Patient Management

Chapter 2 Patient Management
Copyright 2005 Lippincott Williams & Wilkins
Patient Management Model

Examination
Evaluation
5 Elements
Diagnosis
Prognosis
Intervention
Outcome
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.
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
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.)
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.
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.
Modified Disablement Model
Patient Management
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.
Impairments
Evaluate What We Treat
Musculoskeletal Neuromuscular Cardiovascular Pulmonary Integumentary
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.
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).
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.
Disability
Involves social context of functional loss Limits patients 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
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
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!
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.
Prognosis and Plan of Care based on:

Patients health status, risk factors, and response to intervention. Patients safety, needs, and goals. Natural history and expected clinical course of pathology, impairment, or diagnosis. Results of examination, evaluation, and diagnostic processes.
Intervention
The purposeful and skilled interaction of the physical therapist with the patient using various methods and techniques to produce changes in the patients condition consistent with the evaluation, diagnosis, and prognosis.
Key is to do the right things well
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?
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)
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
Intervention
Patient-Related Instruction
Educate the patient (and involved people therapists, etc.) regarding the entire process. Treat all involved as a team.
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.
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.
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.
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?
Therapeutic Exercise Intervention Model
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
Elements of Movement System

1. 2. 3. 4. Support Functional status of cardiac, pulmonary and metabolic systems. Base Functional status of the muscular and skeletal systems. Modulator Physiologic status of the neuromuscular system. Biomechanical Functional status of static and dynamic kinetics and kinematics. Cognitive or Affective Functional status of psychological system as it relates to movement.
5.
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.
Therapeutic Exercise
Activities/Techniques
Stretching (active/passive) ROM exercises Strengthening Neuromuscular re-education Developmental activities Breathing exercises Aquatic exercises
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.
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
Dosage
1. Consider physiologic status/stage of tissues, anatomic elements, and patients ability to learn 2. Type of contraction 3. Intensity 4. Speed of activity or technique 5. Duration 6. Frequency
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.
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!
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, SEMGtriggered NMES.
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.
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.

Patient Management

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Chapter 2 Patient Management

Copyright 2005 Lippincott Williams & Wilkins