Chapter 2

Patient Management

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Patient Management Model
Examination

Evaluation
5 Elements

Diagnosis

Prognosis

Intervention Outcome
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 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.

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 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

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 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.)

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 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.

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 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.

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Modified Disablement Model

Patient Management

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 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.

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 Impairments
Evaluate What We Treat

 Musculoskeletal
 Neuromuscular
 Cardiovascular
 Pulmonary
 Integumentary

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 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.

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 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).

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 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.

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 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
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 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
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 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!
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 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.

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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.

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 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

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 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?

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 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)

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 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

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 Intervention
Patient-Related Instruction

 Educate the patient (and involved people –

therapists, etc.) regarding the entire process.
 Treat all involved as a “team.”

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 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.

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 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.

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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.

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 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?

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Therapeutic Exercise
Intervention Model

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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

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 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.

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 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.

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 Therapeutic Exercise
Activities/Techniques
 Stretching (active/passive)
 ROM exercises
 Strengthening
 Neuromuscular re-education
 Developmental activities
 Breathing exercises
 Aquatic exercises

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 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.

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 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

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 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

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 Exercise Modification

Required when patient outcome is not met in reasonable timeframe.

 PT may have chosen the wrong activity

and/or dosage.
 PT may not be able to effectively implement
or teach the exercise.

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 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!

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 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.

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 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.

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 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.

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