Clinical Decision-Making in Physical Therapy

Clinical Decision-Making

• Clinical decision-making always begins with a question that needs answering.
• Questions addressed include the most appropriate examination method, determination of the physical therapy diagnosis, and the best intervention approach/technique.
• Clinical decision-making requires ongoing, intentional adaptations and adjustments to the therapeutic plan.
• Clinical decision-making is based on knowing patients as individuals, a focus on function, expecting functional recovery through neural plasticity, and understanding neural plasticity in both intact and pathological central nervous systems (CNS).
• Skilled clinical decision-making incorporates values such as functional goals from the start, intentional prevention for optimal health, patient-centered and family-centered decisions, a holistic approach to disability, evidence-based practice, and an emphasis on carryover to home activities.

Elements of Clinical Decision-Making

• Clinical decision-making processes are multifaceted, complex, and patient-centered
• Processes involved include:
  • Clinical reasoning
  • Judgement
  • Problem-solving
• Mastery of discipline-specific knowledge and skills related to patients with neurological is essential.
• Patient participation is required.
• Therapists draw conclusions, make judgements, make decisions, and develop a plan of care (POC) with outcome assessments through clinical reasoning.
• Judgement in clinical reasoning arises from a balance of personal clinical experiences and decision algorithms.
• Decision algorithms include disability-based models and models specific to motor control & neurorehabilitation.

Review of Disability-Based Models

• There are 3 models used in rehabilitation; Nagi Model, World Health Organization (WHO), and National Center for Medical Rehabilitation Research (NCMRRR).
• The WHO uses two models;
  • International Classification of Functioning, Disability, and Health (ICF): This is the current model.
  • International Classification of Impairments, Disabilities and Handicaps (ICIDH): This is the old model.

ICF Framework

• Key components of the ICF framework include:
  • Health Condition (Disorder or Disease)
  • Body Functions and Structures
  • Activity
  • Participation
  • Environmental Factors
  • Personal Factors

Motor Control Framework: Movement Continuum

• Proposed by Hedman et al in 1996
• Serves as a conceptual framework for neurotherapeutics, providing a foundation for the analysis and treatment of movement dysfunction.
• Four basic clinical questions are used:
  • What is the problem?
  • Where in the movement continuum does the problem interfere with function?
  • What are the underlying determinants of the problem?
  • How do we treat the problem?

What is the problem?

• Identify movement dysfunction problems related to clinical components of movement.
• Components of movement: Cognitive & Psychological, Mobility, Force Generation, Adaptive capacity, Muscle tone, Sensory Information, Selective capacity, Pain, Coordination, Speed, Balance, Endurance, Posture.

Where in the movement continuum does the problem interfere with function?

• Determine how the problem impacts function across the movement continuum, which includes initial conditions, preparation, initiation, execution, and termination phases.

What are the underlying determinants of the problem?

• Identify the neural, musculoskeletal, biomechanical, and behavioral aspects of the movement that contribute to the problem.

Neurological Diagnosis

• Includes differential and physical therapy diagnosis

Neurologic Differential Diagnosis

• Sullivan et al (2004) offers a clinical decision-making model, that helps physical therapists determine if therapy is appropriate for patients with neurological pathology, or if a referral is more suitable.

Physical Therapy Diagnosis

• Information can be found in the Guide to Physical Therapist Practice, specifically within the Patient/Client Management model.
• The Patient/Client Management model includes:
  • Examination
  • Evaluation
  • Diagnosis
  • Prognosis
  • Intervention
  • Outcomes

Evaluation

• Physical Therapists make clinical judgements based on the data gathered during the examination by synthesizing all findings from history, systems review, and tests and measures to establish a diagnosis prognosis and plan of care.

Diagnosis

• Diagnosis is a label encompassing a cluster of signs and symptoms associated with a disorder, syndrome, or category of impairments in body structures and functions, activity limitations, or participation restrictions.
• Physical therapists establish diagnoses to make appropriate management decisions for individuals and determine the most appropriate intervention strategy.
• A medical diagnosis identifies a disease, disorder, or condition at the level of cell, tissue, organ, or system.
• The diagnostic process directs the therapist's priorities toward alleviating symptoms, remediating impairments, and restoring individuals to their highest levels of activity and participation.
• Diagnostic Classifications:
  • ICD-10
  • ICF
  • Movement systems

Scheets, Sahrmann, and Norton

• Proposed a system for PT diagnosis of patients with neuromuscular disorders based on movement-related impairments in 1999.
• The 1999 system focused on the impairment level signs characterizing a patient's primary movement system problem.
• A revision was published in 2007

Movement System Diagnoses

• Movement system diagnoses are based on tests & measures administered during a standardized examination.
• Includes tests for specific impairments and analyzing the observation of performance of critical tasks

Movement System Diagnoses for Patients with Neuromuscular Conditions

• Includes 9 diagnoses:
  • Movement Pattern Coordination Deficit
  • Force Production Deficit
  • Sensory Selection and Weighting Deficit
  • Perceptual Deficit
  • Fractionated Movement Deficit
  • Hypermetria
  • Hypokinesia
  • Cognitive Deficit
  • Sensory Detection Deficit