Top-down or bottom-up assessment?
Article Type: Letter to the editor
Author: Kolehmainen, Niina
Pub Date: 05/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: May, 2010 Source Volume: 73 Source Issue: 5
Accession Number: 227280909
Full Text: Madam,

I read with great interest the editorial by Ted Brown and Chi-Wen Chien (BJOT March 2010) about top-down versus bottom-up approaches to assessment. I would like to contribute to the discussion about this important topic.

I view the question about which approach we should use for assessment as a question about the nature of the goal for our intervention. Brown and Chien highlight that the focus of a top-down approach is 'on the client's participation in his or her living contexts' whereas a bottom-up approach focuses 'primarily on the body structure and function ...'.

Research in a range of fields (for example, chronic pain, stroke and child health) has shown that individuals' health (including their activity and participation) is likely to be influenced by a range of factors (see, for example, Fisher and Johnston 1996, King et al 2006, Johnston et al 2007, Majnemer et al 2008, Williams et al 2008, Fauconnier et al 2009). These factors can be grouped in three domains, included in the International Classification of Functioning, Disability and Health (World Health Organisation 2001):

(i) bodily structure and functioning (for example, gross motor ability, presence of pain);

(ii) personal factors (for example, the client's age, preferences, emotions and motivation); and

(iii) environment (for example, the preferences and behaviour of significant others, the client's region of residence).

It is likely that the factors explaining an individual's health and participation reside within more than one domain. Similarly, interventions likely to be effective in producing health and reducing disability target factors in more than one domain.

This seems to suggest that if the goal is solely to 'fix' a problem in bodily structure and function, then a bottom-up approach may be sufficient. However, if the goal is to increase the client's participation, then a bottom-up approach is unlikely to be sufficient for identifying all the factors that need to be targeted.

I would therefore propose that we can continue to embrace the importance of assessing bodily structure and function as part of establishing the potential causes of the client's illness and disability. Yet, we need a top-down approach for improving his or her overall health and participation.

Fauconnier J, Dickinson HO, Beckung E, Marcellin M, Manus V, Michelsen SI, Parkes J, Parkinson KN, Thyen U, Arnaud C, Colver A (2009) Participation in life situations of 8-12 year old children with cerebral palsy: cross sectional European study. British Medical Journal, 338(b1458), DOI:10.1136/bmj.b1458.

Fisher K, Johnston M (1996) Experimental manipulation of perceived control and its effects on disability. Psychology and Health, 11, 657-69.

Johnston M, Bonetti D, Joice S, Pollard B, Morrison V, Francis J, MacWalter R (2007) Recovery from disability after stroke as a target for a behavioural intervention: results of a randomized control trial. Disability and Rehabilitation, 29(14), 1117-27.

King G, Law M, Hanna S, King S, Kurley P, Rosenbaum P, Kertoy M, Pertenchik T (2006) Predictors of the leisure and recreation participation of children with physical disabilities. A structural equation modelling analysis. Child: Health, Care and Development, 35(3), 209-34.

Majnemer A, Shevell M, Law M, Birbaum R, Chilingaryan G, Rosenbaum P, Poulin C (2008) Participation and enjoyment of leisure activities in school-aged children with cerebral palsy. Developmental Medicine and Child Neurology, 50(10), 751-58.

Williams B, Powell A, Hoskins G, Neville R (2008) Exploring and explaining low participation in physical activity among children and young people with asthma: a review. BMC Family Practice, 9(40), DOI:10.1186/1471-2296-9-40.

World Health Organisation (2001) International Classification of Functioning, Disability and Health: ICF. Geneva: WHO.

Dr Niina Kolehmainen, Clinical Research Fellow and Senior Occupational Therapist, Health Services Research Unit, University of Aberdeen.
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