Therapeutic exercise foundation and techniques

Therapeutic exercise foundation and concepts Part II

PATIENT MANAGEMENT AND CLINICAL DECISIONMAKING:

AN INTERACTIVE RELATIONSHIP

Clinical decision making

refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations in the

context of patient care.

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 search4. Integrate the appraisal of the evidence with clinicalexpertise and experience and the patient’s unique circumstancesand values to make decisions.5. Incorporate the findings and decisions into patient management.6. Assess the outcomes of interventions and ask anotherquestion if necessary.

Online database resources

•Cochrane Database of Systematic Review

http://www.updatesoftware.com/publications/cochrane/

•PEDro website www.PEDro.fhs.usyd.edu.au/

A Patient Management ModelThe process of patient management has five basiccomponents.

1.Examination

Three distinct elements of a comprehensive examination

1. The patient’s health history2. A relevant systems review3. Specific tests and measures

Information Generated from the Initial History

Systems Review

Specific Tests and Measures

Some examples of specific tests and measures for musculoskeletal system:– Assessment of pain– Goniometry– Joint mobility, stability, and integrity tests (including

ligamentous testing)– Tests of muscle performance (manual muscle testing,– dynamometry)– Posture analysis– Gait analysis– Assessment of assistive, adaptive, or orthotic devices

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.

Evaluation

• A patient’s general health status and its impact on current and potential function

• The acuity or chronicity and severity of the current condition(s)• The extent of impairments of body systems and impact on

functional abilities• A patient’s current, overall level of physical function (limitations

and abilities) compared with the functional abilities needed, expected, or desired by the patient

• The impact of physical dysfunction on social/emotional function

• The impact of the physical environment on a patient’s function• A patient’s social support systems and their impact on current,

desired, and potential function

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

Diagnostic Process

• Through the diagnostic process a physical therapist classifies dysfunction (most often, movement

dysfunction), whereas a physician identifies disease.• For the physical therapist, the diagnostic process

focuses on the consequences of a disease or health disorder and is a mechanism by which discrepancies and consistencies between a patient’s desired level of function and his or her capacity to achieve that level of function are Identified.

Key Questions to Consider During theEvaluation and Diagnostic Processes

Diagnostic Category

A diagnostic classification system recently developed

by physical therapists is useful for delineating

the knowledge base and scope of practice of

physical therapy

Prognosis and Plan of CareA 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

PROGNOSIS IS A CHALLANGING PROCESS

Prognosis prediction is easier foran otherwise healthy and fit 70-year-old patient who was just discharged from the hospital after a total knee replacement is referred for home-based physical therapy services, OR a patient who has sustained multiple fractures and soft tissue injuries as the result of an automo-bile accident.

Plan of careThe plan of care, an integral component of the prognosis,delineates the following.•Anticipated goals•Expected functional outcomes that are meaningful, 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

Intervention

Intervention, a component of patient management, refersto any purposeful interaction a therapist has with the patient,

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,Documentation2. Procedural interventions3. Patient-related instruction

OutcomesOutcomes are monitored throughout an episode of physical therapy care, that is, intermittently during

treatment and at the conclusion of treatment

Functional Outcomes

Functional outcomes must be meaningful, practical, and sustainable

Discharge PlanningA patient is discharged when •Anticipated Goals •Expected Outcomes have 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)

Discontinuation of services is differentiated from discharge

Discontinuation refers to the ending of servicesprior 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.