Clinical Decision Making and Treatment Interventions

types of interventions

- direct interventions

- coordination, communication, documentation

- patient/client related instructions

steps to effective treatment intervention

- careful examination and evaluation

- identify patient problems

- develop a prioritized problem list

- identify impairments and functional limitations leading to problems

- identify impairments/functions which would respond to PT intervention

- develop a treatment plan with appropriate interventions

- reassess! and change interventions appropriately

components of patient examination

history, systems review, tests and measures

examples of primary impairments

tone, strength, sensation

three categories of impairments

primary, secondary, composite

examples of secondary impairments

contracture, pain, edema, alignment

examples of composite impairments

movement deficits, atypical movements, compensations, balance, posture, endurance

which type of impairments are preventable

secondary impairments

life role in participation (disability)

age, gender

environmental factors that play a role in participation (disability)

family support, accessibility, economics

TRUE/FALSE: persons with the same impairments and functional limitations can have different degrees of disability

TRUE

things to consider when developing a treatment plan

- What are my expected goals?

- What problems are limiting this patient the most (prioritizing)?

- How can I treat these problems and get the most out of my treatment?

- How will I order my treatment?

- How will I progress the patient?

general treatment considerations

- address key impairments in strength, power, ROM, endurance, posture, and balance as needed

- task specific functional training of sufficient intensity

- educate patient

- provide assistive, adaptive devices as needed

- promote long term wellness

specific evidence based neurological interventions

- intensive task oriented/functional training

- functional electrical stimulation (FES)

- strength training

- endurance training

- flexibility/ROM

what is intensive task oriented activity

- organized around the accomplishment of a task that provides the max stimulus for functional improvement

- can involve increased time, frequency, repetitions, attention/problem solving, and/or physiologic effect

- intensity if relative!

does intensity matter?

YES - the harder you work someone, the more benefits they receive

how can we provide intensive task oriented therapy with limited time, budgets, personnel and space

- create an environment conducive to the approach

- flexibility in scheduling

- use of selected equipment and devices

- providing quality of self directed practice opportunities for our patients

- treating more patients in appropriate group activities

examples of intensive task oriented training

- intensive (high intensity) gait and balance training

- constraint induced movement therapy (CIMT) and forced use

- intensive functional circuit training

- independent practice

- group practice

important aspects of high intensity locomotor and balance training research

- no magic in harness support

- most benefit noted in protocol that progressively and systematically increased treadmill speed

- similar benefits to treadmill training alone

- may be most appropriate for lower level patients to initiate walking or as a protection for higher level patients

- no better than aggressive bracing assisted walking

effect of high intensity locomotor and balance training in CVA patients

- increased gait speed and walking distance

- decreased energy cost of walking

- increased stance time on affected side and decreased double limb support

- improved stance and swing symmetry ratios

- normalized EMG activity of ankle

effect of high intensity locomotor and balance training in SCI

- increased gait speed and distance

- increased economy in gait

effect of high intensity locomotor and balance training in MS patients

- increased gait speed, endurance, and balance

in general, do not exceed what percent BWS during ambulation

40-50%

what percent BWS is preferred during ambulation

<30%

when assessing quality of gait, you should pay particular attention to what parameter of gait

step length

what is constraint induced movement therapy

- attempt to overcome 'learned non-use'

- restrain less affected UE 90% of waking hours with mitt or sling

- training of the more affected UE is given 6hrs/day for 10 consecutive weekdays (intensive massed practice with behavioral learning component)

- minimum motor requirement for this therapy is 20 degrees wrist extension and 10 degrees digit extension in affected UE

e-stim has generally more benefit in the (UE/LE)

LE

is e-stim more beneficial when used in isolation or during functional activities

used during functional activities

effect of strength training in CVA patients

increased strength, function, balance, gait (speed, step length, symmetry), and UE strength and function

effect of strength training in Parkinson's

increased strength, balance, and gait (speed, stride length)

effect of strength training in MS patients

- increased strength, function, gait (speed, step length, symmetry)

- decreased fatigue

important aspects of strength training research

- use various types of resistance (isokinetic, T-band, weight machines, cuff weights)

- use both open and closed chain types of exercises

- no adverse events found

- used patients with mild to moderate disability

- mostly neuro effects on strength

- no increases in spasticity

recommended frequency for strength training

2-3x/week

recommended intensity for strength training

2-3 sets of 8-12 reps at 60-80% of 1 rep max

knee extensor strength highly correlated with

gait speed and sit to stand performance

plantar flexor strength highly correlated with

gait speed

basic considerations for strength training

- make it functional when possible (specificity of training)

- give appropriate resistance (60-80% of 1 rep max)

- when considering speed of movement and type of contraction, consider what functional task muscle of interest will be used for

- remember to progress patient, change exercises periodically and work on power

- monitor vitals

what type of muscle contraction exercises should you use with very weak muscles

eccentric exercises

effect of endurance training in CVA patients

Increased VO2 peak, workload (watts), aerobic efficiency, aerobic fitness correlated with increased sensorimotor function (Fugl-Meyer)

effect of endurance training in Parkinson's

Increased VO2 peak, habitual activity level, mood state, functional performance (6 MWT), movement initiation

effect of endurance training in MS patients

22% increase VO2 max, 48% increase in work capacity
No exacerbations
Severely impaired improved less

important points from endurance training research

- people with neurological disorders responded similarly to aerobic training as healthy people

- patients become more efficient and fit (improved functional reserve and potential)

- very low incidence of adverse events

general considerations for endurance training

- monitor vitals

- exercise at 60-80% of age predicted HRmax or 50-70% of HR reserve

- start with frequent brief sessions (5-10 min) and progress to 20-60 min sessions

- if patient is on meds, use RPE to monitor exertion due to the possibility of the patient having a blunt heart rate response to exercise

detrained intensity %

40-50%

low fit intensity %

50-60%

average fit intensity %

60-75%

athlete intensity %

75-85%

most important LE joint ROMs for flexibility

- ankle dorsiflexion

- hip extension

- knee extension

most important UE joint ROMs for flexibility

- shoulder external rotation

- combined elbow/wrist/finger extension

most important trunk ROMs for flexibility

extension and rotation

how should interventions be ordered during a treatment session

significant impairments (i.e. contracture, tone) should be addressed prior to functional training