Shayna Gavin, Splash Principal Physiotherapist
Participation is the key (the ICF-CY model)
We help babies and children to learn day to day functional activities so they can participate in life at home, school, and in the community.
Participation is the focus of everything we do here at Splash Physitotherapy.
When teaching, I often give this example:
A child comes to me and he can't balance on one leg for more than a moment.
If he can balance for 8 seconds at the end of our block of therapy, have I done enough as a physiotherapist?
If he can stand on one leg and kick a soccer ball to me 2 metres away, have I done enough?
But if he can kick the soccer ball to his team mate during Saturday's game, with the sun in his eyes as he runs through the muddy grass, and feel like he is a part of the game?
Then we're getting somewhere.
We use a "top down" approach. That means we start with the participation goals identified by the child and/ or their family.
This is based on the World Health Organisation's International Classification of Function for Children and Youth (ICF-CY). It's a long name, here's their diagram to help explain:
Here's the brief explanation of the components from the WHO:
Participation is involvement in a life situation
Activity is the execution of a task or action by an individual
Body Functions are physiological functions of body systems (inclding psychological functions)
Body Structures are anatomical parts of the body such as organs, limbs and their components
Environmental Factors make up the physical, social and attitudinal environment in which people live and conduct their lives.
Personal Factors include gender, age, coping styles, social background, education, profession, past and current experience, overall behaviour pattern, character or other factors that influence how disability is experienced by the individual.
So here's my example in the the model:
Step 1: Participation
You can see that we started with the participation goal, to play soccer with his mates on Saturday mornings as a part of the team.
Step 2: Activity
The thing that this child was struggling with the most, that was affecting his confidence, was his ability to kick a soccer ball with direction to a team mate. His coach said 2 meters would be a great distance for him to be able to manage.
When we did some task anaylsis, we saw that that activity has plenty of parts:
following the game, seeing the ball and your team mate positions, hearing team mates yell out to each other
seeing the ball come towards you, anticipating and making the postural adjustments needed to get yourself into the right position to receive the ball, and to line yourself up to kick it to your team mate
anticipating the postural adjustments to keep your balance while you kick the ball, using your senses to know where you are in space and where you want the ball to go
kicking the ball, staying on your feet, and running off to follow the play
There's a lot in that!!
Step 3: Body Function and Systems
There's a huge long list in there of the sorts of systems we looked at. It's about being able to register and process all the information from your senses, to put that together to make a motor plan, and then have the physical ability to do it, and then using your perceptual system to see how you went (Did I connect with the ball? Did it go far enough? Did it go the right way? If not, what can I try next time?)
This is where a lot of our intervention is targeted, in problem solving through what strengths the child has in performing the activity, and what areas do they need help to practise in. The point of the ICF model is that even if we spend much of a session working on balancing on one leg to kick a ball, we're doing it within the context of the big participation goal. That keeps us on track, and we practise the small component pieces withint the bigger picture framework.
Feeding in: Environment & personal factors
Sometimes this is where intervention needs to be focussed.
Perhaps the coach needs some help with how to best cater towards this child's specific learning needs.
Perhaps a super - competetive parent on the team is really keen on winning and doesn't see why all of the 7 year olds should have a go each game (!)
Perhaps there's a bunch of stairs up to the field that this child is exhausted after struggling to get up before the game, and we need to find another way around.
Often these factors can be the major limit to participation.
They can also be the things that MAKE it possible!
Maybe the coach is eager to include this child and make sure he's a part of the team.
Maybe this child's big brother has been loving spending time with him practising kicking a soccer ball in the drive way after school.
Maybe this child's motivation is the thing that drives everyone around him.
Of course most goals require a team effort.
In this case, there's the child, their family, their soccer coach / team / other parents. But there was also their sport teacher at school, the orthotist who adjusted the AFO which had got a bit small, and a psychologist who had been helping with worries about being able to do things with friends at school or in leisure.
For other goals, other team members often include:
GPs, paediatricians, neurologists, and other medical staff
teachers and specialist teachers
allied health such as occupational therapists, speech pathologists, psychologists, dieticians
equipment prescribers and suppliers
It's through this coordinated approach, doing all of this problem solving 'behind the scenes', that we're able to help children target the areas they need so they can achieve their functional, and ultimately their participation goals.