Physical Therapy: Patient and Client Management

• Chapter 4 focuses on patient and client management in physical therapy.
• It emphasizes comprehensive examination principles, disablement models, continuum of care components, history taking, systems review, and test/measure use.

Chapter Objectives

• Comprehend examination principles for comprehensiveness
• Outline disablement models, noting strengths and weaknesses
• Explain impairment distinctions and functional limits
• List continuum of care components
• Take a detailed patient history
• Explain systems review importance
• List test/measure components in the examination
• Understand value and info gained from patient observation
• Describe differences in traditional and postsurgical exams
• Explain examination vs. evaluation differences
• Explain how to determine if a technique is clinically useful
• Outline clinical documentation components

Overview

• Physical therapists must use the best research and consider patient values within evidence-based practice (EBP).
• The exam aims to ensure clinician-patient rapport for effective data exchange.
• Clinicians must communicate well, reason clinically, judge critically, decide creatively, and possess strong competence.
• Making well informed decisions in the patient's best interest is the primary duty of a clinician.
• Fundamental examination components exist even with changing patient conditions and approaches.
• Clinicians must commit to lifelong learning, seek experts, read relevant materials, attend courses, watch videos, and observe experts.
• Exceptional clinicians pair technical skills with people skills like interest, acceptance, and empathy.
• Patients serve as valuable resources, increasing clinician knowledge and skills through continuous interaction.
• The nonverbal communication, voice volume, posture, gestures, and eye contact that a clinician uses are especially important.
• Sensitivity to cultural diversity and appropriate introduction in a professional yet empathetic manner to the patient are crucial.
• Empathy involves grasping communicated ideas and emotions to gain true understanding of the patient's experience.
• Each session should end with an opportunity for patient questions and a suitable closure.

Disablement Models

• The importance of patient perception and functional outcomes has impacted physical therapy examination, evaluation and diagnosis focus.
• Traditional biomedical methods have been problematic for describing how patients function.
• Disablement patterns describe the functional consequences and connections of pain, disease, impairment, and functional limitations.
• The Guide to Physical Therapist Practice uses Nagi model with ICF consistency.
• The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization's (WHO) measurement framework.
• The Biopsychosocial Model dictates health status via biological, psychological and social interplay.

The Examination

• Examination involves gathering data from charts, caregivers, the patient, family, caretakers, and friends to identify the patient's problem.
• It confirms pre-examination hypotheses on pathology and movement dysfunction rooted in patient symptoms.
• Evaluation uses judgment to recognize symptom relationships and signs of disturbed function.
• The exam identifies impairments and functional limitations linked to injuries with scientific rigor and a predictable thought process.
• This process measures deviation from the norm using patient information, and clinical signs and findings.
• Tests are discrete, giving interpretations like present/absent or mild/moderate/severe, or continuous, providing scaled measurement data.
• Useful tests have reliability, validity, and significance.
• A reliable test produces precise, accurate, and reproducible results.
• A valid test measures its intended target.
• Significance indicates statistical probability.
• It comprises patient history, systems review, and tests/measures.
• Observation also occurs throughout.
• The American Physical Therapy Association (APTA) defines telehealth as providing secure electronic communication, healthcare services, and therapy-related information.

History

• History taking usually precedes the systems review and tests/measures.
• It helps to collect clinical data to form a diagnostic hypothesis for a complete differential diagnosis at the pathology level.

Data from Patient History

• Includes demographics like age, height, weight, marital status, and primary language.
• Includes social history of support systems, resources, culture, beliefs, and behaviors.
• Can include information about occupation, employment, and work environments.
• Includes info about patients developmental background, and hand or foot dominance.
• Includes knowledge of the patients living situation including entrances and exits to the house.
• Includes current and prior functional level information with particular reference to performed activities.
• Includes past history of the current condition including successive onsets of similar symptoms in the past and their effect on recovery.
• Includes past medical surgical history, allergies, childhood illnesses, previous traumas and any health conditions with regard to healing and exercise tolerance.
• Details about certain diseases such as rheumatoid arthritis, diabetes, and cardiovascular disease, and cancer related to familial tendencies,
• General heath is information pertaining to a review of the patients health, with particular reference to perception, function and psychology.

Subjective Examination

• Detailed effects of injury or illness on patient quality of life (including function).
• The value of the exam is to develop a working relationship and communication the patient.
• Interview of the patient should be conducted in a quiet, well-lit room that offers privacy.
• Clinician and patient should be at a similar eye level, facing each other, with comfortable space between them
• It is essential to record the history in a systematic fashion so that every question has purpose, and no subject areas are neglected.
• Formal questioning using a questionnaire helps to ensure all important questions are asked.
• The aim is to establish rapport using language they understand with open-ended questions to determine chief complaint + more specific questions to deter information.
• Clinician response should be encouraging with relevant nods of the head and questions should be neutral and unbiased of the patient.

Key Questions

• Chief complaint, mechanism of injury, it severity, and its impact on function must be determined.
• It's worth is remembering that a patient's chief complaint and chief concern can differ.
• The amount of activity is determine for symptom worsening or improvements.
• Establish baseline measurements.
• It is important that the clinician and the patient determine goals and expected outcomes.
• Determine if the patient has realistic expectations or anticipate education, treatment, etc.
• Symptoms can be experienced without clinical signs, and vice versa.
• Determine any potentially life-threatening symptoms.

Influences on Examination

• Age can play a role when identifying a patient.
• Mode of onset relates to gradual/insidous, circumstances, manner of symptoms, progression, time lines and event during the course time span to a major traumatic event like a fall.
• Location of the symptoms can be related to source conditions.
• Pain intensity and response can be a valuable way to establish patterns to indicate to potential antalgic response.
• Irritable stuctures has particular characteristics including a progressive increase in the severity of hte symptoms, increased latent responses, movement limitations, etc.
• Frequency to duration of symptoms classified to it's stage of healing: acute, subacute and chronic.

Physical Examination: Acute vs. Chronic

• Acute conditions: Present for 7-10 days
• Subacute conditions: Typically present for 10 days to weeks
• Chronic: Typically present for more than several weeks.

Behavior of Symptoms

• Whether the pain is doing, improving or unchanging that effects the clinicians view on a positive or negative outcome.
• Decrease the frequency and duration generally indicate the conditions are improving.

Aggrativaing/Easing Factors

• Effect of walking and bending, as well as sleeping position.

Nature of the Symptoms

• Determined number of symptom factros.
• Any weakness indicated should be determined, including spinal nerve root compression, etc.
• Increased sweet can also help with detection as many factors are involved, with body temperatures as results to the auntonomous system.

Other Factors

• Quality of the symptoms depends on the receptor and stimulated with the MPQ, that gives further indicators on assessing potential impairments.
• Patients with a psychosomaitc overlay and those who are involved in litigation are difficult to deal with due to certain patient types.
• What level of physcial activity the patient will require including work, leisure, and sport.
• imaging studies are more useful to test a hyopohesis.
• limitations can be used via patients history that relates back to limited examination times.

Observation

• Observational information helps with potential early signs to detect abnormalities.
• Position changes and body contour can be signficant.

Key Factors Found in Obeservation

• Initial entry and demeanor, to determine if any guarded manners.
• Gaze of the patient and presence nervousity, or general fear.
• Any exaggerated pain response, or sitting posture.
• Abusive or inappropriate relations with partners, adults, spouses or significant others.
• Unexplained bruising, or assistance requirement.
• Obvious or non-obvious finding depending on the severity of the situations mentioned.
• Deformatie issues, if any, and either structural or functional.
• Patient position of comfort for lateral ress, conjuction, etc.

Cardiovascular and Pumonary Sytem

• Heart rate, respitatoiry rate, blow pressure and edema.
• four Vitals- Temperature, heart rate, blood pressurie, repistatory and considered the 5th being pain.
• Monitoring must be conducted for cardiovascular and pumpnary, or heart disease.

Temperature

• Body Temperature-Indication about the individuals metabolic state
• Fever and pyrexia to Hypothermia

Heart Rate

• Heart contracts the rate by which blood get ejected, at which point aorta stretches.
• Taking measures and pressure points must be understood to know if one is taking accurate measurements.

Respiratory Rate

• Normal chest expanion difference with measurements of the anterior-posterior diameter.

Patterns of Breathing

• Certain respiration patterns such as Cheyenne stokes, Biot's Respiration, Kussmauls respiration,Apneustic, paradoxic.

Blood Pressure

• Measurement of the vascular resistacne to blood flow.
• There can be certain situations to have in take proper procedure, such position changes.
• Measuring, such as Edema should be taken into account.
• Integumetry and musculoskeletal, neurologic and etc must be properly examined for any integrity issues.

Neuromusclar, communication and cognition

• Neuromuscluar has general assessment and function.
• Commnunication has levels with emotional responses.

The Scanning Examination

• Followed by the History if potential issues like unexplained symptoms, or potential serious pathology related concerns.
• The specific examination techniques are then utilized to assist the patient.
• After scans done to assess status inert and corcatile, generating a works hypothesis.

Performing Examination - key facotrs

• Review scan findings and inteventions as per condtiion. -The traditional goals include determingin structure, the symptoms, refutting working hypotheses and an objective data base.

Tests and Measures

• Adjunct as the history and must obtain vaalid consent from patients to follow proper proecedure.
• All categories are provided to assess what must be done with a patient's individual case and needs.
• It requires clinician to understand how to perform.

Types of tests

• Aerobic capacity/endurance • Anthropometric characteristics • Assistive technology • Balance • Circulation (arterial, venous, lymphatic) • Community, social, and civic life • Cranial and peripheral nerve integrity • Education life • Environmental factors • Gait • Integumentary integrity • Joint integrity and mobility • Mental functions • Mobility (including locomotion) • Motor function • Muscle performance (including strength, power, endurance, and length) • Neuromotor development and sensory processing • Pain • Posture • Range of motion • Reflex integrity • Self-care and domestic life • Sensory integrity • Skeletal integrity • Ventilation and respiration • Work life Tele health can assist and be helpful. Can limit exam based on certain issues.

Observation

• Observational information, to seek that the patient can give consistuency and all relevant info that provides better understanding.

Abnormatl Considerations related to Posture

• How the patient greets the clinician to their general status and mood.
• if in fear abusive may be occuriring at homes.
• If required, ambulatory, transferring and change.
• That matches data or previous.

Factors in diagnostic deductions

• Hoarseness of voice.
• Hands, those that have moist may hyperthyroidism, or clod may be anxious.
• Expression and reactions from patients

Changes or body

• Negatie affecting center of gravity.
• Muslce changes like atomhpy
• Obvious abnormalities need clarrification

Systems and Reviews

• Serve as a guide for structures requiring to be determined and investigated.
• the anatomic physiolgic conditions to test and monitor what system.
• 4 Vital sides of tempurture heart rate and respiration all play a critical role!

History

• Patient history helps put together some ideas for diagnosis.
• Subjective parts should be understood via chart
• Certain questions help clarify and determine potential issues related to cases.
• Accurate information on the patients body is crucial to have when testing properly.

Age and Condition

• Age is key for certain factor and cases that deal with diagnosis.
• Onset must be understood, what time is what.

Motion

• Pain levels and what is going on.
• A series of factors provide a direction to follow, where issues that has limitations as needed from certain aspects.

Joint End Fell tests help with diagnosis

Mobility

• Factor of rage all joint related factors must be addressed with the MMT, but the issue can potentially turn back on.
• It. can assist that one can evaluate what's going on via how the individual is tested.