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Overall approach Schools of thought Specific techniques purchase sildenafil line erectile dysfunction groups in mi, procedures sildenafil 75 mg fast delivery erectile dysfunction young living, activities and equipment FIGURE 2 Therapy intervention constructs and their interconnections cheap sildenafil 25mg line constipation causes erectile dysfunction. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 21 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This conceptual model was widely referred to in our interviews. It was clear that it not only offers a language and framework by which therapy interventions can be understood, but has also been a catalyst for change in the overall approach of therapies. It is a 20–22 conceptual model that has been endorsed by all three profession, with guidance issued to support its implementation (e. College of Occupational Therapists, 2004; Royal College of Speech and Language Therapists, 2005) as well as being integrated into the training of new therapists. The meanings of the terms used in this model are as follows. Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may experience in involvement in life situations. Health condition (Disorder or disease) Body functions and Activity Participation structures (Impairments (Limitations) Restrictions) Contextual factors Environmental Personal factors factors FIGURE 3 The ICF model of disability and health. This model can be regarded as the original starting point of all three professions. When interviewees offered a chronology of the emergence of these different models, this approach was described as emerging in the 1990s. Within this approach, addressing dysfunction or impairment is no longer the key focus. This opens up alternative ways of intervening which may be as, or more, successful. One example is achieving independent mobility through the use of a wheelchair rather than through a lengthy and intensive physiotherapy programme. A1 A slightly different, or concurrent, conceptualisation emerged from interviews with occupational therapists. The operationalisation of these approaches A number of issues emerged during our discussions with interviewees regarding these three possible approaches to understanding the objectives of a therapy intervention. First, there was clear evidence that all the approaches are being used by therapists. Furthermore, not all interviewees believed that the different approaches were incompatible. Thus, some viewed them as being necessarily connected, with achievements of particular skills or reducing pain, for example enabling higher-level outcomes (expressed in the goals identified by children or parents) to be achieved, even if not explicitly identified at the outset of the intervention: [Let me give you this example]. He is now independently participating in his own personal care, and this gave him better self-esteem in the classroom. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 23 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. THERAPY INTERVENTIONS: APPROACHES AND TECHNIQUES Start with the child or impairment, working on the body structure and functions as a means to an end to achieving the desired occupation. Start with the occupation, looking both at the child and the environment to see what can be done to achieve the occupation. Yet the same situation can be looked at in different ways, involving different interventions, and with different people. Some favour one, some the other, and others use a bit of both. N1 Second, a goals-focused approach was widely endorsed and, reportedly, operationalised. Then, about 12 years ago, with the second generation, it became much more about targeting an activity and participation. Now a third-generation model is needed, where [we] really target participation. F1 This was also evidenced in some of our interviews when interviewees described goals that ranged across all of the ICF concepts. Thus, a goals-focused approach was being operationalised, but not necessarily within a framework of participation. Participation, as set out in the WHO report, was viewed by some as challenging in terms of its definition and measurement, in terms of both appropriate time points and the indicators of participation used. This is something we discuss in detail in Chapter 7. Finally, new ways of working, intervention programmes and practices have emerged or been developed in response to this shift in approach from deficit to activities or goals-focused approaches. Examples of these referred to by study participants included, for physiotherapy, the MOVE programme (www. This approach was regarded as more prevalent within community, rather than secondary care or acute, settings. First, many interviewees noted the reduction in funding for therapies for children with neurodisability, which had forced changes in the way therapists worked. The way NHS trusts have chosen to address resource constraints has, however, differed. In some trusts, specialty posts have been maintained – albeit operating in a consultative role – whereas in others, posts have been lost and/or downgraded. The therapist will come in one or two times a term so it would be ludicrous to expect a change with that amount of contact. R2 There was a diversity of opinion as to whether or not this change is for the better. The dominant concern was that non-therapists may not be sufficiently skilled or competent to respond to changes in functioning or to evaluate the impact of the interventions and adjust the intervention accordingly: There is something about the skill of the therapist in working with any one child with particularly complex needs, to be able to tune in to how the child is responding to what you are doing with them. To make the kind of adjustment that you need to do to make the therapy work there and then, and to know whether you can push onto something more complex. I think intervention effectiveness is actually being diluted. Z1 A second concern was adherence to intervention programmes. Finally, this represented a very significant change in the day-to-day work of therapists that may be difficult to accept and assimilate: Within practice there is a reluctance to change that [move to less hands-on and more activity-based therapy], particularly among those who have been trained in manual handling of patients and how to support and help them move.

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