Clinical Decision Making: Choosing Outcome Measures, Development and Progression of Treatment Plans

what is purpose does the outcome measure fill?

can be generic or disease specific, can also be performance-based or self-report questionnaire

validity

is the test appropriate to examine the desired constructs

reliability

can the measure be administered with minimal error

responsiveness

will the measure help determine if the intervention produces a change in the patient’s status over time

minimal detectable change (MDC)

the smallest amount of change in score on the outcome measure necessary for the change to be considered truly a change and not simply due to measurement error, used to help us interpret the change score

minimal clinically important difference (MCID)

asks “was the change in score clinically important”; was the change meaningful to the patient in terms of their health status or quality of life.

during early stage of recovery, what kinds of outcome measures should be selected?

focus likely on body structure/function- best markers of prognosis. body structure/function and activity level outcome measures are more likely to be meaningful and often more directly linked to interventions

during the later stage of recovery, what kinds of outcome measures should be selected?

outcome measures are focused on participation and will be more meaningful

describe the decision making process for developing intervention plans

1. perform task analysis

2. fitts and posner’s stage of motor learning

3. motor control theories

4. ICF, PCMM, movement system diagnoses

5. develop PT POC, treat and reassess motor skills

   1. either meet goals or restart the process to step 1

when doing the task analysis, what do we need to take into consideration?

• the task

• the individual

• the environment

what components are part of development of the plan of care?

• best available evidence

• clinical expertise

• pt or client values and circumstances

what does a successful POC have?

will use logical, sequential progression of increasing difficulty tailored toward the patient. Regression may be necessary at times

what are closed tasks?

tasks with stable environments that are unchanging, performer is able to predict what to do

what are variable tasks?

the environment is stable but there is intertrial variability

what are consistent tasks?

the environment is changing by there is no intertrial variability

what are open tasks?

skills are performed in variable and changing environments, the performer must repeatedly adapt to changing demands

what is the cognitive stage of learning?

when the learner is developing the understanding of the task, takes conscious effort to complete

what is the associative stage?

learner practices movements and refines the motor programs

what is the autonomous stage?

learner is focusing on how to succeed, they continue to refine the motor program and task

what do we learn from the reflex and hierarchical theories?

• during exam we test reflexes to predict whether the CNS is intact

• movement behaviors can be interpreted in terms of presence of absence of reflexes and synergistic patterns

• help us explain abnormal motor behaviors in individuals with CNS damage

  • “movement dysfunction after neurological injury due to interruption in higher center’s ability to control lower centers”

what is the impact on PT clinical practice of the reflex/hierarchical theories?

clinical approaches following this theory relied on examination of reflexive behavior, treatment based on inhibition or facilitation of abnormal postural reflex activity, abnormal ms tone, and synergies, optimal sensory input needed for stimulating normal motor output and function

what did we learn from motor programming and schema theories?

• CNS stores generalized motor programs

• variability of practice is important for optimal motor learning and leads to better transfer

• errors can enhance motor learning

should we wait until we have inhibited abnomral reflexes and synergies before working on more normal movements/postures?

no, we should incorporate normal movements and postures early to promote functional recovery and adaptability. We also don’t need to wait until movement quality is perfect before we progress

what is the dynamic systems theory?

describes a “self-organizing system”, movement emerges based on demands of the system and not from control of the higher centers alone, demands come from environment, all body systems, and the task itself. we have “preferred movement patterns” that we use to accomplish daily movement goals

what are the big take aways of the dynamic systems theory?

movement is a product of interactions among the individiual, the test itself, and the environment. variability of motor control is normal and important for retraining movements. Encouraging pts to explore variable movement patterns and environments will lead to success in movement goals, PT need to consider the goal of the motor task

when does learning occur?

when we interact with out environment and actively try to solve a movement problem. error correction processes refine movement

what is gentile’s taxonomy ?

systemic classification system used to categorize motor skills from simple to most complex. factors which increase complexity included in the system: open environment, trial to trial variability, object manipulation, body transport

what is the purpose of gentile’s taxonomy?

guide to establish treatment interventions/treatment plans, helps to give a guide for how to progress activities. can also used to chart/document progress of our patients. also helps to ID the level of complexity of skills and degree of difficulty associated with the task

when do you use compensatory interventions?

use with individuals with severe movement deficits or limited prognosis for recovery of function- pt may use substitution, compensation, adaptations and alternative way to accomplish functional tasks

when do you use augmented interventions?

in the early recovery phase when there is limited motor function, limited motor control or no volitional movement or limited cognitive. therapy here involves more hands-on guidance, assistance, or facilitation techniques to promote movement

when should you be using impairment based interventions?

throughout the course of treatment, try to incorporate remediation of specific impairment into functional mobility training activities

what are restorative interventions?

interventions that are activity based of functional and follow motor learning strategies(task specific, repetitive practice of functional activities, constraint induced practice), saliency matters! focus on movement performance deficits

what needs to be established first, proximal stability or distal mobility?

proximal stability

what do PT interventions during acute care emphasize?

• functional mobility (OOB, upright tolerance in and OOB, standing, walking as able)

• prevent loss of ROM/contractures

• bed positioning and prevention of pressure ulcers

early intervention leads to better functional outcomes!

describe LTAC (long term acute care)

continuation of hospital level care, patient has complex medical needs and high level and prolonged complex care is needed. (around the clock care) main focus is medical needs (NOT PT), average length of stay about 25 days

describe IRF (inpatient rehabilitation facility)

the gold standard for rehab in the US, hospital level care when pt needs intensive 24/hr interdisciplinary rehab care provided under direct supervision of physician. focus is on regaining function after severe illness or injury, intensive daily therapy with multidisciplinary approach

describe SNF

short term stay, assistance with ADLs, general mobility. less complex medical needs, required to have nursing on site 8hr/day, no direct daily supervision by the physician

describe outpatient rehab

main focus is therapy needs, frequency varies from 1-3 times a week, focus typically on higher level mobility, instrumental ADLs that can’t be addressed in home health

what are the qualifications for home health?

must be certified as homebound and unable to leave home except to receive medical care or occasional nonmedical trip (ie church) for medicare patients