Chapter 1: Framework for Clinical Decision-Making and Patient Management

INTRODUCTION

Optimal functional recovery is the primary goal of all rehabilitation. Although people have traditionally been identified or categorized by their disease or medical condition (e.g., spinal cord injury [SCI]), the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) model¹ provides an important framework for examining and treating the patient by clearly defining health condition, impairment, activity limitation, and participation restriction. Along with the ICF framework, physical therapists should work to apply the guiding principles associated with the human movement system as defined by the American Physical Therapy Association’s (APTA’s) House of Delegates newly adopted vision for the profession.^2,3,4 In addition, the APTA, in its Guide to Physical Therapist Practice, version 3.0, has adopted this framework.⁵ Thus the patient with SCI presents with paralysis; sensory loss; autonomic dysfunction (impairments); loss of independent function in bed mobility, dressing, bathing, and locomotion (activity limitations); and an inability to work or go to school (participation restrictions). Physical therapist practice intervenes by understanding the movement system diagnoses and effectively treating at the level of impairments, activity limitations, and participation restrictions. Effective clinical decision-making is based on an understanding of the ICF model and related contextual factors (environmental and personal factors) to arrive at effective choices for intervention. In addition, clinicians must understand factors that improve quality of life, prevention, wellness, and fitness. An effective plan of care (POC) clarifies risk factors and seeks to fully involve the patient in determining meaningful functional goals. This text focuses on identifying movements system disorders and improving motor function (motor control and motor learning) and muscle performance (strength, power, and endurance) through activities and exercises that optimize functional outcomes. Definitions of terminology of functioning, disability, and health are presented in Box 1.1.