It is an intermediate mechanism between theory and practice. A frame of reference (FOR) aims to help the clinician link theory to intervention strategies and apply clinical reasoning to the chosen intervention methods. A frame of reference should be well fitted to meet the client’s goals and hoped-for outcomes.
It consists of 4 components: –
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Theoretical base
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Function-dysfunction continuum
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Behaviour indicative of function-dysfunction
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Postulates regarding change & intervention
1. Theoretical base-
It serves as the basis from which all of the components are derived. It is founded on concepts, definition by postulates from one or more theories that guide evaluation & intervention.
2. Function-dysfunction continuum-
This component applied concepts from the theoretical foundation to identify the nature of the dysfunctional behaviours targeted for change by the frame of reference. The term “continuum” emphasizes the fact that function can only be understood about a patient’s age, cultural background, physiological status, and environmental circumstances. continuum specifies what the therapist will assist during evaluation and the goal or expected outcomes of treatment. A frame of reference may have one or several functional dysfunction continents depending on the scope of the area addressed by the FOR.
3. Behaviour is indicative of function-dysfunction-
Behaviour is indicative of this component and operationally defined the behaviour that demonstrates function or dysfunction within each continuum. This serves as the basis for evaluation tools and activity analysis related to evaluation. Evaluative activities are selected concerning their potential to elicit the behaviour to be observed that differentiates between function and dysfunction.
4. Postulates regarding change and intervention-
This component states the nature, quality, quantity, sequence of interaction with the human and nonhuman environment that can potentially change dysfunctional behaviour. These postulates guide the therapist in selecting long and short-term goals and in sequencing the treatment process. They also form the conceptual framework for analysing the activities prescribed for the treatment.
Biomechanical FOR-
1. Theoretical Base:-
It is properly based on purposeful activities. The goals of this FOR are to the increasing range of motion, strength and endurance.
Baldwin was the first healthcare professional who studies how joints and muscles work during purposeful activities. He also developed evaluating activities for an increasing range of motion, muscle strength and endurance. Before World War-1, purposeful activities were used for diversional purposes.
Biomechanical FOR has four assumptions:-
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Purposeful activities can be used to treat loss of range of motion, strength and endurance.
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After the range of motion, strength and endurance are gained, the patient automatically regains functions.
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The principle of rest and stress (the body must need rest to heal).
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The biomechanical FOR is best suited for patients with an intact CNS. The patient may have limitations in range, strength and endurance but can perform smooth isolated movements.
2. Function-dysfunction continuum-
Eight function dysfunction continents that are a domain of concern for biomechanical FOR are:-
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Structural stability
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Low-level endurance
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Oedema control
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Maintaining range of motion
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Increasing range of motion
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Maintaining Strength
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Increasing Strength
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High-level endurance
3. Behaviour indicative of function-dysfunction-
Behaviour indicative of change is found by using evolution tools. The occupational therapist has former evaluation tools, for example, volumeter for oedema, goniometry for a range of motion (ROM), manual muscle testing (MMT) for strength. Assessment of endurance can also be done by timing the duration of an activity or counting the number of repetitions the patient can perform.
4. Postulates regarding change and intervention–
Postulates regarding the change identify links among:-
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Presenting problems
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Biomechanical goals
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Functional outcomes.
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Intervention:-
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ROM: By ROM exercises like flexion, extension, adduction, abduction, internal and external rotation & circumduction.
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Strengthening exercises like Isometric exercises, isotonic exercises, Progressive resistive exercises, etc.
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Endurance: improved by timing the duration of an activity and increasing the number of repetitions the patient can perform.
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Oedema: Managed by AROM exercises of distal joints, the elevation of the limb, retrograde massage from distal to proximal with the application of lubricant and with the help of thumb or palm, depending upon the area where oedema is present.
Rehabilitation FOR-
1. Theoretical base-
Rehabilitation FOR teaches patients to compensate for underlined deficits that can not be remediated.
It has 5 assumptions:-
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A person can rehabilitate independence through compensation.
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Motivation for independence is inextricably linked to volition, habituation, and subsystem. Long-term values, future rules, and a revenue sense of purpose all have an impact on motivation for independence.
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Motivation for independence can not be separated from the environmental context. Environmental resources on motivation for independence include the demands of the design setting, patients’ financial status, and the emotional resources of the family.
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A minimum of emotional and cognitive prerequisite skills are needed to make independence possible.
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Clinical reasoning should take a top-down approach. It has five steps –
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Environmental demands of decided setting.
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Current functional capacity such as independence in toileting.
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Task demands the patients can not perform. For example, standing balance.
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Type of rehabilitation methods, for example, adaptive devices.
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Specific modalities, for example, long handle creatures, one-handed techniques, etc.
2. Function-dysfunction continuum –
The three function dysfunction continents that are the domain of concern are–
(A). Activities of daily life self-care and home care
(B). Work
(C). Leisure task
3. Behaviour indicative of function-dysfunction–
By using evaluating tools, patients’ behaviour indicative of change can be found. Test scores indicate the level of assistance required.
4.. Postulates regarding change and intervention–
It establishes a link between presenting problems and functional outcomes. Postulates regarding intervention create a link between functional outcomes and specific adaptive devices, modifications and procedures in a specific format.
Neurodevelopmental FOR-
1. Theoretical base-
This was developed by Bobath.
It is based on five assumptions.
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The first assumption states that teaching normal milestones is not the proper focus for treatment.
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It is the belief that you can not impose normal movements on abnormal muscle tone.
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It is stated that damage to higher centres in the brain produces a release phenomena, lower centres greater mass, obligate tree, stereotype movements in the form of hyperactive physic and tonic reflexes and pathological limb synergies.
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It is a belief that normal movement is learnt by experiencing how normal movements feel. Bobath refers particularly to proprioception and tactile sensation.
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It states that the brain is very plastic and capable of recovery. Research has explained CNS recovery.
2. Function dysfunction continuum-
Three domains of concern in NDT FOR-
(A). Axial control
(B). Automatic Reaction
(C). Limb control
(A) Axial control – Until Bobath pointed out the importance of postural adjustments that accompany all limb movements, other FOR ignored axial control of the neck and trunk.
(B). Automatic reactions – which include righting and equilibrium reactions that enable us to risk the movements without the fear of falling, without safety existing only in rigidly holding a posture.
(C). Limb control – how effectively you are controlling the limb.
3. Behaviour indicative of function-dysfunction –
Patients’ behaviour is placed on these three continents by behaviour indicative of change found by using evolution tools. Formal evaluation exists for reflex development and automatic reactions, limb synergy and muscle tone.
4. Postulates regarding the change in intervention–
It identifies the link between presenting problems, NDT goals and functional outcomes. Treatment includes passive stretching, active stretching, active shifting, normalisation of muscle tone, etc.
Developmental FOR-
Proposed by L. Lorens.
1. Theoretical base –
After many years of clinical practice, research and education, Lela Lorens framed a common sense of vision of growth and development. Simply stated, her thesis is that occupational therapy is a facilitation process that assesses the individual in achieving mastery of life task and the ability to cope as efficiently as possible with the life expectations made of him through the mechanism of selected input stimuli and availability of practice in a suitable environment.
2. Function-dysfunction continuum –
L. Lorens constricted 10 premises that fit together in a sequential and fundamental statement to support her vision of growth and development.
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Human development occurs in an old early fashion throughout the life cycle.
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Steps within the developmental process are sequential and none can be skipped.
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The person has an innate drive to encounter his world and master its challenges.
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As a person proceeds through the life cycle, he will encounter life events and changing internal and external conditions that will necessitate reappraisal and change.
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Confrontation and change create tension, equilibrium and stress.
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The person’s ability to master developmental tasks is influenced by his capability to learn skills, his life experiences and the availability of opportunity.
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Successful adaptation tense to read individuals to feel self-satisfaction and to gain societal approval.
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Behaviour is primarily influenced by the extent to which an individual has mastered the previous stages of development.
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The filament is considered as the age and stage process which is sequential.
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The influence of culture, socialisation and morality play an integral part.
3. Behaviour indicative of function-dysfunction-
The growth interruption may cause a wide variety of problems for the child and his ability to interact with the environment. A therapist may recognise that the client is functioning at an earlier level of skills than that required for successful task accomplishment. The deficient skills or mastery of skills available to the growing child at a specific developmental stage are assessed across all domains.
4. Postulates regarding change and intervention –
Growth interruption indicates the need to gain or regain the deficient skills through the clients’ participation in tasks or purposeful activities that are appropriate to facilitate growth and development. This approach includes an element of prevention when problem areas can be addressed before they present major obstacles and maladaptive behaviour in growth and development. The role of an occupational therapist is to identify the gap in development and to provide selective tasks and relationships to promote the continuance of progression both simultaneously and chronologically. This FOR is particularly applicable to children, but it also has inherent usefulness in treating adults with regression or chronic conditions.
Sensory Integration (SI) FOR-
1.Theoretical Base-
Proponent-A. Jean Ayres.
Some measure neural structures such as the brainstem in the thalamus process sensory input from many sources. Convergence of sensory information that comes from any source to the brain stem and the thalamus suggests integration of input at that level. The best ability to filter, organise and integrate masses of sensory information is critical to learning.
2. Function-dysfunction continuum-
The model of child development proposed by ‘Ayres’ denotes the importance of vestibular, tactile and proprioceptor input. In the development of postural control, body scheme, bonding, nourishment, coordination, emotional stability, language and perception.
The end product of sensory integration responses are those that support academic learning, such as concentration, organisation, self-control, self-esteem, self-confidence and abstract thinking. ‘Ayres’ postulated that dysfunction could be treated using selected sensory input with emphasis on the identified dysfunctional system.
3. Behaviour is indicative of function-dysfunction–
To Evaluate Sensory dysfunction, ‘Ayres’ devised the Southern California sensory integration test in 1972, which was revised in 1980. In 1975, she introduced to the South and California post to rotator instead of mass test to assess vestibulo-ocular functions. The sensory integration and praxis test (SIPT) became available in 1985.
4.Postulates regarding change and intervention –
Treatment parameters for this FOR, include control of sensory input through selected activities that emphasise subcortical in other sensory integration. Movement is an implicit component of therapy. A variety of equipment, such as scooter boards, bolsters, and swings, is used to provide moment experiences.
The patients’ response is carefully monitored to determine whether a mature adaptive response appears, to assess whether the size of overstimulation or under-stimulation is present.
This neurobiologically based FOR recognises the hierarchical and interdependent qualities of the function of the brain and focuses on convergence or integration of sensory stimulation. Evaluation tools identify areas or syndromes of sensitive dysfunction and treatment Rely on movement and tactile based activity that promote successful adaptive responses to the demands of the environment.
Canadian occupational performance measures (COPM)-
It was proposed by Mary Law, et al in 1990. It is a client-centred approach that is being introduced in occupational therapy practice. COPM is an excellent example because the client identifies his occupation performance problems and scores them on items of performance, satisfaction with performance and their importance to him.
In using the client-centred approach, it is important that it is the person receiving occupational therapy who identifies their occupation performance issues that would benefit from occupational therapy intervention.
Therefore, an assessment of occupational performance begins with the evaluation of what activities the client needs, wants or expects to accomplish and is having difficulty in performing. Information about an individual’s occupation, roles, development stages and the environment in which he lives is best obtained through an interview.
COPM guides a client to identify problem areas in occupational performance and assists in goalsetting and it measures changes in a person’s perception of his occupational performance over the course of occupational therapy intervention. COPM Measures and individual perception of occupational performance among people with a variety of disabilities and across all developmental stages.
COPM is administered using a semi-structured individualised interview. During the interview, the client or caregiver identifies areas of activities of daily living, work, leisure that are important to him and are in need of occupational therapy and intervention.
COPM is administered in a four-step process which includes –
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Definition
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Problems identified
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Scoring
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Reassessment
For each occupation performance area, the therapist gives several illustrations of the kinds of activities that fall in that area and determines from clients if they need to, want to, or are expected to perform any of these activities.
After all, occupation performance problems are identified in terms of importance, their perception of current problems and current satisfaction with the performance.
Reassessment is completed at a time when the client and therapist believe that is appropriate.
Occupational therapists who have used COPM have found it is helpful in setting priorities for OT intervention. The mean length of administration for COPM was 40 minutes and the medium length of administration time was 30 minutes.
