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Functional limitations: a review of their characteristics and vocational impact.

The concept of functional limitations has occupied a cardinal role in the field of rehabilitation for many years. Despite the centrality of this concept to the daily work of rehabilitation professionals, it has not been without its share of problems. For example, the very notion of a classification of functional limitations has spawned many, and often, rather diverse efforts by researchers and clinicians (e.g., Crewe & Athelstan, 1981; Marsh, Konar, Langton & LaRue, 1980; Sarno, Sarno & Levita, 1973; Wright, 1980). Furthermore, the ever-evolving conceptualization of the terms of impairment, disability and handicap, and their relationship to functional limitations and functional capacities (i.e., residual functions maintained following a disease or injury) has also thwarted efforts at defining, clarifying and categorizing functional limitations (Granger & Gresham, 1984; Halpern & Fuhrer, 1984; Nagi, 1969, 1976; World Health Organization, 1980). Finally, the various systems developed over the past four decades to assess human functions show a remarkable degree of diversity, and range from those directed at measuring only physical functions to those addressing a wide array of life spheres (i.e., physical, psychological, social, educational, vocational and environmental areas) (Agerholm, 1975; Brown, Gordon & Diller, 1983; Granger & Gresham, 1984; Halpern & Fuhrer, 1984).

The intent of this paper is twofold. First, it seeks to familiarize the reader with the concepts of impairment, disability, handicap, functional limitations, functional capacities, and functional assessment, and to discuss the professional benefits of incorporating the client's functional limitations and capacities into the rehabilitation diagnosis and planning process. Second, a model which can facilitate the identification and classification of functional limitations and capacities, and make the efforts of rehabilitation professionals more effective, is presented.

Description of Terms

Impairment

Impairment is defined as "any loss or abnormality of psychological, physiological, or anatomical structure or function" (World Health Organization, 1980, p. 47). Impairment reflects disturbances at the body's organ level (e.g., leg, back, brain). Measures of impairment typically include those concerned with specific restrictions of some physical, mental or emotional capacity (Halpern & Fuhrer, 1984).

Disability

Disability is defined as "any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being" (WHO, 1980, p. 143). Disability reflects disturbances at the person level. In other words, it relates to deficiencies in normally expected function, performance, or behavior (e.g., inability to walk, inability to sit for an extended period of time, limited self-awareness, limited ability for acquisition of knowledge). Measures of disability customarily include those addressing restrictions of skills a person manifests when interacting with the environment (e.g., Activities of Daily Living Scales) (Halpern & Fuhrer, 1984).

The U.S. Bureau of the Census (1989) has defined persons with a work disability as those who are limited, by reason of a physical or mental impairment, in the kind or amount of work they can do.

Handicap

Handicap is defined as "a disadvantage for a given individual, resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual" (WHO, 1980, p. 183). Handicap, therefore, reflects the socio-cultural, economic, and environmental consequences that result from impairment or disability. As such, it represents disadvantage in the fulfillment of social roles. Hence, measures of handicap attempt to designate those comparative disadvantages in social role performance (e.g., work, family relationships, recreational activities, residential environment activities) (Halpern & Fuhrer, 1984). Specific handicaps include occupational, social integration, and economic self-sufficiency handicaps (WHO, 1980).

Functional Limitations

A Functional Limitation (FL) is "a consequence of a health problem and represents an inability to meet a standard of an anatomical, physiological, psychological, or mental nature (impairment). This can lead to reduction in behavioral skills or performance of tasks (disability) or deficits in fulfillment of social role (handicap)" (Granger, 1984, p. 16). As such, FL represents a substandard organismic performance (Nagi, 1976), particularly in performing life activities, using skills and fulfilling social roles. FL, then, is the result of an interaction between an impairment and the environment (Granger, 1984; Indices, 1979).

Functional Capacities

A Functional Capacity (FC) is the "degree of ability to perform a specific role or task which is expected of an individual within a social environment" (Indices, 1979, p. 7). Hence, FC represents the residual physical, cognitive or behavioral capabilities of an individual in his or her task performance and environment negotiation.

Functional Assessment

Functional Assessment (FA) is "the measurement of purposeful behavior in interaction with the environment, which is interpreted according to the assessment's intended uses" (Halpern & Fuhrer, 1984, p. 3). The three primary categories of behavior include (a) physical, cognitive or emotional capacity; (b) performance of useful skills or tasks; and (c) performance of social roles. Environments in which behavior is performed include the home, community and workplace (Halpern & Fuhrer, 1984). Thus, while FL and FC address the object or outcome of assessment, FA refers to the actual process of the assessment.

As can be seen from the above cursory treatment of these concepts, a rather imperfect relationship exists between impairment or disability, and FL or FC (c.f., Sigelman, Vengroff & Spanhel, 1979).

Whereas impairment and disability are terms that pertain to organic and behavioral dysfunctions, respectively, FL and FC imply two additional components, namely, analysis of diagnostic (for impairment) and performance (for disability) indicators, and assessment of abilities and activities (see, for example, Granger, 1984; Halpern & Fuhrer, 1984). Put differently, impairment and disability are general terms that are more concerned with diagnosis and classification of organic conditions and their assumed skill performance. FL and FC, alternatively, are applied terms where specific degrees of limitation or residual capacity are addressed and assessed as they relate to particular life contexts (e.g., workplace).

For example, Nagi (1976) and Wright (1980) view limitations in functioning as representing a bridge between medical impairments and disabling or handicapping conditions. Others (e.g., Frey, 1984) perceive FL as most analogous to impairment, while regarding FC as most analogous to disability. Most professional rehabilitation practitioners might agree that it is not knowledge of the chronic medical condition, but an understanding of the residual functional limitations and functional capacities that are of greatest use when helping their clients develop appropriate rehabilitation plans and programs.

Benefits of Assessing Functional Limitations and Capacities

The advantages accrued from a careful study (i.e., assessment) of the clients' FL and FC are many. First, medical diagnosis provides no information on clients' capacity to engage in various life activities (e.g., walk, relate to others, acquire knowledge) (Crewe & Athelstan, 1981), while FL and FC assessments invariably provide such information. Second, the present medical and psychiatric diagnostic systems offer only limited specificity and functional relevance and are only moderately correlated with observable behaviors (Crewe & Athelstan, 1981). Third, the classification systems currently in use provide little or no pertinent information on socio-cultural and environmental conditions and barriers that may impede (or foster) clients' performance (Crewe & Athelstan, 1981). Fourth, FA assists in identifying clients' existing abilities and limitations, and as such, is directly linked to establishing priorities for setting rehabilitation goals and implementing intervention strategies (Marsh, et al., 1980). Fifth, FA also provides a more objective and measurable basis for client behavioral assessment, rehabilitation planning and outcome evaluation (Crewe & Athelstan, 1981). And finally, FA can be useful in demonstrating program accountability, cost accounting and budgeting (Tenth Institute on Rehabilitation Issues, 1983).

Major Categories and Characteristics of Functional Limitations and Capacities

This section provides the reader with a description of six primary realms where FL's and FC's are manifested and therefore assessable. When used as intended, the authors believe the six realms together represent a "model" for the selection and implementation of intervention strategies. To be useful, a model must first dynamically illustrate the essential elements of the reality it purports to represent. And second, an integrating philosophy or model should form the basis from which the rehabilitation professional develops appropriate assessment and delivery approaches (c.f., Power, 1991; Rubin & Roessler, 1987; Scheer, 1990).

The groupings are partially inspired by previous contributions made by Anthony (1979), Brown, Gordon and Diller (1983), Crewe and Athelstan (1981), Marsh et al. (1980), Sarno, et al. (1973), Sigelman, et al. (1979), and Wright (1980). The conceptualization of human functioning along three life domains, namely, physical, cognitive, and social (or socio-affective) is not new to the field of rehabilitation. Anthony's (1979) psychiatric rehabilitation model is predicated upon such a classification. Likewise, similar categorizations are also implicit in several of the functional assessment systems (e.g., Diller et al.'s, 1983, Rehabilitation indicators--Environmental indicators; Sarno, Sarno & Levita's, 1973, Functional Life Scale). Finally, some efforts to develop models of life functions and associated rehabilitation goals (e.g., Hershenson, 1977; Livneh, 1988; Sigelman, Vengroff & Spanhel, 1979) also view human adjustment as comprised of physical (e.g., mobility, health), psychological (e.g., cognitive, personal) and social (e.g., interpersonal, attitudinal, communicative) domains.

We believe that additional specificity is required in order for such a classification system to be useful and applicable by practitioners. However, no prior work was found that attempted to differentiate life domains at a more detailed level of functional constructs. It was, therefore, decided to propose a model where each of the three domains is divided into two, more discrete categories. The first category in each domain addresses the structural units within each domain (e.g., missing or deformed body parts in the physical domain; diminished mental processes in the cognitive domain). The second focuses more on the dynamic or interactive aspects of each domain (e.g., impaired neurological transmission in the physical domain; impaired interpersonal relationships in the social domain). Hence, the physical domain was classified as to its static (i.e., structural) and dynamic (i.e., neurological) realms. The cognitive domain was divided into the mental (i.e., intellectual processing) realm, as well as that more directly linked to emotions (i.e., cognitive-affective). Finally, the social domain focuses on both communicative problems related to structural or environmental-based anomalies (i.e., structural) and those associated with more fluid, interpersonal difficulties (i.e., social-affective).

Included in the discussion which follows are (a) a definition of each realm; (b) the nature of the manifestation--how functional limitations may be observed in the individual's physical or psychosocial environments; (c) the major underlying medical causes (e.g., injury, disease, genetic, degeneration) associated with each limitation; and (d) the vocational impact of the types of limitations noted.

Realm: Physical-Structural

Context

Included here are structural-physical abnormalities. Functional limitations are a product of body parts that are missing, deformed or damaged (e.g., amputation, birth defect).

Nature of Manifestation

Abnormal or missing bone and/or muscle tissue often results in mechanical deficiencies, and may impair a person's ability to perform specific types of tasks. Missing limbs may be augmented with prosthetic devices which can increase functional capacities. Impairments of this type include amputation, back injury, dwarfism, giantism, missing or scarred muscle tissue, organ impairment (e.g., one kidney, one lung), obesity, etc. Resultant limitations can impair mobility, manipulation skills, appearance and endurance.

Causes

Causes are typically associated with accidents, birth defects, diseases and injuries. Numerous types of problems can result in structural abnormality. Included are severe burns, severe frostbite, cancerous growths, blood clots and toxic exposure. Assessment must be able to define functional limitations (what the person cannot do), and capacities (what the person can do) in order to determine vocational impact.

Vocational Impact

Suitable work would be that which (a) does not require the physical use of essential missing or impaired body parts; (b) can be modified to reduce the impact of the limitations; (c) can be performed adequately with the assistance of prosthetic augmentation; or (d) includes any combination of these elements. Residual functional capacities should be utilized to the fullest possible extent.

Structural physical impairments often result in increased dependence upon cognitive and social capacities. Impairments involving the back or lower extremities may restrict a person to sedentary jobs where flexibility in sit/stand alternation is afforded. Structural impairments of the upper extremities may limit a person to jobs where manipulation of objects or extensive reaching is not required. However, prosthetic aids and/or worksite modifications may enable the worker to perform other jobs.

Realm: PhysicaI-Neurological

Context

Included here are neurological impairments that affect physical functioning. Functional limitations result from missing or abnormal neural transmission due to organic failure, trauma, birth defect or disease.

Nature of Manifestation

Inability to move various body parts, spasticity, balance and orientation problems resulting from inner ear fistula and other physical/neurological deficiencies often create functional limitations similar to those in the structural realm. Mobility, manipulation, speech, alimentary control, sensory functioning and perception are a few of the many areas that might be impacted by neurological impairments. Limitation may also occur with regard to endurance and rate of movement.

Causes

Trauma, disease, and birth defect are the primary causes of neurological abnormalities leading to functional limitations. There are a growing number of devices which can increase functional capacities. Mobility may be assisted through use of powered wheel chairs, modified motor vehicles, and even electronic stimulators. Speech, sight, hearing, and other neurologically impaired physical structures can be augmented as well.

Vocational Impact

Very often the impact is marked or severe when neurological impairment is manifested. A disease such as multiple sclerosis can impair many physical functions and severely restrict a person's work capacities. Perilymph fistula, for example, may disorient persons to the degree that they cannot move about or deal with complex visual fields without acute distress. Paralysis can impair a person's use of limbs and control of bodily functions. It is vital to fully utilize functional capacities and focus on what the person can do since the functional limitations my be pervasive. A severe impairment should be considered one where numerous physical functions are impaired.

If the person can communicate effectively from a controlled environment, and perform sedentary (e.g., clerical) tasks, then the limitations might be considered moderate. Pervasive abnormal neurological functioning can be a severe impediment to successful employment. This realm in particular requires specific and often unique solutions to foster successful return to work and often involves education, practice, worksite modification, and a great amount of perseverance.

Realm: Cognitive-Processing

Context

Included here are structural abnormalities (e.g., brain dysfunction), or diminished cognitive processes related to information processing, memory and intelligence. Normally, cognitive operations function to allow the individual to develop basic knowledge of an accessible and usable form.

Nature of Manifestation

Functional limitations in this realm are displayed by (a) below average intelligence; (b) a diminished or sub-average capacity to intake and process new data; and (c) impaired or inaccessible memory. A person's capability to relate to the environment is based on the ability to intake, process, store and recall information.

Causes

Primary causes include mental retardation, head trauma, substance abuse, cerebro-vascular accidents, and some psycho-physiological abnormalities. When impaired in this realm, a person is operationally deficient across a broad spectrum of functioning.

Vocational Impact

As a general rule, the greater the functional impairment in this realm, the less complex and more routine a job must be for performance standards to be maintained. At the severe and marked levels of impairment, suitable positions would need to be simple (i.e., one or two step) jobs, with little change and minimal need for independent judgement. Job coaching has proven to be a very beneficial strategy for helping persons with limitations in this realm to become successful in their work environment.

Realm: Cognitive-Affective

Context

Included here are impairments related to judgment, decision making, motivation, concentration, and staying on task. The experience of pain as a cognitive-sensory construct is also included in this realm.

Nature of Manifestation

Functional limitations in this realm are observed in a person's (a) ability to stay on task; (b) lack of judgment when presented with choices; (c) poor motivation; (d) lack of energy; (e) poor impulse control; (f) withdrawal; (g) pain behaviors; (h) poor ability to make decisions; and (i) poor ability to solve problems.

Causes

Many types of organic and psychological impairments can be manifested as functional limitations in this realm. As a person's experienced level of pain increases, there is a decrease in functional capacity in many or all of the areas noted above. Depression, anxiety and other psychological impairments also reduce functional capacities. Substance abuse can contribute to functional limitations in this realm. On occasion, the medication used to help alleviate problems in this and other realms contribute to other difficulties (e.g., side-effects such as lethargy).

Vocational Impact

Even if unimpaired in other realms, a person with severe limitations in this area may have difficulties in functioning successfully in a job setting. Limited success with completing tasks, staying on track, or even showing up for work can create many problems. Once again, complete and accurate assessment must be undertaken. The specific functional limitations may be successfully addressed through focus on residual functional capacities. Medication may be used to stabilize a person's cognitive-affective functioning to the degree that normal functioning is possible. Moderate to marked limitations may be addressed through either simple and routine jobs that require minimal cognitive involvement. If possible, job restructuring can have a tremendous positive effect on this realm. Creating situations where the worker is in a rewarding job that has been structured to minimize the possibilities of negative events, can greatly enhance successful return to work.

Realm: Social-Structural

Context

Included here are impairments which may interfere with a person's capacity to associate with or communicate effectively with others due to structural or environmental conditions.

Nature of Manifestation

Functional limitations in this realm include (a) physical deformities that are more cosmetic than functional; (b) impaired ability to be with others (e.g., susceptibility to disease or having a communicable disease); and (c) impaired ability to communicate through normal channels (e.g., speech impairment, deafness).

Causes

These include disfigurements (e.g., facial scarring, severe bums, cleft palate), deformative (e.g., misshapen head, dwarfism), skin disorders, and certain neurological disorders (e.g., neurofibromatosis). All may contribute to attitudinal barriers, aversive reactions in others and social withdrawal. Susceptibility to disease may prompt a person to avoid contact with others or may require protective devices (i.e., surgical mask).

Having a disease, such as AIDS, often prompts others to avoid contact with the person afflicted. Limitations on a person's ability to communicate may stem from many sources. Deafness and blindness hamper communication. Cancer of the larynx, emphysema and other diseases or injuries to the throat can greatly reduce a person's ability to communicate via speech. Phobias and social anxieties may limit a person's choices regarding contact with others.

Vocational Impact

A severe limitation in sustaining interpersonal relationships can be minimized through working in jobs requiring little to no face to face contact with others. The vocational impact of functional limitations in this realm is highly person-dependent and society-dependent. Many, if not all, of the limitations listed can be overcome if focus is placed on what people are capable of doing. To do this, rehabilitation professionals provide the type of assistance which will defuse, or at least minimize, personal anxieties and stereotypes regarding persons with disabilities.

Realm: Social-Affective

Context

Included here are inabilities or limited ability to form or maintain meaningful, rewarding or safe interpersonal relationships. Problems with social and interpersonal adjustment also pose difficulties in this realm.

Nature of Manifestation

Anger, abuse, social anxiety, suspiciousness, disregard for the welfare of others, hostility, and criminality are a few ways that limitations are manifested in this realm. Functional limitations may result in incarceration, court imposed psychological treatment and the person being viewed as a threat to self or to others.

Causes

Mental disorders (e.g., schizophrenia, personality disorders, severe mood disorders), traumatic experiences (e.g., rape, incest, abuse, neglect), substance abuse and organic brain impairments are typically associated with limitations in this realm.

Vocational Impact

Severe limitations in this realm often preclude a person's ability to sustain employment. While cognitive functions may not be impaired, the cognitive-affective realm is often involved. Work often requires interaction with at least a few others, and if a person is perceived to be difficult to relate to, not trustworthy, or if others (e.g., co-workers, the public) experience apprehension when dealing with this person, then employers may be reluctant to maintain employment for this person. A severe limitation in this realm implies that such a person is unpredictable and at least occasionally has difficulties with behavior control. Solitary jobs require that the person be capable of adhering to task and maintaining quality control without much supervision.

Model Utility and Application

The evaluation of FC's and FL's occurs in many different arenas, each with its own set of rules, procedures, purposes, and presentation needs. A rehabilitation professional may do FA's for the Social Security Administration, Workers' Compensation Departments, State Vocational Rehabilitation, independent living determination, or career change, to name but a few of the possibilities. While each agency, arena, and client has its own set of guidelines and expectations, it would be helpful if the assessment process had a consistent set of assessment domains to analyze and report about. As stated previously, a useful model presents the essential elements necessary to perform an FA and the means by which FC's and FL's can be effectively determined. While rehabilitation professionals must conform to specific needs manifested by a variety of clients, they can nevertheless use such a model to structure their effort.

Let us examine how this might work in practice. When a Vocational Expert (VE) is asked by the Social Security Administration (Office of Hearings and Appeals) to provide a Residual Functional Capacity Assessment, or more directly, to provide an expert opinion as to whether or not the claimant is competitively employable, the following process typically occurs. First, the VE reviews the claimant's file for all "vocationally relevant" information. Such information may be found in the form of medical and psychological reports, work history data, physical and mental capacity reports, forms, letters, etc. It is helpful when reviewing such an extensive number of documents to have in mind what one is looking for. The model presented previously provides the guidelines and parameters needed to perform this task efficiently. The VE can use the model to help identify physical-structural or neurological, cognitive-processing or affective, social-structural or affective data in the file and possibly even note it by category. Next, the VE can match these data with the worker trait characteristics of jobs to determine the claimant's past relevant work, and make preliminary decisions about the claimant's capacity to do this work or any other work. The identification of FL's and FC's in the six realms organizes the VE's task and allows the fulfillment of the client's expectations in a manner consistent with established procedures. When the VE appears at the heating to give testimony, it is expected that the above has occurred. During the hearing, additional information is obtained in the form of testimony and occasionally additional documentation. Once again, it is helpful for the VE to have a set of guidelines (e.g., a model) to use when integrating these data into what was previously used to form the pre-hearing opinion.

Normally, the VE testifies when everyone else has finished. The Administrative Law Judge (ALJ) will provide the VE with a "hypothetical" person which presents a set of FL's and FC's and asks whether or not such a person can perform any of the past relevant work performed by the claimant and/or whether or not there is any work that such a person could do in the competitive marketplace (also what are these jobs and how many of them exist). The VE may have to respond to numerous hypotheticals posed by the ALJ and then to additional ones under cross examination by the claimant's attorney. It would seem obvious that the VE must be able to promptly and efficiently integrate new data (or assumptions) into the FA context if the above process is to be performed in an effective manner. Use of a model, such as described in this paper, will facilitate the rehabilitation professional's ability to perform the required tasks in a consistent and professional manner. While the Social Security disability hearing process takes great care to include "all" vocationally relevant data, this is not the case for some other arenas.

The Workers' Compensation (WC) arena may focus solely on FL's identified as directly related to a specific work injury, yet depend on the injured worker's full range of FC's when making decisions about vocational goals, training, or disability levels. This type of approach may be consistent with the WC rules and regulations, but the rehabilitation professional must be concerned with the "whole person" when making decisions or forming professional opinions. The model proposed, when used, provides the type of structure needed to insure that the total person is assessed in relation to the occupational environment. The same parameters which facilitate the efficient organization of data also provides for the inclusion, or at least examination, of all relevant elements.

A rehabilitation professional who works for a State Division of Vocational Rehabilitation (DVR) often has to decide which applicants to provide services to, and the amount of support that can be provided to each eligible client. The decisions about how to allocate the available resources are typically based on the needs of the applicant and the likelihood that programmatic support will foster positive change in the client and result in job placement. Rehabilitation professionals in DVR settings can use data obtained from personal-social, vocational-educational, and medical-environmental sources to reach conclusions on the client's FC's and FL's in each of the model's six realms. Areas where significant discrepancies exist between a client's present level of functioning (i.e., skill deficits), and environmental (e.g., work setting) demands can then assume priority as personalized goals on the client's Individualized Written Rehabilitation Program (IWRP).

Use of a model as proposed will help the rehabilitation professional to effectively assess the needs of clients and allocate resources to maximize positive change. Identifying FL's and FC's in each realm will allow the counselor to select and implement specific assessment and programmatic resources (e.g., psychosocial assessment, work samples, assisted work programs, prosthetic aids). In this arena, as in the others noted, use of this model can facilitate the FA process by providing (a) organization to insure that all pertinent functional aspects are considered; and (b) specificity to facilitate decision making.

Additional examples of how the model may be used, could be presented, but space considerations preclude an exhaustive set. It has been suggested here how this model can be used to identify, organize, analyze, and report relevant data. A logical extension of this discussion would lead to the conclusion that if rehabilitation professionals used this, or a similar model, then the FA process would be simplified in all areas. Although this is not likely to occur in the near future, rehabilitation professionals can control and standardize the methods that they use to conduct FA's, regardless of who their clients are. The consistent use of a model, such as the one presented here, can make the rehabilitation professional more efficient, consistent, and effective.

Summary

The purpose of this article was to examine commonly used forms and processes and propose the use of a comprehensive model for relating functional analysis data to vocational rehabilitation activities. Included in the discussion were (a) definitions of the concepts of impairment, disability, handicap, functional limitation, functional capacity and functional assessment; (b) delineation of the potential benefits to the practitioner who assesses client's functional limitations and capacities; and (c) the presentation of a classification system of functional limitations and capacities. Discussion of this classification system included a brief presentation of six realms where limitations and capacities are manifested, the nature of the manifestation, the underlying causes, and the vocational impact. Finally, it was suggested how this model might be used by practitioners in various rehabilitation arenas.

References

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Hanoch Livneh, Ph.D, Associate Professor and Coordinator of the Rehabilitation Counseling Specialization, Portland State University, Portland, Oregon 97207. Robert Male, Ph.D., Adjunct Faculty, Portland State University, Portland, Oregon 97207.
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Author:Male, Robert
Publication:The Journal of Rehabilitation
Date:Oct 1, 1993
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