Foundations of clinical practice

Abstract:

This chapter provides the clinician the foundational concepts for clinical practice in neurological rehabilitation. In this chapter, five foundational elements will be discussed: the complexity of the central nervous system; professional roles in rehabilitation for the patient with neurological conditions; the movement system and the physical therapist’s identity; models and constructs for the different elements of the patient care management cycle and the practitioner-patient partnership.

Keywords:

clinical problem solving, patient/client management model, International Classification of Functioning, Disability and Health (ICF) learning environment movement system

Objectives

After reading this chapter the student or therapist will be able to:

1.

Analyze the concepts of a systems model and discuss how cognitive, affective, sensory, and motor subsystems influence normal and abnormal function of the nervous system.
2.

Use an efficient and effective physical therapy diagnostic process that is centered on the patient/client management model.
3.

Apply the International Classification of Functioning, Disability and Health (ICF) to the clinical management of patients/clients with neuromuscular dysfunction.
4.

Discuss the evolution of enablement, health classification models, neurological therapeutic approaches, and health care environments in the United States and worldwide.
5.

Discuss the interactions and importance of the patient, therapist, and environment in the clinical triad and the generation of movement.
6.

Consider how varying aspects of the clinical therapeutic environment can affect learning, motivation, practice, and ultimate outcomes for patient/client.
7.

Define, discuss, and give examples of a holistic model of health care.
8.

Describe the relevance of the movement system to the practice of physical therapy.

What are the foundations of clinical practice in neurological rehabilitation?

The foundations of physical (PT) and occupational (OT) therapy practice are continuously being retooled. Even at the writing of this edition, professional leaders are still working to refine the identity of their respective professions to clarify the core knowledge and skills a therapist should possess. This clarification is necessary to justify consumer access to therapy services, to improve entry-level professional education, and to convey to society the professions’ commitment to improve health, function, and quality of life for all. Both professions face the challenges of the current health care climate, which demands therapeutic care models that are efficient, cost-effective, and result in measurable outcomes. In the particular branch of neurological rehabilitation, practitioners must be skilled not only in the choice and application of system-specific interventions but also in their understanding of the patient’s/client’s function in all aspects, including the central nervous system (CNS) as a movement control center. In this chapter, five foundational elements will be discussed: the complexity of the CNS; professional roles in rehabilitation for the patient with neurological conditions; the movement system and the PT’s identity; models and constructs for the different elements of the patient care management cycle and the practitioner-patient partnership.

Complexity of the nervous system as a control center

The concept of the CNS as a control center is based on a therapist’s observations and understanding of the sensory-motor performance patterns that are reflective of that system. This understanding requires an in-depth background in neuroanatomy, neurophysiology, motor control, motor learning, and neuroplasticity, and gives the therapist the basis for clinical application and treatment. Understanding the intricacies and complex relationships of these neuromechanisms provides therapists with direction as to when, why, and in what order to use clinical interventions. Motor behaviors emerge based on maturation, potential, and degeneration of the CNS. Each movement behavior observed, sequenced, and integrated as part of the intervention strategies should be interpreted according to neurophysiological and neuroanatomical principles, as well as the principles of learning and neuroplasticity. As science moves toward a greater understanding of the neuromechanisms by which behaviors occur, therapists will be in a better position to establish efficacy of intervention. Unfortunately, our observation of behavior is ahead of our understanding of the intricate mechanisms of the CNS that create it. Thus the future will continue to expand the reliability and validity of therapeutic interventions designed to modify functional movement patterns as we better understand the neuromechanisms responsible for the change. First, therapists need to determine what interventions are effective within a clinical environment. Then the efficacy of specific treatment variables can be studied and more clearly identified. The rationale for the use of certain treatment techniques will likely change over time as we better understand the CNS.

Professional roles in neurological rehabilitation

Identity, efficacy, and advocacy

The rich history of neurological rehabilitation was built upon the foundation of master clinicians who developed unique models of therapeutic interventions through well-honed observations of human movement and how impairments in the neuromusculoskeletal system alter motor behavior and functional mobility. These approaches include those developed by Ayers (sensory integration), Bobaths (Neuro Developmental Treatment [NDT]), Brunnstrom (movement therapy approach), Feldenkrais (Functional Integration and Awareness Through Movement), Knott and Voss (Proprioceptive Neuromuscular Facilitation [PNF]), and Rood (Rood’s sensorimotor approach), among others. These were the first behaviorally based models introduced within the health care delivery system, and they have been used by practitioners within the professions of physical and OT since the middle of the 20th century. These individuals, as master clinicians, tried to explain what they were doing and why their respective approaches worked using the available science of the time. From their teachings, various philosophical models evolved. These isolated models of therapeutic intervention were based on successful treatment procedures as identified through observation and described and demonstrated by the teachers of those approaches. In the decades that followed, content related to these techniques has been taught as individual units; many continuing education courses still teach these specific techniques individually. The general model of health care delivery under which these approaches were used was the allopathic model, which began with physician-diagnosed disease and pathology. Various models of health care delivery will be discussed in later sections of this chapter.

In a broader sense, the roles of PTs and OTs in neurological rehabilitation have moved beyond impairment-based interventions. Because a specific treatment has a potential effect on multiple body systems and interactions with the unique characteristics of each patient/patient clinical problem, establishing efficacy for interventions is extremely difficult. The rationale often used to explain the effectiveness of interventions was based on an understanding of the nervous system as described in the 1940s, 1950s, and 1960s. That understanding has dramatically changed; although this does not negate the potential usefulness of any treatment intervention, it does create a dilemma regarding efficacy of practice.

Efficacy has been defined as the “ability of an intervention to produce the desired beneficial effect in expert hands and under ideal circumstances.” When any model of health care delivery is considered, the question the therapist must ask is “Which model will provide the most efficacious care?” Therapists are not responsible for the diagnosis of a pathological disease, but they are in a position of responsibility to examine body systems for existing impairments, to analyze movement, and to determine appropriate interventions for activity-based functional problems. Some differences in this responsibility may exist between practice settings. In selecting the most appropriate examination tools, the therapist must consider several issues independently or in combination: existing levels of evidence, applicability to the setting and population, practicality, availability of norms, and a test’s clinimetric properties.

Within some hospital-based systems, therapists may be expected to use specific tools that are considered a standard of care for that facility, regardless of the applicability and evidence. In some hospitals and rehabilitation settings, a clinical pathway may be used that defines the roles and responsibilities of each person on a multidisciplinary team of medical professionals that may limit the decision making process. The therapist is strongly encouraged to use existing evidence, to consider all the issues related to selecting the most appropriate tests and measures, and to reflect on their own professional values during the decision making process.

Regardless of which clinical setting or role the therapist plays, it is always the responsibility of the therapist to be sure that the plan of care meets the needs of the patient/client, challenges the patient/client to progress appropriately, and renders successful outcomes. If the needs of the particular patient/client do not match the progression of the pathway, it is the therapist’s responsibility to recommend a change in the patient’s/client’s plan of care. Efficacy does not come because one is taught that an examination tool or intervention procedure is efficacious; it comes from the judicious use of tools to establish impairments, activity limitations, and participation restrictions, to identify movement diagnoses, to create functional improvements, and to improve quality of life in individuals who come to us for therapy. When a holistic view of the patient/client is the foundation in therapy, it is apparent that outcome tools are not yet available to simultaneously measure the interactions of all body systems, making it difficult to apply models that purport to balance quality and cost of care. We must guard against the tendency to default to a narrow bank of “efficacious” interventions and measurement tools, and to the exclusion of techniques that have clinical effectiveness.

Evidence-based practice is basic to the care process. Therapists should always be able to defend their choice and use of intervention approaches; this becomes even more relevant as the cost of health care rises. Clinicians need to identify which of their therapeutic interventions have demonstrated positive outcomes for particular clinical problems or patient populations and which have not. Those that remain in question may still be judged as useful. The basis for that judgment may be a patient satisfaction, an outcome that has become a critical variable for many areas in health care delivery ^, with a growing body of supportive evidence. A discussion of patient satisfaction will be expanded in following section on the patient-practitioner relationship.

The potential for OTs and PTs to become primary providers of health care in the 21st century is becoming a greater reality (e.g., within the military system as well as in some large health maintenance organizations [HMOs]). The role a therapist in the future will play as that primary provider will depend on that clinician’s ability to screen for disease and pathological conditions and to examine and evaluate clinical signs that will lead to diagnoses and prognoses that fall inside and outside of the scope of practice. These clinicians must also select appropriate interventions that will lead to the most efficacious, cost-effective treatment.

The foundation of neurological clinical practice is expanding for both the professions of OT and PT. In recent years, OTs are advocating for practice and policy changes to address the negative effects of fragmented health care on patients/clients. Examples of these issues as identified in professional OT literature are (1) inconsistent patient/client access to care based on region of the country and type of insurance, (2) poor information hand-off between practitioners and clinician-patient, and (3) lack of transition services to bridge patient/client needs between home and work environment. In response, a key action of the OT profession is to advocate for practitioners in their discipline to seek credentialing as Certified Care Managers (CCMs). As described by Robinson and colleagues (2016) “occupational therapists have the training and skills to understand the complexity of medical issues and care, and the ways complex conditions disrupt everyday functioning.”

Relevant to both OTs and PTs in neurological rehabilitation settings is clear communication in multidisciplinary teams, which is paramount to patient safety and service delivery efficacy. Improvements in patient safety have been closely tied to interprofessional practice and clinician education.

To conclude this section’s highlights on professional identity, efficacy, and advocacy, the reader should refer to the sections in this chapter on the movement system and movement system diagnosis —two rapidly evolving topics in the profession that will most assuredly shape the future of the doctoring profession in the United States.

The present and our future: The movement system and the physical therapist’s identity

Movement has long been implied as the core of PT practice for more than 40 years; however, the concept of movement as a physiological system surfaced more recently. Many leaders in the profession have alluded to a professional identity with a component of movement as central the profession.

In 1975, Helen Hislop, PT, PhD, FAPTA, one of the founding leaders in PT, called attention to the profession’s identity crisis and proposed pathokinesiology as defining science of PT during the profession’s 1975 prestigious lectureship, the Mary McMillan lecture. Florence Kendall, PT, FAPTA, in the 1980 McMillan lecture, pointed out the distinction of PTs beyond procedures or modalities. She associated many medical specialties with specific body systems and proposed the musculoskeletal system, being the linked most to movement, as the PT’s focus. The American Physical Therapy Association (APTA) House of Delegates in 1983 adopted a definition of PT that identified the diagnosis and treatment of human movement dysfunction as the primary focus of PT patient management. In 1990, with input from Kendall and another leader in the profession, Scott Irwin, the movement system was defined in Steadman’s Medical Dictionary as a physiological system that functions to produce motion as a whole or of its body parts. ^, Years later, Shirley Sahrmann, PT, PHD, FAPTA, in her 1998 McMillan lecture, challenged the profession in defining its identity and to further develop the concept of movement as a physiological system. Only at a later time did the concept gain ground again when Dr. Cynthia Coffin-Zadai, in the John Maley Lecture in 2004, discussed the human movement system, the complexity of the diagnostic process related to movement, and called for advancing diagnostic classification categories. Two years later, the Diagnosis Dialog, a series of conferences to discuss diagnosis in PT, was convened by Barbara Norton, PT, PhD, FAPTA, and continued for the next 10 years.

Clearly, evolving discussions on movement as the profession’s focus have been occurring for many years, and attempts to organize and get consensus on the body of knowledge has been challenging. Agreement on defining, describing, organizing, and labeling concepts of movement as the profession’s “system” has proven to be daunting. Consider that PTs—clinicians, educators, and researchers—come from multiple philosophies in examination and intervention approaches, in addition to varied frameworks of clinical decision making and practice. The lack of professional consensus on the language and definitions related to movement, and the complexity of the diagnostic process on labeling movement dysfunction, have limited the profession from establishing a unique and singular statement on who and what PTs do. The lack of professional identity has been a dialogue extending many years, even if there seems to be unanimous agreement across many PTs that we are “movement experts.”

Finally, after many years of discussion and debate on movement, in 2013 the House of Delegates of the APTA adopted a vision that highlighted and asserted that movement is an integral part of the PT profession. The vision states, “The physical therapy profession will transform society by optimizing movement to improve health and participation in life.” With this vision came guiding principles to communicate how the profession and society will look when the vision is achieved. The first principle, on Identity, articulates that the movement system will be the core of PT practice, education, and research.

One of the first steps undertaken to meet this vision was the development of a definition of the movement system to standardize the framework and language. In 2015 the APTA released its definition along with a description of the relationship of the movement system to PT practice. The movement system is defined as a “collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its body parts.” ( Fig. 1.1 ).

The Identity statement reiterates the long-standing discussion on the PT identity associated with the movement system. The new vision and Identity statement linked the profession to a system of the body, a feature that has long been associated with established professions but has been missing in PT. Discussions that began more than 40 years ago are currently coming into fruition with defining the PT’s role in health care as experts in the movement system.

Shortly then, the House of Delegates adopted the position, the Management of the Movement System, in which APTA endorses the development of diagnostic labels and/or classification systems that reflect and contribute to the PT’s ability to properly and effectively manage disorders of the movement system. The formation of the APTA Movement System Task Force, along with the position statement, iterates commitment to moving the profession towards the movement system as the profession’s core and identity.

In 2016, APTA held the Movement System Summit, with more than 100 PT clinicians, educators, researchers, and leaders, with the goals of describing the implications of using movement system diagnostic labels and developing an action plan to integrate movement system concepts into practice, education, and research. Participants’ tasks included identifying activities or tasks that are essential to a movement system examination and criteria for diagnostic labels specific to the movement system. Recommendations from the Summit and the APTA Task Force were forwarded to the APTA Board of Directors for review and action.

In 2018 the APTA Movement System Task Force assembled two work groups to move forward with an action plan item from the Summit to “promote the development, implementation and dissemination of diagnostic classification systems/labels that adhere to the established and validated criteria.” As of spring of 2019, templates developed from the two work groups, the Movement System Diagnosis Work Group and the Task Analysis Work Group, are currently under review of the APTA Board of Directors for consideration. Over the next several years, the integration of the movement system is expected to continue as the profession debates and discusses strategies to infuse the movement system into practice, education, and research.

With many systems interacting to produce movement, so must the PT consider all of the systems contributing to movement. An individual moves the way they do because of many contributing factors—it is the therapists’ task to determine which system contributes most to movement dysfunction and eventually prioritize which impairments need to be addressed. Therapists who focus on the movement system must consider the effects of all the components involved rather than examining a specific part of the anatomical system affected by a lesion.

The Guide to Physical Therapist Practice (The Guide) describes examination as a comprehensive screening and specific testing process comprised by the patient history, systems review, and tests and measures of body structure and function, activities, and participation. It is during the examination leading to the evaluation that the therapist develops a hypothesis of the possible impairments that cause movement dysfunction based on the information from the history, results of the systems review and standardized tests, and movement analysis. However, the movement observation as envisioned to assist the choice of outcome measures and the diagnosis specific to the movement system is not explicitly identified in The Guide as a component of the patient/client management (PCM) model, nor is it a standard component clearly documented as part of clinical examination.

The Academy of Neurologic Physical Therapy (ANPT) Movement System Task Force posits that movement observation and analysis is central to the process of assigning a movement system diagnosis. While the diagnostic process is a common in clinical practice, a clear, straight-forward movement observation and analysis of tasks or activities are not typically included in practice or in documentation. The ANPT Task Force further acknowledged the absence of validated tools that accurately identify movement system dysfunction and recommend the development of a systematic process of observation and analysis. To date, the recommendation is to have the patient/client perform key tasks methodically and to observe performance that will provide insight on potential impairments that contribute to movement dysfunction. The core tasks recommended for movement observation include sitting, standing, sit-to-stand and stand-to-sit, step up and down, and reach, grasp, and manipulation. Hedman et al, 2018. These tasks are likely to change or to be added onto with further discussions regarding what activities/tasks at the minimum should be observed to provide the most insight on movement dysfunction, impairments that contribute to it, and lead to a diagnosis. Currently, there are no standardized methods on the performance of recommended tasks across patient populations. The ANPT Task Force has formed two subgroups, one that specifically is developing diagnostic labels for individuals with postural control dysfunction and the other is developing methods for task analysis that will lead to standardized movement observation. Over time, these diagnostic labels and movement observation procedures will be validated and refined for clinical use.

Movement system diagnosis: What is this?

The PCM model identifies a PT diagnosis determined after the evaluation process. A movement system diagnosis is determined after a consideration of all possible sources of movement dysfunction ( Fig. 1.2 ), along with pertinent information from the patient history, systems review, and results of tests and outcome measures from the examination. Prior PT-related diagnostic labels were typically based on pathoanatomical models in which the diagnosis process focused on identification of pathology or anatomical causes that produced movement dysfunction. ^, In contrast to medical diagnoses or pathoanatomical-based diagnosis, movement system diagnostic labels are envisioned to be based on clear description of clusters or patterns of movement observations and associated examination findings that have a greater potential drive interventions. ^, Movement system diagnoses are envisioned to help identify targeted interventions that address specific movement patterns or impairments that limit the ability to function or participate in the environment. Examples of diagnostic labels specific to the movement system have been published ^, ; however, these have not been validated through rigorous research nor are they universally used in clinical practice.

The ANPT Task Force recommended characteristics for the development of clinically meaningful movement system diagnosis. These include: a theoretical framework grounded on movement science, an emphasis on movement observation and analysis of core standardized tasks central to the examination, a cluster of movement observation and examination findings across tasks and health conditions, and nonambiguous labels that are descriptive, unique, and applicable across health conditions.

To date, activities are occurring across the profession at the APTA and its component levels to promote and develop the transition to the movement system throughout the profession. There is much work to do to integrate the movement system across practice, education, and research. Initial steps include the development of standardized movement observation and analysis that will inform therapists’ clinical decision making leading to diagnostic labels. Movement system diagnoses, once developed, will need to be validated and examined for clinical utility. Academic curricula based on the movement system and movement system diagnosis will need to permeate entry-level education and diffuse to both academic and clinical faculty. Similarly, research on the clinical utility, validity, and predictability of diagnostic labels will be necessary as PTs characterize diagnoses of the movement system and associate these diagnoses first and foremost with PT. The transition will likely be lengthy and challenging, and universal professional acceptance will be dependent on the entire profession embracing the concepts of the movement system and claiming it as the profession’s identity.

Models and constructs for the different elements of the patient care management cycle

Therapeutic models of neurological rehabilitation: What are “models” of intervention? How are they useful?

In the development of a prescriptive therapy plan, the therapist’s clinical decision making is informed by knowledge of the patient’s health condition, the function of all the body systems, and the relationship to activity limitations and/or inability or difficulty in participating in functional tasks and activities. Therapists are also responsible for analyzing the interactions of all other systems and how they compensate for or are affected by the original medical problem. To accomplish these tasks, therapists use a variety of models in the patient/client care management cycle. Models of practice serve as road maps for foundation for clinical outcomes. They are also used to create a common language for health professionals. Practice models that focus on disablement—what the patient/client cannot do—were used by clinicians early on. As the practices evolved, clinicians realized the power of recognizing what the patient can do enhances their ability to improve their activity and participation.

To understand how and why disablement, enablement, and health classification models have become the accepted models used by PTs and OTs, it is important for the reader to review the evolution of health care within our culture. The dominant model of health care in Western society began with the allopathic model, and even nowadays it forms the conceptual basis for health care in industrialized countries. The allopathic model assumes that illness has an organic base that can be traced to discrete molecular elements. The origin of disease is found at the molecular level of the individual’s tissue. The first step toward alleviating the disease is to identify the pathogen that has invaded the tissue and, after proper identification, apply appropriate treatment techniques including surgery, drugs, and other proven methods.

It is implicit in the allopathic model that licensed physicians have the sole responsibility for the identification of the cause of the illness and for the judgment as to what constitutes appropriate treatment. PTs and OTs have never been responsible for the medical diagnosis or treatment of diseases or pathological conditions but rather are responsible for providing therapeutic interventions to help patients achieve their desired quality of life. Improvements in movement function and task participation can be achieved, even when the patient/client disease or pathology is chronic and unchanged; thus the evolution to more holistic models of diagnosis and health classifications.

A holistic model ( holos, from the Greek, meaning “whole”), also known as the biopsychosocial model of health care, seeks to involve the patient/client in the process and take the mystery out of health care for the consumer. It acknowledges that multiple factors are operating in disease, trauma, and aging and that there are many interactions among those factors. An expanded biopsychosocial model includes emotional, environmental, political, economic, psychological, and cultural factors as influences on the individual’s potential to maintain health, to regain health after insult, or to maintain a quality of health in spite of existing disease or illness. Measures of success in health care delivery have shifted from the traditional standard of whether the person lives or dies to the assessment of the extent of the person’s quality of life and ability to participate in life after some neurological insult. Moreover, “quality of life” or living implies more than physical health. It implies that the individual is mentally and emotionally healthy as well. It takes all dimensions of a person’s being into consideration regarding health. From the beginning, even Hippocrates emphasized treatment of the person as a whole, and the influence of society and of the environment on health.

An approach that takes this holistic perspective centers its philosophy on the patient/client as an individual. The individual with this orientation is less likely to have the physician look only for the chemical basis of his or her difficulty and ignore the psychological factors that may be present. Similarly, the importance of focusing on an individual’s strengths while helping to eliminate impairments, and activity limitations in spite of existing disease or pathological conditions, plays a critical role in this model. This influences the roles PTs and OTs will play in the future of health care delivery and will continue to inspire expanded practice in these professions.

Since 2001, when 191 members states of the World Health Organization adopted the International Classification of Functioning, Disability and Health (WHO-ICF), the degree and quality human function has been the focus and framework for population health research and health policy actions. Application of this model is reshaping PT and OT professional education and clinical practice, including diagnosis, prognosis, outcomes measurement, and multidisciplinary patient management. The ICF model evolved from a linear disablement model to a progressive model that encompasses more than disease, impairments, and disablement. It includes personal and environmental factors that contribute to the health condition and overall well-being of individuals. The ICF model is considered an enablement model as it not only considers dysfunctions, but helps practitioners and researchers to understand and use an individual’s abilities in the clinical presentation. The ICF recognizes disability not only as a medical or biological dysfunction but as a result of multiple overlapping factors including the impact of the environment on the functioning of individuals and populations. The ICF model is presented in Fig. 1.3.

It is easy to integrate the ICF model into behavioral models for the examination, evaluation, diagnosis, prognosis, and intervention of individuals with neurological system pathologies ( Fig. 1.4 ). Whether an individual’s activity limitations, impairments, and strengths lead to a restriction in the ability to participate in life activities, the perception of poor health or restriction in the ability to adapt and adjust to the new health condition will determine the eventual quality of life of the person and the amount of empowerment or control he or she will have over daily life. The importance of the unique qualities of each person and the influence of the inherent environment helped to drive changes in world health models. The ICF is widely accepted and used by therapists throughout the world.