PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Clinical Reasoning in Adult Neurologic Rehabilitation
Review of Clinical Reasoning (MSK 2)
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Thinking skills and knowledge used to make clinical decisions and judgments through the evaluation, diagnosis,
and management of a patient problem.
Influenced by: Therapist’s Perspective, Patient/Client’s Characteristics, Environmental Factors
Elements of Clinical Reasoning
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The Clinical Problem – Medical Diagnosis (ex. (R) Supraspinatus Tendinitis 2˚ to Impingement)
The Environment – Resources, Time, Aggravating & Relieving Factors (ex. Spiking & Serving)
Patient/Client’s Input – Patient’s chief complaint (ex. Pain)
Discipline-Specific Knowledge Base – knowledge on the condition (ex. Impingement during Shoulder Abd ->
Supraspinatus Tendinitis)
• Biomedical Knowledge – basic medical & surgical knowledge
• Clinical Knowledge – experience-acquired knowledge in the field
• Everyday Knowledge – common knowledge, attitudes, values we have
Cognition – reflective inquiry or thinking skills; Tests & Measures done for the patient (ex. ROM, MMT, Special
Tests then evaluate)
• Sorting out information based on the case and then applying it.
• Perception of relevant information from irrelevant information (ex. Supraspinatus tendinitis, no need to
ask # of steps stairs)
• Interpretation of information (clinical implications based on examination)
• Hypothesis testing, synthesis, analysis, interpretation, and evaluation of data.
Metacognition – thinking about your thinking (ex. How well did my patient/my intervention performed?)
• Refers to therapist’s awareness, self-monitoring, and reflective process (Is my intervention of choice
beneficial or not?)
• Requires:
o Reflection in action (while you act)
o Reflection about action (in hindsight)
o Reflection on currently held knowledge and beliefs.
Models of Clinical Reasoning
Hypotheticodeductive
Reasoning
Backward Reasoning
• Clinician builds case by adding finding
after finding (repeated assessments)
• Patient History + Clinician Findings +
Imaging Findings + Special Test Findings
= Final PT Dx
• Involves information from the patient,
constructing a hypothesis, and testing it
out
• Done by Novice/Inexperience Clinicians
Four Stages by Elstein et al:
• Cue Acquisition
• Hypothesis Generation
• Cue Interpretation
• Hypothesis
Evaluation In summary: gathering information
until hypothesis is confirmed based on cues
(tests & measures)
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Forward Reasoning
a. Clinician actively organizes clinical perceptions into construct wholes
b. Ability to make clinical decisions in absence of complete information
Pattern
c. Recognition of patterns of clinical presentations (ex. Spiker + pain on abd + tenderness on
Recognition
shoulder -> PT Dx)
d. Management strategy is used again
e. Done by Experts with plentiful clinical experience.
Errors in Clinical Reasoning
1. Not using a clinical reasoning process but rather following a routine set of questions and tests (Over reliance on
Patterns)
2. Not tailoring the physical examination tests to a specific patient problem
3. Overemphasis on findings that support a chosen hypothesis
4. Ignoring, or not enough attention to searching for findings that could negate a hypothesis
5. Failing to continue with hypothesis testing through on-going reassessment of treatment
6. Error in perception, interpretation, inquiry, synthesis, and planning occur at any stage of the clinical reasoning
process
7. Obtain redundant/not useful information
8. Not taking the physical examination far enough to tailor it to specific patient presentation
9. Poor organization of knowledge so unable to retrieve knowledge that is needed
Review Clinical Decision Making (MSK 2)
EXAMINATION
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History: Subjective examination, take patient chief complaint until patient goal.
Systems Review: Quick assessment of involved system (ex. Gross ROM & MMT), also check patient’s chart
Tests & Measures: Objective examination, from Vital Signs until Functional Assessment
EVALUATION
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ICF: International Classification of Functioning, Disability, and Health.
o Combines Nagi Model of Disablement with Contextual Factors related with the patient’s case
Health Condition – pathological condition of the body or abnormal entity with characteristic group of signs &
symptoms.
Body Structures
anatomic parts of the body (ex. Shoulder)
Impairment
problems in body function such as deviation or loss
Body Functions
physiologic & psychological function
Activity
execution of task or action by an individual
Activity Limitation
difficulty in execution of activities
Participation
involvement in life situation
Participation Restriction
problem in involvement in participation
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
• Contextual Factors – represent entire background of individual’s life and living situation.
o Environmental – physical, social, and attitudinal environment in which people live and conduct their
lives
o Personal – gender, age, coping styles, social background, education, profession, past & current
experience, overall behaviour pattern, character, and other factors that influence how disability is
experienced by and individual
• Incidental Findings – subjective & objective findings not important in the case
• Types of Impairments
Direct Impairment
Composite
Impairment
Direct result of the disease
ex: Balance problem d/t
Cerebellar Pathology
Indirect
Impairment
Complication from other
systems
Combined effects of direct & indirect impairments
ex: Balance problem d/t weakness, pain, gait abnormality, postural deviation
Example: To classify the patient’s case, create a Problem List.
• Pain graded 6/10 on (R) posterolateral aspect of
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shoulder
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• (+) Grade 2 tenderness over the (R) posterolateral
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aspect of shoulder
• (+) Muscle guarding on (R) shoulder towards abduct
and IR
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• (+) Tightness on (B) hamstrings
• LOM on (R) shoulder abduct (0-120˚, AROM) and IR
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(0-45˚, AROM)
• Weakness of (R) shoulder abductors and internal
rotators graded 4/5
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• (+) Neer Impingement test on (R)
• NOTE: classification should be complete documentation
(+) Hawkins-Kennedy test on (R)
(+) Empty Can test on (R)
Mod diff in spiking the ball in all direction as
manifested by able to spike the ball for 5/10 s
minimal pain
Min diff in serving the ball as manifested by able to
serve the ball for 7/10 s minimal pain
Min diff in receiving and digging the ball as
manifested by able to receive and dig the ball 7/10
trails s min hesitation & slowness of movement
Role as student athlete
Health
Condition
(R) supraspinatus tendinitis 2˚ to
Impingement
Impairment
Pain & Tenderness (direct)
Muscle Guarding (Indirect)
LOM & Weakness (Composite)
Activity
Limitation
Diff in reaching objects overhead
Participation
Restriction
Diff in spiking, serving, receiving, digging
Personal
Factors
19 y/o, (R) Handed (-) Htn, DM, & Asthma
No hx of trauma or surgery
Member of UST MVT
Position: Open Spiker
Enjoys playing basketball
Environmenta
l Factors
Overhead cabinets & volleyball net
c height ~8 ft
Trains 2x a day for ~6hrs
Incidental
Findings
Tightness of Hamstrings
Not part of
ICF
Special Tests
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
DIAGNOSIS – names the primary dysfunction toward which the physical therapist directs treatment.
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Focuses on the level of impairment and the activity limitation not the MEDICAL DIAGNOSIS (ex. (R)
Supraspinatus Tendinitis)
Physical Therapy Diagnosis (PT Dx) is an elaboration of Medical Diagnosis (MD Dx); identifies the altered
physical status causing activity limitation and focuses on functional consequences.
PT Impression – can be added after the Medical Diagnosis to further expound the medical diagnosis
o Example: Stage of Adhesive Capsulitis (Freezing, Frozen, Thawing)
Format for writing PT Dx:
A> PT Dx: MD Dx of (Health Condition) further defined by (activity & participation restrictions, all abnormal FA
results) 2˚ to (impairments which hinder the task, indicate the worst impairment first)
• Can also be: PT Dx of (activity & participation restrictions) 2° to (impairments) further defined by (MD Dx).
Example:
MD Dx: (R) Supraspinatus Tendinitis 2˚ Impingement
A> PT Dx: MD Dx of (R) Supraspinatus Tendinitis 2˚ to impingement further defined by mod diff in spiking the
ball and min diff in serving, receiving, digging the ball and reaching object on the overhead cabinets 2˚ to pain,
muscle guarding, LOM, and weakness.
INTERVENTION SCENARIO – must be coherent with patient’s long-term goal (aimed on highest functioning the patient wants)
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Restore – correction of impairment leads to correction of disabilities; “amb s any support; able to s pain or diff”
Compensate – correction of disability by enhancement of existing strength; Orthopaedic Conditions rarely
Compensates.
• Adapt – compensation of non-correctable limitation through alterations in external environment or task.
o Patient’s case is recurrent or does not recover completely; “amb c proper pacing/assistive device”
o Include 1-2 sentence explanation why this is the Intervention Scenario
Example:
PT Dx: MD Dx of (R) Supraspinatus Tendinitis 2˚ to impingement further defined by mod diff in spiking the ball
and min diff in serving, receiving, digging the ball and reaching object on the overhead cabinets 2˚ to pain,
muscle guarding, LOM, and weakness.
Intervention Scenario: RESTORE since correction of all impairments will lead to ability of the patient to play
volleyball again. Proper biomechanics shoulder also be emphasized to decrease the reoccurrence of the injury.
PROGNOSIS
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Determination of the level of optimal improvement that may be attained trough intervention and amount of
time required to reach that level.
Based on severity, environmental & personal factors of the patient’s case.
Include 1-2 sentence explanation of the Pt’s prognosis.
Grading of Prognosis
Limited potential for
Question for potential for
Poor
Guarded
improvement
improvement
Potential to improve c deficits
Potential to improve c slight deficits
Fair
Good
Greater Negative PF
Greater Positive PF
Excellent
Potential to fully recover with no residual deficits
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Factors Affecting Patient’s Prognosis
Body of available literature review relevant to health
Previous level of functioning or disability (athlete or
condition/prognosis
sedentary?)
Therapist’s own clinical judgement (will he reach goals?)
Living environment (poor ergonomics)
Data from test and measure obtained (severe or no?)
Patient’s and/or family goals (high demands or not?)
Past experiences with similar patients
Patient’s motivation and adherence and responses to
Complexity, severity, acuity, or chronicity of pathology
previous interventions
Patient’s general health status and presence of
Safety issues and concerns
comorbidities
Extent of support (physical, emotional, and social)
Example:
Prognosis: GOOD
Positive Prognosticating Factors
Negative Prognosticating Factors
19 /yo
(R) handed
(-) Htn, DM, and Asthma
Member of UST men’s volleyball team
No hx of trauma or surgical operation
Usually trains at least 2x a day for ~6hours
Member of UST men’s volleyball team
Position: open spiker
Usually trains at least 2x a day for ~6 hours
Overhead cabinets and volleyball net c height of ~8
Enjoys playing basketball
feet
Explanation: GOOD prognosis because patient is young, trains daily, and lives an active lifestyle c no
medical history and no comorbidities which makes healing and rehabilitation easier for him. However,
his sport and position require power & repetitive stress which makes chances of reoccurrence high
therefore the prognosis is towards GOOD than EXCELLENT.
Review of Plan of Care & Outcome Setting (MSK 2)
GOALS – helps plan treatment to meet specific needs of the patient
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Prioritize treatment and measure effectiveness
Assist with monitoring cost effectiveness
Communicate therapy goals for the patient to other health professionals
Must be SMART (Specific, Measureable, Attainable, Realistic, and Time Bound)
Components of Goals
Who will exhibit the skill?
What specific behaviour is done?
Audience
Behaviour
(Always Patient/Caregiver never PT)
(A verb followed by object of behaviour)
How long will it take?
In what condition is the behaviour
Condition
Degree
Minimum: 2 weeks (↑ muscle grade: 4
measured?
weeks)
For short term goals concerning Impairments
Functional Carry over
Not included in goals addressing Activity & Participation
Example:
1.
Pt will be able to play volleyball as an open spiker for 3-5 sets s pain and difficulty p 4 weeks of PT sessions
A
B
C
D
2.
Pt will report ↓ pain on (R) posterolateral aspect of shoulder from 6/10 -> 3/10 p 2 weeks of PT sessions
A
B
C
D
to be able to spike the ball s difficulty
F
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
LONG TERM GOAL – patient’s anticipated level of function by end of an episode care
• Final product to be achieved by physical therapy
• Equivalent to expected functional outcomes
• Rehabilitative Goal: aims to rehabilitate/treat the impairment
• Preventive Goal: aims to prevent further impairment in the future.
Example:
LTG:
Rehabilitative> Pt will be able to play volleyball as an open spiker for 3-5 sets s pain and difficulty p 4 weeks of
PT sessions.
Preventive> Pt will be able to comply on all HEP given p 2 PT sessions.
PROBLEM LIST is analyzed on which specific problem to address first based on patient’s highest level of function or LTG
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Since the Intervention Scenario is RESTORE, #1 Priority is Impairment.
If ADAPT & COMPENSATE, #1 Priority is Activity Limitation & Participation Restriction.
Example:
Problem List:
1. Pain graded 6/10 on (R) posterolateral aspect of shoulder
2. Weakness of (R) shoulder abductors & internal rotators graded 4/5
3. LOM on (R) shoulder abduct (0-120, AROM) and IR (0-45, AROM)
4. Mod diff in spiking the ball
5. Min diff in serving the ball
6-10. Other problems of the patient
Root cause of dysfunction is (1) pain due to inflammation process undergoing, if this is corrected,
patient can already play volleyball. Weakness of (R) shoulder abductors and internal rotators (2) is
addressed next because as an open spiker the patient needs to spiker as hard as he can which demands
a lot for his muscle. (3) LOM is prioritized since optimal power is achieved with optimal length. (4)
Difficulty in spiking is prioritized because the patient’s role is to spike.
**Reminders: For problems 5 onwards, still include explanation regarding its prioritization
SHORT TERM GOAL – bridge between patient’s status & LTG
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Steppingstones to help PT determine if the patient is making the expected progress within a reasonable time.
Revised periodically as progress is expected
Prioritized based on problem list.
Examples:
2. Pt will manifest ↑ strength on (R) shoulder abductors and internal rotators from 4/5 -> 5/5 p 4 weeks of PT
sessions to be able to spike the ball c full force
a. May indicate “by 1 grade” if many weak muscles c different muscle grades. (ex. 4/5 abductors & 3/5 IRs)
3. Pt will demonstrate ↑ ROM of (R) shoulder abduct from 0˚-120˚ -> 0˚-150˚ and IR from 0˚-45˚ ->0˚-60˚ p 2 weeks
of PT sessions to be able to reach objects overhead
a. May indicted “by (specific degree)” if many LOM c different degrees
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
4. Pt will demonstrate ↓ difficulty in spiking from mod -> min as manifested by able to spike the ball from 5/10 ->
8/10 s difficulty p 2 weeks of PT sessions
a. If the functional difficulty of the patient has a condition (ex. trials), you will have to double condition in
STG. Example given shows MOD -> MIN and 5/10 ->8/10
INTERVENTION
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Art of clinical practice by correct application of techniques & modalities. PT must also have good body
mechanics & proper draping and positioning skills
Levels of Intervention
Intervention
Prevention
Health Condition
Medical treatment/care or Medication
Health promotion, Nutrition, Immunization
Impairment
Medical treatment/care, Medication, or
Surgery
Prevention of development of other A/L
Assistive devices, Personal Assistance, Rehab
Preventive rehab & development of other P/R
Accommodations, Public Education
Anti-discrimination Law, Universal Design
Environmental change, employment strategies
Accessible services, Universal design
Lobbying for change
Activity Limitation
Participation
Restriction
TREATMENT PROPER – written in sequence of intervention not by prioritized problem
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Treatment plan – modality for treatment
Parameters of Treatment – intensity &/or duration of treatment
Location of Treatment – body location, laterality, range (if applicable), patient position
Purpose/Rationale of Treatment – goal of the treatment
Frequency of Treatment – how many times must the PT or patient do it?
Examples:
Cold packs on (R) posterolateral aspect of shoulder x 20 mins to ↓ pain.
PRE using blue theraband on (R) shoulder abductors & IRs x 10 reps x 2 sets to ↑ strength.
AROM exercise on (R) shoulder towards abduction & IR x 10 reps x 2 sets to maintain joint integrity.
OUTCOMES
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Re-examination – base on Progress Notes if patient’s condition is improving
Revision of POC – if the patient is not improving, maybe change intensity or modality.
Effective Discharge planning:
o Home environment
o Follow-up care or referral
o PATIENT, FAMILY, CAREGIVER EDUCATION
▪ Sentence form
▪ Ex. Pt must not overuse the shoulder
o HOME EXERCISE PROGRAM
▪ Same format as plan
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Clinical Reasoning in Neurologic Rehabilitation
Comparison Between Musculoskeletal and Adult Neurologic Rehabilitation
Musculoskeletal Rehabilitation
PT Diagnosis
Type of Injury
(ex. Carpal Tunnel Syndrome)
Classification of Injury
(ex. Nerve injury)
Stages (ex. Stages of Ad Caps)
Adult Neurologic Rehabilitation
Stroke:
Brunnstromm Bobath staging, Type of stroke syndrome
Parkinson’s Disease:
Hoehn-Yahr Classification
Multiple Sclerosis:
Type of MS (Definite, Probable, Possible)
Spinal Cord Injury
Level & Type of Syndrome, ASIA Impairment Scale
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Format of PT Dx is still the same:
o PT Dx: MD Dx of <_____> (c PT Impression of <_____>) further defined by <functional difficulties> 2° to
<impairments>
o PT Impression can be added to expound on the Medical Diagnosis
• Restore – focus on
• Restore – focus on impairments
impairments
Intervention
• Compensate (Adapt + Compensate) – focus on
Scenario
• Adapt – focus on
environment adaptation + strengthening of the
Depends on
environment adaptation
unaffected extremity
severity of the
• Compensate – focus on
• Prevent – rare in neurologic cases; more appropriate
condition
strengthening the
on Acute neurologic cases to prevent secondary
unaffected part
complications of the disease.
Stages of Healing
Time Frame: “Golden Period” (1st 6 mos after onset)
• Acute: Day 0 – Day 6
• During the 1st 6 months, there is higher chance of
• Subacute: Week 2 – 3
healing which warrants more aggressive therapeutic
intervention to regain more functional capabilities
• Chronic: 6 Months – 1 Year
Hand Function
• Presence of Pincer Grasp, Fine Motor Skills presents
much better prognosis after Acute CVA
Prognosis
Positive and Negative Prognosticating Factors
Poor
• Identify modifiable & non-modifiable risk factors
Guarded
Based on Classification
which may affect prognosis
Fair
• Example: Grade 1 vs 2 vs 3
• Example: Hypertension in CVA
Good
Ligament Sprain
For Spinal Cord Injury
Excellent
• Severe injury due to Grade
• Level of the Lesion – cervical lesions have worse
3 sprain has significantly
prognosis than thoracic or lumbar lesions because it
worse prognosis than a
may cause Quadriplegia.
Grade 1 sprain
• Complete or Incomplete Lesion – incomplete lesions
have much favorable prognosis than complete lesions
• ASIA Impairment Scale – classified into A (Complete),
B (Sensory Incomplete), C & D (Motor Incomplete), E
(Normal)
• Same as Musculoskeletal Evaluation, provide explanation on why your chose the Intervention Scenario and
Prognosis for the Patient.
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Musculoskeletal Rehabilitation & Adult Neurologic Rehabilitation
• Rehabilitative – aims to attain the highest function of the patient, not the therapist.
Goal Setting
• Should be function-based in accordance to the status of the patient
• Should be SMART (Specific, Measurement, Attainable, Reasonable, Time bound)
• Remember the ABCDFs of Goals:
A: Audience
Always the patient, not the therapist (ex. Pt……)
B: Behavior
What will the patient do (verb)? (ex. Demonstrate, Manifest, Show)
o Object of the Behavior – what will demonstrate, manifest, or show? Must be consistent c behavior.
▪ Example: Pt will demonstrate ↓ pain……
▪ Is wrong because you cannot demonstrate pain, the patient will “report” is better
Measurable component of goals
C: Condition
Example: ↑ ROM by 10 degrees; ↑ muscle strength by 1 grade
Example: 6 weeks of PT
D: Degree
When do you expect the change in condition?
sessions; 2 PT sessions
F: Functional
Example: “to be able to
Important in goals in relation to impairments
Carryover
negotiate stairs”
ITE Model for Clinical Decision Making
Individual – the patient’s background information and objective findings
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Enablement
Perspective
Resources
Narrative Reasoning
Skills
Hypothetico-Deductive
Reasoning
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Identify the individual’s participation and roles, including selfcare,
social, occupational, and recreational activities
Takes into consideration the skills and resources required
Is the patient the provider for the family?
How heavy is the physical demands of the patient’s
occupation/recreation?
Physical and cognitive mechanisms including musculoskeletal
linkages, control of basic movement type, and ability to plan
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Understanding the patient’s story, his beliefs, feelings, and health
behavior (taken from Subjective Examination)
Initial cues (information) → Tentative Hypotheses → Ongoing Analyses
Impairment → Activity Limitation → Participation Restriction
• Step-by-step approach in which the treatment plan is tailor fit to
the patient’s problems & background information
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
• Focuses on the underlying disease or pathology
• Must be avoided, this perspective follows pattern recognition in
Disablement
diseases which makes the therapist follow his/her own experience
Perspective
in treating the disease without keeping in mind the patient’s
background information & specific problems
Hypothesis Oriented
Algorithm
Systems Review at the
Level of Tasks
Systems Review
through Impairments
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Patient-centered & hypothesis driven
Remember to always tailor fit your treatment plan to your
patient’s background information & objective findings!
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Task-specific activities used as outcome measures to assess
integrity of a system (ex. Timed Up and Go Test, Functional Reach
Test, and Berg Balance Test)
Minimal Detectable Change & Minimal Clinically Important
Difference must be assessed in every outcome measure to ensure
the objectivity of the tool.
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May include ROM, MMT, and other objective measures to assess
the impairments of the patient.
Task – task analysis is a detailed observational analysis of a patient’s body movement patterns during task performance
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Look for compensatory movements during a task
Example: Activation of Quadratus Lumborum during Gait causes Circumduction Gait
Motor Learning and Control Approach
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Analysis of a certain task in terms of movement (ex. STS)
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Analysis of a certain task in terms of what aspects of ADL’s will a
specific task be used (ex. STS is needed for Toilet use)
Training should be
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Feasible (possible to do easily or conveniently)
Practical (useful in realistic situations)
Amount of practice
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Number of repetitions and sets matter
Type of practice
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Whole Practice (ex. Walking)
Part Practice (ex. Strengthening of TA for walking or for initial
contact)
Task-specific
Context-specific
Environment – can change, force, and prevent the patient’s compensation after Task Analysis
Regulatory
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No change in the environment; more one cuing
Example: cuing the patient to prevent leg to hit the parallel bars
upon gait which forces the activation of Iliopsoas
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PT10117 – Neurologic Evaluation & Intervention (USTCRS – Mahimer)
Non-regulatory
Modifiable
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Presence of change in the environment to prevent compensation
Example: moving the patient in a narrow hallway which may act as
if walking in a parallel bar
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Any change in environment to shape the patient’s behavior
Example: in patients with TBI RLA 4 to 6 the patient is moved into
isolation to prevent possible harm caused by the patient’s
eccentric behavior
Treatment
• Organized around the patient’s goals (Long-term Goal – to be able to walk? To stand? To lift objects?)
• Rendered based on the manipulation of the environment and principles of exercise and motor learning
• Task-specific training is advocated which can mimic functional goal
o Problems during a task can be observed which warrants training specific to the components of the task.
o Example: The patient cannot negotiate stairs due to weakness of knee extensors
▪ The therapist should help the patient train his knee extensors before stair negotiation training.
• Cost-effectiveness/availability – make sure that the change in environment will be effective and does not cost a
lot. Changing the environment without any result is a waste of time and money.
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