Diving below the surface of progressive disability: considering compensatory strategies as evidence of sub-clinical disability

Abstract

Objectives: To provide a comprehensive review regarding the role of activity and participation compensations within the disablement process, identify directions for future research, and discuss the implications of compensation pertaining to public health initiatives aimed at preventing and reversing disability.

Method: This article evaluated how using compensatory strategies to cope with functional deficits reveals important transitions within the disablement process and signifies a unique opportunity to identify early declines in function.

Results: Previous research suggests that (a) adopting compensatory strategies to maintain activity/participation is strongly associated with functional decline and disease severity and significantly predicts the onset of limitations/restrictions; (b) compensation can be reliably quantified; and (c) contextual knowledge about how individuals adapt to functional decline can be used to describe transitions in the disablement process.

Discussion: Characterizing subtle adaptations prior to the onset of activity limitations and participation restrictions will not only aid in understanding the complex disablement process but also help inform social services and future prevention strategies. Overall, this article integrates the concept of compensation into the current model of disability and proposes a framework for identifying and interpreting compensatory behavior.

Keywords: Compensation; ICF; Preclinical disability; Subclinical disability..

Figures

Figure 1.

(A) Fried et al. (1991, originally conceptualized preclinical disability as a transitional stage between impairment and disability, which parallels functional limitation (as illustrated earlier within Verbrugge and Jette’s disablement pathway). Accordingly, descriptive information about compensatory behavior during functional tasks, activities of daily living, and instrumental activities of daily living can be implemented to identify transitional phases during disablement. * denotes corresponding International Classification of Impairment, Disability, and Handicap terminology to demonstrate where preclinical disability occurs within the International Classification of Impairment, Disability, and Handicap model. (B) Expanding the International Classification of Functioning, Disability, and Health to incorporate transitional phases (denoted by the dashed lines) will more accurately account for how individuals adapt to functional decline prior to experiencing outright activity limitations or participation restrictions.

Figure 2.

(A) The conceptual figure demonstrates how the selective optimization with compensation (SOC) subprocesses change across the life span. Transitional phases are characterized by significant declines in selection and optimization and increases in compensation. The point at which the subprocesses intersect is the theoretical onset of limitation/restriction. * denotes when a person becomes dependent and selection, optimization, and compensation cease to occur. (B) A schematic diagram illustrating how Baltes’ (1987) SOC framework informs predictions about disability. This model provides a theoretical rationale regarding changes in function during the progression of disability, which is depicted here using the International Classification of Functioning, Disability, and Health (WHO, 2001). This conceptual model illustrates one potential pathway through which an individual might adapt to underlying functional changes by altering selective optimization with compensation subprocesses to maintain activity and compensation.

Figure 3.

Relative risk of future disability for adults reporting no difficulty but use of compensatory strategies compared with individuals reporting no difficulty and no modification on functional tasks and activities of daily living (ADLs)/instrumental activities of daily living (IADLs). // denotes truncated upper limit >7.