Therapeutic exercise

foundation and techniques

Part II
PATIENT MANAGEMENT AND CLINICAL DECISIONMAKING:

AN INTERACTIVE RELATIONSHIP
 Clinical decision making

A dynamic, complex process of reasoning and

analytical (critical) thinking that involves making
judgments and determinations in the context of
patient care.
Requirements for Skilled Clinical Decision Making During Patient
Management
 Requirements for Skilled Clinical Decision Making During Patient Management

• Knowledge of pertinent information about the problem(s)

• Prior clinical experience with the same or similar problems
• Ability to recall relevant information
• Cognitive and psychomotor skills
• Ability to integrate new and prior knowledge
• An efficient information-gathering and information processing
• Ability to obtain, analyze, and apply evidence from the
literature
 Requirements for Skilled Clinical Decision
Making During Patient Management

• Ability to critically organize,

categorize and prioritize
• Ability to recognize clinical patterns
• Ability to form working hypotheses
• An understanding of the patient’s
values and goals
• Ability to determine options and
make strategic plans
• Use of reflective thinking and self-
monitoring strategies
Evidence-Based Practice
 Evidence-Based Practice
“The conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of an individual patient.”

Steps in evidence based practice

1.Identify a patient problem and convert it into a specific
question.
2. Search the literature and collect clinically relevant, scientific
studies that contain evidence related to the question.
3. 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.
 Steps in evidence based practice

4. Integrate the appraisal of the evidence with

clinical expertise and experience and the patient’s
unique circumstances and values to make
decisions.
5. Incorporate the findings and decisions into
patient management.
6. Assess the outcomes of interventions and ask
another question if necessary.
 A Patient Management Model

The process of patient management has five basic

components
•Examination
•Evaluation
•Diagnosis
•Plan of care ,patient-oriented goals
•Interventions
 1.Examination
Three distinct elements of a comprehensive examination
1. The patient’s health history
2. A relevant systems review
3. Specific tests and measures
Information Generated from the Initial
History
Demographic Data
• Age, sex, race, ethnicity
• Primary language
• Education
Social History
• Family and caregiver resources
• Cultural background
• Social interactions/support systems
Occupation/Leisure
• Current and previous employment
• Job/school-related activities
• Recreational, community activities/tasks
Growth and Development
• Developmental history
• Hand and foot dominance
 Information Generated from the Initial
History
Living Environment
• Current living environment
• Expected destination after discharge
• Community accessibility
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
 Information Generated from the Initial
History
Cognitive/Social/Emotional Status
• Orientation, memory
• Communication
• Social/emotional interactions

Current Conditions/Chief Complaints/Concerns

• Conditions/reasons physical therapy services sought
• Patient’s perceived level of disability
• Patient’s needs, goals
• History, onset (date and course), mechanism of injury
 Information Generated from the Initial
History (Contd)

•Functional Status and Activity Level

•Other Laboratory and Diagnostic Tests
 Systems Review
• Cardiovascular/ pulmonary
Heart rate
Respiratory rate
Blood pressure;
Pain or heaviness
Pulsating pain; lightheadedness;
Peripheral edema
 Systems Review

Musculoskeletal
Height
Weight
Symmetry
Gross ROM
Strength
 Systems Review
Neuromuscular
• General aspects of motor control(balance, locomotion, coordination);
•Sensation
•Changes in hearing or vision;
•Severe headaches
 Systems Review

Integumentary
Skin sensetions
Skin temperature
Color
Texture
Integrity
Scars
Lumps
Growths
 Systems Review(contd)
Gastrointestinal/ genitourinary
Heartburn, diarrhea, vomiting, severe
abdominal pain, problems swallowing, problems with bladder function,
unusual menstrual cycles, pregnancy
Cognitive and social/emotional
Communication abilities (expressive
and receptive), cognition, affect, level of arousal, orientation, ability
to follow directions or learn, behavioral/emotional stressors and responses
General/ Miscellaneous
Persistent fatigue, malaise,
unexplained weight gain or loss,
fever, chills, sweats
 Evaluation

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.
 Diagnosis

•It refers to either a process or a category (label) within a

classification system.

•The diagnosis is an essential element of patient

management because it directs the physical therapy
prognosis (including the plan of care) and interventions
 Diagnostic Process

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)
(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
Key Questions to Consider During the
Evaluation and Diagnostic Processes
 Key Questions to Consider During the
Evaluation and Diagnostic Processes
• What is the extent, degree, or severity of impairments, functional limitations, or
disability?
• What is the stability or progression of dysfunction?
• Is the current condition(s) acute or chronic?
• What actions/events change (relieve or worsen) the patient’s signs and symptoms?
• How do pre-existing conditions (co-morbidities) 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 functional limitation or disability?
• What are the causal factors that seem to be contributing to the patient’s
impairments, functional limitations, or disability?
 Diagnostic Category
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)
 Prognosis and Plan of Care
A prognosis is a prediction of a patient’s optimal level of function
expected as the result of a course of treatment and the anticipated
length of time needed to reach specified functional outcomes
Factors That Influence a Patient’s Prognosis/Expected Outcomes
• Complexity, severity, acuity, or chronicity and expected
course of the patient’s condition(s) (pathology), impairments,
and functional limitations
• Patient’s general health status and presence of co morbidities
and risk factors
• 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)
 Plan of care
The plan of care, an integral component of the prognosis,
delineates the following.
•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
 Setting Goals and Outcomes in the
Plan of Care

•Anticipated goals
•Expected outcomes
•Patient-centered
 Key Questions to Establish Patient-Centered Goals and Outcomes in the Plan of Care

• What activities are most important to you at home, school, work, or

during your leisure time?
• What activities do you 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?
That is, the goals and outcomes must be meaningful to
the patient.
These goals and outcomes must also 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 that seem to be limiting the patient’s
functional abilities comes are associated with the
amelioration of functional limitations and disability to the
greatest extent possible coupled with achieving the
optimal level possible of function, general health, and
patient satisfaction
 Treatment goals should be

Specific
Measureable
Achievable
Realistic
Timely
 Intervention
Intervention, a component of patient management, refers
to any purposeful interaction a therapist has that directly
relates to a patient’s care
There are three broad areas of intervention that occur during
the course of patient management.

1. Coordination,Communication
2. Procedural interventions
3. Patient-related instruction
 Outcomes
Outcomes are monitored throughout an episode of
physical therapy care, that is, intermittently during
treatment and at the conclusion of treatment
Areas of Outcomes Assessed by Physical Therapists
• Level of a patient’s physical function
• Extent of prevention or reduced risk of occurrence
• Patient’s general health status
• Degree of patient satisfaction
 Functional Outcomes
Functional outcomes must be
Meaningful
Practical
Sustainable
 Measuring the Impact of Physical
Therapy Interventions
Outpatient
Physical
Therapy
Improvement in
Movement
Assessment
Log
developed for measuring the impact of physical
therapy interventions on function and has been
tested for validity and reliability
 Discharge Planning
A patient is discharged when

•Anticipated Goals
•Expected Outcomes has been attained

• The discharge plan often includes

•Home Program,
•Appropriate Follow-up,
•Possible Referral To Community Resources
•Reinitiation of physical therapy services(an additional episode of care) if
the patient’s needs change over time and if additional services are
approved.
 Discontinuation of services is differentiated from
discharge
Discontinuation refers to the ending of services
prior to the achievement of anticipated goals and
expected outcomes.
Factors in discontinuation of services
•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.