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Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients
and their families. A number of frameworks have been applied to guide
clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision
making in the management of individuals who have neurologic dysfunction.
The framework integrates both enablement and disablement perspectives.
The framework has the following attributes: (1) it is patient-centered, (2) it is
anchored by the patient/client management model from the Guide for Physical
Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for
Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to
task analysis for interpretation of movement dysfunction. This framework
provides a mechanism for making clinical decisions, developing clinical
hypotheses, and formulating a plan of care. Application of the framework is
illustrated with a case example of an individual with neurologic dysfunction.
[Schenkman M, Deutsch JE, Gill-Body KM. An integrated framework for
decision making in neurologic physical therapist practice. Phys Ther. 2006;86:
16811702.]
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M Schenkman, PT, PhD, is Professor and Director, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of
Colorado at Denver and Health Sciences Center, Denver, CO 80262 (USA). Address all correspondence to Dr Schenkman at:
margaret.schenkman@uchsc.edu.
JE Deutsch, PT, PhD, is Professor and Director of the Rivers Lab, Graduate Programs in Physical Therapy Program, Department of Developmental
and Rehabilitation Sciences, University of Medicine and Dentistry of New Jersey, Newark, NJ.
KM Gill-Body, PT, DPT, NCS, is Adjunct Clinical Associate Professor, Graduate Programs in Physical Therapy, MGH Institute of Health Professions,
Boston, Mass.
All authors contributed to each part of the manuscript, including conceptualization, writing, and editing. The authors thank Jody Cormack, PT,
DPT, for her insight and suggestions in the final drafts of the manuscript. They acknowledge substantive discussions with a number of colleagues
at the III STEP symposium and in particular thank James Gordon, PT, EdD, Lois Hedman, PT, MS, Lori Quinn, PT, EdD, and Anne
Shumway-Cook, PT, PhD. They also thank Jeffrey Lewis, who assisted with preparation of the figures.
This work was supported by National Institutes of Health grants #5 R01 HD 43770-03 and #M01 RR00051-44 and the University of Medicine and
Dentistry of New Jersey Master Educator Guild.
This article is based on a presentation at the III STEP Symposium on Translating Evidence Into Practice: Linking Movement Science and
Intervention; July 1521, 2005; Salt Lake City, Utah.
This article was received August 18, 2005, and was accepted July 14, 2006.
DOI: 10.2522/ptj.20050260
1682 . Schenkman et al
Figure 1.
Overview of the unifying framework demonstrating the steps in the clinical decision-making process. This framework is patient centered, integrates
both enablement and disablement perspectives, and incorporates a variety of existing conceptual models and analyses at various points in the patient
management process. HOACHypothesis-Oriented Algorithm for Clinicians.
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Analysis of task performance for a variety of functional activities under various environmental conditions; and
Possible reasons underlying the difficulty or inability to perform the task, including relevant impairments and environmental barriers.
The examination begins by observation of functional
activities (eg, walking, getting up from a bed or a chair).
The clinician decides the order in which the examination data will be obtained. For example, the clinician
might begin with a detailed task analysis of specific
functional activities and work backward toward underlying resources and impairments. Using this approach,
the clinician performs the detailed task analysis, develops hypotheses related to likely underlying impairments,
and proceeds with the specific tests and measures that
are most likely to identify the presence and severity of
existing impairments. This detailed task analysis is more
specific and systematic than the task analysis used during
the systems review, as is illustrated below.
The use of task analysis to make judgments during the
examination requires knowledge of the literature linking performance and impairments and clinical experience to recognize patterns of performance and their
implications regarding underlying impairments. Therefore, this strategy may be difficult for the novice
clinician.
Alternatively, the clinician might begin by examining
those impairments identified during the systems review
as well as those known to occur with the specific underlying disorder and its sequelae, as well as comorbid
conditions. The clinician might proceed next to a
detailed analysis of task performance. Using this route
into the examination process, the clinician works forward from impairments to ability to perform functional
tasks.
Whatever examination approach is used, the clinician is
judicious in determining what should be examined so
that the maximum information can be obtained from
the fewest possible tests and measures. To make judgments, the clinician draws from the patients problems
and goals, the clinicians knowledge of the disorder, and
premorbid and comorbid conditions. In reality, examination often proceeds as a combination of these 2
approaches. For clarity, however, these 2 approaches are
discussed as distinct processes beginning with task
analysis.
Examination at the Level of Task Analysis
Task analysis is a detailed observational analysis of the
patients total body movement patterns during task
performance.42 Task analysis helps clinicians to deter-
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Figure 3.
The temporal sequence identifies 5 stages of task performance that can be considered during task analysis and the specific features of importance
for each stage. Reprinted with permission of the publisher from: Hedman LD, Rogers MW, Hanke TA. Neurologic professional education: lining the
foundation science of motor control with physical therapy interventions for movement dysfunction. Journal of Neurologic Physical Therapy.
1996;20:9 13.
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Schenkman et al . 1689
chanical (referring to structure and properties of muscles, joints, and soft tissue), and behavioral (referring to
cognitive, motivational, perceptual, and emotional
aspects). These authors acknowledged that not all determinants can be identified by observing the patients task
performance. However, 2 aspects of the determinants
can be considered as the patient is observed: (1) the
possible underlying sensory, motor, and musculoskeletal
impairments and (2) the synergistic coordination of
groups of muscles during performance of tasks. These 2
aspects are discussed below.
Determinants (impairments) are considered at each
stage in the temporal sequence of the task to guide
decisions regarding which impairments to examine in
detail. Identification of the contributing impairments
eventually helps the clinician to determine optimal
interventions. For example, if force production is one of
the main causes of difficulty with the execution stage
during the sitting-to-standing activity, it may be necessary
to include interventions that improve force production.
Analysis of individual impairments in isolation may only
partially explain difficulty with task performance. For
example, just because a muscle can fire, does not mean
that it will fire in the appropriate synergistic combination during performance of a task. Appropriate synergistic firing of muscles can be problematic for any patient
and can be of particular concern for those with underlying neurologic dysfunction. For this reason, it can be
important to examine synergistic coordination of muscle
groups.
The coordination of synergistic groups of muscles has
some overlap with Hedman and colleagues concept of
determinants of movement,46,47 but goes beyond those
concepts. From a kinesiological perspective, purposeful,
functional movement is accomplished by coordination
of muscle groups throughout the body. Included are
prime movers, secondary movers, synergists (helping
and stabilizing), and whole-body stabilizers.50 With neurologic injury, appropriate coordination of these various
muscle groups is frequently disrupted. At times, individuals have the ability to produce adequate force when
muscles are examined in isolation, but they are unable to
produce force in appropriate synergistic combinations
during functional activities. Conversely, it may be possible to produce force in a muscle group only during
whole-body movements (or in combination with other
muscle groups) but not during isolated limb or joint
movements. Thus, examination of force production in
isolation may not be adequate to fully identify the
underlying causes of movement dysfunction. When patterns of movement appear inappropriate or inefficient
for the task, the clinician can use observational and
manual skills to determine which muscles within a
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Figure 4.
Plan of care. The 3 distinct approaches to intervention are identified as
well as the elements important to address within any intervention
approach (environment, learning variables, dose).
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To elaborate on how these roles are performed, intervention is organized into 3 categories: (1) remediation,
(2) compensation or adaptation, and (3) prevention.
The terms remediation, compensation or adaptation, and prevention have been used by other
authors.48(p125) Remediation consists of enhancing skills
and resources or reversing impairments. A remediation
approach assumes that potential for change exists in the
system and the person (eg, neurologic plasticity, ability
of muscles to become stronger or to lengthen). Use of
body weightsupported treadmill training for a person
with a stroke80 is an example of remediation. Compensation or adaptation refers to the alteration of the environment or the task. This intervention approach is taken
when it is determined that remediation is not possible.
Examples include the use of a walker to widen the base
of support for a patient with balance problems, avoiding
multitask activities for patients with motor planning
problems, and the use of prism lenses for patients with
visual deficits. Prevention refers to the management of
anticipated problems (or N-PIPs in the HOAC model).
An example of a preventive intervention related to the
integumentary system in a person with spinal cord injury
is the use of a combined educational program regarding
the need for frequent skin inspection with direct intervention for training in ischial weight relief to prevent
skin breakdown.
Interventions are rendered based on manipulation of
the environment and principles of exercise and motor
learning. The specific components of the intervention
are directly related to the results of the task analysis, in
which tasks, environments, and movement problems
were identified. The therapist uses the task analysis
findings to consider the environmental context under
which the person should practice the task in order to
acquire and generalize the skill. Task-specific training
has been advocated as the unit of therapy.48,81,82 Learning variables serve as an outline for the specific treatment. Therapists select the appropriate schedule of
practice and type of feedback given the goal and the
state of the learner. The final consideration is dose,
which includes frequency, intensity, and duration. Dose
is an important variable of therapy and is included in
the framework based on the knowledge that intensive
practice (goal-directed) is an important factor is rehabilitation.83
A case example is provided to illustrate the process by
which these models and frameworks are integrated for
patient care. This case example is not intended to be
comprehensive, but rather is used to illustrate certain
features of the decision-making process, up through the
development of the initial plan of care.
1694 . Schenkman et al
Case Example
History and Interview
Mr C was an 88-year-old man who sought physical
therapy following a diagnosis of PD. He lived in a life
care community with his wife of 60 years. He was the
president of a company and drove himself to the office
every day, although his son effectively ran the company.
Mr C reported that he was diagnosed with PD approximately a year previously and that since that time everything has become more difficult for him, takes time, and
is just plain slow. He traversed the length of his office
(36.6 m [120 ft]) several times daily, and this was a slow
process. He had severe osteoarthritis, especially of the
knees and lumbar spine. Getting up from the seated
position could be quite painful, and the crepitus was
loud enough to hear from several feet away. Getting in
and out of cars was difficult (a contortionist activity).
When he returned from the office, he ate dinner and
went to bed by 7:30 pm.
On probing by the clinician, Mr C reported that he has
difficulty with balance control on uneven surfaces and
that, when walking from his apartment to the elevator,
he uses the walls for support. He reported frequent near
falls, which he indicated tended to occur in the morning. He also reported difficulty getting out of the bed in
the morning. Mr Cs goal in seeking treatment was to be
able to function more easily, including the ability to
complete his daily activities more efficiently, with less
painful knees, and with greater stability.
At present, Mr Cs medical management included
carbidopa-levodopa for the PD. He reported that his
symptoms did not vary according to time of dosage;
therefore, it would not be necessary to plan the intervention around his medication schedule. He also had
ongoing treatment for the osteoarthritis, including ibuprofen daily and injections of hyaline G-F 20 every 4
months.
The clinician summarized Mr Cs history and interview
from both enablement and disablement perspectives
(Fig. 5). From the enablement perspective, it was important to assess his roles, the skills that he needs to fulfill
these roles, and his resources. From the disablement
perspective, it was important to assess those factors that
limited his ability to fulfill his roles and to identify
potential contributing impairments.
Systems Review
Based on the history and interview, as well as knowledge
of PD, the clinician determined choices and the rationale for the systems review. Two tasks were included: bed
mobility and sit to stand. These tasks were chosen both
Figure 5.
The enablement and disablement perspective for Mr C. PDParkinson disease, ROMrange of motion.
Examination
The examination strategy was based on Mr Cs goals as
well as the findings from the systems review. He reported
functional problems due to difficulty with bed mobility,
coming from a sitting position to a standing position,
and walking. Therefore, the examination strategy
focused on understanding the causes for difficulty with
these functional activities. The clinician chose to begin
the examination using task analysis. The 3 tasks were
analyzed in detail and under a variety of environmental
and task conditions, which were made progressively
more difficult to elicit Mr Cs underlying difficulty with
functional movement. Findings are presented in Table 2.
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Table 1.
Systems Review of Mr Ca
Nature of
Information
Obtained
System
Reviewed/Specific
Tests
Observation/query
Cognitive/behavioral
Confidence
Cardiovascular
Vital signs
HR
BP
Neurologic
Somatosensory
Response to
posterior pull
Romberg test
Task analysis
Neurologic/
musculoskeletal
Bed mobility
Sit to stand
Result/Comment
HR:
Resting: sitting55 bpm, standing61
bpm
5-min post-exercise test73 bpm
BP:
Resting: sitting174/70,
standing136/70
5-min post-exercise test154/70
Intact
Integumentary
Direct examination
Rationale
Proprioception: intact
Vibratory sense: impaired
5 steps; would fall if not caught (Hoehn
and Yahr Scale86 score2.5)
Romberg test: stable with eyes open and
eyes closed
Sharpened Romberg test: unable to perform
with eyes open, falls to left
ate contact between the femur and tibia, but bone-onbone contact between the right patella and femur.
Evaluation
From the enablement perspective, it was evident that
work was very important for Mr C and that he greatly
valued his independence. The plan of care should be
focused around helping him to retain his independence
(to the extent possible) and his ability to continue to go
Table 2.
Examination Findings for Mr C: Task Analysis
Task and
Environment
Temporal
Sequence
Walking in a stationary
environmenta
Initial conditions
Posture
Initiation
Direction
Smoothness
Execution
Amplitude
Direction
Speed
Smoothness
Related Impairments
Lack of mobility throughout spine,
resulting in excessive
thoracolumbar flexion, forward
head, left lateral flexion
Lack of mobility with hips, knees
in flexion
Lack of mobility throughout spine,
resulting in inability to shift
weight from pelvis
appropriately
Painful right knee
Lack of mobility throughout spine
Painful right knee
Bradykinesia
Standing up from a
seated position and
walking as a
continuous action in
a stationary
environment (walking
performed within a
serial task)b
Initiation
Timing
Execution
Stability
Termination
Stability
Walking in a moving
environment (surface
moves beneath feet)c
Preparation
Appears impaired
Initiation
Timing
Fear/anxiety
Execution
Stability
Termination
Unstable
Sensorimotor organization
Fear/anxiety
Painful right knee
Sensorimotor organization
Postural alignment
Sensorimotor organization
Painful right knee
Fear/anxiety
Postural alignment
Sensorimotor organization
Postural alignment
to his office daily. At the same time, the fact that he was
driving himself to work was of some concern, both
because of his limited mobility and because of his own
report that his thought processes seemed slower. Therefore, it might be important to discuss driving with Mr C
and with his children as appropriate.
From the disablement perspective, Mr C identified his
main problems as knee pain when getting up from a
seated position, slowness during all functional activities,
and instability. The physical therapist identified further
underlying problems, including substantially impaired
axial range of motion and sensorimotor organization.
Based on the task analysis, Mr Cs movement problem was summarized as follows: in stationary environments, Mr C
moved slowly but was relatively stable;
as the task and environmental conditions were made more challenging, he
had increasing difficulty with performance and stability. Based on the temporal sequence, the clinician observed consistent problems with initial conditions
and execution of tasks. Under more
challenging circumstances, problems
also emerged with initiation and termination. For example, his problems
were more evident with serial tasks
than with discrete tasks and with moving environments compared with stationary environments.
Based on analysis of possible determinants, the clinician hypothesized that
limited mobility of the spine and resulting altered alignment were a source of
problems with initial conditions. Limited spinal mobility, coupled with the
painful right knee, interfered with
direction and smoothness of execution.
These impairments, coupled with bradykinesia resulted in limited amplitude.
Together, these impairments affected
stability throughout all phases of the
task. Under more challenging conditions, fatigue, problems with sensorimotor organization, and fear and anxiety related to the challenging
circumstances further affected performance, explaining the slow and ineffective initiation and the instability during
termination of walking.
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Table 3.
Summary measure
Unified Parkinsons Disease Rating Scale37
Performance-based measures
Functional Reach Test22
360 turn33
Six-Minute Walk Test25
Timed Up & Go Test (with hands)23
Rationale
Findings
Overall score44.5/124
ADL subscale score17/52
Motor subscale score27/56
Mentation0/16
15.2 cm (6 in)
Right: 14 steps, 6.4 s
Left: 14 steps, 6.5 s
175.6 m (576 ft)
31.6 s
CTSIBModified Clinical Test for Sensory Interaction of Balance, PDParkinson disease, ADLactivities of daily living.
Table 4.
Proposed Outcome Measures for Mr C
Patient-Desired Outcome
Indicators
Less pain
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