Therapeutic Exercise: Foundational Concepts PDF

5850_Ch01_001-042 17/08/17 5:59 PM Page 1 CHAPTER...

5850_Ch01_001-042 17/08/17 5:59 PM Page 1 CHAPTER I 1 General Concepts Therapeutic Exercise: Foundational Concepts VICKY N. HUMPHREY, PT, MS LYNN ALLEN COLBY, PT, MS Therapeutic Exercise: Impact on Models of Functioning and Strategies for Effective Exercise Physical Function 1 Disability—Past and Present 4 and Task-Specific Instruction 27 Definition of Therapeutic Components of the ICF and Health Literacy 27 Exercise 2 Applications in Physical Preparation for Exercise Components of Physical Function Therapy 6 Instruction 27 Related to Movement: Definition Principles of Comprehensive Patient Concepts of Motor Learning: A of Key Terms 2 Management 11 Foundation for Exercise and Types of Therapeutic Exercise Clinical Decision-Making 12 Task-Specific Instruction 27 Interventions 3 Coordination, Communication, Adherence to Exercise 35 Exercise Safety 3 and Documentation 12 Independent Learning Activities 37 Classification of Health Status, Evidence-Based Practice 13 Functioning, and Disability—Evolution A Patient Management Model 14 of Models and Related Terminology 4 Background and Rationale for Classification Systems 4 A lmost everyone, regardless of age, values the ability to func- develop therapeutic exercise programs that culminate in pos- tion as independently as possible during activities of everyday itive and meaningful functional outcomes for patients and life. Health-care consumers (patients and clients) typically seek clients, a therapist must understand the relationships among out or are referred for physical therapy services because of phys- physical functioning, health, and disability and apply these ical impairments associated with disorders of the movement conceptual relationships to patient/client management to fa- system caused by injury, disease, or health-related conditions cilitate the provision of effective and efficient health-care that restrict their ability to participate in any number of activ- services. Lastly, a therapist, as a patient/client educator, must ities that are necessary or important to them. Physical therapy know and apply principles of motor learning and motor skill services may also be sought by individuals who have no im- acquisition to exercise instruction and functional training. pairments or functional deficits but who wish to improve their Therefore, the purpose of this chapter is to present an overall level of fitness and quality of life or reduce the risk of overview of the scope of therapeutic exercise interventions injury or disease. An individually designed therapeutic exercise used in physical therapy practice. This chapter also discusses program is almost always a fundamental component of the several models of health, functioning, and disability as well physical therapy services provided. This stands to reason be- as patient/client management as they relate to therapeutic cause the ultimate goal of a therapeutic exercise program is the exercise and explores strategies for teaching and progressing achievement of an optimal level of symptom-free movement exercises and functional motor skills based on principles of during basic to complex physical activities. motor learning. To develop and implement effective exercise interventions, a therapist must understand how the many forms of exercise affect tissues of the body and body systems and how those exercise-induced effects have an impact on key aspects of Therapeutic Exercise: Impact physical function as they relate to the human movement sys- on Physical Function tem. A therapist must also integrate and apply knowledge of anatomy, physiology, kinesiology, pathology, and the behav- Of the many procedures used by physical therapists in the ioral sciences across the continuum of patient/client manage- continuum of care of patients and clients, therapeutic exercise ment from the initial examination to discharge planning. To takes its place as one of the key elements that lies at the center 1 5850_Ch01_001-042 17/08/17 5:59 PM Page 2 2 Therapeutic Exercise: Impact on Physical Function of programs designed to improve or restore an individual’s function or to prevent dysfunction.4 Definition of Therapeutic Exercise Therapeutic exercise 4,5 is the systematic, planned performance of physical movements, postures, or activities intended to provide a patient/client with the means to: Remediate or prevent impairments of body functions and structures. Improve, restore, or enhance activities and participation. Prevent or reduce health-related risk factors. Optimize overall health, fitness, or sense of well-being. The beneficial effects of therapeutic exercise for individuals with a wide variety of health conditions and related physical impairments are documented extensively in the scientific literature182 and are addressed in each of the chapters of this textbook. Therapeutic exercise programs designed by physical ther- apists are individualized to the unique needs of each patient or client. A patient is an individual with impairments and FIGURE 1.1 Interrelated components of physical function. functional deficits diagnosed by a physical therapist and is re- ceiving physical therapy care to improve function and prevent disability.4 A client is an individual without diagnosed move- jogging, cycling, swimming, etc.) over an extended period of ment dysfunction who engages in physical therapy services time.2,115 A synonymous term is cardiopulmonary fitness. to promote health and wellness and to prevent dysfunction.4 Coordination. The correct timing and sequencing of muscle Because the focus of this textbook is on the management of firing combined with the appropriate intensity of muscular individuals with body function and structure impairments, contraction leading to the effective initiation, guiding, and activity limitations, and participation restrictions, the authors grading of movement. Coordination is the basis of smooth, have chosen to use the term “patient,” rather than “client” or accurate, efficient movement and occurs at a conscious or “patient/client,” throughout this text. We believe that all in- automatic level.139,142,165 dividuals receiving physical therapy services must be active participants rather than passive recipients in the rehabilitation Flexibility. The ability to move freely, without restriction; process to learn how to self-manage their health needs. used interchangeably with mobility. Mobility. The ability of structures or segments of the body Components of Physical Function to move or be moved in order to allow the occurrence of Related to Human Movement: range of motion (ROM) for functional activities (functional ROM).4,177 Passive mobility is dependent on soft tissue (con- Definition of Key Terms tractile and noncontractile) extensibility; in addition, active The ability to function independently at home, in the work- mobility requires neuromuscular activation. place, within the community, or during leisure and recre- Muscle performance. The capacity of muscle to produce ational activities is contingent upon physical as well as tension and do physical work. Muscle performance encom- psychological and social function. The multidimensional as- passes strength, power, and muscular endurance.4 pects of physical function encompass the diverse yet interre- lated areas of movement performance that are depicted in Neuromuscular control. Interaction of the sensory and Figure 1.1. These elements of function are characterized by motor systems that enables synergists, agonists, and antago- the following definitions. nists, as well as stabilizers and neutralizers, to anticipate or re- spond to proprioceptive and kinesthetic information and, Balance. The ability to align body segments against gravity subsequently, to work in correct sequence to create coordinated to maintain or move the body (center of mass) within the movement.102 available base of support without falling; the ability to move the body in equilibrium with gravity via interaction of the Postural control, postural stability, and equilibrium. sensory and motor systems.4,94,107,125,166,169,170 Used interchangeably with static or dynamic balance.73,166,169 Cardiopulmonary endurance. The ability to perform Stability. The ability of the neuromuscular system through moderate-intensity, repetitive, total body movements (walking, synergistic muscle actions to hold a proximal or distal body 5850_Ch01_001-042 17/08/17 5:59 PM Page 3 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 3 segment in a stationary position or to control a stable base exercise interventions presented in this textbook are listed in during superimposed movement.73,169,177 Joint stability is the Box 1.1. maintenance of proper alignment of bony partners of a joint NOTE: Although joint mobilization and manipulation procedures by means of passive and dynamic components.122 often are categorized as manual therapy techniques, not thera- The human movement system is the foundation for phys- peutic exercise,4 the authors of this textbook have chosen to ical therapy and the focus for physical function.160 The sys- include joint manipulative procedures under the broad definition tems of the body that interact to control each of these of therapeutic exercise to address the full scope of soft tissue elements of physical function react, adapt, and develop in stretching techniques. response to forces and physical stresses (stress = force / area) placed upon tissues that make up the component parts of movement.115,121,160 Gravity, for example, is a constant force Exercise Safety that affects the musculoskeletal, neuromuscular, and circulatory Regardless of the type of therapeutic exercise intervention, systems. Additional forces, incurred during routine physical ac- safety is a fundamental consideration whether the exercises tivities, help the body maintain a functional level of strength, are performed independently or under a therapist’s direct su- cardiopulmonary fitness, and mobility. Imposed forces and pervision. Patient safety, of course, is paramount; nonetheless, physical stresses that are excessive can cause acute injuries, such the safety of the therapist also must be considered, particu- as sprains and fractures, or chronic conditions, such as repeti- larly when the therapist is directly involved in the application tive stress disorders.121 The absence of typical forces on the of an exercise procedure or a manual technique. body also can cause degeneration, degradation, or deformity. Many factors can influence a patient’s safety during exercise. For example, the absence of normal weight bearing associated Prior to engaging in exercise, a patient’s health history and cur- with prolonged bed rest or immobilization weakens muscle rent health status must be explored. A patient unaccustomed to and bone.2,3,17,121 Prolonged inactivity also leads to decreased physical exertion may be at risk for the occurrence of an adverse efficiency of the circulatory and pulmonary systems.2 effect from exercise associated with a known or an undiagnosed Impairment of any one or more of the body systems and health condition. Medications can adversely affect a patient’s subsequent impairment of any aspect of the human movement balance and coordination during exercise or cardiopulmonary system, separately or jointly, can limit or restrict an individual’s response to exercise. Therefore, risk factors must be identified ability to carry out or participate in daily activities. Therapeutic and weighed carefully before an exercise program is initiated. exercise interventions involve the application of carefully Medical clearance from a patient’s physician may be indicated graded physical stresses and forces that are imposed on the before beginning an exercise program. human movement system, specific tissues, or individual struc- The environment in which exercises are performed also tures in a controlled, progressive, safely executed manner to affects patient safety. Adequate space and a proper support enhance movement and improve the human experience.5,160 surface for exercise are necessary prerequisites for patient safety. If exercise equipment is used in the clinical setting or NOTE: In a recent article, Sahrmann160summarized the culmi- at home, to ensure patient safety the equipment must be nation of several decades of research by physical therapy leaders well maintained and in good working condition, must fit the to more clearly define the role of physical therapy in health care. patient, and must be applied and used properly. It has been proposed that physical therapy identify as a profes- Specific to each exercise in a program, the accuracy with sion with a specific body system rather than with a type of inter- which a patient performs an exercise affects safety, including vention in order to gain professional recognition for content proper posture or alignment of the body, execution of the cor- expertise. These proponents have defined the human movement rect movement patterns, and performance of each exercise system as a physiological system that represents the scope of practice and expertise of physical therapy. In this context, the human movement system is described as a separate physiolog- ical system comprised of interacting organs and systems includ- BOX 1.1 Therapeutic Exercise Interventions ing the nervous and musculoskeletal systems that produce movement and the pulmonary, cardiovascular, endocrine and Aerobic conditioning and reconditioning integumentary systems that support movement. Muscle performance exercises: strength, power, and endurance training Stretching techniques including muscle-lengthening Types of Therapeutic Exercise procedures and joint mobilization/manipulation techniques Interventions Neuromuscular control, inhibition, and facilitation techniques and posture awareness training Therapeutic exercise embodies a wide variety of activities, Postural control, body mechanics, and stabilization exercises movements, and techniques. The individualized therapeutic ex- Balance exercises and agility training ercise program is based on a therapist’s determination of the Relaxation exercises underlying risk or cause of impairments in body function or Breathing exercises and ventilatory muscle training structure, activity limitations, or participation restrictions as Task-specific functional training identified in the patient examination.5 The types of therapeutic 5850_Ch01_001-042 17/08/17 5:59 PM Page 4 4 Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology with the appropriate intensity, speed, and duration. A patient variables and social support, the disabling course is altered and must be informed of the signs of fatigue, the relationship of fa- levels of functioning vary among patients with the same med- tigue to the risk of injury, and the importance of rest for recov- ical diagnosis.85,123,176,193 Defining a person’s ability to function ery during and after an exercise routine. When a patient is being in the presence or absence of a health condition is a complex directly supervised in a clinical or home setting while learning task that is better understood if practitioners, researchers, an exercise program, the therapist can control these variables. educators, policy makers, and legislators are using the same However, when a patient is carrying out an exercise program vocabulary and classification system. independently at home or at a community fitness facility, pa- tient safety is enhanced and the risk of injury or re-injury is minimized by effective exercise instruction and patient educa- Models of Functioning and tion. Suggestions for effective exercise instruction and patient Disability—Past and Present education are discussed in a later section of this chapter. Early Models As mentioned, therapist safety also is a consideration to Several models that describe disability have been proposed avoid work-related injury. For example, when a therapist is worldwide over the past several decades. Two early theories using manual resistance during an exercise designed to were the Nagi model 123,124 and the International Classification improve a patient’s strength or is applying a stretch force of Impairments, Disabilities, and Handicaps (ICIDH) model manually to improve a patient’s ROM, the therapist must for the World Health Organization (WHO).67,75 The National incorporate principles of proper body mechanics and joint Center for Medical Rehabilitation Research (NCMRR) created protection into these manual techniques to minimize his or a third model that introduced individual risk factors for dis- her own risk of injury. ability based on both physical and social risks.126 Throughout each of the chapters of this textbook, pre- During the 1990s, physical therapists began to explore the cautions, contraindications, and safety considerations are potential use of disablement models and suggested that disable- addressed for the management of specific health condi- ment schema and related terminology provided an appropri- tions, impairments, activity limitations, and participation ate framework for clinical decision-making in practice and restrictions and for the use and progression of specific research.64,84,162 In addition, practitioners and researchers sug- therapeutic exercise interventions. gested that adoption of disablement-related language could be a mechanism to standardize terminology for documentation and communication in the clinical and research settings.65 The American Physical Therapy Association (APTA) subsequently Classification of Health Status, incorporated an extension of the Nagi disablement model and Functioning, and Disability— related terminology in its consensus document, the Guide to Physical Therapist Practice 4 (often called the Guide) in both its Evolution of Models and first edition in 1997 and second edition in 2001. Within the pro- Related Terminology fession, this created a unifying force for documentation, com- munication, clinical practice, and research by designating a Background and Rationale disablement framework for organizing and prioritizing clinical decisions made during the continuum of physical therapy care. for Classification Systems The conceptual frameworks of the Nagi, ICIDH, and Knowledge of the complex relationships among health status, NCMRR models, although applied widely in clinical practice functioning, and disability provides a foundation for the and research, have been criticized internationally for their delivery of effective health-care services.87,153,174 Without a perceived focus on pathology.41 These early models all de- common conceptual understanding and vocabulary, the abil- scribe a unidirectional path toward disability caused directly ity to communicate and share information across disciplines by the consequences of disease based on a medical-biological and internationally is compromised for research, clinical description without consideration of environmental or social practice, academia, policy making, and legislation.153,176,199 influences.41,176 In response to these criticisms, the WHO un- Disablement refers to the impact and functional conse- dertook a broad revision of its ICIDH model, and in 2001 the quence of acute or chronic conditions, such as disease, injury, International Classification of Functioning, Disability, and and congenital or developmental abnormalities, that compro- Health (ICF) was introduced and characterized as a biopsy- mise basic human performance and an individual’s ability to chosocial model where environmental factors and personal meet necessary, customary, expected, and desired societal factors are integrated into the concept of functioning and dis- functions and roles.85,123,193 Disability is more than a conse- ability (Fig. 1.2).76,77,173,174,175 quence of a medical condition; rather, it is part of the human While the ICF is used to classify functioning and disabil- condition that is experienced by everyone either temporarily ity associated with health conditions, the WHO has a com- or permanently.76,199 The disabling process depends on count- panion classification system to classify health conditions less factors, such as access to quality care, severity and duration (diseases, disorders, and injuries) called the International of the condition, motivation and attitude of the patient, and Classification of Disease (ICD). Together, the use of these support from family and society. Depending on individual two classification systems provides a broader and more 5850_Ch01_001-042 17/08/17 5:59 PM Page 5 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 5 Health Condition also includes both environmental and personal factors that (disorder or disease) influence how people with or without disability live and par- ticipate in society.41,77,199 As shown in Table 1.1, the ICF model organizes information about health into two basic parts. The first, labeled Part 1: Func- tioning and Disability, is subdivided into two components: Body Functions (1) Body Functions and Structures and (2) Activities and Par- Activity Participation & Structure ticipation. The two umbrella terms, functioning and disability, are based on the classification of body functions and structures combined with activities and participation. Functioning is char- acterized by positive interactions that are defined by the integrity of body functions and structures and the ability to perform activities and participate in life situations. In contrast, disability is characterized by the negative interactions of health situations defined as impairments in body functions and structures, Environmental Factors Personal Factors activity limitations, and participation restrictions.76,77 Contextual Factors The second, labeled Part 2: Contextual Factors, also shown FIGURE 1.2 The ICF Framework. in Table 1.1, is subdivided into two components: (1) Environ- mental Factors and (2) Personal Factors. Contextual factors represent the complete background of an individual’s life and meaningful picture of the health of both individuals and living situation.77 Environmental factors make up the physi- populations worldwide.77 cal, social, and attitudinal circumstances in which the indi- vidual lives either with or without a health problem.77 These The ICF—An Overview of the Model factors are external to the individual but have either facilitat- Unlike previous models, the ICF does not focus on disability ing or hindering influences on the individual’s performance or on disease, but is intended to classify and code different at the levels of body functions and structures, execution of health and health-related states experienced by everyone. The activities, and participation in society. For this reason, Part 1 ICF takes a neutral approach to the human experience as it of the model is not classified separately from Part 2 as they relates to components of health and functioning, experienced are hierarchal in their coding to represent the biopsychosocial by all people, not just people with disabilities.76,77,199 The ICF paradigm of a person’s health condition.1,77,144 TABLE 1.1 An Overview of the International Classification of Functioning, Disability and Health (ICF)* Part 1: Functioning and Disability Part 2: Contextual Factors Body Functions Activities and Components and Structures Participation Environmental Factors Personal Factors Domains Body functions Life areas External influences on Internal influences Body structures (tasks, actions) functioning and on functioning and disability disability Constructs Changes in body Capacity: Executing Facilitating or hindering Impact of attitudes functions tasks in a standard impact of features of of the person (physiological) environment the physical, social, Changes in body Performance: Executing and attitudinal world structures (anatomical) tasks in the current environment Functioning Positive aspect Functional and Activities Facilitators Not applicable structural integrity Participation Disability Negative Functional and/or Activity limitation Barriers Not applicable aspect structural Impairment Participation restriction Hindrances *From International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization, 2008, p 13, with permission. 5850_Ch01_001-042 17/08/17 5:59 PM Page 6 6 Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology Definitions of key terms are summarized in Box 1.2.76,77,184 In 2008, the APTA officially endorsed the biopsychosocial Numerous examples of these components are identified later framework, vocabulary, and classification system of the ICF. in this chapter. This began a continuing initiative over the past decade to inte- grate this framework and vocabulary into research, clinical doc- NOTE: The ICF classification and coding methodology is also umentation, education, policy making, and legislation.5,77,141 unique from other models in its unit of measure. The individ- To facilitate use of the ICF in clinical practice, several articles ual is not placed in a classification, but rather the coding have been published to provide suggestions for integrating the describes the situation of each person within an array of ICF into specific components of physical therapy practice, health and health-related domains. The coding used in ICF is ethics, and patient management.1,48,49,144,153 In 2013, the third complex and multifactorial, with inclusion of health, function- edition of the Guide was published and is available only in an ing, and environmental elements combined to describe the electronic version in order to facilitate timely updates to reflect ability of an individual to perform activities and participate in the rapid changes in physical therapy practice, including the society.1,41,77,88,174,175 integration of ICF as the adopted framework for defining the realm of functioning and disability.5 Components of the ICF and For example, use of ICF language for documentation in Applications in Physical Therapy the clinical setting is being encouraged.16,141 The most note- worthy application of the ICF can be found in a series of clin- Background ical practice guidelines developed and published by the Traditionally, the physical therapy profession has been defined specialty sections of the APTA. These guidelines use the ICF by a body of knowledge and clinical applications that are di- as the basis for describing and classifying care provided by rected toward the elimination or remediation of disability.150 physical therapists.58,95 Information from the guidelines However, as the physical therapy profession has evolved, the addressing the efficacy of therapeutic exercise interventions scope of practice has moved beyond solely the management for health conditions and associated impairments commonly and remediation of disability and now includes promoting the seen in orthopedic physical therapy practice is discussed in well-being of healthy individuals and preventing or reducing the regional chapters of this textbook. risk factors that may lead to disability while considering the external environmental and internal personal factors that Health Conditions influence each person’s response to their health condition.6 Health conditions, based on the terminology of the ICF framework, are acute or chronic diseases, disorders, or injuries or circumstances such as aging, pregnancy, or stress that have an impact on a person’s level of function (see Fig. 1.2).76,77 BOX 1.2 Definition of Key Terms in the ICF Health conditions are the basis of a medical diagnosis and are coded using the WHO’s companion classification system, the Impairments in body function: Problems associated with International Classification of Disease (ICD).77 the physiology of the body systems (including psychological Physical therapists in all areas of practice treat patients with functions). a multitude of health conditions. Knowledge of health condi- Impairments in body structure: Problems with the tions is important background information, but it does not tell anatomical features of the body. the therapist how to assess impairments in body function or Activity limitations: Difficulties an individual may have in structure or how to assess when activities are limited or partic- executing actions, tasks, and activities. ipation is restricted as a result of the health condition. Despite Participation restrictions: Problems an individual may an accurate medical diagnosis and a therapist’s thorough experience with involvement in life situations, including knowledge of specific health conditions, the experienced ther- difficulties participating in self-care; responsibilities in the apist knows that two patients with the same medical diagnosis, home, workplace, or the community; and recreational, leisure and social activities. such as rheumatoid arthritis, and the same extent of joint de- Contextual factors: The entire background of an struction (confirmed radiologically) may have very different individual’s life and living situation composed of: severities of impairment, activity limitation, and participation Environmental factors: Factors associated with the restriction. Consequently, they may have very different degrees physical, social, and attitudinal environment in which of disability. This emphasizes the need for physical therapists people conduct their lives; factors may facilitate to always assess the impact of a particular health condition on functioning (facilitators) or hinder functioning and movement and function when designing meaningful manage- contribute to disability (barriers). ment strategies to improve functional abilities. Personal factors: Features of the individual that are not part of the health condition or health state; includes age, gender, race, lifestyle habits, coping Body Functions and Body Structures skills, character, affect, cultural and social background, As noted previously, the first component of classification in Part education, etc. 1 of the ICF is body functions and structures (see Table 1.1). Body functions are the physiological functions of the body, 5850_Ch01_001-042 17/08/17 5:59 PM Page 7 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 7 whereas body structures describe the anatomical parts of the Physical therapists typically provide care and services to pa- body. These domains of classification occur at the cellular, tissue, tients with impairments associated with the musculoskeletal, or body system level. neuromuscular, cardiovascular/pulmonary, and integumen- tary body systems when movement is compromised. In a Types of Impairments biopsychosocial model, like the ICF, impairments are identi- Impairments are defined by the loss of integrity of the phys- fied and documented as a first step to investigating the impact iological, anatomical, and/or psychological functions and that a health condition has on activities and participation structures of the body and are a partial reflection of a person’s within the specific environment of the patient. health status. Primary and secondary impairments. Impairments may Some impairments of body structure are readily apparent arise directly from the health condition (direct/primary im- during a physical therapy examination through visual inspec- pairments) or may be the result of preexisting impairments tion. Such impairments include joint swelling, scarring, pres- (indirect/secondary impairments). A patient, for example, ence of an open wound, lymphedema or amputation of a limb, who has been referred to physical therapy with a medical or through palpation, such as adhesions, muscle spasm, and diagnosis of impingement syndrome or tendonitis of the joint crepitus. Other structural impairments must be identi- rotator cuff (pathological condition), may exhibit primary fied by a variety of imaging techniques, such as radiographic impairments of body function, such as pain, limited ROM imaging to identify joint space narrowing associated with of the shoulder, and weakness of specific shoulder girdle arthritis or magnetic resonance imaging (MRI) to identify a and glenohumeral musculature during the physical therapy ex- torn muscle or ligament. amination (Fig. 1.3 A and B). The patient may have developed Impairments of body function such as pain, reduced sensa- tion, decreased ROM, deficits in muscle performance (strength, power, and endurance), impaired balance or coor- dination, abnormal reflexes, and reduced ventilation are those most commonly identified by physical therapists and managed with therapeutic exercise interventions. Some representative examples are noted in Box 1.3. BOX 1.3 Common Body Function Impairments Managed With Therapeutic Exercise Musculoskeletal Pain Muscle weakness/reduced torque production Decreased muscular endurance Limited range of motion due to: Restriction of the joint capsule A Restriction of periarticular connective tissue Decreased muscle length Joint hypermobility Faulty posture Muscle length/strength imbalances Neuromuscular Pain Impaired balance, postural stability, or control Incoordination, faulty timing Delayed motor development Abnormal tone (hypotonia, hypertonia, and dystonia) Ineffective/inefficient functional movement strategies Cardiovascular/Pulmonary Decreased aerobic capacity (cardiopulmonary endurance) Impaired circulation (lymphatic, venous, and arterial) Pain with sustained physical activity (intermittent B claudication) FIGURE 1.3 (A) Impingement syndrome of the shoulder and asso- Integumentary ciated tendonitis of the rotator cuff (health condition/pathology) lead- Skin hypomobility (e.g., immobile or adherent scarring) ing to (B) limited range of shoulder elevation (impairment of body function) are identified during the examination. 5850_Ch01_001-042 17/08/17 5:59 PM Page 8 8 Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology the shoulder pathology from a preexisting postural impairment Activities and Participation (secondary impairment), which led to altered use of the upper The second component of Part 1 of the ICF is Activities and extremity and impingement from faulty mechanics. Participation (see Table 1.1). Activity is defined as the execu- Composite impairments. When an impairment is the re- tion of a task or action by an individual, whereas participation sult of multiple underlying causes and arises from a combi- is the involvement of the individual in a life situation. The nation of primary or secondary impairments, the term ICF structure of classification for this component is based on composite impairment is sometimes used. For example, a pa- one single list of activities and life areas.77 The therapist is tient who sustained a severe inversion sprain of the ankle encouraged to differentiate the components on a case by case resulting in a tear of the talofibular ligament and whose basis depending on the patient’s life situation. There has been ankle was immobilized for several weeks is likely to exhibit extensive research to determine if these two components of a balance impairment of the involved lower extremity after functioning are distinct or interrelated.1,26,89,144 Because of the immobilizer is removed. This composite impairment the varied environmental and personal influences (contextual could be the result of chronic ligamentous laxity (body factors), there is not a clear distinction between an individual’s structure impairment) and impaired ankle proprioception ability to perform a task and participation. Additional empir- from the injury or muscle weakness (body function impair- ical research is recommended to provide a clearer operational- ments) due to immobilization and disuse. ization of the two components to enhance data comparison Regardless of the types of physical impairment exhibited between disciplines and countries.77 by a patient, a therapist must keep in mind that impairments Activity Limitation and Participation Restriction manifest differently from one patient to another. An important In the language of the ICF, activity limitations occur when a key to effective patient management is to identify functionally person has difficulty executing or is unable to perform tasks relevant impairments, in other words, impairments that or actions of daily life (see Box 1.2).41,76,77,173,174,175,184 For ex- directly contribute to current or future activity limitations and ample, as shown in Figure 1.4, restricted ROM (impairment participation restrictions in a patient’s daily life. Impairments of body function) of the shoulder as the result of adhesive cap- that can predispose a patient to secondary health conditions sulitis (health condition) can limit a person’s ability to reach or impairments also must be identified. overhead (activity limitation) while performing personal Equally crucial for the effective management of a grooming or household tasks. patient’s condition is the need to analyze and determine, or at least infer and certainly not ignore, the underlying causes of the identified physical impairments of body function or body structure, particularly those related to impaired move- ment.158,159,160 For example, are biomechanical abnormali- ties of soft tissues the source of restricted ROM? If so, which soft tissues are restricted, and why are they restricted? This information assists the therapist in the selection of appro- priate, effective therapeutic interventions that target the underlying causes of the impairments, the impairments themselves, and the associated activity limitations and participation restrictions. Although most physical therapy interventions, including therapeutic exercise, are designed to correct or reduce physical impairments of body function, such as decreased ROM or strength, poor balance, or limited cardiopulmonary endurance, the focus of treatment ultimately must be to im- prove performance of activities and participation in life events. From a patient’s perspective, successful outcomes of treatment are determined by restoration of activities and participation levels.144 A therapist cannot simply assume that FIGURE 1.4 Limited ability to reach overhead (activity limitation) as the result of impaired shoulder mobility may lead to loss of intervening at the impairment level (e.g., with strengthening independence in self-care and difficulty performing household or stretching exercises) and subsequently reducing physical tasks independently (participation restriction). impairments (by increasing strength and ROM) generalize to improvement in a patient’s level of activity and participation in work and social roles. Mechanisms for integrating task-specific Many studies have linked body function impairments with training within the therapeutic exercise intervention are ex- activity limitations, particularly in older adults. Links have plored in a model of effective patient management presented been identified between limited ROM of the shoulder and dif- in a later section of this chapter. ficulty reaching behind the head or back while bathing and 5850_Ch01_001-042 17/08/17 5:59 PM Page 9 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 9 dressing,185 between decreased isometric strength of lower extremity musculature and difficulty stooping and kneel- BOX 1.4 Common Tasks Related to Activity ing,71 as well as a link between decreased lower extremity Limitations peak power and reduced walking speed and difficulty mov- ing from sitting to standing.140 However, it should also be Difficulties with or limitation of: noted that a single or even several mild impairments of Reaching and grasping body function or structure do not consistently result in Lifting, lowering, and carrying Pushing and pulling activity limitations for all individuals. For example, results Bending and stooping of a 2-year observational study of patients with sympto- Turning and twisting matic hip or knee osteoarthritis (OA) demonstrated that Throwing and catching increased joint space narrowing (a body structure impair- Rolling ment that is considered an indicator of progression of Sitting or standing tolerance the disease) confirmed radiologically was not associated Squatting (crouching) and kneeling with an increase in activity limitations as measured on a Standing up and sitting down (from and to a chair, the self-report assessment of physical functioning.24 Further- floor) more, evidence from other studies suggests that the severity Getting in and out of bed Moving around (crawling, walking, and running) in various and complexity of impairments must reach a critical level, which is different for each person, before degradation of environments Ascending and descending stairs functioning begins to occur.134,143 These examples reinforce Hopping and jumping the ICF construct that environmental and personal factors Kicking or swinging an object interact with all aspects of functioning and disability. Thus, each individual experiences a unique response to a health condition. Activity limitation. Activities and participation require the performance of sensorimotor tasks—that is, total body This analysis helps the therapist determine why a patient is actions that typically are components or elements of func- unable to perform specific daily living tasks. This informa- tional activities. Activity limitations involve technical and tion, coupled with identification and measurement of the physiological problems that are task-specific and related to impairments that are associated with the altered or absent performance. Box 1.4 identifies a number of activity limi- component movement patterns, in turn, is used for treatment tations that can arise from physical impairments in body planning and selection of interventions to restore the ability function or structure, involve whole-body movements or ac- to complete activities or to participate in personal, social, tions, and are necessary component motions of simple to work, or life situations. complex daily living tasks. Defining limitations in this way Participation restrictions. As identified in the ICF model highlights the importance of identifying abnormal or ab- (see Table 1.1), participation restrictions are defined as prob- sent component motions of motor skills through task analysis lems a person may experience in his or her involvement in during the physical therapy examination and later integrating life situations as measured against social standards (see task-specific functional motions into a therapeutic exercise Box 1.2).76,77,173,174,175,184 More specifically, participation program. restriction is about not being able to take part in social prac- When a person is unable or has only limited ability to tices in situations of significance or meaningfulness in the perform any of the whole-body component motions iden- context of a person’s attitudes and environment (contextual tified in Box 1.4, activities may be limited and participation factors). 26,144 may be restricted. The following is an example of the inter- Social expectations or roles that involve interactions with play of activities and participation in everyday life. To per- others and participation in activities are an important part of form a basic home maintenance task such as painting a the individual. These roles are specific to age, gender, sex, and room, a person must be able to grasp and hold a paintbrush cultural background. Categories of activities or roles that, or roller, climb a ladder, reach overhead, kneel, or stoop if limited, may contribute to participation restrictions are down to the floor. If any one of these component move- summarized in Box 1.5. ments is limited, it may not be possible to perform the over- all task of painting the room. If the individual views home maintenance as a personal or social role, the inability to Contextual Factors perform the task of painting may result in participation In the ICF, Part 2 consists of contextual factors, once again restriction. divided into two components: (1) environmental factors An essential element of a physical therapy examination and (2) personal factors. These classifications represent the and evaluation is the analysis of motor tasks to identify the external and internal domains that influence functioning component motions that are difficult for a patient to perform. and disability, taking into consideration the complete 5850_Ch01_001-042 17/08/17 5:59 PM Page 10 10 Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology and knee extensors (impairments in body function) could BOX 1.5 Areas of Functioning Associated indeed lead to restricted participation in life’s activities and dis- With Participation Restrictions ability in several areas of everyday functioning. Disability could be expressed by problems in self-care (inability to get in and out Self-care of a tub or stand up from a standard height toilet seat), home Mobility in the community management (inability to perform selected housekeeping, Occupational tasks gardening, or yard maintenance tasks), or community mobility School-related tasks (inability to get into or out of a car or van independently). Home management (indoor and outdoor) Caring for dependents The perception of disability possibly could be minimized Recreational and leisure activities if the patient’s functional ROM and strength can be improved Socializing with friends/family with an exercise program and the increased ROM and Community responsibilities and service strength are incorporated into progressively more challenging functional activities or if the physical environment can be altered sufficiently with the use of adaptive equipment and assistive devices. Adjusting expected roles or tasks within the family might background of an individual’s life and living situation (see also have a positive impact on the prevention or reduction Table 1.1). of disability. Factors within the individual also can have Environmental factors are outside of the individual, but an impact on the prevention, reduction, or progression every feature of the physical, social, and attitudinal world has of disability. Those factors include level of motivation or either a facilitating or hindering impact on functioning and willingness to make lifestyle changes and accommodations disability. 77 as well as the ability to understand and cope with an ad- Because disability is such a complex concept, the extent to justed lifestyle.193 This example highlights that inherent in which each aspect of functioning affects one’s perceived level any discussion of disability is the assumption that it can be of disability is not clearly understood. An assumption is made prevented or remediated.25 that when impairments and activity limitations are so severe or of such long duration that they cannot be overcome to a Categories of prevention. Prevention falls into three degree acceptable to an individual, a family, or society, the categories.4 perception of “being disabled” occurs.143 The perception of Primary prevention: Activities such as health promotion disability is highly dependent on a person’s or society’s expec- designed to prevent disease in an at-risk population. tations of how or by whom certain roles or tasks should be Secondary prevention: Early diagnosis and reduction of the performed. severity or duration of existing disease and sequelae. Personal factors are unique to the individual and may Tertiary prevention: Use of rehabilitation to reduce the include characteristics such as race, gender, family back- degree or limit the progression of existing disability and ground, coping styles, education, fitness, and psychological improve multiple aspects of function in persons with assets.77 chronic, irreversible health conditions. NOTE: Because personal factors are features of the individual, Therapeutic exercise, the most frequently implemented they are not part of the health condition, and they are not clas- physical therapy intervention, has value at all three levels of sified or coded in the ICF (see Table. 1.1). However, they must prevention. Health and wellness have moved to the forefront be considered in any provision of care because they will influ- of health care, and physical therapists are becoming involved ence the outcome of the intervention.77 in wellness screens, community health fairs, and annual check- ups as a form of primary prevention. The use of resistance ex- The Role of Prevention ercises and aerobic conditioning exercises in weight-bearing Understanding the relationships among a health condition, postures is often advocated for the primary and secondary pre- impairments, activity limitations, participation restrictions, vention of age-related osteoporosis.40,70 In addition, therapists and the impact of environmental and personal factors who work with patients with chronic musculoskeletal or neu- on functioning is fundamental to the prevention or reduc- romuscular diseases or disorders routinely are involved with tion of disability.25,61,85 Disability is not caused by any tertiary prevention of disability. one level of impairment or activity limitation or participa- tion restriction; rather, the process is bidirectional and Risk Factors complex. Modifying risk factors through an intervention, such as Take, for example, a relatively inactive person with long- therapeutic exercise, is an important tool for preventing or standing osteoarthritis of the knees. The inability to get up reducing the impact of health conditions and subsequent from the floor or from a low seat (activity limitation) because impairments, activity limitations, and participation restric- of limited flexion of the knees and power deficits of the hip tions associated with disability. Risk factors are influences 5850_Ch01_001-042 17/08/17 5:59 PM Page 11 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 11 or characteristics that predispose a person to impaired lifestyle behaviors to reduce the risk of disease or injury.50 functioning and potential disability. As such, they exist prior This demonstrates that increased knowledge does not nec- to the onset of a health condition and associated impair- essarily change behavior. ments, limitations, or restrictions.25,85,193 Some factors that When a health condition exists, the reduction of risk fac- increase the risk of disabling conditions are biological char- tors by means of buffers (interventions aimed at reducing the acteristics, lifestyle behaviors, psychological characteristics, progression of a pathological condition, impairments, limi- and the impact of the physical and social environments. Ex- tations, restrictions, and potential disability) is appropriate.85 amples of each of these types of risk factor are summarized This focus of intervention is categorized as secondary or in Box 1.6. tertiary prevention. Initiating a regular exercise program, Some of the risk factors, in particular lifestyle character- increasing the level of physical activity on a daily basis, or istics and behaviors and their impact on the potential for altering the physical environment by removing architectural disease or injury, have become reasonably well known be- barriers or using assistive devices for a range of daily activities cause of public service announcements and distribution of are examples of buffers that can reduce the risk of disability. educational materials in conjunction with health promo- (Refer to Chapter 2 of this textbook for additional information tion campaigns, such as Healthy People 2010188 and Healthy on prevention, reduction of health-related risk factors, and People 2020.189 Information on the adverse influences of wellness.) health-related risk factors, such as a sedentary lifestyle, obe- sity, and smoking, has been widely disseminated by these Summary public health initiatives. Although the benefits of a healthy An understanding of the concepts of functioning and dis- lifestyle, which includes regular exercise and physical activ- ability; of the relationships among the components of func- ity, are well founded and widely documented,2,188,189 initial tioning, disability, and health; and of the various models and outcomes of a previous national campaign, Healthy People classification systems that have been developed over the past 2000,191 suggest that an increased awareness of risk factors several decades provides a conceptual framework for practice has not translated effectively into dramatic changes in and research. This knowledge also establishes a foundation for sound clinical decision-making and effective communi- cation and sets the stage for delivery of effective, efficient, meaningful physical therapy care and services for patients. BOX 1.6 Risk Factors for Disability Biological Factors Age, sex, and race Principles of Comprehensive Height/weight relationship Congenital abnormalities or disorders (e.g., skeletal Patient Management deformities, neuromuscular disorders, cardiopulmonary diseases, or anomalies) An understanding of the concepts of functioning and disabil- Family history of disease; genetic predisposition ity, coupled with knowledge of the process of making in- formed clinical decisions based on evidence from the scientific Behavioral/Psychological/Lifestyle Factors literature, provides the foundation for comprehensive man- Sedentary lifestyle agement of patients seeking and receiving physical therapy Cultural biases Use of tobacco, alcohol, and/or other drugs services. Provision of quality patient care involves the ability Poor nutrition to make sound clinical judgments; solve problems that are im- Low level of motivation portant to a patient; and apply knowledge of the relationships Inadequate coping skills among a patient’s health condition(s), impairments, limita- Difficulty dealing with change or stress tions in daily activities, and participation restrictions through- Negative affect out each phase of management. Physical Environment Characteristics The primary purpose of this section of the chapter is to Architectural barriers in the home, community, and describe a model of patient management used in physical ther- workplace apy practice. Inasmuch as clinical reasoning and evidence- Ergonomic characteristics of the home, work, or school based decision-making are embedded in each phase of environments patient management, a brief overview of the concepts Socioeconomic Factors and processes associated with clinical decision-making and Low economic status evidence-based practice is presented before exploring a sys- Low level of education tematic process of patient management in physical therapy. Inadequate access to health care Relevant examples of the clinical decisions a therapist Limited family or social support must make are highlighted within the context of the patient management model. 5850_Ch01_001-042 17/08/17 5:59 PM Page 12 12 Principles of Comprehensive Patient Management Clinical Decision-Making improve the accuracy of prognoses, whereas others identify subgroupings of patients within large, heterogeneous groups Clinical decision-making refers to a dynamic, complex process who are most likely to benefit from a particular approach to of reasoning and analytical (critical) thinking that involves treatment or specific therapeutic interventions. To date, some making judgments and determinations in the context of pa- prediction tools in physical therapy have been developed to tient care.93 One of the many areas of clinical decision-making assist in the diagnosis of health conditions, including os- in which a therapist is involved is the selection, implementa- teoarthritis in patients with hip pain178 and deep vein throm- tion, and modification of therapeutic exercise interventions bosis in patients with leg pain.147 However, a greater number based on the unique needs of each patient or client. To make of CPRs in physical therapy have been established to predict effective decisions, merging clarification and understanding likely responses of patients to treatment. As examples, CPRs with critical and creative thinking is necessary.101 A number have been developed to identify a subgrouping of patients of requisite attributes are necessary for making informed, re- with patellofemoral pain syndrome who are most likely to sponsible, efficient, and effective clinical decisions.46,101,113,167 respond positively to lumbopelvic manipulation,78 patients Those requirements are listed in Box 1.7. with low back pain most likely to respond to stabilization ex- There is a substantial body of knowledge in the literature ercises,72 and those with neck pain for whom thoracic spine that describes various strategies and models of clinical manipulation is most likely to be effective.35 decision-making in the context of patient management by It is important to note, however, that little research, thus physical therapists.43,46,65,79,80,92,93,148,151,152 One such model, the far, has focused on validation of published CPRs15 or their Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), impact on the effectiveness of patient care from specific ther- describes a series of steps involved in making informed clin- apeutic interventions. The results of two systematic reviews ical decisions.152 The use of clinical decision-making in the of the literature underscore these points. One review15 con- diagnostic process also has generated extensive discussion in cluded that there is considerable variation in the quality of the literature.19,22,42,46,59,62,83,84,149,158,183,187,201 studies used to validate CPRs developed for interventions To assist in the decision-making process and ultimately im- used by physical therapists. The results of the other review of prove patient care, tools known as clinical prediction rules CPRs for musculoskeletal conditions172 demonstrated that (CPRs), first developed in medicine, also have been developed currently there is only limited evidence to support the use of for use by physical therapists.32,52 Some CPRs contain predic- these rules to predict the effectiveness of specific interventions tive factors that help a clinician establish specific diagnoses or or to optimize treatment. Additional information from stud- ies directed toward clinical decision-making is integrated into the remainder of this section on patient management or is addressed in later chapters. BOX 1.7 Requirements for Skilled Clinical Decision-Making During Patient Coordination, Communication, Management and Documentation Knowledge of pertinent information about the problem(s) Health care continues to move in the direction of physical ther- based on the ability to collect relevant data by means of apists being primary practitioners through whom consumers effective examination strategies gain access to services without physician referral. As the coor- Cognitive and psychomotor skills to obtain necessary dinator of physical therapy care and services, the therapist has knowledge of an unfamiliar problem the responsibility to communicate verbally and through written Use of an efficient information-gathering and information- documentation with all individuals involved in the care of a processing style patient. The adoption of direct access has been scrutinized in Prior clinical experience with the same or similar problems Ability to recall relevant information regard to the ability of physical therapists to make sound clin- Ability to integrate new and prior knowledge ical decisions and the potential for therapists to miss critical Ability to obtain, analyze, and apply high-quality evidence signs and symptoms (red flags) and neglect to refer patients from the literature when appropriate.91 However, the literature shows several cir- Ability to critically organize, categorize, prioritize, and cumstances where therapists have shown evaluative and diag- synthesize information nostic skills resulting in appropriate decisions to involve other Ability to recognize clinical patterns providers in the coordination of care of the patient.23,68,91 Ability to form working hypotheses about presenting The following are descriptions of circumstances where it problems and how they might be solved is appropriate for the physical therapist to communicate and Understanding of the patient’s values and goals coordinate care of the patient with another provider.5 Ability to determine options and make strategic plans Application of reflective thinking and self-monitoring Comanagement: Sharing responsibility. strategies to make necessary adjustments Consultation: Providing or seeking professional expertise/ judgement. 5850_Ch01_001-042 17/08/17 5:59 PM Page 13 CHAPTER 1 Therapeutic Exercise: Foundational Concepts 13 Supervision: Delegation of some portion of treatment while 3. Critically analyze the pertinent evidence found during the remaining responsible for the care provided. literature search and make reflective judgments about the Referral: Includes both referring to another provider and quality of the research and the applicability of the infor- receiving referrals from another provider. mation to the identified patient problem. 4. Integrate the appraisal of the evidence with clinical expert- Even during the intervention or discharge phase of patient ise and experience and the patient’s unique circumstances management, a therapist might make the clinical decision that and values to make decisions. referral to another practitioner is appropriate and complemen- 5. Incorporate the findings and decisions into patient tary to the physical therapy services. This requires coordination management. and communication with other health-care practitioners. For 6. Assess the outcomes of interventions and ask another example, a therapist might refer a patient who is generally de- question if necessary. conditioned from a sedentary lifestyle and who is also obese to a nutritionist for dietary counseling to complement the physical This process enables a practitioner to select and interpret therapy program designed to improve the patient’s aerobic the findings from the evaluation tools used during the exami- capacity (cardiopulmonary endurance) and general level of nation of the patient and to implement effective treatment pro- fitness. cedures that are rooted in sound theory and scientific evidence Coordination, communication, and documentation are (rather than anecdotal evidence, opinion, or clinical tradition) required of the physical therapist throughout the entire to facilitate the best possible outcomes for a patient. episode of patient management. This role encompasses many patient-related administrative tasks and professional respon- sibilities, such as writing reports (evaluations, plans of FOCUS ON EVIDENCE care, and discharge summaries); designing home exercise programs; contacting third-party payers, other health-care In a survey of physical therapists, all of whom were members practitioners, or community-based resources; and partici- of APTA, 488 respondents answered questions about their pating in team conferences. beliefs, attitudes, knowledge, and behavior about evidence- based practice.90 Results of the survey indicated that the ther- apists believed that the use of evidence in practice was Evidence-Based Practice necessary and that the quality of care for their patients was better when evidence was used to support clinical decisions. Physical therapists who wish to provide high-quality patient However, most thought that carrying out the steps involved care must make informed clinical decisions based on sound in evidence-based practice was time consuming and seemed clinical reasoning and knowledge of the practice of physical incompatible with the demands placed on therapists in a therapy. An understanding and application of the principles busy clinical setting. of evidence-based practice provide a foundation to guide a clinician through the decision-making process during the course of patient care. It is impractical to suggest that a clinician must search In recent years, evidence-based practice has been high- the literature for evidence to support each and every clinical lighted in the strategic plans of the APTA by establishing decision that must be made. Despite time constraints in the guidelines, setting goals for therapists to be engaged in clinical setting, when determining strategies to solve complex applying and integrating research findings into everyday patient problems or when interacting with third-party payers practice, and encouraging use of validated clinical practice to justify treatment, the “thinking therapist” has a profes- guidelines.8 sional responsibility to seek out evidence that supports the selection and use of specific evaluation and treatment Definition and Description of the Process procedures.12 Evidence-based practice is “the conscientious, explicit, and judicious use of current best evidence in making decisions Accessing Evidence about the care of an individual patient.”156 Evidence-based One method for staying abreast of evidence from the current practice also involves combining knowledge of evidence from literature is to read one’s professional journals on a regular well-designed research studies with the expertise of the clini- basis. It is also important to seek out relevant evidence from cian and the values, goals, and circumstances of the patient.157 high-quality studies (randomized controlled trials, systematic The process of evidence-based practice involves the reviews of the literature, etc.) from journals of other profes- following steps:37,157 sions.38 Journal articles that contain systematic reviews of the 1. Identify a patient problem and convert it into a specific literature or summaries of multiple systematic reviews are an question. efficient means to access evidence because they provide a con- 2. Search the literature and collect clinically relevant, scien- cise compilation and critical appraisal of a number of scientific tific studies that contain evidence related to the question. studies on a topic of interest. 5850_Ch01_001-042 17/08/17 5:59 PM Page 14 14 Principles of Comprehensive Patient Management Evidence-based clinical practice guidelines for manage- To further assist therapists in retrieving and applying evi- ment of specific physical conditions or groupings of impair- dence in physical therapist practice from the Cochrane online ments also have been developed; they address the relative library, the Physical Therapy journal publishes a recurring fea- effectiveness of specific treatment strategies and procedures. ture called Linking Evidence and Practice (LEAP). This feature These guidelines provide recommendations for management summarizes a Cochrane review and other scientific evidence based on systematic reviews of current literature.139,161 Ini- on a single topic relevant to physical therapy patient care. In tially, clinical practice guidelines that address