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  1. Development and Delivery of Treatment Protocols Chapter 3

  2. Remember from chapter one Therapeutic Modalities are used to create the proper environment for healing. • Many components of the injury response process are intertwined • Edema causes pain • Pain causes spasm • Spasm causes pain • Although pain may be your patients primary complaint, simply focusing your tx on pain relief does little to resolve the underlying cause of discomfort or dysfunction.

  3. The ability to plan a Tx and rehabilitation program is perhaps the most complex skill that rehabilitation clinicians must master. • This process integrates • Physical evaluation skills • Knowledge of pathology • Knowledge of applicable therapeutic techniques and principles • Goal setting • And patient motivation and education

  4. No one source is sufficient to gain proficiency in this skill. • Your ability in this area will grow and be perfected with experience • The Problem-solving Approach (PSA) • Is a logic-based technique used in developing the patient’s Tx plan to achieve a long-term goal

  5. The Problem-solving Approach • Although “logical thinking” is something that we usually do not do consciously, we practice it as part of our daily routine. • It involves basic skills • For example getting dressed • And more complicated tasks • Such as finding one’s way around an unfamiliar city for a job interview. • Either way, you use logical thinking

  6. Extending the logical thinking into treatment of the patient • As described in Chapter 1, each individual responds differently to trauma. • This fact alone illustrates the need to treat each patient differently, based on his or her own needs • Generalized Tx protocols should not be viewed as, or used as, unyielding individual treatment plans. • Individual Tx plans that specify each patient’s case leads to a more efficient and successful outcome.

  7. PSA describes an ongoing process of evaluation, analysis, and planning. • It is comprised of four steps • Recognition of the patients problem • Prioritization of the problems • Goal setting • Treatment planning • Although our focus is on Therapeutic Modalities, the role of these devices is to prepare the patient for Therapeutic exercise and manual techniques. • Modalities are also used after these techniques as a way of controlling exercise-induced inflammation

  8. Regardless of expertise and the number of years of experience, not every clinician is capable of managing every condition. • You as clinicians should not hesitate to seek the input and advice of others who possess more knowledge or have more experience managing a specific condition. • The knowledge of when to refer a patient to a more appropriate rehabilitation setting or to another healthcare or medical professional should be considered a high ethical priority. • Its also an important element in your learning process.

  9. Components of the Problem-solving Approach • Recognition of the problems: • Identify the type and depth of the involved tissues • Identify the nature of the pathology • Determine the stage of healing • Recognize any contraindications to the use of modalities or exercises

  10. Prioritization of the problem • Develop the logical treatment order based on a cause-and-effect relationship between the pathology and the signs and symptoms • Goal Setting • Develop structure and sequence in the treatment plan • Treatment planning • Determine the modalities and exercises to be used and their sequence based on the patient’s problems and treatment goals.

  11. Recognition of the Problems • To provide proper care, you must know what condition(s) you are treating. • However, again recalling Chapter 1, you are treating more than a “sprained ankle”. • This stage is designed to identify: • The type of tissues involved • Anatomy, function, size, depth • The effects of pathology • Pain, ↓ROM, Strength loss • The stage of the healing process • Acute inflammation, proliferation, maturation

  12. Each type of tissue responds differently to various modalities. • The properties of the traumatized tissues • Their depth below the skin • Their stage in the inflammation and healing process • All of these will dictate which modalities can effectively stimulate them. • Using a superficial modality to treat structures that are deep within may produce little or no benefit • Using a modality that can accelerate the inflammatory response on tissues that are already actively inflamed can result in further cell destruction

  13. Always begin the problem identification by reviewing any existing medical records describing the course of the patient’s condition. • Valuable information is stored in these records on your patient. • Some records include • Treatment notes • Operative notes • Diagnostic test results • Physicians referral or prescription notes • All potential contraindications to treatment approaches, devices, and modalities should also be identified. • Formal patient evaluations and re-evaluations should be conducted at timely intervals.

  14. Patient Interviews • Less detailed patient interviews should be done prior to each Tx session to identify the patients • Physical status • Mental status • As well as to gain the patients overall perspective of the Tx protocol.

  15. Info gained during patient interview • Subjective information • Chief complaint • Medical history • Medications • MOI • Nature of the trauma • Types of tissues involved • Stage of injury response • Patient goals • Contraindications to purposed Tx’s.

  16. A wealth of information can be obtained during your formal interview as well as an informal discussion. • Good clinicians require a keen listening skill and the ability to identify and solicit pertinent information offered by the patient. • Example: Your patient comment is “I am unable to tuck my shirt tail in” what can this identify to you as a clinician?? • Restricted internal glenohumeral rotation. • Post treatment the patient complains of feeling “worse” what does this indicate to you as a clinician? • The exercise and/or treatment protocol was too intense. • When applicable these comments should be noted in the patients file.

  17. Avoid the temptation to focus on observable signs such as • Swelling • Discoloration • Decreased ROM • And the reported symptom of pain • Numbness, etc. • Although the short-term objective Tx of any given Tx session is to provide symptomatic relief, the long-term foal of proper healing and return to normal lifestyle will not be met until the underlying pathology is identified and managed.

  18. As we will see in the following sections, symptomatic Tx are required in the early Tx phases, but only as a transition to curative Tx. • Many conditions may be identified during the evaluation process. • The use of valid and reliable tools, correct measurement techniques, consistency during re-evaluation, and proper documentation of the results contribute to the accumulation of documented evidence of the patients progress. • However, all of these tools are not appropriate for every condition, and the patient may have one or more contraindications to their use, see table 3.4 on handout

  19. You should also assess your patients mental and emotional state. • The patient should be educated regarding • The nature of the injury • The Tx plan • And the goals • To maximize participation, the patient must be able to understand and comprehend • The nature of the injury • The Tx plan • The Tx goals • And the expectations for recovery • Also assessing the patients motivational level is a must. • Patients who lack motivation or disinterest in recovery may need the assistance of a mental health care provider

  20. The info collected during evaluation and the Tx sessions should be identified and recorded in the patients file using measurable and objective terms • This allows you to track the patient’s progress toward recovery • Although each Tx session should begin with a patient interview, a full re-evaluation of the patients condition should be conducted at regular intervals. • IE. At the end of a goal period. • This allows for comparative baseline info and a determination can be made whether a patient has improved as expected or if the Tx plan needs to be modified because of a lack of progress

  21. Case Study #1 See handout and answer why each of the problem recognitions are important DUE THURSDAY!!!!

  22. Prioritization of the Problems

  23. Prioritizing the patients problems assists you in developing the logical order of treatment. • Determining the logical order of treatment requires knowledge of the pathophysiology, the events associated with each stage of the healing process, and the beneficial effects (or hazardous effects) that each modality has on the injury response process. • Prioritize problems based on their cause-and effect relationship to the chief complaints • This gives you an orderly treatment sequence • It also helps prevent mistakes and allows the patient to return to preinjury state in the safest most expedient manner

  24. Multiple chief complaints • Usually all are intertwined • The key find the patients functional deficit that is triggering all of the problems • A question that can be used to do this is • “what other signs and symptoms will be reduced if this problem is resolved?” • Consider a patient who can not bear weight secondary to pain, ↓ ROM, and swelling in the left ankle. • Which treatment should receive the highest priority? • Pain? • Pt would still be unable to walk properly because of swelling, ↓ ROM, and lack of strength • ↓ ROM? • Can not be adequately preformed because of pain and swelling. • Swelling? • This would be the highest priority

  25. Once the anti-inflammatory process has been controlled, swelling is reduced, and limited pain-free ROM has been restored • Functional exercises should be initiated • ROM exercises • Stretching • Balancing • Proprioception • And finally a strengthening protocol • All of these will lead to a normal gait and return to the pre injury activity level

  26. Case Study #1 Prioritize your problems

  27. Goal Setting

  28. Clear, concise, and measurable goals translate the prioritized problem list into a well-constructed treatment plan. • 2 types • Short term (1-14 days) • Long term (> 14 days) • These types of goals will identify your outcomes, establish timelines, and measure the effectiveness of the treatment protocol

  29. Patients ability to meet the established goals indicates advancement to the next stage. • While a patients inability to progress indicates a modification in treatment is necessary • Also, properly written and documented goals are used for insurance and legal purposes and demonstrates the criteria used to decide when to discharge you patient from care

  30. Tx goals are an estimation of where you expect the patients progress to be at a specific point in time • Should be consistent with the patients priorities, lifestyle, and expectations (when feasible) • The patient should be encouraged to participate in the treatment goals • Compliance with the protocol and the programs effectiveness are ↑ when the goals are fully understood and agreed upon by everyone involved • The most important reason to establish goals is to motivate the patient • Each goal that is met marks another milestone on the road to recovery

  31. Measurable Goals • Problem • The patient has an inversion ankle sprain. Active ROM produces 2°of dorsiflexion and the patient cannot ambulate with a normal gait • Nonobjective goal • To ↑ active dorsiflexion • Objective goal • To ↑ active dorsiflexion to 10° • Re-evaluation • The patient has 8° of active dorsiflexion • Assessment • The patient has met the nonobjective goal to ↑ active dorsiflexion but has not met the objectively stated goal. Because a min. of 10° of dorsiflexion is required for normal gait, we can assume that the patient still has an altered gait.

  32. Goal Pyramid

  33. Developing Written Goals

  34. You should start by taking all of the prioritized problems, and in an orderly fashion, formulate the final treatment outcomes, a list of long term goals, and a list of short term goals • Note on short term goal may apply to more than one long term goal • Final step determining what goals should be reasonably accomplished in the given time frame

  35. Use the ABCD format • This is stated in terms of what will be accomplished in the estimated time period • Rather than what limitations will be present • This serves to motivate the patient and also keep you focused on how the plan must be altered to facilitate the patients progress • Last, to avoid confusion, the goals should be written in precise vs general terms for each problem

  36. Long term goals • Provide direction to the treatment plan by • Identifying and quantifying the final outcomes of the treatment program • Are often used as outcome measures • In most cases the long-term goal is to return to the preinjury level of function • But is not always feasible • Although long term goals are subject to modification throughout your rehab, they are revised less often than short term goals. • Last, but most important, these goals should identify the patients needs as the focus of their treatment rather than in individual pathologies afflicting the person

  37. You should make every attempt to make long term goals measurable, however they should also be functional. • Example • To return to full competition in college football • Or, To return to the preinjury level of activity at the sawmill • These define the final outcome of the patients therapy, and their use should be encouraged • Because LTG attempt to describe the final outcome the number of these goals should be less than the number of short term goals

  38. Case Study #1 Write some long term goals

  39. Short term goals • Describe the functional progression that the patient will obtain in a specific time frame. • Usually focus on the specific problems identified • If met, will achieve the long term goals • In general, the time established for meeting these goals is the time that you feel is needed to produce a measurable change in the patients condition

  40. STG’s serve as a measuring stick for the treatment plan. • During re-eval, you should be able to determine that goals are being met and progress is being made. • If STG’s are not being met, you should re-evaluate the treatment program and change it accordingly.

  41. Case Study #1 Write some short term goals

  42. Treatment Planning

  43. Once the problems have been determined, prioritized, and goals have been established, the planning of treatment follows naturally • The stage of healing and the choice of therapeutic technique largely determine what modality types will be used • Once the type of modality to use has been determined, the application is determined based on physical characteristics of the surface being treated

  44. Example • If a chronic ankle sprain is being treated and there is little or no swelling, the modality of choice would probably be heat. • In this scenario, the physical characteristics of an ankle sprain would most likely call for the use of a warm whirlpool rather than a moist heat pack.

  45. A common area of frustration is that in many cases there is no one “best” choice modality. • Often the final decision on which one to use is based on personal comfort, past experience, and patient input. • However this frustration can work to your advantage, if satisfactory results are not being obtained from the 1st modality, the treatment protocol can easily be modified to incorporate an alternate one.

  46. Case Study #1 Plan treatments

  47. Always consider the healing stage Acute Inflammatory stage Proliferation phase Maturation Phase

  48. Evaluation of the treatment plan

  49. Re-evaluation of the patient serves as an evaluation of the treatment plan. • You assess the findings of the re-eval to determine if the plan has been successful • Have you been successful in meeting STG’s • Are you progressing towards your LTG’s • If your goals are not being met you must make necessary adjustments and you must identify why they were not successful.

  50. Case study #1 Identify changes that can be made in the program if the 1st treatment was not working