1. Copyright 2005 Lippincott Williams & Wilkins Chapter 2 Patient Management

2. Copyright 2005 Lippincott Williams & Wilkins Patient Management Model Examination Evaluation Diagnosis Prognosis Intervention Outcome 5 Elements

3. Copyright 2005 Lippincott Williams & Wilkins Examination Process of obtaining a history, performing a relevant systems review, and selecting and administering specific tests and measurements to obtain data.  Used to generate a diagnosis.  Ongoing process throughout treatment to evaluate response to intervention.

4. Copyright 2005 Lippincott Williams & Wilkins Examination – History  Demographic profile and social history  Occupation  Living and working environments  General health history  Past and current history of the physical condition  Extra-individual and intra-individual interventions

5. Copyright 2005 Lippincott Williams & Wilkins Examination – Systems Review  Cardiopulmonary (e.g., heart rate, etc.)  Musculoskeletal (e.g., gross ROM, etc.)  Neuromuscular (e.g., coordinated movement)  Integumentary (e.g., skin integrity, etc.)  Communication ability, affect, cognition, language, and learning style (e.g., consciousness, orientation, etc.)

6. Copyright 2005 Lippincott Williams & Wilkins Evaluation The dynamic process in which the physical therapist makes judgments based on data gathered during the examination.  Prioritize problems to be assessed based on medical history and systems review.  Implement the examination.  Interpret the data.

7. Copyright 2005 Lippincott Williams & Wilkins Evaluation = Interpretation of Data Interpretation used to determine:  Progression and stage of the signs and symptoms.  Stability of condition.  Presence of preexisting conditions.  Relationships among involved systems and sites.

8. Copyright 2005 Lippincott Williams & Wilkins Modified Disablement Model Patient Management

9. Copyright 2005 Lippincott Williams & Wilkins Evaluation – Pathology  Laboratory tests  Radiologic studies  Neurologic examination These tests identify the pathology. Physical therapy focus should be on examination and evaluation of impairments, functional limitations, and disabilities.

10. Copyright 2005 Lippincott Williams & Wilkins Impairments Evaluate What We Treat  Musculoskeletal  Neuromuscular  Cardiovascular  Pulmonary  Integumentary

11. Copyright 2005 Lippincott Williams & Wilkins Impairment Questions  Is the impairment directly related to a functional limitation?  Is the impairment secondary to the pathology or impairment?  Can the impairment be related to future functional limitation?  Is the impairment unrelated to the functional limitation? IMPORTANT!! – Target impairments that are related to functional limitations.

12. Copyright 2005 Lippincott Williams & Wilkins Functional Limitations  Lack of function (e.g., unable to make the bed) is why the patient seeks therapy.  Which and to what degree are the impairments linked to functional limitations?  Success = Ability to achieve functional outcomes (e.g., making the bed).

13. Copyright 2005 Lippincott Williams & Wilkins Tests/Measures of Physical Functional Limitations  Self reports or proxy reports of the level of difficulty performing tasks.  Observation of performance of functional tasks, rating the level of difficulty, such as measuring distances, weight lifted, number of repetitions, or quality of motion based on kinesiologic standards.  Clinical tests of physical mobility.  Equipment-based evaluation of performance.

14. Copyright 2005 Lippincott Williams & Wilkins Disability Involves social context of functional loss – Limits patient’s ability to function socially  Social interaction is limited due to functional limitation (e.g., unable to leave the home)  Social activity is limited due to functional limitation (e.g., unable to attend functions where stair climbing is required)  Social role is limited due to functional limitation (e.g., unable to perform tasks that require stair climbing) Each sphere requires a clear quantity of physical ability, thus, social milieu is affected

15. Copyright 2005 Lippincott Williams & Wilkins Diagnosis  The process and end result of information obtained in the examination and evaluation. Includes:  Examination (history and systems review, etc.)  Evaluation (interpretation)  Diagnosis = Clinical Classification – organization into cluster, syndrome, or category

16. Copyright 2005 Lippincott Williams & Wilkins Cluster, Syndrome, Diagnosis  Cluster – A set of observations or data that frequently occur as a group or single patient.  Syndrome – An aggregate of signs and symptoms that characterize a given disease or condition.  Diagnosis – A label encompassing a cluster of signs and symptoms commonly associated with a disorder, syndrome, or category of impairment, functional limitation, or disability. Goal of diagnostic process is to establish a diagnosis!

17. Copyright 2005 Lippincott Williams & Wilkins Prognosis and Plan of Care Prognosis – The process of determining the level of optimal improvement that may be obtained from intervention, and the amount of time required to reach that level. Plan of Care – Specify interventions to be used and the proposed duration and frequency of intervention(s) that are required to reach the anticipated goals and outcomes.

18. Copyright 2005 Lippincott Williams & Wilkins Prognosis and Plan of Care – based on:  Patient’s health status, risk factors, and response to intervention.  Patient’s safety, needs, and goals.  Natural history and expected clinical course of pathology, impairment, or diagnosis.  Results of examination, evaluation, and diagnostic processes.

19. Copyright 2005 Lippincott Williams & Wilkins Intervention The purposeful and skilled interaction of the physical therapist with the patient using various methods and techniques to produce changes in the patient’s condition consistent with the evaluation, diagnosis, and prognosis. Key is to do the right things well

20. Copyright 2005 Lippincott Williams & Wilkins Intervention – Clinical Decision-Making  Will the patient benefit from the intervention? (e.g., will treatment improve function?)  Are there any possible negative effects of the treatment?  What is the cost:benefit ratio?

21. Copyright 2005 Lippincott Williams & Wilkins Intervention – Types  Direct intervention (e.g., therapeutic exercise, manual therapy, etc.)  Patient-related instruction (e.g., education provided to the patient and other caregivers involved, etc.)  Coordination, communication, and documentation (e.g., patient care conferences, record views, discharge planning)

22. Copyright 2005 Lippincott Williams & Wilkins Intervention Selecting Treatment Interventions  Therapeutic Exercise  Functional Training in Self Care  Manual Therapy  Airway Clearance Techniques  Integumentary Repair and Protection Techniques  Physical Agents  Electrotherapeutic Modalities

23. Copyright 2005 Lippincott Williams & Wilkins Intervention Patient-Related Instruction  Educate the patient (and involved people – therapists, etc.) regarding the entire process.  Treat all involved as a “team.”

24. Copyright 2005 Lippincott Williams & Wilkins Outcome Successful when:  Physical function is improved, or maintained whenever possible.  Functional decline is minimized or slowed when status quo cannot be maintained.  The patient is satisfied.

25. Copyright 2005 Lippincott Williams & Wilkins Clinical Decision-Making Patient Management Examination – Prioritize problems and tests. Evaluation – Consider and analyze findings. Diagnosis – Segregate findings into clusters and signs by common causes, mechanisms, and effects.

26. Copyright 2005 Lippincott Williams & Wilkins Clinical Decision-Making (cont.) Intervention – Determine correlation between impairment and functional limitation. Select and justify method of intervention. Outcome – Measure success of intervention plan; modify if necessary.

27. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention  Which elements of movement system need to be addressed to restore function?  Which activities or techniques are chosen to achieve a functional outcome?  What is the purpose of each specific activity or technique chosen?  What is the posture, mode, and movement for each activity or technique?  What are the dosage parameters for each activity or technique?

28. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention Model

29. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention Model 1.Elements of the movement system as they relate to the purpose of each activity or technique 2.The specific activity or technique chosen 3.The specific dosage

30. Copyright 2005 Lippincott Williams & Wilkins Elements of Movement System 1.Support – Functional status of cardiac, pulmonary and metabolic systems. 2.Base – Functional status of the muscular and skeletal systems. 3.Modulator – Physiologic status of the neuromuscular system. 4.Biomechanical – Functional status of static and dynamic kinetics and kinematics. 5.Cognitive or Affective – Functional status of psychological system as it relates to movement.

31. Copyright 2005 Lippincott Williams & Wilkins Clinical Decision-Making Elements of the Movement System  Identify functional limitations and related impairments to be treated.  Relate functional limitations and impairments to be treated with the appropriate elements of the movement system.  Prioritize elements of the movement system.

32. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Activities/Techniques  Stretching (active/passive)  ROM exercises  Strengthening  Neuromuscular re-education  Developmental activities  Breathing exercises  Aquatic exercises

33. Copyright 2005 Lippincott Williams & Wilkins Stages of Movement Control Factor When Choosing an Activity Mobility – Functional range through which to move and the ability to sustain active movement through the range. Stability – Ability to provide stable foundation from which to move. Controlled Mobility – Ability to move w/in joints and b/t limbs following the optimal path of instant center of rotation (PICR). Skill – Ability to maintain consistency in performing functional tasks with economy of effort.

34. Copyright 2005 Lippincott Williams & Wilkins Mode, Posture, Movement Follows Choice of Activity Mode – Method of performing activity (e.g., strengthening – mode may be weights, manual resistance, etc.) Posture – Initial AND ending postures (base of support) Movement – Quality of performance

35. Copyright 2005 Lippincott Williams & Wilkins Dosage 1.Consider physiologic status/stage of tissues, anatomic elements, and patient’s ability to learn 2.Type of contraction 3.Intensity 4.Speed of activity or technique 5.Duration 6.Frequency

36. Copyright 2005 Lippincott Williams & Wilkins Exercise Modification  PT may have chosen the wrong activity and/or dosage.  PT may not be able to effectively implement or teach the exercise. Required when patient outcome is not met in reasonable timeframe.

37. Copyright 2005 Lippincott Williams & Wilkins Exercise Modification (cont.)  Patient may not be able to learn the exercise well, or misunderstand or forget the instructions or dosage.  Patient may not follow through with prescription.  Recurrent examinations & evaluations are necessary!

38. Copyright 2005 Lippincott Williams & Wilkins Adjunctive Interventions May be complementary to therapeutic exercise prescription, not essential components.  Physical Agents – ice, heat, sound, etc.  Mechnical Modalities – traction, CPM, tilt tables, compression devices, etc.  Electrotherapy – NMES, TENS, SEMG, SEMG- triggered NMES.

39. Copyright 2005 Lippincott Williams & Wilkins Summary Physical therapist integration of elements – examination, evaluation, diagnosis, prognosis, intervention. Understanding of each element assists the therapist in maximizing patient satisfaction & delivering the most efficient & effective services possible. Clinical knowledge and expertise are determinants for successful PT outcome.

40. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Clinical decision is related to functional limitation and disability. Patient-related instruction is an integral part of physical therapy intervention. The 3-D model is designed to help organize and assist in clinical decision-making. Exercises must be continually monitored and modified to be effective and may be complemented with adjunctive interventions.