Model of disablement and recovery: knowledge translation in rehabilitation research and practice

Disablement is a multifactorial and complex process that creates a challenge for both the rehabilitation researcher and the clinical practitioner; however, each seeks to improve quality health outcomes for the adult or child with disability. Knowledge translation (KT) is an approach to evidence-based medicine where various evidence sources are aggregated so that clinical decisions regarding intervention selection and dosing result in beneficial care for an individual. Structural equation modeling was used to test a theoretical model of disablement based on the impairment, activity, and participation categories of the International Classification of Functioning, Disability and Health (ICF) level of functioning. Using available cohort data from a randomized controlled trial of people with poststroke walking disability, exploratory and confirmatory factor analysis revealed that the latent variables-impairment and activity-are separate disablement constructs that limit participation for a person with disability. Path analysis revealed that the direct effect of impairment on participation was not statistically significant; however, the indirect path from impairment to participation through activity was significant (indirect effect). The direct effect of activity on participation was significant. Model assumptions were tested with postintervention data from the same cohort. For people with disability after stroke, the probability that functional tasks could be performed with less effort was greater for those individuals who met or exceeded a physiologic walking threshold after a structured, progressive intervention provided by a physical therapist 6 months earlier. This article discusses how structural equation modeling can be used as a statistical method to explore the causal paths from disability to ability. The knowledge inquiry and synthesis phases of the knowledge-to-action KT framework parallel the essential elements of structural equation modeling; knowledge is created that is theoretically driven, supported by prior research, and analyzed, refined, validated, and tailored to address real-world problems. Using a theoretical framework of disablement with clinical judgment and quantitative research methods, a clinically intuitive model of disablement was validated. The positive dimension is a model of recovery where causal paths lead from disablement to ablement. Innovative approaches in rehabilitation research design along with pragmatic application of research to practice are needed to improve today's health outcomes for people with disability.