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An understanding of the concepts of functioning and disability coupled with knowledge of the process of making informed clinical decisions based on evidence from the scientific literature provides the foundation for comprehensive management of patients seeking and receiving physical therapy services. Provision of quality patient care involves the ability to make sound clinical judgments, solve problems that are important to a patient, and apply knowledge of the relationships among a patient's health condition(s), impairments, limitations and restrictions in daily activities, and resulting disability throughout each phase of management.
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The primary purpose of this section of the chapter is to describe a model of patient management used in physical therapy practice. Inasmuch as clinical reasoning and evidence-based decision-making are embedded in each phase of patient management, a brief overview of the concepts and processes associated with clinical decision-making and evidence-based practice is presented before exploring a systematic process of patient management in physical therapy. Relevant examples of the clinical decisions a therapist must make are highlighted within the context of the patient management model.
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Clinical Decision-Making
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Clinical decision-making refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations in the context of ptient care.84 One of the many areas of clinical decision-making in which a therapist is involved is the selection, implementation, and modification of therapeutic exercise interventions based on the unique needs of each patient or client. To make effective decisions, merging clarification and understanding with critical and creative thinking is necessary.91 A number of requisite attributes are necessary for making informed, responsible, efficient, and effective clinical decisions.39,91,103,152 Those requirements are listed in Box 1.7.
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BOX 1.7 Requirements for Skilled Clinical Decision-Making During Patient Management
Knowledge of pertinent information about the problem(s) based on the ability to collect relevant data by means of effective examination strategies
Cognitive and psychomotor skills to obtain necessary knowledge of an unfamiliar problem
Use of an efficient information-gathering and information-processing style
Prior clinical experience with the same or similar problems
Ability to recall relevant information
Ability to integrate new and prior knowledge
Ability to obtain, analyze, and apply high-quality evidence from the literature
Ability to critically organize, categorize, prioritize, and synthesize information
Ability to recognize clinical patterns
Ability to form working hypotheses about presenting problems and how they might be solved
Understanding of the patient's values and goals
Ability to determine options and make strategic plans
Application of reflective thinking and self-monitoring strategies to make necessary adjustments
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There is a substantial body of knowledge in the literature that describes various strategies and models of clinical decision-making in the context of patient management by physical therapists.* One such model, the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), describes a series of steps involved in making informed clinical decisions.139
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The use of clinical decision-making in the diagnostic process also has generated extensive discussion in the literature.† To assist in the decision-making process and ultimately improve patient care, tools known as clinical prediction rules, first developed in medicine, also have been developed for use by physical therapists.25,44 Some clinical prediction rules (CPRs) contain predictive factors that help a clinician establish specific diagnoses or improve the accuracy of prognoses, whereas others identify subgroupings of patients within large, heterogeneous groups who are most likely to benefit from a particular approach to treatment or specific therapeutic interventions. To date, some prediction tools in physical therapy have been developed to assist in the diagnosis of health conditions, including osteoarthritis in patients with hip pain162 and deep vein thrombosis in patients with leg pain.134 However, a greater number of CPRs in physical therapy have been established to predict likely responses of patients to treatment. As examples, CPRs have been developed to identify a sub-grouping of patients with patellofemoral pain syndrome who are most likely to respond positively to lumbopelvic manipulation,70 patients with low back pain most likely to respond to stabilization exercises,64 and those with neck pain for whom thoracic spine manipulation is most likely to be effective.28
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It is important to note, however, that little research, thus far, has focused on validation of published CPRs10 or their impact on the effectiveness of patient care from specific therapeutic interventions. The results of two recent systematic reviews of the literature underscore these points. One review10 indicated that the quality of the studies on which CPRs to determine treatment effectiveness have been based varies considerably. The results of the other review of CPRs for musculoskeletal conditions157 demonstrated that currently there is only limited evidence to support the use of these rules to predict the effectiveness of specific interventions or to optimize treatment. Additional information from studies directed toward clinical decision-making is integrated into the remainder of this section on patient management or is addressed in later chapters.
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Health care continues to move in the direction of physical therapists being the first-contact practitioners through whom consumers gain access to services without physician referral. Hence, the need to make sound clinical judgments supported by scientific evidence during each phase of patient management has become more essential for physical therapy practitioners.
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Evidence-Based Practice
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Physical therapists who wish to provide high-quality patient care must make informed clinical decisions based on sound clinical reasoning and knowledge of the practice of physical therapy. An understanding and application of the principles of evidence-based practice provide a foundation to guide a clinician through the decision-making process during the course of patient care.
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Definition and Description of the Process
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Evidence-based practice is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of an individual patient."142 Evidence-based practice also involves combining knowledge of evidence from well-designed research studies with the expertise of the clinician and the values, goals, and circumstances of the patient.143
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The process of evidence-based practice involves the following steps29,143:
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Identify a patient problem and convert it into a specific question.
Search the literature and collect clinically relevant, scientific studies that contain evidence related to the question.
Critically analyze the pertinent evidence found during the literature search and make reflective judgments about the quality of the research and the applicability of the information to the identified patient problem.
Integrate the appraisal of the evidence with clinical expertise and experience and the patient's unique circumstances and values to make decisions.
Incorporate the findings and decisions into patient management.
Assess the outcomes of interventions and ask another question if necessary.
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This process enables a practitioner to select and interpret the findings from the evaluation tools used during the examination of the patient and to implement effective treatment procedures that are rooted in sound theory and scientific evidence (rather than anecdotal evidence, opinion, or clinical tradition) to facilitate the best possible outcomes for a patient.
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FOCUS ON EVIDENCE
In a survey of physical therapists, all of whom were members of the American Physical Therapy Association, 488 respondents answered questions about their beliefs, attitudes, knowledge, and behavior about evidence-based practice.82 Results of the survey indicated that the therapists believed that the use of evidence in practice was necessary and that the quality of care for their patients was better when evidence was used to support clinical decisions. However, most thought that carrying out the steps involved in evidence-based practice was time-consuming and seemed incompatible with the demands placed on therapists in a busy clinical setting.
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It is impractical to suggest that a clinician must search the literature for evidence to support each and every clinical decision that must be made. Despite time constraints in the clinical setting, when determining strategies to solve complex patient problems or when interacting with third-party payers to justify treatment, the "thinking therapist" has a professional responsibility to seek out evidence that supports the selection and use of specific evaluation and treatment procedures.7
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One method for staying abreast of evidence from current literature is to read one's professional journals on a regular basis. It is also important to seek out relevant evidence from high-quality studies (randomized controlled trials, systematic reviews of the literature) from journals of other professions.30 Journal articles that contain systematic reviews of the literature or summaries of multiple systematic reviews are an efficient means to access evidence, because they provide a concise compilation and critical appraisal of a number of scientific studies on a topic of interest.
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Evidence-based clinical practice guidelines for management of specific physical conditions or groupings of impairments also have been developed; they address the relative effectiveness of specific treatment strategies and procedures. These guidelines provide recommendations for management based on systematic reviews of current literature.127,146 Initially, clinical practice guidelines that address four broadly defined musculoskeletal conditions commonly managed by physical therapists—specifically knee pain,123 low back pain,124 neck pain,125 and shoulder pain126—were developed by the Philadelphia Panel, a panel of experts from physical therapy and medicine.
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As mentioned previously in this chapter, a series of clinical practice guidelines has been created and recently published by the Orthopedic Section of the APTA. These guidelines provide evidence-based recommendations for orthopedic physical therapy management (diagnosis, prognosis, selection of therapeutic interventions, and use of outcome measures) of a number of impairment/function-based groupings that are based on the ICF.50 Some examples include clinical practice guidelines for management of neck pain,26 knee pain and mobility impairments,94 knee stability impairments,95 hip pain and mobility deficits associated with osteoarthritis,27 heel pain associated with plantar fasciitis,107 and deficits associated with Achilles tendonitis.22 More specific information from these guidelines is integrated into the regional chapters of this textbook.
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If articles that contain systematic reviews of the literature on a specific topic have not been published, a therapist may find it necessary and valuable to perform an individual literature search to identify evidence applicable to a clinical question or patient problem. Journals exclusively devoted to evidence-based practice are another means to assist the practitioner who wants to identify well-designed research studies from a variety of professional publications without doing an individual search. These journals provide abstracts of research studies that have been critically analyzed and systematically reviewed.
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Online bibliographic databases also facilitate access to evidence. Many databases provide systematic reviews of the literature relevant to a variety of health professions by compiling and critiquing several research studies on a specific patient problem or therapeutic intervention.7,29,109 One example is the Cochrane Database of Systematic Reviews, which reports peer-reviewed summaries of randomized controlled trials and the evidence for and against the use of various interventions for patient care, including therapeutic exercise. Although a recent study108 identified CENTRAL (Cochrane Central Registry of Controlled Trials), PEDro (Physiotherapy Evidence Database), PubMed, and EMBASE (Excerpta Medica Database) as the four most comprehensive databases indexing reports of randomized clinical trials of physical therapy interventions, only PEDro exclusively reports trials, reviews, and practice guidelines pertinent to physical therapy.99 Easily accessed online databases such as these streamline the search process and provide a wealth of information from the literature in a concise format.
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To further assist therapists in retrieving and applying evidence in physical therapist practice from the Cochrane online library, the Physical Therapy journal publishes a recurring feature called Linking Evidence and Practice (LEAP). This feature summarizes a Cochrane review and other scientific evidence on a single topic relevant to physical therapy patient care. In addition, LEAP presents case scenarios to illustrate how the results of the review of evidence can be applied to the decision-making process during patient management.
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In support of evidence-based practice, relevant research studies are highlighted or referenced throughout each of the chapters of this text in relationship to the therapeutic exercise interventions, manual therapy techniques, and management guidelines presented and discussed. However, there is also an absence of research findings to support the use of some of the interventions presented. For such procedures, a therapist must rely on clinical expertise and judgment as well as each patient's response to treatment to determine the impact of these interventions on patient outcomes. Examples of how to incorporate the ongoing process of clinical decision-making and application of evidence into each phase of patient management are presented in the following discussion of a model for patient management.
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A Patient Management Model
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The physical therapy profession has developed a comprehensive approach to patient management designed to guide a practitioner through a systematic series of steps and decisions for the purpose of helping a patient achieve the highest level of functioning possible. This model is illustrated in Figure 1.5.
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As described in the Guide to Physical Therapist Practice, the process of patient management has five basic components.3,14,46
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A comprehensive examination 2. Evaluation of data collected 3. Determination of a diagnosis based on impairments of body structure and function, functional limitations (activity limitations), and disability (participation restrictions)
Establishment of a prognosis and plan of care based on patient-oriented goals
Implementation of appropriate interventions
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The patient management process culminates in the attainment of meaningful functional outcomes by the patient, which then must be re-examined and re-evaluated before a patient's discharge from care. As the model indicates, the re-examination and re-evaluation process occurs not only at the conclusion of treatment but throughout each phase of patient management. The ability to make timely decisions and appropriate judgments and to develop or adjust an ongoing series of working hypotheses makes transition from one phase of management to the next occur in an effective, efficient manner.
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The first component of the patient management model is a comprehensive examination of the patient. Examination is the systematic process by which a therapist obtains information about a patient's problem(s) and his or her reasons for seeking physical therapy services. During this initial data collection, the therapist acquires information from a variety of sources. The examination process involves both comprehensive screening and specific diagnostic testing. It is the means by which the therapist gathers sufficient information about the patient's existing or potential problems (health conditions, impairments, activity/functional limitations, participation restrictions/disabilities) to ultimately formulate a diagnosis and determine whether these problems can be appropriately treated by physical therapy interventions. If treatment of the identified problems does not fall within the scope of physical therapy practice, referral to another health-care practitioner or resource is warranted. The examination is also the means by which baseline measurements of current impairments, functional deficits and abilities are established as a reference point from which the results of therapeutic interventions can be measured and documented.
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There are three distinct elements of a comprehensive examination.3
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The patient's health history
A relevant systems review
Specific tests and measures
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Throughout the examination process, a therapist seeks answers to an array of questions and concurrently makes a series of clinical decisions that shape and guide the examination process. Examples of some questions to be asked and decisions to be made are noted in Box 1.8.
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BOX 1.8 Key Questions to Consider During the Initial Examination
What are the most complete and readily available sources for obtaining the patient's history?
Is there a need to obtain additional information about the patient's presenting health condition or a medical diagnosis if one is available?
Based on initial working hypotheses, which of the patient's signs and symptoms warrant additional testing by physical therapy or by referral to another health-care practitioner?
Do the patient's problems seem to fall within or outside the scope of physical therapy practice?
What types of specific tests and measures should be selected to gather data about the patient's impairments, activity/functional limitations, or extent of participation and resulting disability?
Based on scientific evidence, which diagnostic tests have a high level of accuracy to identify impairments, functional deficits, or disability?
What are the most important tests to do first? Which could be postponed until a later visit with the patient?
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The history is the mechanism by which a therapist obtains an overview of current and past information (both subjective and objective) about a patient's present condition(s), general health status (health risk factors and coexisting health problems), and why the patient has sought physical therapy services. It has been shown in a multi-center study that patients seen in outpatient physical therapy practices have extensive health histories, including use of medications for a variety of medical conditions (e.g., hypertension, pulmonary disorders, and depression) and surgical histories (e.g., orthopedic, abdominal, and gynecological surgeries).13
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The types of data that can be generated from a patient's health history are summarized in Box 1.9.3,14,15,87 The therapist determines which aspects of the patient's history are more relevant than others and what data need to be obtained from various sources.
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BOX 1.9 Information Generated from the Initial History Demographic Data
Social History Occupation/Leisure Current and previous employment
Job/school-related activities
Recreational, community activities/tasks
Growth and Development Developmental history
Hand and foot dominance
Living Environment General Health Status and Lifestyle Habits and Behaviors: Past/Present (Based on Self or Family Report) Perception of health/disability
Lifestyle health risks (smoking, substance abuse)
Diet, exercise, sleep habits
Medical/Surgical/Psychological History Medications: Current and Past Family History Health risk factors
Family illnesses
Cognitive/Social/Emotional Status Current Conditions/Chief Complaints or Concerns Conditions/reasons physical therapy services sought
Patient's perceived level of daily functioning and disability
Patient's needs, goals
History, onset (date and course), mechanism of injury, pattern and behavior of symptoms
Family or caregiver needs, goals, perception of patient's problems
Current or past therapeutic interventions
Previous outcome of chief complaint(s)
Functional Status and Activity Level Current/prior functional status: basic ADL and IADL related to self-care and home
Current/prior functional status in work, school, community-related IADL
Other Laboratory and Diagnostic Tests
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Sources of information about the patient's history include:
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Self-report health history questionnaires filled out prior to or during the initial visit.
Interviews with the patient, family, or other significant individuals involved in patient care.
Review of the medical record.
Reports from the referral source, consultants, or other health-care team members.
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The extent of information about a patient's health history that is necessary or available may be extensive or limited and may or may not be readily accessible prior to the first contact with the patient. Compare, for example, the information available to the therapist working in an acute care facility who has ready access to a patient's medical record versus the home health therapist who may have only a patient's medical diagnosis or brief surgical history. Regardless of the extent of written reports or medical/surgical history available, reviewing this information prior to the initial contact with the patient helps a therapist prioritize the questions asked and areas explored during the interview with the patient.
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The interview is crucial for determining a patient's chief concerns and functional status—past, current, and desired. It also helps a therapist see a patient's problems from the patient's own perspective, specifically with regard to the perception of limitations in daily functioning or disability. A patient almost always describes a current problem in terms of limited abilities or perceived quality of life, not the presenting impairment(s). For example, a patient might report, "My elbow really hurts when I pick up something heavy" or "I'm having trouble playing tennis (or bowling or unloading groceries from the car)." During the interview, questions that relate to symptoms (in this case, elbow pain) should identify location, intensity, description, and factors that provoke (aggravate) or alleviate symptoms in a 24-hour period.
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Collecting health history data through a self-report questionnaire has been shown to be an accurate source of information from patients seen in an outpatient orthopedic physical therapy practice.17 In addition, depending on a patient's condition and individual situation, the perceptions of family members, significant others, caregivers, or employers are often as important to the overall picture as the patient's own assessment of the current problems.
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While taking a health history, it is useful to group the interview questions into categories to keep the information organized. Gathering and evaluating data simultaneously makes it easier to recognize and identify patterns or clusters of signs and symptoms and even to begin to formulate one or more initial, "working" hypotheses about the patient's problem(s), which later will be supported or rejected. Making these judgments helps organize and structure the examination.138,139,167 Experienced therapists tend to form working hypotheses quite early in the examination process, even while reviewing a patient's chart before the initial contact with the patient.71,72,83,104,176 This enables a therapist to determine and prioritize which definitive tests and measures should be selected for the later portion of the examination.72
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A brief but relevant screening of the body systems, known as a systems review,3 is performed during the patient interview as a part of the examination process after organizing and prioritizing data obtained from the health history. The greater the number of health-related risk factors identified during the history, the greater is the importance of the review of systems. The systems typically screened by therapists are the cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular systems, although problems in the gastrointestinal and genitourinary systems also may be relevant.14,16 This screening process gives a general overview of a patient's cognition, communication, and social/emotional responses. Only limited information on the anatomical and physiological status or function of each system is obtained. Table 1.3 identifies each system and gives examples of customary screening procedures used by physical therapists.
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NOTE: Some of the information noted in Table 1.3, such as the patient's psychosocial status, may have been gathered previously while reviewing and taking the patient's history and need not be addressed again.
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The purpose of screening each system is to identify any abnormalities or deficits that require further or more specific testing by a therapist or another health-care practitioner.3,14,16,87 The systems review serves to identify a patient's symptoms that may have been overlooked during the investigation of the patient's chief symptoms that precipitated the initial visit to therapy.16 Findings from the systems review coupled with information about a patient's chief complaints secured from the patient's health history enable a therapist to begin to make decisions about the possible causes of a patient's impairments and functional deficits and to distinguish between problems that can and cannot be managed effectively by physical therapy interventions. If a therapist determines that a patient's problems lie outside the scope of physical therapy practice, no additional testing is warranted and referral to another health-care practitioner is appropriate.3,14,16,51
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Specific Tests and Measures
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Once it has been decided that a patient's problems/conditions are most likely amenable to physical therapy intervention, the next determination a therapist must make during the examination process is to decide which aspects of physical function require further investigation through the use of specific tests and measures.
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Specific (definitive/diagnostic) tests and measures used by physical therapists provide in-depth information about impairments, activity limitations, participation restrictions/disabilities.3,45,49,87 The specificity of these tests enables a therapist to support or refute the working hypotheses formulated while taking the patient's health history and performing the systems review. In addition, the data generated from these definitive tests are the means by which the therapist ascertains the possible underlying causes of a patient's impairments and functional deficits. These tests also give the therapist a clearer picture of a patient's current condition(s) and may reveal information about the patient not previously identified during the history and systems review. If treatment is initiated, the results of these specific tests and measures establish objective baselines from which changes in a patient's physical status as the result of interventions are measured.
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Given the array of specific tests available to a therapist for a comprehensive physical therapy examination, the guidelines summarized in Box 1.10 should be considered when determining which definitive tests and measures need to be selected and administered.3,45,46,133
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BOX 1.10 Guidelines for Selection of Specific Tests and Measures
Consider why particular tests are performed and how the interpretation of their results may influence the formulation of a diagnosis.
Select tests and measures that provide accurate information and are valid and reliable and whose efficacy is supported by evidence generated from sound scientific studies.
Administer tests that target multiple levels of functioning and disability: impairments, activity/functional limitations, the patient's perceived level of participation restrictions.
Prioritize tests and measures selected to gather in-depth information about key problems identified during the history and systems review.
Decide whether to administer generic tests or tests that are specific to a particular region of the body.
Choose tests that provide data specific enough to support or reject working hypotheses formulated during the history and systems review and to determine a diagnosis, prognosis, and plan of care when the data are evaluated.
Select tests and measures that help determine the types of intervention that most likely are appropriate and effective.
To complete the examination in a timely manner, avoid collecting more information than is necessary to make informed decisions during the evaluation, diagnosis, and treatment planning phases of management.
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There are more than 20 general categories of specific tests and measures commonly performed by physical therapists.3,164 These tests are selected and administered to target specific impairments of the structure and function of body systems. Typically, testing involves multiple body systems to identify the scope of a patient's impairments. When examining a patient with chronic knee pain, for example, in addition to performing a thorough musculoskeletal examination, it also would be appropriate to administer tests that identify the impact of the patient's knee pain on the neuromuscular system (by assessing balance and proprioception) and the cardiopulmonary system (by assessing aerobic capacity).
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Because many of the health-related conditions as the result of injury or disease discussed in this textbook involve the neuromusculoskeletal system, some examples of specific tests and measures that identify musculoskeletal and neuromuscular impairments are noted here. They include but are not limited to:
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Assessment of pain
Goniometry and flexibility testing
Joint mobility, stability, and integrity tests (including ligamentous testing)
Tests of muscle performance (manual muscle testing, dynamometry)
Posture analysis
Assessment of balance, proprioception, neuromuscular control
Gait analysis
Assessment of assistive, adaptive, or orthotic devices
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An in-depth examination of impairments by means of diagnostic tests provides valuable information about the extent and nature of the impairments and is the foundation of the diagnosis(es) made by a physical therapist. A thorough examination of impairments also helps a therapist select the most appropriate types of exercise and other forms of therapeutic intervention for the treatment plan.
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Although specific testing of impairments is crucial, these tests do not tell the therapist how the impairments are affecting the patient's functional capabilities. Therefore, every examination should also include use of instruments that specifically measure extent of activity/functional limitations, participation restrictions, and disability. These tools, often referred to as functional outcome measures, are designed to reflect the impact of a patient's health condition and resulting impairments on functional abilities and health-related quality of life.6 These instruments typically supply baseline measurements of subjective information against which changes in a patient's function or perceived level of disability are documented over the course of treatment. These tests may be generic, covering a wide range of functional abilities, or specific to a particular body region, such as upper extremity function. Generic instruments can be used to assess the global functioning of patients who have a wide array of health conditions and impairments but yield less site-specific data than regional tests of functional abilities or limitations.133
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The format of functional testing procedures and instruments varies. Some tests gather information by self-report (by the patient or family member);86 others require observation and rating of the patient's performance by a therapist as various functional tasks are carried out.6 Some instruments measure a patient's ease or difficulty of performing specific physical tasks. Other instruments incorporate temporal (time-based) or spatial (distance-based) criteria, such as measurement of walking speed or distance, in the format.5 Test scores also can be based on the level of assistance needed (with assistive devices or by another person) to complete a variety of functional tasks.
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Indices of disability measure a patient's perception of his or her degree of participation restriction. These self-report instruments usually focus on BADL and IADL, such as the ability or inability to care for one's own needs (physical, social, emotional) or the level of participation in the community that is currently possible, desired, expected, or required. Information gathered with these instruments may indicate that the patient requires consultation and possible intervention by other health-care professionals to deal with some of the social or psychological aspects of disability.
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NOTE: It is well beyond the scope or purpose of this text to identify and describe the many tests and instruments that identify and measure physical impairments, functional deficits, or disability. The reader is referred to several resources in the literature that provide this information.1,5,6,23,98
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Evaluation is a process characterized by the interpretation of collected data. The process involves analysis and integration of information to form opinions by means of a series of sound clinical decisions.3 Although evaluation is depicted as a distinct entity or phase of the patient management model (see Fig. 1.5), some degree of evaluation goes on at every phase of patient management, from examination through outcome. Interpretation of relevant data, one of the more challenging aspects of patient management, is fundamental to the determination of a diagnosis of dysfunction and prognosis of functional outcomes. By pulling together and sorting out subjective and objective data from the examination, a therapist should be able to determine the following:
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A patient's general health status and its impact on current and potential function
The acuity or chronicity and severity of the current condition(s)
The extent of structural and functional impairments of body systems and impact on functional abilities
Which impairments are related to which activity limitations
A patient's current, overall level of physical functioning (limitations and abilities) compared with the functional abilities needed, expected, or desired by the patient
The impact of physical dysfunction on social/emotional function
The impact of the physical environment on a patient's function
A patient's social support systems and their impact on current, desired, and potential function
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The decisions made during the evaluation process may also suggest that additional testing by the therapist or another practitioner is necessary before the therapist can determine a patient's diagnosis and prognosis for positive outcomes from physical therapy interventions. For example, a patient whose chief complaints are related to episodic shoulder pain but who also indicates during the health history that bouts of depression sometimes make it difficult to work or socialize should be referred for a psychological consultation and possible treatment.14 Results of the psychological evaluation could be quite relevant to the success of the physical therapy intervention.
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Addressing the questions posed in Box 1.11 during the evaluation of data derived from the examination enables a therapist to make pertinent clinical decisions that lead to the determination of a diagnosis and prognosis and the selection of potential intervention strategies for the plan of care.
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BOX 1.11 Key Questions to Consider During the Evaluation and Diagnostic Processes
What is the extent, degree, or severity of structural and functional impairments, activity/functional limitations, or participation restrictions/disability?
What is the stability or progression of dysfunction?
To what extent are any identified personal and environmental barriers to functioning modifiable?
Is the current health condition(s) acute or chronic?
What actions/events change (relieve or worsen) the patient's signs and symptoms?
How do preexisting health conditions (comorbidities) affect the current condition?
How does the information from the patient's medical/surgical history and tests and measures done by other health-care practitioners relate to the findings of the physical therapy examination?
Have identifiable clusters of findings (i.e., patterns) emerged relevant to the patient's dysfunction?
Is there an understandable relationship between the patient's extent of impairments and the degree of activity/functional limitation or participation restriction/disability?
What are the causal factors that seem to be contributing to the patient's impairments, activity/functional limitations, or participation restriction/disability?
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During the evaluation, it is particularly useful to ascertain if and to what extent relationships exist among measurements of impairments, activity/functional limitations, participation restrictions, and the patient's perceived level of disability. These relationships often are not straightforward as indicated in the following investigations.
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FOCUS ON EVIDENCE
In a study of patients with cervical spine disorders,62 investigators reported a strong correlation between measurements of impairments (pain, ROM, and cervical muscle strength) and functional limitations (functional axial rotation and lifting capacity) but a relatively weak statistical relationship between measurements of functional limitations and the patient's perceived level of disability, as determined by three self-report measures. In another study169 that compared shoulder ROM with the ability of patients to perform basic self-care activities, a strong correlation was noted between the degree of difficulty of performing these tasks and the extent of shoulder motion limitation.
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Although the results of these studies to some extent are related to the choice of measurement tools, these findings highlight the complexity of evaluating disability and suggest that identifying the strength or weakness of the links among the levels of functioning and disability may help a therapist predict more accurately a patient's prognosis, with the likelihood of functional improvement the result of treatment. Evaluating these relationships and answering the other questions noted in Box 1.11 lays the foundation for ascertaining a diagnosis and prognosis and developing an effective plan of care.
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The term diagnosis can be used in two ways—it refers to either a process or a category (label) within a classification system.54 Both usages of the word are relevant to physical therapy practice. The diagnosis is an essential element of patient management because it directs the physical therapy prognosis (including the plan of care) and interventions.3,45,87,144,167,183
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The diagnostic process is a complex sequence of actions and decisions that begins with: (1) the collection of data (examination); (2) the analysis and interpretation of all relevant data collected, leading to the generation of working hypotheses (evaluation); and (3) organization of data, recognition of clustering of data (a pattern of findings), formation of a diagnostic hypothesis, and subsequent classification of data into categories (impairment-based diagnoses).3,36,51,136,145,167,183
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The diagnostic process is also necessary to develop a prognosis (including a plan of care) and is a prerequisite for treatment.35,77,136,144,167,183 Through the diagnostic process a physical therapist classifies dysfunction (most often, movement dysfunction), whereas a physician identifies disease.51,77,87,136,171 For the physical therapist, the diagnostic process focuses on the consequences of a disease or health disorder183 and is a mechanism by which discrepancies and consistencies between a patient's current level of performance and desired level of function and his or her capacity to achieve that level of function are identified.3
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A diagnostic classification system developed by physical therapists is useful for delineating the knowledge base and scope of practice of physical therapy.3,35,54,77,136,144,182 The use of a common diagnostic classification scheme not only guides treatment,64 it fosters clarity of communication in practice and clinical research.45,77
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A diagnostic category (clinical classification) is a grouping that identifies and describes patterns or clusters of physical findings (signs and symptoms of impairments of body functions or structures associated with activity/functional limitations, participation restrictions, and the extent of disability). A diagnostic category also describes the impact of a condition on function at the system level (musculoskeletal, neuromuscular, cardiovascular/pulmonary, integumentary) and at the level of the whole person.3 Within each body system are a number of broad-based diagnostic categories defined by the primary impairments and based on clusters of common impairments exhibited by a patient. Box 1.12 lists the impairment-based diagnostic classifications developed by consensus by physical therapists for the musculoskeletal system.3 The groupings of impairments exhibited by patients with most of the health conditions discussed in this textbook can be classified into at least one of these diagnostic categories.
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BOX 1.12 Diagnostic Classifications for the Musculoskeletal System
Primary prevention/risk reduction for skeletal demineralization (pattern 4A)
Impaired posture (pattern 4B)
Impaired muscle performance (pattern 4C)
Impaired joint mobility, motor function, muscle performance, and range of motion (ROM) associated with connective tissue dysfunction (pattern 4D)
Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation (pattern 4E)
Impaired joint mobility, motor function, muscle performance, ROM, and reflex integrity associated with spinal disorders (pattern 4F)
Impaired joint mobility, muscle performance, and ROM associated with fracture (pattern 4G)
Impaired joint mobility, motor function, muscle performance, and ROM associated with joint arthroplasty (pattern 4H)
Impaired joint mobility, motor function, muscle performance, and ROM associated with bony or soft tissue surgery (pattern 4I)
Impaired motor function, muscle performance, ROM, gait, locomotion, and balance associated with amputation (pattern 4J)
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Patients with different health conditions but similar impairments may be classified by the same diagnostic category. Moreover, it is not uncommon during the diagnostic process for a therapist to identify more than one diagnostic category to describe a patient's impaired function. Complete descriptions of impairment-based diagnostic categories for each body system can be found in the Guide to Physical Therapist Practice.3
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Preferred practice patterns, which are identified by the diagnostic categories, represent consensus-based opinions that outline broad patient management guidelines and strategies used by physical therapists for each diagnostic category.34,56,183 These patterns are not designed to indicate a specific pathway of care, such as an exercise protocol for a specific postoperative condition, but rather are descriptions of all components of patient management from examination through discharge for which physical therapists are responsible. In other words, the preferred practice patterns describe what it is that physical therapists do. For a detailed description of the suggested procedures for each preferred practice pattern for the musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary systems, refer to the Guide.3
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NOTE: The impairment/function-based diagnoses in the clinical practice guidelines developed by the Orthopedic Section of the APTA are an alternative to the diagnostic categories identified in the Guide and are based on the classification and coding system described in the ICF. The diagnostic classifications are linked to recommendations for physical therapy interventions based on "best evidence" from the scientific literature.22,26,27,94,95,107
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Prognosis and Plan of Care
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After the initial examination has been completed, data have been evaluated, and an impairment-based diagnosis has been established, a prognosis (see Fig. 1.5), including a plan of care, must be determined before initiating any interventions. A prognosis is a prediction of a patient's optimal level of function expected as the result of a plan for treatment during an episode of care and the anticipated length of time needed to reach specified functional outcomes.3,87 Some factors that influence a patient's prognosis and functional outcomes are noted in Box 1.13.
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BOX 1.13 Factors That Influence a Patient's Prognosis/Expected Outcomes
Complexity, severity, acuity, or chronicity and expected course of the patient's health condition(s) (pathology), impairments, and activity/functional limitations
Patient's general health status and presence of comorbidities (e.g., hypertension, diabetes, obesity) and risk factors
The patient's previous level of functioning or disability
The patient's living environment
Patient's and/or family's goals
Patient's motivation and adherence and responses to previous interventions
Safety issues and concerns
Extent of support (physical, emotional, social)
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Determining an accurate prognosis is, indeed, challenging even for experienced therapists. The more complex a patient's problems, the more difficult it is to project the patient's optimal level of function, particularly at the onset of treatment. For example, if an otherwise healthy and fit 70-year-old patient who was just discharged from the hospital after a total knee arthroplasty is referred for home-based physical therapy services, it is relatively easy to predict the time frame that will be needed to prepare the patient to return to independence in the home and community. In contrast, it may be possible to predict only incremental levels of functional improvement at various stages of rehabilitation for a patient who has sustained multiple fractures and soft tissue injuries as the result of an automobile accident.
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In these two examples of establishing prognoses for patients with musculoskeletal conditions, as with most other patient problems, the accuracy of the prognosis is affected in part by the therapist's clinical decision-making ability based on the following3:
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Familiarity with the patient's current health condition(s) and the surgical intervention(s) and previous history of diseases or disorders
Knowledge of the process and time frames of tissue healing
Experience managing patients with similar surgical procedures, pathological conditions, impairments, and functional deficits
Knowledge of the efficacy of tests and measures performed, accuracy of the findings, and effectiveness of the physical therapy interventions
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The plan of care, an integral component of the prognosis, delineates the following3:
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Anticipated goals.
Expected functional outcomes that are meaningful, utilitarian, sustainable, and measurable.
Extent of improvement predicted and length of time necessary to reach that level.
Specific interventions.
Proposed frequency and duration of interventions.
Specific discharge plans.
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Setting Goals and Outcomes in the Plan of Care
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Developing a plan of care involves collaboration and negotiation between the patient (and, when appropriate, the family) and the therapist.3,77,87 The anticipated goals and expected outcomes documented in the plan of care must be patient-centered—that is, the goals and outcomes must be meaningful to the patient. These goals and outcomes also must be measurable and linked to each other. Goals are directed at the reduction or elimination of the physical signs and symptoms of pathology and impairments in body function and/or structure that seem to be limiting the patient's functional abilities.3 Outcomes are associated with the amelioration of functional deficits and participation restrictions to the greatest extent possible coupled with achieving the optimal level possible of function, general health, and patient satisfaction.3
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Establishing and prioritizing meaningful, functionally relevant goals and determining expected outcomes requires engaging the patient and/or family in the decision-making process from a therapist's first contact with a patient. Patients come to physical therapy not to get stronger or more flexible, but rather, to be able to perform physical activities they enjoy doing or must do in their lives with ease and comfort. Knowing what a patient wants to be able to accomplish as the result of treatment and ascertaining which accomplishments are the most important to the patient helps a therapist develop and prioritize intervention strategies that target the patient's functional limitations and functionally related impairments. This, in turn, increases the likelihood of successful outcomes from treatment.120,130 Some key questions a therapist often asks a patient or the patient's extended support system early in the examination while taking the history that are critical for establishing anticipated goals and expected outcomes in the plan of care are listed in Box 1.14.4,87,120,130
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BOX 1.14 Key Questions to Establish and Prioitize Patient-Centered Goals and Outcomes in the Plan of Care
What activities are most important to you at home, school, work, in the community, or during your leisure time?
What activities do you currently need help with that you would like to be able to do independently?
Of the activities you are finding difficult to do or cannot do at all at this time, which ones would you like to be able to do better or do again?
Of the problems you are having, which ones do you want to try to eliminate or minimize first?
In what areas do you think you have the biggest problems during the activities you would like to do on your own?
What are your goals for coming to physical therapy?
What would you like to be able to accomplish through therapy?
What would make you feel that you were making progress in achieving your goals?
How soon do you want to reach your goals?
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An integral aspect of effective goal and outcome setting is explaining to a patient how the health condition and identified impairments are associated with the patient's activity/functional limitations and participation restrictions and why specific interventions will be used. Discussing an expected time frame for achieving the negotiated goals and outcomes puts the treatment plan and the patient's perception of progress in a realistic context. This type of information helps a patient and family members set goals that are not just meaningful but realistic and attainable. Setting up short-term and long-term goals, particularly for patients with severe or complex problems, is also a way to help a patient recognize incremental improvement and progress during treatment.
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The plan of care also indicates the optimal level of improvement that will be reflected by the functional outcomes as well as how those outcomes will be measured. An outline of the specific interventions, their frequency and duration of use, and how the interventions are directly related to attaining the stated goals and outcomes also must appear in the plan. Finally, the plan of care concludes with the criteria for discharge. These criteria are addressed following a discussion of elements of intervention in the patient management process.
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NOTE: Periodic re-examination of a patient and re-evaluation of a patient's response to treatment may necessitate modification of the initial prognosis and plan of care.
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Intervention, a component of patient management, refers to any purposeful interaction a therapist has that directly relates to a patient's care3 (see Fig. 1.5). There are three broad areas of intervention that occur during the course of patient management.3
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Coordination, communication, and documentation
Procedural interventions
Patient-related instruction
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Each of these areas is an essential aspect of the intervention phase of patient management. Absence of just one of these elements can affect outcomes adversely. For example, inclusion of the most appropriate, functionally relevant exercises (procedural intervention) in a treatment program does not lead to a successful outcome if the therapist has not communicated with the necessary parties for an approval or extension of physical therapy services (communication) or if the patient has not learned how to perform the exercises in the program correctly (patient-related instruction). A brief discussion of the three major components of intervention is presented in this section with additional information in the final section of the chapter on exercise instruction, an aspect of patient-related instruction that is most relevant to the focus of this textbook.
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Coordination, Communication, and Documentation
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The physical therapist is the coordinator of physical therapy care and services and must continually communicate verbally and through written documentation with all individuals involved in the care of a patient. This aspect of intervention encompasses many patient-related administrative tasks and professional responsibilities, such as writing reports (evaluations, plans of care, discharge summaries); designing home exercise programs; keeping records; contacting third-party payers, other health-care practitioners, or community-based resources; and participating in team conferences.
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NOTE: Even during the intervention phase of patient management, a therapist might decide that referral to another practitioner is appropriate and complementary to the physical therapy interventions. This requires coordination and communication with other health-care practitioners. For example, a therapist might refer a patient, who is generally deconditioned from a sedentary lifestyle and who is also obese, to a nutritionist for dietary counseling to complement the physical therapy program designed to improve the patient's aerobic capacity (cardiopulmonary endurance) and general level of fitness.
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Procedural Interventions
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Procedural intervention pertains to the specific procedures used during treatment, such as therapeutic exercise, functional training, or adjunctive modalities (physical agents and electrotherapy). Procedural interventions are identified in the plan of care. Most procedural interventions used by physical therapists, including the many types of therapeutic exercise, are designed to reduce or correct impairments, as depicted in Figure 1.6.
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If procedural interventions are to be considered effective, they must result in the reduction or elimination of functional deficits and participation restrictions and, whenever possible, reduce the risk of future dysfunction. Moreover, the efficacy of procedural interventions should be supported by sound evidence, preferably based on prospective, randomized, controlled research studies.
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Although the intended outcome of therapeutic exercise programs has always been to enhance a patient's functional capabilities or prevent loss of function, until the past few decades the focus of exercise programs was on the resolution of impairments. Success was measured primarily by the reduction of the identified impairments or improvements in various aspects of physical performance, such as strength, mobility, or balance. It was assumed that if impairments were resolved, improvements in functional abilities would subsequently follow. Physical therapists now recognize that this assumption is not valid. To reduce functional limitations and improve a patient's health-related quality of life, not only should therapeutic exercise interventions be implemented that correct functionally limiting impairments, but whenever possible, exercises should be task-specific—that is, they should be performed using movement patterns that closely match a patient's intended or desired functional activities. In Figure 1.7, strengthening exercises are performed using task-specific lifting patterns.
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The importance of designing and implementing exercises that closely replicate the desired functional outcomes is supported by the results of many studies, such as the following study.
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FOCUS ON EVIDENCE
Task-specific functional training was investigated in a study of the effects of a resistance exercise program on the stair-climbing ability of ambulatory older women.31 Rather than having the subjects perform resisted hip and knee extension exercises in nonweight-bearing positions, they trained by ascending and descending stairs while wearing a weighted backpack. This activity not only improved muscle performance (strength and endurance), it directly enhanced the subjects' efficiency in stair climbing during daily activities.
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Another way to use therapeutic exercise interventions effectively to improve functional ability is to integrate safe but progressively more challenging functional activities that utilize incremental improvements in strength, endurance, and mobility into a patient's daily routine as early as possible in the treatment program. With this functionally oriented approach to exercise, the activities in the treatment program are specific to and directly support the expected functional outcomes. Selection and use of exercise procedures that target more than one goal or outcome are also appropriate and efficient ways to maximize improvements in a patient's function in the shortest time possible.
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Effective use of any procedural intervention must include determining the appropriate intensity, frequency, and duration of each intervention and periodic re-examination of a patient's responses to the interventions. While implementing therapeutic exercise interventions, a patient's response to exercise is continually monitored to decide when and to what extent to increase the difficulty of the exercise program or when to discontinue specific exercises. Each of the chapters of this textbook provides detailed information on factors that influence selection, application, and progression of therapeutic exercise interventions.
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Patient-Related Instruction
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There is no question that physical therapists perceive themselves as patient educators, facilitators of change, and motivators.24,47,74,96,116 Patient education spans all three domains of learning: cognitive, affective, and psychomotor domains. Education ideally begins during a patient's initial contact with a therapist and involves the therapist explaining information, asking pertinent questions, and listening to the patient or a family member.
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Patient-related instruction, the third aspect of intervention during the patient management process, is the means by which a therapist helps a patient learn how to reduce his or her impairments and functional deficits to get better24 by becoming an active participant in the rehabilitation process. Patient-related instruction first may focus on providing a patient with background information, such as the interrelationships among the primary health condition (pathology) and the resulting impairments and limitations in activity or explaining the purpose of specific interventions in the plan of care. Instruction, such as physical therapist-directed exercise counseling,165 may be implemented as an alternative to direct supervision of an exercise program and typically focuses on specific aspects of a treatment program, such as teaching a patient, family member, or caregiver a series of exercises to be carried out in a home program; reviewing health and wellness materials; or clarifying directions for safe use of equipment to be used at home.
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A therapist must use multiple methods to convey information to a patient or family member, such as one-to-one, therapist-directed instruction, videotaped instruction, or written materials. Each has been shown to have a place in patient education as highlighted by the following studies.
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FOCUS ON EVIDENCE
It has been shown that patients, who were taught exercises by a therapist, performed their exercises more accurately in a home program than patients whose sole source of information about their exercises was from reading a brochure.43 In another study, the effectiveness of three modes of instruction in an exercise program were evaluated. The subjects who received in-person instruction by a therapist or two variations of videotaped instruction performed their exercise program more accurately than subjects who received only written instructions.132
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However, written materials, particularly those with illustrations, can be taken home by a patient and used to reinforce verbal instructions from a therapist or videotaped instructions.
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To be an effective patient educator, a therapist must possess an understanding of the process of learning, which most often is directed toward learning or modifying motor skills. As a patient educator, a therapist also must be able to recognize a patient's learning style, implement effective teaching strategies, and motivate a patient to want to learn new skills, adhere to an exercise program, or change health-related behaviors.
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A therapist's skillful, creative use of all three components of intervention, coupled with vigilant re-examination and re-evaluation of the effectiveness of the interventions selected, paves the way for successful outcomes and a patient's discharge from physical therapy services.
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Simply stated, outcomes are results. Collection and analysis of outcome data related to health-care services are necessities, not options.59 Measurement of outcomes is a means by which quality, efficacy, and cost-effectiveness of services can be assessed. Patient-related outcomes are monitored throughout an episode of physical therapy care—that is, intermittently during treatment and at the conclusion of treatment.120 Evaluation of information generated from periodic re-examination and re-evaluation of a patient's response to treatment enables a therapist to ascertain if the anticipated goals and expected outcomes in the plan of care are being met and if the interventions that have been implemented are producing the intended results. It may well be that the goals and expected outcomes must be adjusted based on the extent of change or lack of change in a patient's function as determined by the level of the interim outcomes. This information also helps the therapist decide if, when, and to what extent to modify the goals, expected outcomes, and interventions in the patient's plan of care.
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There are several broad areas of outcomes commonly assessed by physical therapists during the continuum of patient care. They are listed in Box 1.15.
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BOX 1.15 Areas of Outcomes Assessed by Physical Therapists
Level of a patient's physical functioning, including impairments, activity/functional limitations, participation restrictions, and perceived disability
Extent of prevention or reduced risk of occurrence or recurrence of future dysfunction related to health conditions, associated impairments, activity/functional limitations, participation restrictions, or perceived disability
Patient's general health status or level of well-being and fitness
Degree of patient satisfaction
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The key to the justification of physical therapy services in today's cost-conscious health-care environment is the identification and documentation of successful patient-centered, functional outcomes that can be attributed to interventions.3,5,23,55,163 Functional outcomes must be meaningful, practical, and sustainable.163 Outcomes that have an impact on a patient's ability to function at work, in the home, or in the community in ways that have been identified as important by the patient, family, significant others, caregivers, or employers are considered meaningful. If the formulation of anticipated goals and expected outcome has been a collaborative effort between patient and therapist, the outcomes will be meaningful to the patient. The practical aspect of functional outcomes implies that improvements in function have been achieved in an efficient and cost-effective manner. Improvements in function that are maintained over time after discharge from treatment (to the extent possible given the nature of the health condition) are considered sustainable.
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The expected outcomes identified in a physical therapy plan of care must be measurable. More specifically, changes in a patient's status over time must be quantifiable. As noted in the previous discussion of the examination component of the patient management model, many of the specific tests and measures used by physical therapists traditionally have focused on measurement of impairments (i.e., ROM, muscle performance, joint mobility/stability, balance). The reduction of impairments may reflect the impact of interventions on the pathological condition but may or may not translate into improvements in a patient's health-related quality of life, such as safety and functional abilities. Hence, there is the need for measurement not only of impairments but also of a patient's levels of physical functioning and perceived disability to assess accurately patient-related outcomes that include but are not limited to the effectiveness of physical therapy interventions, such as therapeutic exercise.
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Impact of interventions on patient-related, functional outcomes. In response to the need to produce evidence that supports the effectiveness of physical therapy interventions for reducing movement dysfunction, a self-report instrument called OPTIMAL (Outpatient Physical Therapy Improvement in Movement Assessment Log) has been developed for measuring the impact of physical therapy interventions on function and has been tested for validity and reliability.55 The instrument measures a patient's difficulty with or confidence in performing a series of actions, most of which are related to functional mobility, including moving from lying to sitting and sitting to standing, kneeling, walking, running, and climbing stairs, reaching, and lifting. In addition, to assist the therapist with setting goals for the plan of care, the patient is asked to identify three activities that he or she would like to be able to do without difficulty.
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A number of studies that have investigated the benefits of exercise programs for individuals with impaired functional abilities79,88,141 reflect the trend in research to include an assessment of changes in a patient's health-related quality of life as the result of interventions. Assessment of outcomes related to the reduction of risks of future injury or further impairment, prevention of further functional limitations or disability, adherence to a home program, or the use of knowledge that promotes optimal health and fitness may also help determine the effectiveness of the services provided. To substantiate that the use of physical therapy services for prevention is cost-effective, physical therapists are finding that it is important to collect follow-up data that demonstrate a reduced need for future physical therapy services as the result of interventions directed toward prevention and health promotion activities.
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Patient satisfaction. Another area of outcomes assessment that has become increasingly important in physical therapy practice is that of patient satisfaction. An assessment of patient satisfaction during or at the conclusion of treatment can be used as an indicator of quality of care. Patient satisfaction surveys often seek to determine the impact of treatment based on the patient's own assessment of his or her status at the conclusion of treatment compared to that at the onset of treatment.140 Instruments, such as the Physical Therapy Outpatient Satisfaction Survey (PTOPS)140 or the MedRisk Instrument for Measuring Patient Satisfaction with physical therapy (MRPS),8,9 also measure a patient's perception of many other areas of care. An important quality of patient satisfaction questionnaires is their ability to discriminate among the factors that influence satisfaction. Identification of factors that adversely influence satisfaction may enable the clinician to take steps to modify these factors to deliver an optimal level of services to patients.9
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Factors that may influence the extent of patient satisfaction are noted in Box 1.16.8,9,20,140
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BOX 1.16 Examples of Determinants of Patient Satisfaction*
Interpersonal attributes of the therapist (communication skills, professionalism, helpfulness, empathy) and the impact on the patient-therapist relationship
Perception of a therapist's clinical skills
Extent of functional improvement during the episode of care
Extent of participation in goal setting in the plan of care
The acuity of the patient's condition (higher satisfaction in acute conditions)
Convenience of access to services
Administrative issues, such as continuity of care, flexible hours for scheduling, waiting time at each visit, duration of treatments, and cost of care
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FOCUS ON EVIDENCE
A recent systematic review of the literature addressed the degree of patient satisfaction with musculoskeletal physical therapy care and identified the factors that were associated with high patient satisfaction in outpatient settings across North America and Northern Europe.66 The review included articles if they were a survey, clinical trial, qualitative study, or patient interview. Only 15 of several thousand articles met the inclusion criteria. A meta-analysis of pooled data from the included studies revealed that on a 1–5 scale (5 being the highest level of satisfaction), the degree of patient satisfaction was 4.41 (95% confidence interval = 4.41–4.46), indicating that patients are highly satisfied with physical therapy care directed toward musculoskeletal conditions. One finding of interest in the studies reviewed is the quality of the patient-therapist relationship consistently ranked higher as an indicator of patient satisfaction than the extent of improvement in the patient's physical functioning as a result of the episode of care.
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Planning for discharge begins early in the rehabilitation process. As previously noted, criteria for discharge are identified in a patient's plan of care. Ongoing assessment of outcomes is the mechanism by which a therapist determines when discharge from care is warranted. A patient is discharged from physical therapy services when the anticipated goals and expected outcomes have been attained.3 The discharge plan often includes some type of home program, appropriate followup, possible referral to community resources, or re-initiation of physical therapy services (an additional episode of care) if the patient's needs change over time and if additional services are approved.
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Discontinuation of services is differentiated from discharge.3 Discontinuation refers to the ending of services prior to the achievement of anticipated goals and expected outcomes. Several factors may necessitate discontinuation of services, which may include a decision by a patient to stop services, a change in a patient's medical status such that progress is no longer possible, or the need for further services cannot be justified to the payer.
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In conclusion, the patient management model discussed in this section establishes a comprehensive, systematic approach to the provision of effective and efficient physical therapy care and services to patients and clients. The model is a mechanism to demonstrate the interrelationships among the phases of the continuum of patient care set in a conceptual framework of functioning and disability; it is aimed at improving a patient's function and health-related quality of life. The management model also places an emphasis on reducing risk factors for disease, injury, impairments, or disability and promoting health and well-being in patients and clients seeking and receiving physical therapy services.
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