Clinical Decision Making | Physical Rehabilitation, 6e | F.A. Davis PT Collection (2022)

Steps in patient/client management include (1) examination of the patient; (2) evaluation of the data and identification of problems; (3) determination of the physical therapy diagnosis; (4) determination of the prognosis and POC; (5) implementation of the POC; and (6) reexamination of the patient and evaluation of treatment outcomes (Fig. 1.2).4

Figure 1.2

Elements of patient management leading to optimal outcomes. (From APTA Guide to Physical Therapist Practice 4, p. 35 with permission.)

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Examination

Examination involves identifying and defining the patient's problem(s) and the resources available to determine appropriate intervention. It consists of three components: the patient history, systems review, and tests and measures. Examination begins with patient referral or initial entry (direct access) and continues as an ongoing process throughout the episode of care. Ongoing reexamination allows the therapist to evaluate progress and modify interventions as appropriate.

History

Information about the patient's past history and current health status is obtained from review of the medical record and interviews (patient, family, caregivers). The medical record provides detailed reports from members of the health care team; processing these reports requires an understanding of disease and injury, medical terminology, differential diagnosis, laboratory and other diagnostic tests, and medical management. The use of resource material or professional consultation can assist the novice clinician. The types of data that may be generated from a patient history are presented in Figure 1.3.4

Figure 1.3

Types of data that may be generated from patient history. (From APTA Guide to Physical Therapist Practice 4, p. 36 with permission.)

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The interview is an important tool used to obtain information and gain understanding directly from the patient. The therapist asks the patient a series of questions regarding general health, past and present medical conditions/complications, and treatment. Specifically the patient is asked to describe the current problems, primary complaint (reason for seeking physical therapy), and anticipated goals/expected outcomes for the episode of care. The patient will often describe his or her difficulties in terms of activity limitations or participation restrictions (what he or she can or cannot do). The patient is then asked a series of questions designed to explore the nature and history of the current problems/primary complaint. General questions about functional activities and participation should be directed toward delineating the difference between capacity and performance. For example, "Since your stroke, how much difficulty do you have walking long distances?" "How does this compare to before you had the stroke?" (capacity). Questions directed toward examining performance can include "How much of a problem do you have in walking long distances?" "Is this problem with walking made worse or better with the use of an assistive device?" Questions are also posed regarding the patient's social and physical environment, vocation, recreational interests, health habits (e.g., smoking history, alcohol use), exercise likes and dislikes, and frequency and intensity of regular activity. Sample interview questions are included in Box 1.2.4,5

Pertinent information can also be obtained from the patient's family or caregiver. For example, patients with central nervous system (CNS) involvement and severe cognitive and/or communication impairments and younger pediatric patients will be unable to accurately communicate their existing problems. The family member/caregiver then assumes the primary role of assisting the therapist in identifying problems and providing relevant aspects of the history. The perceived needs of the family member or caregiver can also be determined during the interview.

The therapist should be sensitive to differences in culture and ethnicity that may influence how the patient or family member responds during the interview or examination process. Different beliefs and attitudes toward health care may influence how cooperative the patient will be. During the interview, the therapist should listen carefully to what the patient says. The patient should be observed for any physical manifestations that reveal emotional context, such as slumped body posture, grimacing, and poor eye contact. Finally, the interview is used to establish rapport, effective communication, and mutual trust. Ensuring effective communication with the patient and cooperation serves to make the therapist's observations more valid and becomes crucial to the success of the POC.

Systems Review

The use of a brief screening examination allows the therapist to quickly scan the patient's body systems and determine areas of intact function and dysfunction in each of the following systems: cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular. Information is also obtained about cognitive functions, communication, learning style, and emotional status. Areas of deficit together with an accurate knowledge of the main health condition (disorder or disease) (1) confirm the need for further or more detailed examination; (2) rule out or differentiate specific system involvement; (3) determine if referral to another health care professional is warranted (triage); and (4) focus the search of the origin of symptoms to a specific location or body part. An important starting point for identification of areas to be screened is consideration of all potential (possible) factors contributing to an observed activity limitation or participation restriction. Consultation is appropriate if the needs of the patient/client are outside the scope of the expertise of the therapist assigned to the case. For example, a patient recovering from stroke is referred to a dysphagia clinic for a detailed examination of swallowing function by a dysphagia specialist (speech-language pathologist).

Screening examinations are also used for healthy populations. For example, the physical therapist can screen individuals to identify risk factors for disease such as decreased activity levels, stress, and obesity. Screening is also conducted for specific populations such as pediatric clients (e.g., for scoliosis), geriatric clients (e.g., to identify fall risk factors), athletes (e.g., in pre-performance examinations), and working adults (e.g., to identify the risk of musculoskeletal injuries in the workplace). These screens may involve observation, chart review, oral history, and/or a brief examination. Additional screening examinations may be mandated by institutional settings. For example, in a long-term care facility, the therapist may be asked to review the chart for indications of changes in functional status or need for physical therapy. The therapist then makes a determination of the need for further physical therapy services based on completing a screening examination.

Tests and Measures

More definitive tests and measures are used to provide objective data to accurately determine the degree of specific function and dysfunction. Examination begins at the level of impairments, for example, diminished muscle strength (manual muscle test [MMT]) and impaired range of motion (ROM) (goniometric measurements), and progresses to functional activities (6-minute Walk Test, Timed Up and Go, Berg Balance Test). Alternatively, the therapist may begin with an examination of functional performance, during which the therapist analyzes the differences between the patient's performance and the "typical" or expected performance of a task. For example, the patient with stroke is asked to transfer from bed to wheelchair. The therapist observes the performance and determines that the patient lacks postural support (stability), adequate lower extremity (LE) extensor strength to reach the full upright position, and adequate ROM in ankle dorsiflexors. The therapist then progresses to a detailed examination of impairments. The decision as to which approach to use is based on the results of the screening examination and the therapist's knowledge of the health condition. Key information to obtain during an examination of function is the level of independence or dependence, as well as the need for physical assistance, external devices, or environmental modifications.

Box 1.2: Sample Interview Questions

  1. Interview questions designed to identify the nature and history of the current problem(s):

    • What problems bring you to therapy?

    • When did the problem(s) begin?

    • What happened to precipitate the problem(s)?

    • How long has the problem(s) existed?

    • How are you taking care of the problem(s)?

    • What makes the problem(s) better?

    • What makes the problem(s) worse?

    • What are your goals and expectations for physical therapy?

    • Are you seeing anyone else for the problem(s)?

  2. Interview questions designed to identify desired outcomes in terms of essential functional activities include the following:

    • What activities do you normally do at home/work/school?

    • What activities are you unable to do?

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    • What activities are done differently and how are they different (i.e., extra time, extra effort, different strategy)?

    • What activities do you need help to perform that you would rather do yourself?

    • What leisure activities are important to you?

    • How can I help you be more independent?

  3. Interview questions designed to identify environmental conditions in which patient activities typically occur include the following:

    • Describe your home/school/work environment.

    • How do you move around/access areas in the home (i.e., bathroom, bedroom, entering and exiting the home)? How safe do you feel?

    • How do you move around/access areas in the community (i.e., workplace, school, grocery store, shopping center, community center, stairs, curbs, ramps)? How safe do you feel?

  4. Interview questions designed to identify available social supports include the following:

  5. Interview questions designed to identify the patient's knowledge of potential disablement risk factors include the following:

    • What problems might be anticipated in the future?

    • What can you do to eliminate or reduce the likelihood of that happening?

Sources: Section I: from the Documentation Template for Physical Therapist Patient/Client Management in the Guide to Physical Therapist Practice (4, pp. 707–712); Sections II–IV adapted from Randall (5, p. 1,200).

Adequate training and skill in performing specific tests and measures are crucial in ensuring both validity and reliability of the tests. Failure to correctly perform an examination procedure can lead to the gathering of inaccurate data and the formation of an inappropriate POC. Later chapters focus on specific tests and measures and discuss issues of validity and reliability. The use of disability-specific standardized instruments (e.g., for individuals with stroke, the Fugl-Meyer Assessment of Physical Performance) can facilitate the examination process but may not always be appropriate for each individual patient. The therapist needs to carefully review the unique problems of the patient to determine the appropriateness and sensitivity of an instrument. Box 1.3 presents the categories for tests and measures identified in the Guide to Physical Therapist Practice.4

Novice therapists should resist the tendency to gather excessive and extraneous data in the mistaken belief that more information is better. Unnecessary data will only confuse the picture, rendering clinical decision making more difficult and unnecessarily raising the cost of care. If problems arise that are not initially identified in the history or systems review, or if the data obtained are inconsistent, additional tests or measures may be indicated. Consultation with an experienced therapist can provide an important means of clarifying inconsistencies and determining the appropriateness of specific tests and measures.

Evaluation

Data gathered from the initial examination must then be organized and analyzed. The therapist identifies and prioritizes the patient's impairments, activity limitations, and participation restrictions and develops a problem list. It is important to accurately recognize those clinical problems associated with the primary disorder and those associated with co-morbid conditions. Table 1.1 presents a sample prioritized problem list.

Table 1.1Sample Prioritized Problem List for a Patient With Stroke

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Table 1.1 Sample Prioritized Problem List for a Patient With Stroke

Direct Impairments Indirect Impairments Composite Impairments Activity Limitations Participation Restrictions
R hemiparesis RUE > RLE R shoulder subluxation Balance deficits Standing > sitting Dep bed mobility: minA Dec community mobility
Dec ROM R shoulder Gait deficits Dep BADL: min/mod A IADL: unable
Hypotonicity RUE Kyphosis, forward head Dec endurance Dep transfers: modAX 1 Dec ability to perform social roles: husband
Spasticity RLE: knee ext, plant i'flexors Dep locomotion: modAX 1
Synergy patterns RLE > RUE Stairs: unable
Mild dysarthria Inc fall risk
Mild cognitive deficits: dec STM
Dec motor planning ability
CO-MORBIDITIES: Diabetic Peripheral Neuropathy
Dec sensation both feet Dec balance Inc fall risk
Small ulcer L foot (5th toe) Dec endurance
Gait deficits: requires special shoes Dec community mobility

Contextual factors: physical, social, attitudinal

One-level ranch house; entry with 2 steps, no handrails

Highly motivated

Personal factors: individual's life and living situation

Spouse is primary caregiver; has osteoporosis and decreased vision (bilateral cataracts).

Has 2 involved sons living within 30 mile radius.

Key: BADL: basic activities of daily living; Dec: decreased; Dep: dependent; IADL: instrumental activities of daily living; Inc: increased; minA: minimal assistance; modA: moderate assistance; RLE: right lower extremity; RUE: right upper extremity;

STM: short term memory.

Impairments, activity limitations, and participation restrictions must be analyzed to identify causal relationships. For example, shoulder pain in the patient with hemiplegia may be due to several factors, including hypotonicity and loss of voluntary movement, which are direct impairments, or soft tissue damage/trauma from improper transfers, which is an indirect impairment, resulting from an activity. Determining the causative factors is a difficult yet critical step in determining appropriate treatment interventions and resolving the patient's pain.

Box 1.3: Categories for Tests and Measures

Aerobic Capacity/Endurance

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Anthropometric Characteristics

Arousal, Attention, and Cognition

Assistive and Adaptive Devices

Circulation (Arterial, Venous, Lymphatic)

Cranial and Peripheral Nerve Integrity

Environmental, Home, and Work (Job/School/Play) Barriers

Ergonomics and Body Mechanics

Gait, Locomotion, and Balance

Integumentary Integrity

Joint Integrity and Mobility

Motor Function (Motor Control and Motor Learning)

Muscle Performance (Including Strength, Power, and Endurance)

Neuromotor Development and Sensory Integration

Orthotic, Protective, and Supportive Devices

Pain

Posture

Prosthetic Requirements

Range of Motion (Including Muscle Length)

Reflex Integrity

Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living)

Sensory Integrity

Ventilation and Respiration/Gas Exchange

Work (Job/School/Play), Community, and Leisure

Integration or Reintegration (Including Instrumental Activities of Daily Living)

Adapted from APTA Guide to Physical Therapist Practice.4

The skilled clinician is able to identify the role barriers and facilitators in the patient's environment in order to incorporate measures to minimize or maximize these factors into the POC. A POC that emphasizes and reinforces facilitators enhances function and the patient's ability to experience success. Improved motivation and engagement are the natural outcomes of reinforcement of facilitators. For example, the patient with stroke may have intact communication skills, cognitive skills, and good function of the uninvolved extremities. Facilitators can also include supportive and knowledgeable family members/caregivers and an appropriate living environment.

Diagnosis

A medical diagnosis refers to the identification of a disease, disorder, or condition (pathology/pathophysiology) by evaluating the presenting signs, symptoms, history, laboratory test results, and procedures. It is identified primarily at the cellular level. Physical therapists use the term diagnosis to "identify the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person."4 Thus, the term is used to clarify the professional body of knowledge as well as the role of physical therapists in health care. For example:

Medical diagnosis: Cerebrovascular accident (CVA)

Physical therapy diagnosis: Impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system—acquired in adolescence or adulthood4, p. 365

Medical diagnosis: Spinal cord injury (SCI)

Physical therapy diagnosis: Impaired motor function, peripheral nerve integrity, and sensory integrity associated with nonprogressive disorders of the spinal cord4, p. 437

The diagnostic process includes integrating and evaluating the data obtained during the examination to describe the patient/client condition in terms that will guide the prognosis and selection of intervention strategies during the development of the POC. The Guide to Physical Therapist Practice organizes diagnostic categories specific to physical therapy by preferred practice patterns.4 There are four main categories of conditions: Musculoskeletal, Neuromuscular, Cardiovascular/Pulmonary, and Integumentary, with preferred practice patterns identified in each (see Appendix 1.A). The patterns are described fully according to the five elements of patient/client management (i.e., examination, evaluation, diagnosis, prognosis, and intervention). Each pattern also includes reexamination to evaluate progress, global outcomes, and criteria for termination of physical therapy services. Inclusion and exclusion criteria for each practice pattern and criteria for multiple-pattern classification are also presented. The patterns represent the collaborative effort of experienced physical therapists who detailed the broad categories of problems commonly seen by physical therapists within the scope of their knowledge, experience, and expertise. Expert consensus was thus used to develop and define the diagnostic categories and preferred practice patterns. Given the central role of physical therapists as movement specialists, the therapist will need to focus the diagnosis on the results of activity analysis and movement problems identified during the examination when formulating the prognosis and POC.

The use of diagnostic categories specific to physical therapy, as Sarhman points out, (1) allows for successful communication with colleagues and patients/caregivers about the conditions that require the physical therapist's expertise, (2) provides an appropriate classification for establishing standards of examination and treatment, and (3) directs examination of treatment effectiveness, thereby enhancing evidence-based practice.6 Physical therapy diagnostic categories also facilitate successful reimbursement when linked to functional outcomes and enhance direct access of physical therapy services.

Prognosis

The term prognosis refers to "the predicted optimal level of improvement in function and amount of time needed to reach that level."4, p. 46 An accurate prognosis may be determined at the onset of treatment for some patients. For other patients with more complicated conditions such as severe traumatic brain injury (TBI) accompanied by extensive disability and multisystem involvement, a prognosis or prediction of level of improvement can be determined only at various increments during the course of rehabilitation. Knowledge of recovery patterns (stage of disorder) is sometimes useful to guide decision making. The amount of time needed to reach optimal recovery is an important determination, one that is required by Medicare and many other insurance providers. Predicting optimal levels of recovery and time frames can be a challenging process for the novice therapist. Use of experienced, expert staff as resources and mentors can facilitate this step in the decision making process. For each preferred practice pattern, the Guide to Physical Therapist Practice includes a broad range of expected number of visits per episode of care.4

Plan of Care

The plan of care (POC) outlines anticipated patient management. The therapist evaluates and integrates data obtained from the patient/client history, the systems review, and tests and measures within the context of other factors, including the patient's overall health, availability of social support systems, living environment, and potential discharge destination. Multisystem involvement, severe impairment and functional loss, extended time of involvement (chronicity), multiple co-morbid conditions, and medical stability of the patient are important parameters that increase the complexity of the decision making process.

A major focus of the POC is producing meaningful changes at the personal/social level by reducing activity limitations and participation restrictions. Achieving independence in locomotion or activities of daily living (ADL), return to work, or participation in recreational activities is important to the patient/client in terms of improving quality of life (QOL).7 QOL is defined as the sense of total well-being that encompasses both physical and psychosocial aspects of the patient/client's life. Finally, not all impairments can be remediated by physical therapy. Some impairments are permanent or progressive, the direct result of unrelenting pathology such as amyotrophic lateral sclerosis (ALS). In this example, a primary emphasis on reducing the number and severity of indirect impairments and activity limitations is appropriate.

Essential components of the POC include (1) anticipated goals and expected outcomes; (2) the predicted level of optimal improvement; (3) the specific interventions to be used, including type, duration, and frequency; and (4) criteria for discharge.

Goals and Expected Outcomes

An important first step in the development of the POC is the determination of anticipated goals and expected outcomes, the intended results of patient/client management. Goal and outcome statements address patient-identified priorities and predicted changes in impairments, activity limitations, and participation restrictions. They also address predicted changes in overall health, risk reduction and prevention, wellness and fitness, and optimization of patient/client satisfaction. The difference is in terms of time frame. Outcomes define the patient's expected level at the conclusion of the episode of care or rehabilitation stay, whereas goals define the interim steps that are necessary to achieve expected outcomes.4

Goal and outcome statements should be realistic, objective, measurable, and time limited. There are four essential elements:

  • Individual: Who will perform the specific behavior or activity required or aspect of care? Goals and outcomes are focused on the patient/client. This includes individuals who receive direct care physical therapy services and/or individuals who benefit from consultation and advice, or services focused on promoting, health, wellness, and fitness. Goals can also be focused on family members or caregivers, for example, the parent of a child with a developmental disability.

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  • Behavior/Activity: What is the specific behavior or activity the patient/client will demonstrate? Goals and outcomes include changes in impairments (e.g., ROM, strength, balance) and changes in activity limitations (e.g., transfers, ambulation, ADL) or participation restrictions (e.g., community mobility, return to school or work).

  • Condition: What are the conditions under which the patient/client's behavior is measured? The goal or outcome statement specifies the specific conditions or measures required for successful achievement, for example, distance achieved, required time to perform the activity, the specific number of successful attempts out of a specific number of trials. Statements focused on functional changes should include a description of the conditions required for acceptable performance. For example, the functional levels of performance in the Functional Independence Measure (FIM) are used in the majority of rehabilitation centers in the United States. This instrument grades levels from No Helper/Independence (grade 7) to No Helper/Modified Independence (grade 6; device), to Helper/Modified Dependence (grades 5, 4, and 3; supervision, minimal, moderate, assistance), to Helper/Complete Dependence (grades 2 and 1; maximal, total assistance) (see Chapter 8 and Figure 8.5 for a complete description of this instrument).8 The type of environment required for a successful outcome of the behavior should also be specified: clinic environment (e.g., quiet room, level floor surface, physical therapy gym), home (e.g., one flight of eight stairs, carpeted surfaces), and community (e.g., uneven grassy surfaces, curbs, ramps).

  • Time: How long will it take to achieve the stated goal or outcome? Goals can be expressed as short-term (generally considered to be 2 to 3 weeks) and long-term (longer than 3 weeks). Outcomes describe the expected level of functional performance attained at the end of the episode of care or rehabilitation stay. In instances of severe disability and incomplete recovery, for example, the patient with traumatic brain injury, the therapist, and team members may have difficulty determining the expected outcomes at the beginning of rehabilitation. Long-term goals can be used that focus on the expectations for a specific stage of recovery (e.g., minimally conscious states, confusional states). Goals and outcomes can also be modified following a significant change in patient status.

Each POC has multiple goals and outcomes. Goals may be linked to the successful attainment of more than one outcome. For example, attaining ROM in dorsiflexion is critical to the functional outcomes of independence in transfers and locomotion. The successful attainment of an outcome is also dependent on achieving a number of different goals. For example, independent locomotion (the outcome) is dependent on increasing strength, ROM, and balance skills. In formulating a POC, the therapist accurately identifies the relationship between and among goals and sequences them appropriately. Box 1.4 presents examples of outcome and goal statements.

In rehabilitation settings, the POC also includes a statement regarding the patient's overall rehabilitation potential. This is typically a one-word statement: excellent, good, fair, or poor. The therapist considers multiple factors when determining rehabilitation potential, such as the patient's condition and onset date, co-morbidity, mechanism of injury, and baseline data.

Box 1.4 Examples of Outcome and Goal Statements

The following are examples of expected outcomes, all to be achieved within the anticipated rehab stay:

The patient will be independent and safe in ambulation using an ankle-foot orthosis and a quad cane on level surfaces for unlimited community distances and for all daily activities within 8 weeks.

The patient will demonstrate modified dependence with close supervision in wheelchair propulsion for limited household distances (up to 50 feet) within 8 weeks.

The patient will demonstrate modified dependence with minimum assistance of one person for all transfer activities in the home environment within 6 weeks.

The patient will demonstrate independence in basic activities of daily living (BADL) with minimal setup and equipment (use of a reacher) within 6 weeks.

The patient and family will demonstrate enhanced decision making skills regarding the health of the patient and use of health care resources within 6 weeks.

The following are examples of anticipated goals with variable time frames:

Short-Term Goals

The patient will increase strength in shoulder depressor muscles and elbow extensor muscles in both upper extremities from good to normal within 3 weeks.

The patient will increase ROM 10 degrees in knee extension bilaterally to within normal limits within 3 weeks.

The patient will be independent in the application of lower extremity orthoses within 1 week.

The patient and family will recognize personal and environmental factors associated with falls during ambulation within 2 weeks.

The patient will attend to task for 5 min out of a 30-min treatment session within 3 weeks.

Long-Term Goals

The patient will independently perform transfers from wheelchair to car within 4 weeks.

The patient will ambulate with bilateral knee-ankle-foot orthoses (KAFOs) and crutches using a swing-through gait and close supervision for 50 feet within 5 weeks.

The patient will maintain static balance in sitting with centered, symmetrical weight-bearing and no upper extremity support or loss of balance for up to 5 minutes within 4 weeks.

The patient will sequence a three- to five-step routine task with minimum assistance within 5 weeks.

Interventions

The next step is to determine the intervention, defined as the purposeful interaction of the physical therapist with the patient/client and, when appropriate, other individuals involved in the care of the patient/client, using various physical therapy procedures and techniques to produce changes in the condition. Components of physical therapy intervention include coordination, communication, and documentation; patient/client-related instruction; and procedural interventions (Fig. 1.4).4

Figure 1.4

The three components of physical therapy intervention. (From APTA Guide to Physical Therapist Practice 4, p. 98 with permission.)

Coordination and Communication

Case management requires therapists to be able to communicate effectively with all members of the rehabilitation team, directly or indirectly. For example, the therapist communicates directly with other professionals at case conferences, team meetings, or rounds or indirectly through documentation in the medical record. Effective communication enhances collaboration and understanding.

Therapists are also responsible for coordinating care at many different levels. The therapist delegates appropriate aspects of treatment to physical therapy assistants and oversees the responsibilities of physical therapy aides. The therapist coordinates care with other professionals, family, or caregivers regarding a specific treatment approach or intervention. For example, for early transfer training to be effective, consistency in how everyone transfers the patient is important. The therapist also coordinates discharge planning with the patient and family and other interested persons. Therapists may be involved in providing POC recommendations to other facilities such as restorative nursing facilities.

Patient/Client-Related Instruction

In an era of managed care and shorter time allocations for an episode of care, effective patient/client-related instruction is critical to ensuring optimal care and successful rehabilitation. Communication strategies are developed within the context of the patient/client's age, cultural backgrounds, language skills, and educational level, and the presence of specific communication or cognition impairments. Therapists may provide direct one-on-one instruction to a variety of individuals, including patients, clients, families, caregivers, and other interested persons. Additional strategies can include group discussions or classes, or instruction through printed or audiovisual materials. Educational interventions are directed toward ensuring an understanding of the patient's condition, training in specific activities and exercises, determining the relevance of interventions to improve function, and achieving an expected course. In addition, educational interventions are directed toward ensuring a successful transition to the home environment (instruction in home exercise programs [HEP]), returning to work (ergonomic instruction), or resuming social activities in the community (environmental access). It is important to document what was taught, who participated, when the instruction occurred, and overall effectiveness. The need for repetition and reinforcement of educational content should also be documented in the medical record.

Procedural Interventions

Skilled physical therapy includes a wide variety of procedural interventions, which can be broadly classified into three main groups. Restorative interventions are directed toward remediating or improving the patient's status in terms of impairments, activity limitations, participation restrictions, and recovery of function. The involved segments are targeted for intervention. This approach assumes an existing potential for change (e.g., neuroplasticity of brain and spinal cord function; potential for muscle strengthening or improving aerobic endurance). For example, the patient with incomplete spinal cord injury (SCI) undergoes locomotor training using body weight support and a treadmill (BWSTT). Patients with chronic progressive pathology (e.g., the patient with Parkinson's disease) may not respond to restorative interventions aimed at resolving direct impairments; interventions aimed at restoring or optimizing function and modifying indirect impairments can, however, have a positive outcome.

Compensatory interventions are directed toward promoting optimal function using residual abilities. The activity (task) is adapted (changed) in order to achieve function. The uninvolved or less involved segments are targeted for intervention. For example, the patient with left hemiplegia learns to dress using the right upper extremity (UE); the patient with complete T1 paraplegia learns to roll using upper extremities (UEs) and momentum. Environmental adaptations are also used to facilitate relearning of functional skills and optimal performance. For example, the patient with TBI is able to dress by selecting clothing from color-coded drawers. Compensatory interventions can be used in conjunction with restorative interventions to maximize function or when restorative interventions are unrealistic or unsuccessful.

Preventative interventions are directed toward minimizing potential problems (e.g., anticipated indirect impairments, activity limitations, and participation restrictions) and maintaining health. For example, early resumption of upright standing using a tilt table minimizes the risk of pneumonia, bone loss, and renal calculi in the patient with SCI. A successful educational program for frequent skin inspection can prevent the development of pressure ulcers in that same patient with SCI.

Interventions are chosen based on the medical diagnosis, the evaluation of examination, the physical therapy diagnosis, the prognosis, and the anticipated goals and expected outcomes. The therapist relies on knowledge of foundational science and interventions (e.g., principles of motor learning, motor control, muscle performance, task-specific training, and cardiovascular conditioning) in order to determine those interventions that are likely to achieve successful outcomes. It is important to identify all possible interventions early in the process, to carefully weigh those alternatives, and then to decide on the interventions that have the best probability of success. Narrowly adhering to one treatment approach reduces the available options and may limit or preclude successful outcomes. Use of a protocol (e.g., predetermined exercises for the patient with hip fracture) standardizes some aspects of care but may not meet the individual needs of the patient. Protocols can foster a separation of examination/evaluation findings from the selection of treatments.

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Watts suggests that clinical judgment is clearly an elegant mixture of art and science.9 Professional consultation with expert clinicians and mentors is an effective means of helping the novice sort through the complex issues involved in decision making, especially when complicating factors intervene. For example, a consultation would be beneficial for the inexperienced therapist who is treating a patient that is chronically ill, has multiple co-morbidities or complications, impaired cognition, inadequate social supports, and severe activity limitations.

A general outline of the POC is constructed. Schema can be used to present a framework for approaching a specific aspect of treatment and assist the therapist in organizing essential intervention elements of the plan. One such commonly used schema for exercise intervention is the FITT equation (frequency-intensity-time-type), presented in Box 1.5.

The therapist should ideally choose interventions that accomplish more than one goal and are linked to the expected outcomes. The interventions should be effectively sequenced to address key impairments first and to achieve optimum motivational effect, interspacing the more difficult or uncomfortable procedures with easier ones. The therapist should include tasks that ensure success during the treatment session and, whenever possible, should end each session on a positive note. This helps the patient retain a positive feeling of success and look forward to the next treatment.

Discharge Planning

Discharge planning is initiated early in the rehabilitation process during the data collection phase and intensifies as goals and expected outcomes are close to being reached. Discharge planning may also be initiated if the patient refuses further treatment or becomes medically or psychologically unstable. If the patient is discharged before outcomes are reached, the reasons for discontinuation of services must be carefully documented. Elements of an effective discharge plan are included in Box 1.6.

The therapist should also include the discharge prognosis, typically a one-word response such as excellent, good, fair, or poor. It reflects the therapist's judgment of the patient's ability to maintain the level of function achieved at the end of rehabilitation without continued skilled intervention.

Implementation of the Plan of Care

The therapist must take into account a number of factors in structuring an effective treatment session. The patient's comfort and optimal performance should be a priority. The environment should be structured appropriately to reduce distractions and focus the patient's attention on the task. Patient privacy should be respected, with adequate draping and positioning. The therapist should consider good body mechanics, effective use of gravity and position, and correct application of techniques and modalities. Any equipment should be gathered prior to treatment and be in good working order. All safety precautions must be observed.

Box 1.5 The FITT Equation for Exercise Intervention

Frequency: How often will the patient receive skilled care?

This is typically defined in terms of the number of times per week treatment will be given (e.g., daily or three times per week), or the number of visits before a specific date.

Intensity: What is the prescribed intensity of exercises or activity training?

For example, the POC includes sit-to-stand repetitions, 3 sets of 5 reps each, progressing from high seat to low.

Time (duration): How long will the patient receive skilled care?

This is typically defined in terms of days or weeks (e.g., three times per week for 6 weeks). The duration of an anticipated individual treatment session should also be defined (e.g., 30- or 60-minute sessions).

Type of intervention: What are the specific exercise strategies or procedural interventions used?

Necessary components that should be identified include the following:

  • Posture and activity: a description of the specific posture and activity the patient must perform (e.g., sitting, weight shifting or standing, modified plantigrade, reaching).

  • Techniques used: mode of therapist action or intervention used (e.g., guided, active-assisted, or resisted movement), or specific technique (e.g., rhythmic stabilization, dynamic reversals).

  • Motor learning strategies used: strategies specific to type of feedback (e.g., knowledge of results, knowledge of performance) and scheduling of feedback (e.g., constant or variable), practice schedule (e.g., blocked, serial, or random order), and environment (e.g., closed/structured or open/variable).

  • Additional required elements: those elements necessary to assist the patient in the exercise or activity (e.g., verbal cues, manual contacts) or equipment (e.g., elastic band resistance, therapy ball, body weight support system with motorized treadmill).

Box 1.6 Elements of the Discharge Plan

Patient, family, or caregiver education: instruction includes information regarding the following:

  • Current condition (pathology), impairments, activity limitations, and participation restrictions

  • Ways to reduce risk factors for recurrence of condition and developing complications, indirect impairments, activity limitations, and participation restrictions

  • Ways to maintain/enhance performance and functional independence

  • Ways to foster healthy habits, wellness, and prevention

  • Ways to assist in transition to a new setting (e.g., home, skilled nursing facility)

  • Ways to assist in transition to new roles

Plans for follow-up care or referral to another agency: patient/caregiver is provided with the following:

  • Information regarding follow-up visit to rehabilitation center or referral to another agency (e.g., home care agency, outpatient facility) as needed

  • Information regarding community support group and community fitness center as appropriate

Instruction in a home exercise plan (HEP): patient/caregiver instruction regarding the following:

  • Home exercises, activity training, ADL training

  • Use of adaptive equipment (e.g., assistive devices, orthoses, wheelchairs)

Evaluation/modification of the home environment:

  • Planning regarding the home environment and modifications needed to assist the patient in the home (e.g., installation of ramps and rails, bathroom equipment such as tub seats, raised toilet seats, bathroom rails, furniture rearrangement or removal to ease functional mobility)

  • All essential equipment and renovations should be in place before discharge

The patient's pretreatment level of function or initial state should be carefully examined. General state organization of the CNS and homeostatic balance of the somatic and autonomic nervous systems are important determinants of how a patient may respond to intervention.

A wide range of influences, from emotional to cognitive to organic, may affect how a patient reacts to a particular treatment. Patients who are overly stressed may demonstrate altered homeostatic responses. For example, the patient with TBI who presents with high arousal and agitated behaviors can be expected to react to treatment in unpredictable ways, characterized by "fight or flight" responses. Similarly, patients with TBI who are lethargic may be difficult to arouse and demonstrate limited ability to participate in therapy sessions. Responses to treatment should be carefully monitored throughout the episode of care, and treatment modifications should be implemented as soon as needed to ensure successful performance. Therapists develop the "art of clinical practice" by learning to adjust their input (e.g., verbal commands and manual contacts) in response to the patient. Treatment thus becomes a dynamic and interactive process between patient and therapist. Shaping of behavior can be further enhanced by careful orientation to the purpose of the tasks and how they meet the patient's needs, thereby ensuring optimal cooperation and motivation.10

Reexamination of the Patient and Evaluation of Expected Outcomes

This last step is ongoing and involves continuous reexamination of the patient and a determination of the efficacy of treatment. Reexamination data are evaluated within the context of the patient's progress toward anticipated goals and expected outcomes set forth in the POC. A determination is made whether the goals and outcomes are reasonable given the patient's diagnosis and progress. If the patient attains the desired level of competence for the stated goals, revisions in the POC are indicated. If the patient attains the desired level of competence for the expected outcomes, discharge is considered. If the patient fails to achieve the stated goals or outcomes, the therapist must determine why. Were the goals and outcomes realistic given the clinical problems and database? Were the interventions selected at an appropriate level to challenge the patient, or were they too easy or too difficult? Were facilitators appropriately identified and the patient sufficiently motivated? Were intervening and constraining factors (barriers) identified? If the interventions were not appropriate, additional information is sought, goals modified, and different treatment interventions selected. Revision in the POC is also indicated if the patient progresses more rapidly or slowly than expected. Each modification must be evaluated in terms of its overall impact on the POC. Thus, the plan becomes a fluid statement of how the patient is progressing and what goals and outcomes are achievable. Its overall success depends on the therapist's ongoing clinical decision making skills and on engaging the patient's cooperation and motivation. Patient involvement in the development and monitoring of the POC should be documented.

Videos

1. Patient Management
(Nicole Patterson)
2. Neurodynamics | ULTT (active progressions - Part 1)
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3. Dr. Julie Tilson- USC Hybrid DPT Program
(Healthcare Education Transformation Podcast)
4. Critical Thinking and Nursing Process- Practice Q&A
(Nexus Nursing)
5. Episode 373 - What does a leader DO?
(The Institute of Clinical Excellence)
6. How to Answer Behavioral Interview Questions Sample Answers
(Self Made Millennial)

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