need’ is about selected cultural values and norms, not about innate ability. The notion of care The notion of providing ‘care’ is similarly located within cultural norms and customs. ‘Care’ is inherently about being needy or being looked after. Care in relation to disability (and old age) could be argued to be not only about being in need, but having needs which are directly located within the body of the indi- vidual within which the person/identity/status is located in western culture (Marks, 1999). Such caring is, therefore, highly personal or intimate, being reflected in notions of social worth, identity and powerlessness. Such cultural norms and values also mean that the person providing the care is particularly well placed to

A reflective challenge ᭿ 245 assume power, authority and expertise – particularly when it is linked to techno- logical procedures or knowledge bases. With the emergence of risk as a criterion for eligibility to social care, there is again an equation of human need meaning that one is vulnerable and powerless, unable to look after oneself (Kemshall, 2002). The distinction between ‘caring for’ and ‘caring about’ is crucial in this context: ‘caring for’ is about doing (physical tasks), whereas ‘caring about’ is about ensur- ing individuals have the opportunities, support systems and resources to realise their ambitions and aspirations. Morris (1993) suggests that professionals confuse the concepts of ‘independence’ and ‘autonomy’; whilst the former equates to per- forming physical tasks, the later is about having a sense of control and exercising choice. In other words, Morris is arguing that it should be possible to have control over how one’s care needs are met, without actually carrying out the tasks oneself. Exercising autonomy in relation to receiving care has been discussed both within the disability field and the wider context of health and social care for several decades. The typical consumerist model is based on empowerment through direct payment. The availability of direct payments to clients of social services under the Community Care (Direct Payments) Act 1995 modified this model, where clients were awarded a care budget by their local social service department from which they could put together their own package of care. Evidence to date, however, suggests the managers and professionals are highly selective in terms of which clients and what situations are deemed to be ‘appropriate’ to offer a particular client access to direct payments (Priestley, 2001). The disability move- ment was instrumental in setting up collective organisations run by and for dis- abled people, who planned and ran their own care infrastructure. The independent living movement has developed across Britain and in many instances has secured public funding. Members are educated, supported and empowered in both access- ing their own need and in putting together a care package. Whilst one could argue that such organisations are limited in membership to the relatively vocal, articu- late and educated minority, the principles behind them should provide some interesting ideas; Jones et al. (1998) suggest that occupational therapists could act as a resource, or facilitate clients to develop a sense of control and autonomy over their lives. Perhaps disabled clients could be equipped with knowledge, gradually encouraged to gain insight and experience and provided with the opportunities which enable them to gain a sense of control of the ways in which their needs are met (Priestley, 2001). One could even argue that such a process should develop so that clients can define their own needs more fully, as well as how they are met. Challenge to the reader Reflecting on the distinction between ‘doing’ and ‘facilitating’, select two or three case studies used in the previous chapters. To what extent is it important to enable the client through assessment and the provision of equipment and services, com- pared with the argument that what is really important is to develop a sense of

246 ᭿ Occupational Therapy Evidence in Practice for Physical Rehabilitation autonomy and participation in clients’ lives? To what extent are clients’ needs a product of biological impairment or a disabling society? Need, difference and client-centred professional practice This chapter has explored a number of themes and issues which could be argued to be fundamental to being client-centred: to think critically about what we mean by ‘need’, thinking about the notion of user involvement or participation and by viewing the client as having a potential sense of autonomy and control and not merely being in need and dependent. And yet there are practical constraints (time, resources etc), potential ethical issues relating to acceptable risk and informed consent and professional issues relating to accountability and working on the basis of available evidence and organisational culture. Issues relating to the empowerment of clients in terms of defining, assessing and meeting need, with them exercising a sense of control and choice and of realising personal autonomy despite physical dependency and vulnerability place great demands on profes- sionals working within contexts already characterised by tensions, conflicts and pressures (Malin et al., 2002). How can the reality of an approach which incorpo- rates diversity in relation to human need, is grounded in the expectations and aspirations of individual clients and enables individuals to realise a sense of control and autonomy, be developed? Neil Thompson’s (2002) highly readable text on anti-oppressive practice in health and social care explores the tensions produced by trying to promote change whilst faced by practical, ethical and personal constraints. He argues with a con- siderable degree of conviction that there is a process of professional change, rather than simply a predefined set of guidelines or ingredients. Intrinsic to such a process is the ability of professionals to engage in a process of constant curiosity or reflection; not to accept every clinical situation at face value, but continually to question the values, beliefs and motivations which underpin professional inter- vention. There is also a sensitivity to the historical forces which have typically disempowered clients; not merely in relation to knowledge, terminology and time factors, but also the relative powerlessness and dependency which is constructed around being a client in health and social care. Language (Tew, 2002) is perceived to be an important element in professional–user relations, not merely in terms of each party’s ability to communicate, but in terms of how norms, values and ste- reotypes are constructed. Inherent to such an approach would be the ability not only to engage with clients, but also to work with a sense of uncertainty and with a ‘blank piece of paper’ rather than with clearly defined strategies and goals. In relation to the themes and issues developed in this chapter, therefore, profes- sionals would not simply accept needs in relation to predefined technical assess- ment tools, but would also engage with clients so as to facilitate an appreciation as to how the perceptions, aspirations and values of each and every individual relate to the concept of need. One can also reflect on the values which underpin how the health and social care system and individual professionals tend to pri-

A reflective challenge ᭿ 247 oritise one particular need in relation to other needs; the issues of the availability of resources, assessment of risk and the impact of statutory regulation need to be appreciated and reflected upon. The section of this chapter devoted to disability invited readers to explore the nature of the independent/dependency dualism, the impact of professional intervention and the potential for individuals to realise a sense of autonomy. Again, such issues could potentially provide the basis of a new approach to practice based upon reflection and analysis, in which practitio- ners constantly question what they are doing and seeking to achieve. In many respects this chapter is distinct from previous chapters; it does not provide clearly defined and articulated suggested models to intervention, or give prescriptive steps which underpin clinical processes. Some of my fellow authors may feel a sense of unease about this. However, the aim of the chapter is to encour- age reflection and thought – not instead of evidence-based formulated interven- tion, but as complementary to it. Remember that science itself is a product of individual curiosity and questioning – the idea that the world was flat, or was the centre of the universe, had to be challenged. Ideas in relation to disability were also displaced by science in modernity – disability was once believed to be the result of a mother’s intercourse with the devil. Therefore to critique, challenge and question scientific ideas is intrinsically not ‘unscientific’, one could even argue that it is a part of scientific reasoning. Questioning, reflection and analysis may not be allied to personal security and comfort, but they will ultimately allow a professional to develop practice which is pitched to ensuring that clients’ indi- vidual needs are met in ways which realise a sense of autonomy and worth. Perhaps it is a case of evidence to all (including clients) and not the few! References Addy, L.M. and Dixon, G. (1996) To label or not to label that is the question. British Journal of Therapy and Rehabilitation, 6(8), 394–397 Abberby, P. (1995) Disabling ideology in health and social care: the case of occupational therapy. Disability and Society, 10, 221–231 Albrecht, G. (1992) The Disability Business: Rehabilitation in America. Sage, London Annandale, E. (1998) The Sociology of Health and Illness: A Critical Introduction. Polity, Cambridge Archeson, D. (1998) Report of Independent Inquiry into Inequalities in Health. Department of Health, London Association of the British Pharmaceutical Industry (1999) The Expert Patient – Survey. ABPI, London. www.abpi.org.uk/publications/publication_details/expert_patient/survey.asp Baggott, R. (2004) Health and Health Care in Britain. Palgrave Macmillan, London Barnes, C., Mercer, G. and Shakespeare, T. (1999) Exploring Disability; a Sociological Introduction. Polity, Cambridge Blakemore, K. (1998) Social Policy: an Introduction. Open University Press, Buckingham Bradshaw, J. (1972) The concept of human need. New Society, 30, 640–643

248 ᭿ Occupational Therapy Evidence in Practice for Physical Rehabilitation Braye, S. and Preston-Shoot, M. (1995) Empowering Practice in Social Care. Open University Press, Buckingham Conrad, P. (2005) The shifting engines of medicalization. Journal of Health and Social Behavior, 46(1), 3–14 Corker, M. and Shakespeare, T. (2002) Disability/Postmodernity: Embodying Disability Theory. Continuum, London Cumming, J. (1994) Core services and priority-setting: the New Zealand experience. Health Policy, 29, 41–60 Department of Health (2001a) The Expert Patient: a New Approach to Chronic Disease Management in the 21st Century. Stationery Office, London Department of Health (2001b) National Service Framework for Older People. Stationery Office, London Department of Health (2002) Shifting the Balance of Power: The Next Steps. Stationery Office, London Department of Health (2003) The NHS Improvement Plan: Putting People at the Heart of Public Ser- vices. Stationery Office, London. Cm 626.8 Doyal, L. and Gough, I. (1991) A Theory of Human Need. Macmillan, Basingstoke Drake, R. (1999) Understanding Disability Politics. Macmillan, Basingstoke Dunford, C. and Richards, S. (2003) ‘Doubly Disadvantaged’ Report of a Survey on Waiting Lists and Waiting Times for Occupational Therapy Services for Children with Developmental Coordination Disorder. COT, London Endacott, R. (1997) Clarifying the concept of need: a comparison of two approaches to concept analysis. Journal of Advanced Nursing, 25(3), 471–476 Finklestein, V. (1999) Professions Allied to Medicine. Unpublished paper Foucault, M. (1972) The Archaeology of Knowledge. Tavistock, London Giarchi, G. (1998) Information Deprivation. Citizens Advice Bureau, Devon Glennester, H. (1995) British Social Policy since 1945. Blackwell, Oxford Gramsci, A. (1977) Selected Writings From the Prison Notebook. Lawrence and Wishcart, London Ham, C. (1999) Health Policy in Britain: the Politics and Organisation of the National Health Service. Palgrave, Basingstoke Hartley, M. (1998) The Social Context of Health. Open University Press, Buckingham Hugman, R. (1991) Power in the Caring Professions. Macmillan, London Hugman, R. (1999) Social Welfare and Social Values. Macmillan, Basingstoke Illich, I. (1977) Limits to Medicine. Medical Nemesis: the Exploration of Health. Penguin, Harmondsworth Jones, D., Blair, S.E.E., Hartery, T. and Jones, R.K. (1998) Sociology and Occupational Therapy: an integrated approach. Churchill Livingstone, Edinburgh Kemshall, H. (2002) Risk, Social Policy and Welfare. Open University Press, Buckingham Klein, R. (2001) The Politics of the New NHS. Prentice Hall, London

A reflective challenge ᭿ 249 Langan, M. (1999) Welfare: Needs, Rights and Risks. Routledge, London Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H. and Pollock, N. (1990) The Canadian occupational performance measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57(2), 82–87 Lukes, S. (1976) Power. Basil Blackwell, Oxford Malin, N., Wilmot, S. and Manthorpe, J. (2002) Key Concepts and Debates in Health and Social Policy. Open University Press, Buckingham Marks, D. (1999) Disability: Contoversial Debates and Psychosocial Perspectives. Routledge, London Medicinenet.com definition of term ‘patient’ (accessed 11 January 2006) Morris, J. (1993) Independent Lives: Community Care and Disabled People. Macmillan, Basingstoke New, B. and Le Grand, J. (1997) Rationing in the N.H.S. King’s Fund, London North, N. and Bradshaw, Y. (1997) Perspectives in Health Care. Macmillan, Basingstoke Oakley, A. (1981) Subject Women. Martin Robertson, Oxford Priestley, M. (2001) Disability and the Life Course: Global Perspectives. Cambridge University Press, Cambridge Randall, W. (1998) Market and Health Care: A Comparative Analysis. Longman, London Saraga, E. (1998) Embodying the Social: Construction of Difference. Routledge, London Scambler, G. (2003) Sociology as Applied to Medicine. Saunders, London Shaw, J. (2004) Expert Patient – dream or nightmare. British Medical Journal, 328, 723–724 Seedhouse, D. (1998) Ethics: the Heart of Healthcare. Wiley, London Tew, J. (2002) Social Theory, Power and Practice. Palgrave Macmillan, Basingstoke Thompson, N. (2002) Theory and Practice in Human Services. Open University Press, Maidenhead Timmins, N. (1995) The Five Giants: A Biography of the Welfare State. Harper-Collins, London Tudor-Hart, J. (1971) The Inverse Care Law. The Lancet, 27, 405–412 Westwood, S. (2002) Power and the Social. Routledge, London Whitehead, M. (2000) The Concepts and Principles of Equity in Health. World Health Organization, Copenhagen en.wikipedia.org/wiki/Patient (grammar) definition of term ‘patient’ (accessed 11 January 2006) Zola, I.K. (1972) Medicine as an institution of social control. Sociological Review, 20, 487–504

Index activity analysis, road traffic accident, falls, 183–8 64–5 initial, 137–8 interviews, 59–60, 105, 207–9 adaptive skills approach, rheumatoid key-worker, 138–9 arthritis, 111 M-ABC, 32–6 motor neurone disease, 137–41 ADHD see attention deficit hyperactivity multiple sclerosis, 85–90 disorder PEGS, 32–6 rheumatoid arthritis, 105–8, 119–22 aging population, falls, 175 road traffic accident, 59–61 ALS see amyotrophic lateral sclerosis screening, 85–90, 139, 140 AMPS see Assessment of Motor and stroke, 207–14 tools, 185 Process Skills VMI, 33–6 amyotrophic lateral sclerosis (ALS), 130 Assessment of Dysexecutive Syndrome Angela’s experience, motor neurone (BADS), motor neurone disease, 139 disease, 136–7 Assessment of Motor and Process Skills approaches (AMPS), stroke, 212–13 adaptive skills, 111 assistive devices, rheumatoid arthritis, biomechanical, 135 client-centred, 135 114–15 compensatory, 58, 111, 183 ataxia, multiple sclerosis, 88 educational, 84–5 attention deficit hyperactivity disorder educative, 58, 111, 136, 162 falls, 182–3 (ADHD), DCD, 27 motor neurone disease, 135–6 multicontext approach, stroke, 199 BADS see Assessment of Dysexecutive multidisciplinary, 136 Syndrome multiple sclerosis, 84–5 neuro-developmental, 135 Behavioural Inattention Test (BIT), stroke, palliative care, 136 209 restorative, 58–9, 84–5 rheumatoid arthritis, 111–12 biomechanical approach, motor neurone road traffic accident, 57–9 disease, 135 stroke, 199 theoretical, 10–13 biomechanical frame of reference, total hip replacement, 161–2 rheumatoid arthritis, 110–11 assessment, 15–16 see also evaluation BIT see Behavioural Inattention Test DCD, 31–6 Bobath Concept, stroke, 199, 216–18 environmental, 138 CAM see Cognitive Assessment of Minnesota

Index ᭿ 251 Canadian Model of Occupational developmental coordination disorder Performance Measure (COPM) (DCD), 24–52 motor neurone disease, 139 ADHD, 27 rheumatoid arthritis, 105–8 assessment, 31–6 Canadian Model of Occupational co-morbidity, 27 CO-OP, 42 Performance, rheumatoid arthritis, criteria, 26 110 critical reflection, 44–5 care, notion of, 244–5 dynamic performance analysis, 42 Carers Recognition and Services Act dynamical systems theory, 31 (1995), motor neurone disease, 134 Excellence for all Children: Meeting Special caring professionals, reflective challenge, 242–6 Educational Needs, 28 case-control studies, 6–7 feedback, 43 case reports, 7 generalisation and transfer of skills, 43 client-centred approach, motor neurone goal planning, 36–8 disease, 135 government directives, 27–9 client-centred professional practice, government policy, 27–9 246–7 grading the task, 42–3 clinical evidence, 8–10 handwriting remediation, 38–41 clinical reasoning, 13–15 intervention structure, 43–4 motor neurone disease, 141 M-ABC, 32–6 road traffic accident, 61–2 motor goals, 42 co-morbidity, DCD, 27 motor skills group, 41–4 CO-OP see Cognitive Orientation to Daily National Service Framework for Performance Cognitive Assessment of Minnesota Children, 29 (CAM), motor neurone disease, 139 neuromaturational theory, 30–1 Cognitive Orientation to Daily objectives, OT, 38–44 Performance (CO-OP), DCD, 42 occupational therapy, 38–44 cognitive-perceptual consequences, stroke, PEGS, 32–6 204–5 Peter’s experience, 29–45 cohort studies, 5–6 prevalence, 25 Community Dependency Index, falls, SENDA, 28–9 186 task adaptation, 43 compensatory approach terminology, 25–6 falls, 183 theoretical rationale, 30–1 rheumatoid arthritis, 111 transfer of knowledge, 38 road traffic accident, 58 verbal developmental dyspraxia, 27 compensatory frame of reference verbal self-guidance, 42–3 rheumatoid arthritis, 110–11 VMI, 33–6 total hip replacement, 161–2 Warnock Report, 28 conditional reasoning, 13–15 developmental dyspraxia see continuing practice, road traffic accident, 67–8 developmental coordination disorder COPM see Canadian Model of DEX see Dysexecutive Questionnaire Occupational Performance Measure directives, government see government critical reflection DCD, 44–5 directives total hip replacement, 168–9 disability, reflective challenge, 242–6 critical review, road traffic accident, 71 documentation, professional, stroke, 205–6 cross-sectional surveys, 7 domestic tasks motor neurone disease, 142–3 multiple sclerosis, 91–3 dressing skills, OT objective, 44

252 ᭿ Index dynamic performance analysis, DCD, National Service Framework for Older 42 People, 174–5, 180–1 dynamical systems theory, DCD, 31 outcome measurement, 185 dyssynergy, multiple sclerosis, 89 PEO model, 182–3 Dysexecutive Questionnaire (DEX), motor reasons, 176–7, 178–9 reflection/comment, 194 neurone disease, 139–41 SAFER TOOL, 185–6 dysmetria, multiple sclerosis, 88–9 Samuel’s, 181 stairs, 178–9, 191–2 education, rheumatoid arthritis, 103 transfers, 192–3 educative approach Westmead Home Safety Assessment, 187 Falls Efficacy Scale, falls, 187 motor neurone disease, 136 familial motor neurone disease (FALS), multiple sclerosis, 84–5 rheumatoid arthritis, 111 131 road traffic accident, 58 fatigue management, motor neurone total hip replacement, 162 energy conservation, rheumatoid arthritis, disease, 143 feedback, DCD, 43 115–16 FIM see Functional Independence Measure environmental assessment, motor neurone fracture management, road traffic disease, 138 accident, 54–5 Ergonon knife, rheumatoid arthritis, frames of reference, 11–12 111–12, 114 biomechanical, 110–11 evaluation compensatory, 110–11, 161–2 humanistic, 135 see also assessment learning, 110–11, 161–2 falls, 193 motor neurone disease, 135–6 rheumatoid arthritis, 119–22 multiple sclerosis, 84–5 stroke therapy, 223–4 physiological, 135 evidence-based practice, 2–8 rehabilitative, 58, 84–5 Excellence for all Children: Meeting Special rheumatoid arthritis, 110–11 road traffic accident, 57–9 Educational Needs, Green Paper, 28 Functional Independence Measure (FIM), falls, 174–98 stroke, 210–11 aging population, 175 approaches, 182–3 generalisation and transfer of skills, DCD, assessment, 183–8 43 Community Dependency Index, 186 defining, 176 goal planning, DCD, 36–8 evaluation, 193 goal setting Falls Efficacy Scale, 187 fear of falling, 193 motor neurone disease, 141 goals, 188–90 multiple sclerosis, 90 government policy, 179–81 rheumatoid arthritis, 108–10 HOME FAST, 187–8, 189, 190 road traffic accident, 62–3 home hazard assessment, 184–5 goals hospital admission, 181 falls, 188–90 incidence, 176–9 post-operative, hospital-based interventions, 190–3 legislation, 179–81 intervention, 164–7 lighting, 193 stroke, 214–15 locations, 177–8 total hip replacement, 164–7 models, 182–3 government directives, 13 multifactorial risk assessment, 184 see also legislation DCD, 27–9

Index ᭿ 253 motor neurone disease, 133–5 joint protection, rheumatoid arthritis, multiple sclerosis, 80–3 112–14 road traffic accident, 55–7 total hip replacement, 157–60 key-worker assessment, motor neurone government policy disease, 138–9 DCD, 27–9 falls, 179–81 knife, Ergonon, rheumatoid arthritis, grading the task, DCD, 42–3 111–12, 114 HADS see Hospital Anxiety and learning frame of reference Depression Scale rheumatoid arthritis, 110–11 total hip replacement, 161–2 handwriting remediation, OT objective, 38–41 legislation see also government directives hemiparesis, stroke, 202 Carers Recognition and Services Act hemiplegia, stroke, 202 (1995), 134 hierarchy of evidence, 3–4 falls, 179–81 hip replacement, total see total hip road traffic accident, 55–7 SENDA, 28–9 replacement stroke, 205–6 Home Falls and Accidents Screening Tool lighting, falls, 193 (HOME FAST), falls, 187–8, 189, 190 long-term goals Hospital Anxiety and Depression Scale falls, 188 (HADS), motor neurone disease, 139 multiple sclerosis, 90 Human Subsystems Influencing rheumatoid arthritis, 109–10 road traffic accident, 62 Occupation Model (HSIO), stroke, 216, Lowenstein Occupational Therapy 217 humanistic frame of reference, motor Cognitive Assessment (LOTCA), neurone disease, 135 stroke, 211–12 hypertonia, stroke, 202–3 hypotonia, stroke, 202 M-ABC see Movement Assessment Battery for Children information needs, motor neurone disease, 144 MAO see Model of Adaptation through Occupations intention tremor, multiple sclerosis, 89 interactive reasoning, 13–15 MDT see multidisciplinary team intervention plan, stroke, 214–20 medium-term goals, falls, 188–90 intervention structure, DCD, 43–4 Model of Adaptation through Occupations interventions (MAO), total hip replacement, falls, 190–3 161–2 motor neurone disease, 142–7 models multiple sclerosis, 90–4 falls, 182–3 post-discharge, total hip replacement, multiple sclerosis, 80–2, 84–5 NHS and Social Care Model, 80–2 167–8 practice, 11–12 post-operative, total hip replacement, rheumatoid arthritis, 110 road traffic accident, 57–9 164–7 stroke, 216, 217 road traffic accident, 63–8 total hip replacement, 161–2 stroke guidelines, 206 motor consequences, stroke, 202 interviews motor goals, DCD, 42 assessment, 59–60, 105, 207–9 motor neurone disease, 128–53 rheumatoid arthritis, 105 adaptations, major, 145 road traffic accident, 59–60 stroke, 207–9

254 ᭿ Index ALS, 130 multidisciplinary team (MDT), Angela’s experience, 136–7 rheumatoid arthritis, 103 approaches, 135–6 assessment, 137–41 multiple sclerosis, 75–100 BADS, 139 approaches, 84–5 CAM, 139 assessment, 85–90 Carers Recognition and Services Act ataxia, 88 benign, 77–8 (1995), 134 case management, 82 clinical reasoning, 141 classification, 77–80 COPM, 139 dinner money issuing, 93–4 DEX, 139–41 disease/care management, 82 domestic tasks, 142–3 domestic tasks, 91–3 FALS, 131 dys-synergy, 89 fatigue management, 143 dysmetria, 88–9 frames of reference, 135–6 educational approach, 84–5 further assessments, 139–41 frames of reference, 84–5 goal setting, 141 goal setting, 90 government directives, 133–5 government directives, 80–3 HADS, 139 guidelines, 83 information needs, 144 intention tremor, 89 intervention, 142–7 intervention, 90–4 interventions, 128–9 ironing, 91–3 leisure, 144 long-term goals, 90 mobility, 144–5 long-term nature, 79–80 multidisciplinary screening assessment mediolateral stability, 92–3 models, 84–5 tool, 139, 140 MSIS-29, 86–8 ongoing commitment, 148 multi-joint movements, 89 outcome measurement, 147–8 National Service Framework for Long- outline, 129–32 Term Conditions, 82 palliative care, 133–5, 145–6 NHS and Social Care Model, 80–2 PBP, 131 outcome measures, 95 person-centred service, 133 outline, 76–7 personal care, 142 primary progressive, 79 PLS, 131 reflective analysis, 95–6 PMA, 131 rehabilitative frame of reference, 84–5 PPC, 134 relapsing/remitting, 78 psychological impact, 132 restorative approach, 84–5 quality of life, 147 screening assessment, 85–90 symptoms, 131–2 secondary progressive, 78–9 motor skills group, OT objective, 41–4 Shirley’s pathway, 83–4 Movement Assessment Battery for short-term goals, 90 supporting self health care, 80–1 Children (M-ABC), DCD, 32–6 MSIS-29 see Multiple Sclerosis Impact Multiple Sclerosis Impact Scale (MSIS-29), 86–8 Scale multi-joint movements, multiple sclerosis, narrative reasoning, 13–15 National Service Framework for Children, 89 multicontext therapy approach, stroke, 199, DCD, 29 National Service Framework for Long- 219–20 multidisciplinary approach, motor Term Conditions, multiple sclerosis, 82 neurone disease, 136 multidisciplinary screening assessment tool, motor neurone disease, 139, 140

Index ᭿ 255 National Service Framework for Older PLS see primary lateral sclerosis People PMA see progressive muscular atrophy policy, government see government policy falls, 174–5, 180–1 post-operative, hospital-based stroke, 200 need concept intervention, total hip replacement, client-centred professional practice, 164–7 PPC see Preferred Place of Care 246–7 practice, models, 11–12 reflective challenge, 231–6, 246–7 pre-operative OT, total hip replacement, neuro-developmental approach, motor 162–4 Preferred Place of Care (PPC), motor neurone disease, 135 neurone disease, 134 neuromaturational theory, DCD, 30–1 primary lateral sclerosis (PLS), 131 NHS and Social Care Model, multiple procedural reasoning, 13–15 professional practice sclerosis, 80–2 caring professionals, 242–6 reflective challenge, 236–46 objectives, OT progressive bulbar palsy (PBP), 131 dressing skills, 44 progressive muscular atrophy (PMA), 131 handwriting remediation, 38–41 psychological impact, motor neurone motor skills group, 41–4 disease, 132 transfer of knowledge, 38 qualitative studies, 7 ongoing commitment, motor neurone quality of life, motor neurone disease, 147 disease, 148 randomised controlled trials, 3–5 osteoarthritis limitations, 4–5 total hip replacement, 155–7 treatment, 156–7 reasoning clinical, 13–15 outcome measurement, 17 conditional, 13–15 falls, 185 interactive, 13–15 motor neurone disease, 147–8 narrative, 13–15 multiple sclerosis, 95 procedural, 13–15 road traffic accident, 69–70 total hip replacement, 168 referral rheumatoid arthritis, 104 palliative care, motor neurone disease, road traffic accident, 68–9 133–5, 136, 145–6 reflective analysis PBP see progressive bulbar palsy multiple sclerosis, 95–6 PEGS see Perceived Efficacy and Goal road traffic accident, 70 Setting Scale reflective challenge, 231–49 PEO model see Person–Environment– care, notion of, 244–5 caring professionals, 242–6 Occupation Model client-centred professional practice, Perceived Efficacy and Goal Setting Scale 246–7 disability, 242–6 (PEGS), DCD, 32–6 need concept, 231–6, 246–7 performance assessment, rheumatoid professional practice, 236–46 service user, 236–42 arthritis, 105–8, 119–22 person-centred service, motor neurone reflective practice, 17–18 rehabilitative frame of reference disease, 133 personal care, motor neurone disease, 142 multiple sclerosis, 84–5 Person–Environment–Occupation (PEO) road traffic accident, 58 Model, falls, 182–3 Peter’s experience, DCD, 29–45 pharmacological management, rheumatoid arthritis, 103–4 physiological frame of reference, motor neurone disease, 135

256 ᭿ Index restorative approach long-term goals, 62 multiple sclerosis, 84–5 models, 57–9 road traffic accident, 58–9 outcome measurement, 69–70 outline, 54–5 rheumatoid arthritis, 101–27 prevalence, 54 action/treatment, 112–19 referral, 68–9 approaches, 111–12 reflective analysis, 70 assessment, 105–8 risk assessment, 65 assistive devices, 114–15 short-term goals, 62–3 Canadian Model of Occupational transfers, 64–6 Performance, 110 treatment sessions, 66–7 clinical features, 102–3 washing, 67–8 COPM, 105–8 wheelchair, 63–4 education, 103 energy conservation, 115–16 Safety, Assessment of Function and the Ergonon knife, 111–12, 114 Environment for Rehabilitation evaluation, 119–22 (SAFER TOOL), falls, 185–6 explanation, 102–4 frames of reference, 110–11 Samuel’s fall, 181 goal setting, 108–10 screening assessment interviews, 105 joint protection, 112–14 multidisciplinary screening assessment learning frame of reference, 110–11 tool, 139, 140 long-term goals, 109–10 management, 103–4 multiple sclerosis, 85–90 MDT, 103 SENDA see Special Educational Needs and models, 110 performance assessment, 105–8, 119–22 Disability Act pharmacological management, 103–4 service user, reflective challenge, 236–42 prevalence, 101 short-term goals referral, 104 short-term goals, 109 falls, 190 splinting, 116–19 multiple sclerosis, 90 surgical management, 104 rheumatoid arthritis, 109 treatment approaches, 111–12 road traffic accident, 62–3 Tricia’s experience, 104–5 spasticity, stroke, 203 Special Educational Needs and Disability risk assessment, road traffic accident, 65 road traffic accident, 53–74 Act (SENDA), DCD, 28–9 splinting, rheumatoid arthritis, 116–19 activity analysis, 64–5 stairs, falls, 191–2 approaches, 57–9 stretch reflex, stroke, 203 assessment, 59–61 stroke, 199–230 clinical reasoning, 61–2 continuing practice, 67–8 AMPS, 212–13 critical review, 71 approaches, 199 Darren’s experience, 57 assessment, 207–14 fracture management, 54–5 BIT, 209 frames of reference, 57–9 Bobath Concept, 199, 216–18 goal setting, 62–3 cognitive-perceptual consequences, government directives, 55–7 intervention, 63–8 204–5 interviews, 59–60 consequences, 201–5 legislation, 55–7 documentation, professional, 205–6 evaluation, therapy, 223–4 explanation, 200 FIM, 210–11 goals, 214–15 hemiparesis, 202

Index ᭿ 257 hemiplegia, 202 intervention, post-operative, 164–7 HSIO, 216, 217 MAO, 161–2 hypertonia, 202–3 models, 161–2 hypotonia, 202 osteoarthritis, 155–7 implementing therapy, 220–3 outcome measurement, 168 intervention implementation, 220–3 post-operative, hospital-based intervention plan, 214–20 interventions, guidelines, 206 intervention, 164–7 interviews, 207–9 pre-operative OT, 162–4 legislation, 205–6 theoretical models, 161–2 LOTCA, 211–12 Tony’s circumstances, 160–1 models, 216, 217 transfer of knowledge, OT objective, 38 motor consequences, 202 transfers multicontext therapy approach, 199, falls, 192–3 road traffic accident, 64–6 219–20 treatment approaches, rheumatoid National Service Framework for Older arthritis, 111–12 People, 200 treatment, osteoarthritis, 156–7 occupational level consequences, 201 treatment sessions, road traffic accident, reflection, 224 spasticity, 203 66–7 stretch reflex, 203 upper motor neurone syndrome, 203–5 upper motor neurone syndrome, stroke, 203–5 task adaptation, DCD, 43 theoretical approaches, 10–13 user involvement, reflective challenge, theoretical models, total hip replacement, 236–42 161–2 verbal developmental dyspraxia, 27 theoretical rationale, DCD, 30–1 verbal self-guidance, DCD, 42–3 total hip replacement, 154–73 Visual Motor Integration (VMI), DCD, approaches, 161–2 33–6 critical reflection, 168–9 functional impairment, 160–1 Warnock Report, DCD, 28 goals, 164–7 washing, road traffic accident, 67–8 government directives, 157–60 Westmead Home Safety Assessment, falls, intervention, post-discharge, 167–8 187 wheelchair, road traffic accident, 63–4