Rehabilitation Approaches (Traditional Vs. Contemporary) and (Bottom-up Vs. Top-down)

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Quality Care is an important aspect for healthcare providing services. Healthcare services are always working to treat and improve patient's health outcomes, status and quality of life. According to the WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred.”

The 'quality care' can be improved and maintained by adopting interdisciplinary team approach for patients and ensuring that all level of management in rehabilitation services are properly coordinated. Occupational therapist and Physiotherapist are one of the important members of this team whose goal is to improve and maintain patients health, functional independence and quality of life. Many research and surveys are done every year to provide evidence and implement new approaches and strategies in intervention plan of patients.  

Now a days, patients wants to regain functional independence as early as possible after any injury. In order to achieve this, intervention strategies and approaches have shifted more towards top-down pattern of rehabilitation rather than bottom-up treatment pattern. We will understand the difference between traditional (older) approaches Vs. contemporary (newer) approaches of rehabilitation.

 

Traditional or older approaches of rehabilitation. Its considerations are:

1. Its main focus is on bottom-up evaluation and intervention strategies.
2. Patients are passive recipients of therapy.
3. Based on Hierarchial control of movements i.e. intervention application is based on Reflex theory and Hierarchial theory of motor control.
4. Interventions are provided in developmental sequences pattern i.e from proximal to distal control.
5. Assumes repetitions of exercises or single  muscle activation will lead to ADL independence. Postural adjustments are viewed and treated separately with task performance.
6. Reflex is served as basic functional unit of movement. This approach considers cortex as highest level of control and spinal cord as lowest level of control of our body.
7. Examples (all are considered in bottom-up approaches) : NDT, SI, PNF, Rood's principal, Brunnstrom approaches.

 

Contemporary or newer approaches of rehabilitation. Its considerations are:

1. Its main focus is on top-down evaluation and intervention strategies but it also considers bottom-up intervention strategies.
2. Patient actively participate in developing new strategies and attempts to solve problems while performing task with or without guidance of therapist. It enhances voluntary control of body. Transfer of training to a new task or to a new environment is emphasized.
3. Based on Heteroarchial organization. It means that control of movement is built by interaction of many subsystems like nervous system, cardiovascular system, musculoskeletal system, environment, effect of gravity, goal of patients etc. This interaction is influenced by development, training, changing environmental conditions. Intervention application is based on dynamic system theory and ecological theory.
4. These approaches are mainly client-centered approaches. Patients are given task-oriented functional training. Approaches are directed to relearn goal-oriented  purposeful control of movements, related to task,  which will help patients to be independent again. Use of adaptations and environmental modifications are emphasized for gaining independence in daily living after any injury or to compensate for permanent loss of any body functions.
5. Postural adjustments are viewed and treated simultaneously with task performance. Simultaneous interventions of proximal and distal segment is given. Postural control and alignment provides a foundation for complex functional skill development.
6. In current rehabilitation plan, contemporary rehabilitation approaches are combined with traditional rehabilitation approaches with emphasis placed on motor relearning principles (explicitly training function) to achieve functional movement.
7. Examples (all are considered in top-down approaches) : MOHO approach, Motor relearning approach, Ecological approaches (PEO or PEOP approaches), Task-oriented approach, CMOP approach, Occupational Adaptation approach, occupational therapy intervention process model, functional  training approach, CO-OP approach for children etc. 

Application of these rehabilitation approaches can be learned by referring to our article "HIGHLIGHTS ON RECENT ADVANCES AND APPROACHES IN STROKE REHABILITATION".  Click on the below link ⬇️

https://otpthealthcarerehab.blogspot.com/2020/06/highlights-on-recent-advances-and.html

What is top-down approach and bottom-up approach and its applications in intervention plan of patient? 

Top-down Approach :

1.  It's main focus of evaluation and treatment plan is to address patient's activity participation. It can be done by adapting activities, environment modification and maximizing existing skills. Thus, this will allow patient's independence in occupation.
2. It is consistent with principles and goals of Occupational therapy profession i.e. emphasis is placed on meaningful occupation and occupational performance.
3. It allows for a holistic approach of care by focusing evaluation and intervention on problems of occupation limitations and not necessarily medical diagnosis that is causing limitations. 
4. It addresses functional performance. Intervention goal is to improve patient's participation in Occupational activities at existing disability level. Examines motivation, routine, habits and roles within their environment. Evaluates how environmental demands influence occupational performance.
5. Drawbacks of these approaches: Assessment used are not always objective. Implementation of this model in treatment setting is not always possible. There are lots of theories base for this model but treatment examples using this approach is less.
6. Evaluation can be done by following assessment tools like Functional Independence measure (FIM) scale, Allen cognitive level, WHO-QOL scale, MOHOST, A-ONE scale, Lower extremity functional scale (LEFS) or Upper extremity functional scale, Canadian Occupational performance measures (COPM) etc.
7. Examples:   

• School based therapy : modified chair or CP chair for spastic CP kids. Changing position and distance of chair for visually deficit kid with respect to blackboard. Real time motivating and helping child to engage in group play. Educate teacher as well as other classmates about affected child's condition and how to help him/her with their school work and participation. Try not to make fun or tease the child for his deficits.
• Prescribing various assistive or adaptive devices like reacher for grabbing objects, ADL universal cuff, built-up handle for  firm grip, writing assist device, swivel spoon or liftware spoon for eating activity, button aid and zipper pull etc. These devices can make patient independent in their ADL. Use of wheelchairs or walker for gaining independence in mobility and improve social participation. 
• Teaching patients compensatory techniques: learning new dressing techniques or cutting techniques ( for preparing food in kitchen) by stroke patient due to affected one side. Learning to write with  non-affected hand if dominant hand is affected. Teaching visual-perceptual deficit patients to self-analyse activities and learn new strategies to manage any task by avoiding clutters, sorting and arranging objects with adequate space, sequential scanning of objects for searching things, mentally imaging object (its shape, size, colour) before searching for it. All these new modification and adaptation will increase patients self-esteem and decrease their level of dependency on others.

• Home or environment modification : installation of commode for bowel and bladder activity, placing commonly used object at easy reach. Installation of grap bars in toilet and bathroom for firm grip and also to prevent slipping. Placing of non-skid mats on floor to decrease chances of fall. Fixing of small floor or stair lights for people with diminished vision. Printing of book with legible large and bold font for children with affected vision.

Fig: Upper limb dressing in Stroke patient (compensatory techniques)

Fig: Lower limb dressing in Stroke patient (compensatory techniques)

Fig: Improve Social participation by using wheelchair for community mobility

Fig: Adaptive or assistive devices for eating (universal cuff) for patients with weak grip or restricted hand movements

Fig: HandSteady Mug (Adaptive device) for patients with movement disorder, decreased muscle power to avoid liquid spillage

Fig: Grap bars in washrooms to ensure firm grip for  geriatric, stroke,  diplegic CP patients

Fig: Typing aid (adaptive devices)

Fig: Bedside Commode chair for patients who has difficulty using Indian style toilet and have weakness of proximal muscle in lower limb 

Bottom-up approach : 

1. It's main focus of evaluation and treatment plan is to address patient's impairment/ deficits and basic foundation skills. It can be done by remediation or restoration of necessary skills or performance components so that patient can participate in occupation.
2. Application of this approach, on patients, is easy. Even patients with affected insight, who can't express their needs or meaningful occupation, can be evaluated and intervened based on physical impairments. Students and novice therapists generally initiate intervention plan by considering bottom-up approach.
3. It is based on biomedical approach which is commonly used in most hospitals and clinics. It is easy to collect and track data for analysing outcomes. It is appropriate for time sensitive interventions in which immediate and focused intervention is integral. For example in case of fractures or burns.
4. It addresses the cause of problems. Intervention goal is to address level of impairment in body function or structure and to improve functional skills (motor skills, process skills)
5. Drawbacks of this approach: it focuses on improving function (performance components) and not necessarily to attain independence in occupational activities. Utilizes theories and frames of reference from other disciplines.
6. Objective evaluations of specific performance components can be done with various assessment tools or scales like berg balance scale (BBS) for balance, Montreal cognitive assessment (MOCA) for cognition and perception, Glasgow coma scale (GCS) for recording patient's consciousness,  Ashworth scale for spasticity, LOTCA test, Six-minute walk test for aerobic capacity amd endurance , Brunnstrom stages of voluntary control recovery etc.
7. Examples: 

• providing splints for radial nerve palsy, burns, facial palsy, after surgical procedure etc to prevent deformity or contracture or for immobilization purpose. 
• Strengthening exercises with or without weights for specific diagnosis.
• NDT and PNF techniques to normalize tone.
• Sensory Integration intervention for ADHD, Down's syndrome and autistic child by using therapy ball, trampoline, bolster, swings, obstacle course etc for integrating proprioceptive or tactile or vestibular needs.
• RICE principle for muscle strain or ligament sprain. 

• Balance training in rehabilitation setup
• Cognitive training with help of puzzle, memory games etc. 
• Lower limb orthosis for diplegic or spastic cerebral palsy to normalize muscle tone, prevent contractures and to maintain the gained range of motion after manual stretching.

Fig: Manual therapy by therapist to improve range of motion and muscle power.

Fig: Knee brace for immobilization or to limit knee mobility after surgery or sprain

Fig: Bolster swing to integrate vestibular needs, facilitate equilibrium reactions, improve core muscle strength

Fig: Therapeutic Exercises with weights, therapy ball. 

Make a note that the evaluation and rehabilitation of patient can't be done by considering any one approach in isolation. Both approaches constitute strengths that have contributed to our practice. Priority given to any one approach is concerned with understanding the client's health condition and needs. 

• If major concern is related to performance component aspect (impairment of body functions) then therapist would begin with bottom-up approach. For example, if patient has suffered tendon injury or has risk of fall or has been operated for any injury then giving adequate rest period for healing is important rather than focusing on task performance.
• Similarly, if major concern is the ability to participate in life activities (performance areas and performance context) then therapist would begin with top-down approach. For example: Intervention will be planned based on patient's concern of being independent in basic ADL or participation in social gatherings or painting or writing poetry or making lunch etc

Thankyou for reading!!!

Dr. Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe