Manual for Functional Training, 3d ed.

The third edition of this book is directed toward students in health care as well as practicing clinicians seeking a reference for instructing individuals who have involvement on one side of the body, both lower limbs and think, or all four limbs or lower-extremity amputations. Four separate chapters are devoted to point-by-point methods of performing bed, wheelchair, transfer, and ambulation activities given the above classifications of impairment. First, however, there are three distinct chapters devoted to spinal cord injury, brain injury, and amputations in which the anatomy, clinical signs, precautions, complications, and patient management are described. Prostheses, orthoses, wheelchairs, and other assistive devices, as well as architectural modifications, are also discussed. Guarding techniques and sample assessment forms complete the book.

The chapter on spinal cord injury presents text and tables of segmental innervation and performance potential for patients with different levels of complete cord transection. The entire eight-page functional description was taken from a 1955 article that estimated performance for average patients who are strong and motivated and who have received comprehensive training. Bowel, bladder, and sexual functions are also addressed.

The presentation on brain injury includes cerebrovascular accidents, trauma, and problems during fetal development or birth. Cortical specialization and specific dysfunction associated with brain injury are described, including memory; aphasias; agnosia; and hearing, visual, and motor impairments. Reference is made to supersensitivity, collateral sprouting, and bouton stripping following neuronal damage. Management of the patient with brain injury includes serial casting to reduce deformities resulting from spasticity, positioning to prevent skin breakdown, and seating systems to ensure proper alignment. There is a single page devoted to behavioral management.

The chapter on amputations and prosthetics covers preprosthetic training with diagrams of elastic wrapping above and below the knee, as well as rigid and semirigid dressings. The traditional prosthetic sockets, suspension, joints, and foot-ankle assemblies are described and accompanied by numerous photographs. Brief comparisons are made to assist in the choice of devices.

These chapters present generic descriptions of limb and trunk involvement without specifying disabilities. Although some attention is given to the management of various disorders (eg, arthritis, multiple sclerosis, cerebral palsy), the emphasis of these chapters is on the management of patients with spinal cord injury, brain injury, and amputations.

One chapter provides an overview of orthotics through a description that is well complemented by photographs illustrating the parts of a shoe as well as many different orthoses for the lower extremities, trunk, and neck. Components, attachments, and the effects of limiting or assisting motion are discussed, along with some account of their advantages and disadvantages. There is an emphasis on metal rather than plastic devices for the lower limbs. As an overview the chapter offers a good sampling, but is neither exhaustive in including all devices nor broad in the discussion of each orthosis.

The seven-page presentation on wheelchairs is very sketchy, almost solely a description of parts with only a brief reference to maintenance. There is no mention of power wheelchairs or even those with low seats, and seat cushions received only a token acknowledgment. A 1990 chart taken from Sports 'N' Spokes, however, is a good supplement for comparing 20 different wheelchairs. A section of the chapter entitled "Home Improvements for the Handicapped Individual" touches on ramps and door, stair, floor, bathroom, kitchen, and bedroom modifications.

The "meat" of the book lies in the four chapters describing the components and training of functional activities for the four categories of patients. The chapters are broken into bed (lying/sitting), mat, wheelchair, and upright activities. These broad categories are divided and subdivided until about two to seven steps define each task. For example, within the chapter for individuals with one-sided involvement, wheelchair mobility is described as a two-step task in which the patient uses the uninvolved upper and lower mobility extremities for forward propulsion over level surfaces. At times, alternate strategies are offered. Compensatory rather than facilitatory methods are emphasized for a lagging affected limb.

The sections on mat activities describe the starting positions, actions, and intended functional carryover. Some tasks are complete functional activities. Some are parts to a whole functional task (eg, crutch walking in kneeling). Others are more exercise by nature (eg, pelvic tilt or prone shifting on elbows).

These chapters contain a broad spectrum of activities supplemented with graphics or photographs mostly within a hospital setting. For those with bilateral lower extremity and trunk involvement, ambulation with bilateral knee-ankle-foot orthoses is described, as are wheelchair and stair-climbing activities. High-level wheelchair activities (eg, ascending and descending curbs) are also explained for those with involvement of all four limbs and trunk, but there is no mention of powered mobility.

The style of this text is well suited for the student who seeks a neat package with clear guidelines. The authors consolidated into one publication everything from anatomy and etiology through training and adaptive equipment. The detailed format of functional training should satisfy anyone seeking concrete direction. Those who use the assessment forms and tasks as guidelines should be comprehensive in generic assessments, but such assessments should be tailored to specific individual needs with in the community. The precise step-by-step instructional style, however, may promote a rigid, memorized manner of intervention, rather than a critical analysis of movement and functional performance. Although motor learning principles were highlighted in the book's brief introduction, it seems that the authors bypassed an opportunity to integrate these principles into the body of the text.

An overview of so many topics does not allow much depth within each area. in contrast to the detail within the sections on training, the information about prostheses, orthoses, wheelchairs, and other devices is sufficient primarily as an introduction.

In addition to its use to students, this publication may serve as a reference for the practicing physical therapist and physical therapist assistant when patient and clinician are stuck at a particular point in a task or in teaching unfamiliar tasks. There are, however, other texts that provide a broader perspective on the therapeutic management for the therapists inexperienced in a concentrated area.