Clinical Decision Making Haneul Lee, DSc, PT
When executing an exercise regimen, PTs must rely on sound knowledge and expertise. Sound knowledge of the functional significance of muscular anatomy and kinesiology is essential. A fine appreciation of synergistic relationships, reversal of muscle actions, passive / active insufficiency, and other concepts clearly influences therapeutic exercise selection and modification.
When must people think of exercise Strength training comes to mind the first Therapeutic exercises include Flexibility Coordination Balance activities Strengthening exercise
Additionally, Therapeutic exercises may be initiated to increase range of motion, improve endurance, and enhance cardiopulmonary function.
Competent PTs use their knowledge of anatomy, pathology, kinesiology ad other clinical sciences when making therapeutic exercise decision. Therapeutic exercise clinical decisions are influenced by the diagnosis, goals, behavior of symptoms, patient needs, long-term goals, and so on. PTs must also make clinical decisions related to number of repetitions and other therapeutic exercise variables.
PTs must understand patient problems and the goals set toward correcting those problems. Improve range of motion Improve strength Improve flexibility Improve endurance Improve balance and coordination Improve cardiac and lung function Common Goals of Therapeutic Exercise Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.84
By carefully cataloging the deficits outlined in the initial evaluation and drawing on a sound knowledge, competent PTs select exercises that target the appropriate muscles, jounts, and/or functions. PTs must prioritize patient problems and goals.
Goal : Independence in transferring sit to stand 1. Muscle weakness in the upper or lower extremities 2. Exercise emphasis on triceps strengthening 3. Exercise emphasis on quadriceps strengthening PTs must be able to recognize underlying patient problems and translate them into exercises that become part of the exercise program.
A patient may have a severely tight gastrocnemius as well as a weak tibialis anterior Goal : Improve strength and range of motion at the ankle. 1. Initially concentrate on gastrocnemius lengthening 2. Strengthening the antagonist muscle group
Specifies each activity Number of repetitions Most effective equipment Dumbbells Cuff weights Elastic resistive
Must be aware of precautions or patient limitations. Related to myriad factors, including age, diagnosis, overall fitness, premorbid condition, and personal and rehabilitation goals. Must monitor patients responses to exercise. Must be able to recognize and understand the signs of and responses to fatigue and the significance of muscle soreness following exercise and be able to alter the exercise program accordingly.
Exercise programs need to carry over to functional activities. Need to understand the specific needs of their patients in reference of their everyday life. A clear understanding of what the patient hopes to achieve in therapy or the difficulties the patient is having at home allows the PT to better customize the exercise program. The more enjoyable exercise the patient has, the more motivated they are.
If a patient with a TBI loves soccer, PT may decide to address coordination and balance deficits by having the patient maneuver a soccer ball through and obstacle course of cones.
Increase Intensity Increase Frequency Increase Duration Decrease Duration & Frequency Decrease Duration & Intensity Decrease Frequency & Intensity Therapeutic Relationship Among Intensity, Duration, and Frequency If a patient is receiving daily physical therapy, a PT may decide to decrease the intensity and/or the duration of the treatment so as not to fatigue the patient Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.89
What type of exercise the patient needs Lack of range of motion requiring stretching? What type of stretch (self vs. passive), position and repetitions? Weakness requiring strengthening exercise? Based on knowledge of MMT and pathology What type of strengthening exercise appropriate for the patient Isotonic, Isometric, or Isokinetic Blanca deficiency requiring static and dynamic exercise?
Isotonic Exercise The muscle contracts, resulting in a change in length and joint movement. Isometric Exercise The muscle contracts without change in length, without resulting joint movement. Isokinetic Exercise Muscle contracts while the velocity of the joint movement is kept constraint by a mechanical device.
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Clinical Decision- Making Considerations for Isotonic Exercise Isotonic Exercise Open chain Closed chain Concentric Eccentric Position Position Gravity eliminated or assisted Against gravity Active ROM Active assisted ROM Resistive exercise Mechanical equipment Manual exercise Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.92
Isotonic and Resistive Exercise Dosage and Progression Regimens Technique Initial Dosage Determination Based on Maximum Number of Repetitions (RM) Progression During Session Delorme 10 rep maximum 1 set at 50%, 10RM 1 set at 75%, 10RM 1 set at 10 RM Oxford 10 rep maximum 1 set at 10 RM 1 set at 75%, 10RM 1 set at 50%, 10 RM DAPRE 6 rep maximum 1 set at 50%, 6RM 1 set at 75%, 6 RM As many reps as possible at 6 RM and adjust for next day Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.93
An exercise can usually be performed in more than one way More enjoyable exercise More related to ADL
Scenario The patient is 27-year-old male recovering from a left meniscectomy that was performed 15 days ago. The patient s range of motion is left knee flex/ext -10 to 105 degrees. The patient s left knee strength is fair - for quadriceps and poor+ for hamstrings. The treatment plan calls for stretching and strengthening exercises for the left knee. 1. Select on self-stretch and on passive stretch for this patient. 2. Select four strengthening exercises for this patient. Offer your rationale for each exercise. https://kittykattheater.files.wordpress.com/2013/04/what-do-you-think.png
Thank Question? you
1. Clinical Decision Making for the physical therapist assistance, Steven B. Skinner, Jones and Bartlett Publishers 2. National Physical Therapy Examination, O sullivan&siegelman, TherapyEd 3. PTEXAM the complete study guide, Scott M Giles, Scorebuilders