Reflections on the specialty and practice of occupational therapist in physical disabilities and functional healh

Abstract

In different professions, specialization helps to guide professional competencies and responsibilities, directing knowledge and expertise. This article discusses the involvement of Occupational Therapy in physical rehabilitation services amidst changes in health concepts and paradigms, as well as within the profession's principles for this field of practice. Thus, it aims to discuss and justify the relevance of professional specialization in parameterizing practice. Accordingly, the study presents and problematizes arguments supported by historical and scientific frameworks, dilemmas, and new paradigms for rehabilitation actions and research, highlighting the need for disciplining the functional health specialty and updating resolutions related to these practices. It is considered that updating this framework by the professional organization contributes to improving practices and ensuring qualified access to health, as the lack of specialist professionals has brought disadvantages to the profession and, consequently, to those requiring the care of these professionals.

Keywords:
Occupational Therapy; Rehabilitation; Specialization; International Classification of Functioning; Disability and Health

Resumo

Nas diferentes profissões, a especialidade contribui para orientar quanto às competências e atribuições profissionais, norteando conhecimento e domínios. Este artigo discute o envolvimento da terapia ocupacional nos serviços de reabilitação física frente às mudanças de conceitos e paradigmas em saúde, bem como nos preceitos da profissão para este campo de atuação. Assim, visa discutir e justificar a relevância da especialidade profissional para parametrizar a prática profissional. O estudo apresenta e problematiza argumentos apoiados em arcabouços histórico, científico, desafios e novos paradigmas para as ações e pesquisas em reabilitação e evidencia a necessidade da disciplinarização da especialidade saúde funcional e atualização de resoluções relacionadas a estas práticas. Considera-se que a atualização deste arcabouço pela entidade de classe contribui para o aprimoramento das práticas e para o acesso qualificado à saúde, visto que a falta de profissionais especialistas tem trazido prejuízos para a profissão e consequentemente para as pessoas que demandam os cuidados desses profissionais.

Palavras-chave:
Terapia Ocupacional; Reabilitação; Especialidade; Classificação Internacional de Funcionalidade; Incapacidade e Saúde

Introduction

The International Classification of Functioning, Disability and Health (ICF), according to the World Health Organization (Organização Mundial de Saúde, 2013), enhanced, in the national scenario, reflections and the use of the term “functionality” related to health conditions. Stucki et al. (2008) highlight that the CIF is an integrative model of human functionality. In this sense, the concept of functional health reached a new dimension, given the paradigm shift in health-related constructs from this perspective, allowing for the destigmatization of guidance regarding contextual factors and participation (Schliehe, 2006; Schuntermann, 2005). This new concept was incorporated into the health system, in particular, related to disability and rehabilitation, and in this sense disability becomes related to the experience of disability, related to structures, limitation in activities and restriction of participation, which allows for definition of a research field related to functionality (Stucki et al., 2008).

In Brazil, the proposal for the National Functional Health Policy, Bill No. 1673/2021, is anchored in looking at the functionality that subjects may suffer in the presence or even absence of diseases, minimizing limitations and avoiding restrictions on participation. This considers that a public health structure needs to include an expansion of the health discussion in a transversal way with a greater variety of social actors in a public policy agenda that can contribute to the prevention of disabilities and improved access to actions and services.

Such a discussion scenario has anchored one of the specialties of occupational therapy, called Functional Health, which addresses interventions related to cognitive, neuropsychomotor, musculoskeletal occupational performance, and engagement with assistive technology. This relevant specialty for the profession encompasses professional practices, both in Brazil and globally, that involve actions for promotion, prevention, protection, education, intervention, recovery, rehabilitation, and palliative care at different levels of health care for individuals with temporary or permanent physical disabilities throughout various life cycles (Brasil, 2012b).

Considering this context, the present essay reflects on the discipline of the specialty of functional health, as it includes the practices of occupational therapists in physical rehabilitation in Brazil. It represents a widely disseminated practice that is fundamental to the profession and of great relevance to the population, consolidated through a critical analysis of the literature, based on professional experiences and regional demands.

The Current Scenario of People with Disabilities in Brazil

Instituto Brasileiro de Geografia e Estatística (IBGE), in partnership with the Ministry of Health, conducted the National Health Survey (PNS) – a household-based population survey that revealed that over 17 million people aged two and older have some form of disability, with physical disabilities being the most frequent (Agência IBGE Notícias, 2023; Instituto Brasileiro de Geografia e Estatística, 2020).

Physical disabilities can result from pathological processes of diverse etiology, course, evolution, and prognosis, compromising functionality and quality of life, and causing various psychosocial and economic repercussions. Brazilian legislation defines physical disability as a “complete or partial alteration of one or more segments of the human body that impairs physical function” (Brasil, 2021, p. 4). However, changes in bodily structures and functions do not define disability or functionality, which are identified through interaction with the environment where activity and participation occur. This represents a significant paradigm shift in health, as advocated in the International Classification of Functioning, Disability and Health (ICF), according to the World Health Organization (Organização Mundial de Saúde (2013, 2022).

According to the Brazilian Inclusion Law, disability occurs when a long-term impairment (which is the complete or partial alteration of bodily structures and functions) interacts with barriers, leading to limitations in full and effective participation in society on equal terms. Therefore, the assessment of disability must consider impairments in bodily structures and functions; socio-environmental, psychological, and personal factors; limitations in activity performance; and restrictions in participation (Brasil, 2015a, 2015b).

The National Health Survey (Instituto Brasileiro de Geografia e Estatística, 2023) revealed that almost all individuals with disabilities had ceased to perform usual activities due to health issues in the two weeks prior to the interview, indicating that disability is directly related to the impairment in carrying out daily activities.

In light of this scenario, access to habilitation and rehabilitation services represents a fundamental opportunity for individuals with disabilities to develop or recover their skills and to participate in daily, social, civil, educational, and labor activities with greater independence and autonomy (World Health Organization, 2012).

Physical Rehabilitation and Functional Health

Understanding disability has implications for how policies and services are structured, and the ICF represents a new framework, as it presupposes that engagement in activities cannot be achieved by considering the individual in isolation from their context. Conditions such as accessibility and the existence/usability of assistive technology are essential.

Therefore, there is a need to rethink treatment approaches and reorganize professional practices based on functionality and participation (Grupo CIF Brasil, 2023; Brasil, 2007). This is one of the most impactful changes in the organization of health services, especially for those dedicated to rehabilitation. In response to this, the concept was incorporated by the Federal Council of Physiotherapy and Occupational Therapy (COFFITO) in 2012, supporting the creation of the National Policy on Functional Health.

Rehabilitation is linked to a “set of interventions aimed at improving functioning and reducing disability arising from the interaction between individuals with health conditions and their environment,” and access to these services is a right that must be ensured by the State (World Health Organization, 2011, 2012; Universidade de São Paulo, 2017; Brasil, 2019).

The rehabilitation process includes a multidisciplinary assessment of the individual's needs, abilities, and potential, through an interdisciplinary team present at all three levels of health complexity: Primary Care, Specialized Rehabilitation Care, and Hospital and Emergency Care (Brasil, 2012a, 2017).

The Network of Care for Persons with Disabilities (RCPD) (Brasil, 2012b), composed of Primary Care; Hospital and Emergency Care; and Specialized Rehabilitation Care for Auditory, Physical, Intellectual, Ostomy, and Multiple Disabilities, is strengthened, expanded, and qualified by the National Health Plan 2020-2023 (Brasil, 2020). According to this document, the network includes 223 Specialized Rehabilitation Centers (CER), with 37.7% in the Southeast region, 33.8% in the Northeast, 11.7% in the Central-West, 7.2% in the North, and 6.7% in the South, along with 37 Orthopedic Workshops.

Although the RCPD and CER have increased coverage of assistance for Persons with Disabilities through physiotherapists, speech therapists, and occupational therapists, according to Gomes et al. (2023), regional distribution still reinforces inequality in access, especially in more vulnerable regions like the Northeast. It also shows that, while the number of professionals increased between 2007 and 2019, the coverage increase for occupational therapists was the least significant.

Regarding the assistance network, it is noteworthy that the state of São Paulo, since 2008, under Decree No. 52.973, has 15 units of the Lucy Montoro Network, aimed at rehabilitation treatment for individuals with physical disabilities. Occupational therapists, focused on improving functional performance, independence, and quality of life, are part of the team (São Paulo, 2008, 2014).

Thus, it is clear that there has historically been a rehabilitation network in the country that requires and involves occupational therapists developing various actions in the services that make up the Sistema Único de Saúde, as stated in the Plano Nacional de Saúde and documents related to the Rede Lucy Montoro (Brasil, 2020; São Paulo, 2008).

The overview presented in this section highlights the principles and discussions incorporated into health, habilitation, and rehabilitation policies in the country. However, health actions still require the reorganization of practices anchored in the biopsychosocial model. To overcome this, it is essential for the health system to be guided by other indicators and management models (Pereira et al., 2011). Additionally, this requires a new profile of competencies and skills among professionals to enhance aspects of activity and participation over the biomedical model, thus constructing a globally recognized and innovative strategy in Brazil (Silva et al., 2022).

Development of Occupational Therapy in Physical Rehabilitation in Brazil

The undergraduate program in Occupational Therapy trains generalist professionals equipped to develop educational, care, and management actions in a comprehensive manner across different levels and complexities of health care, both individually and collectively (Brasil, 2002).

In-depth knowledge in a specific field and practical expertise are acquired through specialization courses, professional residencies, or advanced training. However, with the accelerated pace of knowledge production, new methods and techniques, the incorporation of new technologies has expanded and complicated professional areas, requiring professionals to deepen their knowledge and practice to provide safe care and enhance service excellence (Reis & Lopes, 2018; Lins & Matsukura, 2015).

In Brazil, the profession was regulated, and higher education was recognized in 1969 through Decree-Law No. 938, dated October 13, 1969 (Brasil, 1969), nearly two decades after the establishment of the first technical courses in occupational therapy, which emphasized rehabilitation for individuals with physical disabilities (Reis & Lopes, 2018; Lins & Matsukura, 2015). Only in 1978 did COFFITO publish Resolution No. 08, approving the norms for the professional qualification of occupational therapists and recognizing as a privative act “to prescribe, administer, and supervise occupational therapy,” aimed at functional capacity and improvement of physical and mental performance (Brasil, 1978).

Various changes have been incorporated into professional training, in line with scientific evidence and paradigm shifts. Among the exclusive competencies of occupational therapists is the assessment of functional abilities, the design and execution of training programs for the development of skills to perform daily living and instrumental activities impaired due to motor, sensory, perceptual-cognitive, mental, emotional, behavioral, functional, cultural, social, and/or economic alterations (Brasil, 2006).

The World Federation of Occupational Therapists (2018) highlights the centrality of occupation when discussing professional competence, whose main objective should be to facilitate occupational performance in the occupations that individuals need, want, or expect to engage in. Therefore, in addition to direct intervention with the individual, occupational therapists are responsible for modifying occupations or environments to support occupational engagement.

The goals of the profession reframe new logics concerning the individual's need to be engaged, which occurs in the environment where individuals live and develop their occupational performance. These ideas were discussed by Mary Reilly and other collaborators in the USA and Canada (Castro et al., 2004).

According to WFOT, the profession contributes to occupational performance, as the concept of occupation refers to the everyday activities that individuals engage in and that hold meaning and purpose in their lives (Cruz, 2022). It encompasses individuals' capacity to engage and develop their occupational roles, which result from the interaction between person, environment, and occupation (Polatajko et al., 2007).

When individuals' habits cease to occur and no longer organize their actions automatically, additional efforts are needed to enhance the efficiency required for daily routines. Changes in occupational performance can be analyzed by understanding habits, routines, and occupational patterns. Thus, participation is considered the ultimate goal of occupational therapy services, and discharge is expected when individuals demonstrate a satisfactory level of occupational participation, with the environment acting as a facilitator for performance (Kielhofner, 2005).

This overview of changes indicates that various bodies of knowledge have been synthesized for a practice in occupational therapy, with its own body of knowledge focused on performance and engagement in occupations and occupational roles that promote and support the health and participation of the target population.

Professional Specialties in Occupational Therapy

COFFITO is a federal agency that aims to regulate and exercise ethical, scientific, and social control over occupational therapy. To ensure good professional practice and protect society, this body recognizes the need to promote the development of the profession and highlight it through specialties.

According to Battisti & Bonatti (2008), a specialty pertains to the deepening of components of the cognitive basis, theoretical and practical approaches of the profession to broaden its scope and social reach. The authors also emphasize that care must be taken to avoid creating a division between specialists and generalists, as specialists should, by principle, retain the virtues and cognition of generalists, which is essentially their profession (specialty is not profession).

Currently, occupational therapists have eight recognized specialties. The first five were Mental Health, Functional Health, Collective Health, Family Health, and Social Contexts, followed by Acupuncture (Brasil, 2009a, 2009b). Between 2013 and 2018, the specialties of Hospital Contexts (Brasil, 2013), Gerontology (Brasil, 2016), and School Context (Brasil, 2018) were recognized. Occupational therapy in functional health is the only recognized specialty that has not yet been regulated, meaning that its areas of competence, knowledge disciplines, domains, and responsibilities have not been established, although there are consolidated practices in the country supported by specific foundations of the profession.

The first five specialties were established to maintain coherence with the structures of the thematic areas of the Multiprofessional Residencies, with which the profession was associated (Functional Health/Physical Rehabilitation, Mental Health, Primary Care/Family Health, and Collective Health), constituted and defined at the National Council Seminar in 2008 (Battisti & Bonatti, 2008; Brasil, 2008).

Occupational Therapy Specialty in Functional Health

COFFITO Resolution No. 366/2009 (Brasil, 2009b) presents the areas of exclusive and privative action in Functional Health as Cognitive Occupational Performance, Neuropsychomotor Occupational Performance, Musculoskeletal Occupational Performance, and Occupational Performance in Assistive Technology.

To reinforce the scope, legitimacy, and scientific advances related to this specialty, a summary has been compiled, which is presented below.

According to Nicholson et al. (2020), through a consensus of experts, it was evidenced that occupational therapists assist individuals with physical difficulties to enable participation in daily activities with a focus on function rather than disorders, making them the ideal professionals to work with individuals with neurological sequelae of functional origin through training in sensory, motor, cognitive, and emotional components, sequential reintroduction to daily activities, and the reestablishment of routines. The outcomes are promising, both immediately after treatment and in follow-up.

Oliveira et al. (2024) conducted a scoping review analyzing 28 studies to map the practices and approaches of occupational therapists in Parkinson's disease. The most frequently identified strategy was the use of Occupations and Participation. The authors found that functionality-oriented interventions were the most demanded and yielded the most tangible results. The strategy involving training in daily living and instrumental activities showed moderate outcomes, while the use of technological resources, especially virtual reality, emerged as one of the most favorable outcomes, although not the most frequently used.

The principles of practices are also related to the purpose of the service and the timing of the injury. Techniques and procedures with higher levels of scientific evidence are discussed, such as imagery, task-oriented therapy, and constraint-induced therapy, among other resources aimed at improving functionality and participation (Higgins et al., 2006; Lin et al., 2009).

This is because, for specific task training, procedural principles focused on habitual routines are incorporated, minimizing errors and enabling requalification in areas such as dressing, bathing, eating, and meal preparation, contributing to positive rehabilitation outcomes (Brown et al., 2021).

Occupational therapists also engage in studies on assistive technology, developing and analyzing products, instruments, strategies, services, and practices that enhance autonomy in performing activities and participating while minimizing barriers (Machado & Figueiredo, 2009).

Cognitive Orientation to Daily Occupational Performance (CO-OP) allows for facilitation in occupations through cognitive strategies that involve decision-making about activities and steps to achieve desired goals, resulting in global problem-solving learning that promotes generalization and transfer of occupation across different environments. Thus, it can identify changes in performance, enhance motor, cognitive, psychosocial skills, and motivation (Ahn et al., 2017).

Reinforcing this discussion, Folha et al. (2019) conducted a review aimed at characterizing occupational therapy publications in non-specific profession journals. Of these, journals categorized as rehabilitation, neurology and neuroscience, and orthopedics accounted for 72.85% of the articles published by occupational therapists in non-specific journals, demonstrating scientific production in these scopes.

Mariotti et al. (2016) conducted a study on the profile of occupational therapists in the state of Paraná, while Vasconcelos et al. (2014) focused on the national level. They found that 25% of therapists perform their professional activities or research in Functional Health.

The ethical and scientific relevance of the Federal Councils for providing quality actions across different scopes is well known. COFFITO is also responsible for the National Examination for Granting the Title of Professional Specialist, which is mandatory to obtain the professional qualification certificate.

Despite the solid historical development, without the regulation of the specialty, there are no specialists in functional health in the market due to the lack of requirements or evaluations of practices that are well-established in the profession, such as in physical rehabilitation. Thus, neither the professionals nor the target population are protected from such practices at the national level.

The regulation of the specialty would help professionals orient themselves regarding the competencies, duties, fields, and areas of practice specific to the specialty, as well as the minimum knowledge and domains required for qualification, promoting technical, scientific, and cultural improvement for the benefit of the served population.

Furthermore, the recognition of this specialty could be an important achievement so that, subsequently, the Ministry of Labor (MTE), through the Brazilian Classification of Occupations (CBO), describes the practices of this specialty, distinguishing activities, competencies, and work resources, potentially leading to specific employment contracts.

Therefore, the absence of occupational therapists specializing in Functional Health adversely affects the development of the profession, the professionals working in the field, and the society that requires intervention.

Final Considerations

With the data presented, the development of the profession at the national and international levels is understood, anchored in its own practices and significant scientific evidence related to Functional Health, which have been transformed in light of new scientific evidence.

Undoubtedly, there is a growing culture of seeking specialists for solving health problems, especially those of greater complexity. However, despite this trend, the absence of these occupational therapy professionals in the area of Functional Health hinders access to services provided by such professionals, thus limiting practices in the country, discouraging the development of public policies, and consequently minimizing the availability of quality services, publicly certified by the logic of the Federal Council itself.

In light of this overview, it is undeniable that occupational therapists have their own knowledge regarding occupational performance and participation. They are also trained to work with human functionality based on the curricular guidelines of the profession, with the rehabilitation of individuals with physical disabilities being one of their main areas of expertise.

The regulation of the specialty of occupational therapy in functional health, along with resolutions, rulings, and other legal instruments, can contribute to the more effective consolidation of professional practices in combating disabilities and participation restrictions, resulting in positive impacts on the health and quality of life of the population in need.

• How to cite: Rafani, S. M., Cordeiro, J. J. R., Catini, T. A., Battisti, M. C. G., & Carrijo, D. C. M. (2024). Reflections on the specialty and practice of occupational therapist in physical disabilities and functional healh. Cadernos Brasileiros de Terapia Ocupacional, 32, e3724. https://doi.org/10.1590/2526-8910.ctoEN287537242

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Edited by

• Section editor
  Profa. Dra. Mariana Midori Sime

Publication Dates

• Publication in this collection
  13 Dec 2024
• Date of issue
  2024

History

• Received
  03 Jan 2024
• Reviewed
  22 Jan 2024
• Accepted
  04 July 2024