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doi: 10.2522/ptj.200502602006; 86:1681-1702.PHYS THER.

Gill-BodyMargaret Schenkman, Judith E Deutsch and Kathleen MNeurologic Physical Therapist PracticeAn Integrated Framework for Decision Making in

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An Integrated Framework forDecision Making in Neurologic

Physical Therapist Practice

Decision-making frameworks are used by clinicians to guide patient manage-ment, communicate with other health care providers, and educate patientsand their families. A number of frameworks have been applied to guideclinical practice, but none are comprehensive in terms of patient manage-ment. This article proposes a unifying framework for application to decisionmaking 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 isanchored by the patient/client management model from the Guide for PhysicalTherapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm forClinicians (HOAC) at every step, and (4) it proposes a systematic approach totask analysis for interpretation of movement dysfunction. This frameworkprovides a mechanism for making clinical decisions, developing clinicalhypotheses, and formulating a plan of care. Application of the framework isillustrated with a case example of an individual with neurologic dysfunction.[Schenkman M, Deutsch JE, Gill-Body KM. An integrated framework fordecision making in neurologic physical therapist practice.Phys Ther. 2006;86:

16811702.]

Key Words: Clinical decision making, Models, Neurologic dysfunction.

Margaret Schenkman, Judith E Deutsch, Kathleen M Gill-Body

Physical Therapy . Volume 86 . Number 12 . December 2006 1681

IIIS

TEP

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Decision-making frameworks are instrumentalin guiding clinicians through a comprehen-sive process of patient management, commu-nicating with other health care providers, and

facilitating the educational process. A number of frame-works have been applied to clinical practice over the past2 decades for guiding clinical decision making.17 Early

frameworks were based on disablement models.810

Sub-sequently, other frameworks were described based onenablement perspectives.11,12 Most recently, the Interna-tional Classification of Functioning, Disability and Health(ICF)13was developed, integrating both enablement anddisablement perspectives.14 These various frameworkswere intended to organize aspects of the patients healthcondition for research, policy, and related decisions.However, for clinical care within physical therapy, no oneframework provides enough detail for decision making.For this purpose, it is important to separate out specificcomponents of enablement and disablement and to ana-lyze their implications for patient management.

The framework proposed in this article is designed tolink the larger concepts of health (enablement anddisablement) to the scope of physical therapist practice.The framework is intended to guide physical therapistpractice and to provide a structure for teaching clinicaldecision making to future clinicians. Specifically, thisarticle accomplishes the following:

(1) It presents a unifying framework for making clinicaldecisions by integrating and applying a variety ofconceptual models and analyses at different points

within the management process.

(2) It proposes a systematic approach to task analysis forsummarizing the movement problem.

(3) It illustrates how the generation of clinical hypoth-eses and their progressive refinement drives man-agement choices.

(4) It uses a case example to illustrate application of theunifying framework and systematic task analysis.

Overview of the FrameworkThe decision-making process we describe is patientcentered,1518 which means that the whole process isfocused around the patient as depicted in Figure 1. Thispatient-centered approach contrasts with a pathology-driven approach in which the process is initiated withdisease and culminates in disablement. The patient-centered approach that we propose emphasizes rolesand functions of which the individual is capable and atthe same time identifies limitations in the individualsabilities, with the goal of minimizing barriers to fullparticipation within society or the environment.

The framework that we describe has 4 distinct character-

istics. First, it is anchored by the structure of the patient/

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:

[email protected].

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

The proposed framework is intended

to guide physical therapist practice

and to provide a structure for teaching

clinical decision making to future

clinicians.

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client management model, described in the Guide toPhysical Therapist Practice,19 and organizes patient man-agement from the initial encounter through the devel-opment and implementation of the plan of care and

outcomes measurement. Second, at each step of thepatient management process, clinical hypotheses aregenerated using the Hypothesis-Oriented Algorithm forClinicians (HOAC)1,20 to guide decision making. TheHOAC, which has been described elsewhere,1,20 ispatient centered, hypothesis driven, and iterative. Third,task analysis is used to examine and analyze problemswith performance of functional movement and then tosystematically summarize the movement problem.Finally, enablement and disablement models are appliedthroughout the management process, with particularemphasis on application of the enablement perspective,which we believe has been less well described in theliterature.

This framework was developed to provide a comprehen-sive approach to physical therapy, which can be used toguide clinical decisions and can be used to structure theeducation of future clinicians. In the following sectionsof this article, we elaborate on application of the frame-work for the management of individuals who haveneurologic disorders. Although this article focuses onpeople with neurologic dysfunction, the framework alsoshould be applicable across the life span to people whohave other conditions.

History and InterviewThe purpose of the history and interview is to gain anunderstanding of the patient as an individual, determinewhy the individual seeks physical therapy, identify what

he or she hopes to achieve through physical therapy, andbegin to formulate the examination strategy. The inter-view and history process initiates the collaborative rela-tionship between the patient and the physical therapist.

The interview begins by exploring questions such as thefollowing: What is the persons role in society, and howis that affected by the current condition? Specifically,what does the person do vocationally and for recreation?What are the patients goals and identified problems?What is it that the patient wants to be able to do that heor she currently cannot do; in the patients view, what isneeded to overcome these functional limitations? Whatassistance does the patient expect from the clinician?What assistance does the patient need from the family orcaregivers? What assistance do the family or caregiversneed from the clinician? The patient is the primarysource for this information, but caregivers also contrib-ute; their perspective may be different from the patientsperspective and also is important to include.21 Thisprocess begins during the interview and is further devel-oped during the examination.

In the proposed framework, the interview process drawson enablement and disablement perspectives as well as

Figure 1.Overview of the unifying framework demonstrating the steps in the clinical decision-making process. This framework is patient centered, integratesboth enablement and disablement perspectives, and incorporates a variety of existing conceptual models and analyses at various points in the patientmanagement process. HOACHypothesis-Oriented Algorithm for Clinicians.

Physical Therapy . Volume 86 . Number 12 . December 2006 Schenkman et al . 1683



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the HOAC. To understand the proposed framework, it isnecessary to highlight salient features from theseapproaches.

Application of the Enablement PerspectiveThe enablement model, as described by Quinn andGordon,7 guides the clinician to identify the individuals

participation and roles, including self-care, social, occu-pational, and recreational activities. The enablementmodel also explores the skills and resources that arerequired for fulfilling roles within different environmen-tal contexts (eg, the ability to achieve meaningful goalswith efficiency, flexibility, and consistency). Quinn andGordon defined resources as physical and cognitivemechanisms, including musculoskeletal linkages, con-trol of basic movement types and the ability to plan.7(p7)

In applying Quinn and Gordons enablement conceptsto our integrated framework, we broaden the concept ofresources to also include the social, emotional, andsocietal resources at the patients disposal.

Application of the Disablement PerspectiveThe disablement models begin the analysis from theunderlying disease or pathology.8,9 Relevant informationis revealed during the patients report of past medicalhistory, and review of the medical record guides specificquestions during the interview. Specific questions alsoare derived from knowledge about pathology and typicalor predicted signs, symptoms, and impairments associ-ated with these conditions. The clinicians questionselicit information from the patient regarding the pres-ence and severity of these signs, symptoms, and impair-

ments. This information guides the systems review andselection of examination procedures. Patients may iden-tify underlying impairments that they perceive as limit-ing (eg, weakness, stiffness, loss of feeling, pain). Theclinician may identify possible impairments throughobservation and communication (eg, faulty movementpatterns, cognitive impairments).

Application of the HOACThe HOAC1,20 is an algorithm that allows the clinician toexplore the patients concerns, referred to as thepatient-identified problems (PIPs). The clinician also

explores problems not identified by the patient butrather by the clinician and caregivers. These problemsare referred to as nonpatient-identified problems(N-PIPs). The clinicians perspective can be particularlyimportant in identifying potential future problems (pre-vention) and in identifying functional limitations andunderlying impairments that have not risen to the levelof the patients awareness, but may become progressivelylimiting. The HOAC also prompts the clinician to beginto develop hypotheses surrounding identified problemsthroughout the interview process. These hypothesesshape the plan for further patient examination.

Integration of Perspectives From Enablement,Disablement, and HOACTo illustrate how the models are integrated, we describethe following scenario where questions from each per-spective are asked. First, the physical therapist asks thepatient to identify his or her societal roles and anyproblems he or she has in fulfilling them (eg, problems,

goals of treatment [enablement and HOAC]). Thephysical therapist also solicits input from family mem-bers and caregivers (HOAC). The physical therapistthen explores the specific abilities and skills that thepatient needs to fulfill the identified goals and ascertainsthose areas in which the patient experiences difficulty(enablement). This initial process is accomplished with-out consideration of the primary diagnosis or past med-ical history. When the physical therapist has completedthis portion of the history and interview, it should bepossible to answer the following questions:

What are the patients needs in terms of participa-

tion and activity? Why is the patient here (problem and goals)? What can the family offer? What are the perceived needs of the family? What is the patients social, emotional, and physical

context?

The clinician should be able to answer the above ques-tions prior to analyzing the patients condition from adisablement perspective. From the disablement perspec-tive, the physical therapist explores underlying impair-ments that could contribute to the patients functional

difficulties, based on knowledge of the pathology and itssequelae. For example, the physical therapist proceedswith specific questions aimed at detecting the patientssigns, symptoms, and impairments relevant to the disor-der. All of this information, taken together, informs theexamination strategy.

Transition From Interview to Systems ReviewDuring the history and interview, the clinician begins toformulate hypotheses that guide the transition into thesystems review and examination (HOAC). For example,the clinician may observe cognitive or perceptual limita-

tions that indicate the need for a detailed examinationof these systems. The clinician may observe that a patienttransitions to and from a seated position and walks witha gait pattern typical of someone with intact sensory andmotor systems, suggesting that these systems need not beexamined in detail at the present time. Conversely, theclinician might observe that another individual alwaystransitions to a standing position by pushing up fromarm rests and does not take weight symmetricallythrough both lower extremities. Depending on thepatients diagnosis and premorbid and comorbid condi-tions, the patients task performance could suggest pain,



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loss of lower-extremity range of motion, weakness,impaired sensory perception, or impaired motor organi-zation. These observations, along with knowledge of thedisorder, guide the clinician to specific choices of tests,measures, or activities to be included in the systemsreview.

Systems ReviewThe purpose of the systems review is to rule out thosebody systems with which the physical therapist need notbe concerned, identify systems that are resources for thepatient, guide choices regarding which aspects of theremaining systems to examine in detail, and determinewhether the physical therapist should proceed or shouldrefer the patient to other health care providers. Thesystems review can be conducted at the level of tasks orthe level of impairments, as is illustrated below.

The patient/client management model19 is used toorganize the overall systems review. Included is a review

of arousal, attention, and cognition, as well as a mini-mum data set (eg, height, weight, heart rate after somespecific activity such as push-ups for an individual withspinal cord injury). Four major body systems arereviewed, related to the physical therapist practice pat-terns, including neurologic, musculoskeletal, cardio-pulmonary, and integumentary.

The systems review can be carried out at the level of tasksor level of impairments, or some combination of these 2levels. Reviewing of body systems at the level of tasks hasthe advantage of emphasizing the patient-centered focus.

For this reason, we begin by describing that process.

Systems Review at the Level of TasksWhen beginning the systems review by examining tasks,the clinician analyzes the patients overall performanceon specific relevant tasks to develop hypotheses aboutwhich impairments should be examined in detail. If thepatients performance of a task is outside the typicalperformance range for the age and sex of the patient,the clinician proceeds to examine those specific under-lying impairments associated with problems with perfor-mance of the task (eg, strength [force-generating capac-

ity of a muscle], range of motion, postural control). Inthe systems review, screening is conducted in a variety ofways, including the use of measurable tasks as well asobservational analyses.

With regard to quantitative approaches to screeningtasks, performance on a number of tasks has well-defined implications. For example, the Timed Up &Go Test, Functional Reach Test, and Berg Balance Testall can predict falls.2224 If the patient has difficulty withperformance on these tasks, the clinician is alerted toperform a detailed examination of sensory and motor

organization. However, if performance is within thenormal range on any of these measures, it may not benecessary to assess specific elements of postural control(or balance) such as sensory organization. Similarly, theSix-Minute Walk Test25 can be used to identify potentialproblems with cardiovascular or musculoskeletal endur-ance that need to be further examined.

Observational task analysis also can be used in thesystems review. For example, requirements for the sit-to-stand task include force generation of specific musclegroups, range of motion at specific joints, and balanceand postural control.2628 The clinician might ask apatient to stand from a low seat in order to quicklyobtain an assessment of lower-extremity strength andbalance control. If the patient has difficulty performingthe task, the clinician could be guided to include adetailed assessment of strength and postural control inthe examination. Alternatively, if the patient is able torise to a standing position successfully and smoothly, the

clinician may logically conclude that lower-extremitystrength is, at a minimum, in the fair range and thatpostural control is adequate for this task. The clinicianthen may chose to defer detailed examination of theseareas.

Systems Review at the Level of ImpairmentsThe clinician also can choose to begin the systems reviewby examining specific impairments. Examination ofimpairments can draw on a variety of standard tests andmeasures (eg, reflexes, range of motion, muscle perfor-mance, sensory integrity), many of which are well artic-

ulated in the Guide to Physical Therapist Practice.19 Impair-ments also can be measured using standardized testssuch as the Orpington test,29 which measures 4 areas:motor deficit of the arm, proprioception, balance, andcognition. The scores can be summarized to identifydisease severity. Additionally, looking at test scores ineach of the domains of the test may guide the clinicianto perform a more detailed examination.

Models That Inform the Systems ReviewIn contrast to the interview, where the enablementperspective leads off the process, the systems review is

more heavily focused on a disablement perspective. Thisis because a major purpose of the systems review is toidentify those systems that are impaired.

A number of disablement models provide guidanceregarding systems that are likely to be compromised withspecific diseases, injuries, or disorders. These disable-ment models include, but are not limited to, the WorldHealth Organization (WHO) model8 and the Nagi mod-el.9 The work of Verbrugge and Jette10 draws attention tofactors that should be reviewed as a result of previousmedical history (comorbid conditions). For example,




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when an individual is admitted with a stroke and aprevious history of diabetes mellitus, it is particularlyimportant to screen for impairments associated withdiabetes (eg, sensory and integumentary integrity of thedistal extremities). When an individual has worked inthe mines throughout his adult life, it is particularlyimportant to carefully review the respiratory system.

Schenkman and Butler2 further elaborated on the dis-ablement models to make them applicable to clinicaldecision making for neurologic physical therapist prac-tice. To this end, the models of Schenkman and col-leagues2,3,5 draw attention to systems that may beimpaired as sequelae of the injury or disorder for whichthe patient seeks treatment. For example, an individualwho sustained a stroke some years ago and was sedentarythereafter is likely to have secondary cardiovasculardeconditioning.30 An individual with Parkinson disease(PD) is likely to have lost substantial range of motion inthe axial structures.31,32 Schenkman and colleagues have

applied this model to patients with PD, and the modelhas been tested in several experimental studies, demon-strating relationships between range of motion and bothfunctional and kinematic measures of standing reach aswell as improvement of functional reach following use ofexercises to improve axial range of motion.3133

In contrast, the enablement model draws attention tophysiologic reserves that may be resources to the patient.For example, compared with more sedentary individu-als, the distance runner may have substantial cardio-vascular reserve and the practitioner of yoga may have

enhanced flexibility. Hypotheses regarding the presenceand extent of physiological reserves can be tested in thesystems review or during the examination.

On completion of the initial systems review, the physicaltherapist should be able to accomplish the followingspecific tasks associated with disablement:

Arousal, attention, and cognition: Determine the appropriate style of interaction

with this patient and the need to modify furtherexamination or intervention procedures.

Identify the need for further examination(eg, Mini-Mental State Exam).

The primary disorder: Rule out potential problems and issues that

could occur with patients primary disorder butdo not exist for this particular patient.

Identify those body systems that are impaired andneed further examination to determine theseverity of involvement.

Determine which specific impairments will beexamined.

Impairments associated with comorbid conditions(pathology or disease)10: Determine which specific impairments will be

examined in-depth, based on factors such as age,recreational activities, and work history.

Secondary impairments2:

Identify which impairments are present amongthose that typically occur as sequelae to theprimary disorder in systems other than the onefor which the patient sought physical therapycare.

With respect to the enablement model, the clinicianshould be able to accomplish the following tasks:

Communication Determine the patients preferred style of com-

munication and learning.

Resources Identify those systems that are particularly well

developed for the patient and can be or are usedto facilitate functional ability.

Transition From Systems Review to ExaminationAs information is gathered during the systems review,the clinician integrates findings with those obtainedduring the history and continues to develop clinicalhypotheses. These hypotheses may explain relationshipsamong existing impairments and functional abilities;hypotheses also may identify key issues that should be

examined related to the patients environment. Forexample, the clinician may make decisions about whichtasks to examine further and how to manipulate theenvironment during further examination. Additionally,the clinician often develops initial hypotheses aboutprognosis.

ExaminationThe specific purposes of the examination may vary anddepend on the reason for which it is carried out. Thelevel of examination is adjusted to reflect patient-identified problems and goals and can be drawn from

elements of the continuum of the ICF model. Forexample, the examination takes into account relevantresources (enablement), activities, participation, andquality of life, as well as underlying impairments (dis-ablement). For the purposes of this discussion, a distinc-tion is made between the initial examination and subse-quent re-examination, although examination takes placethroughout the patient management process.1,20

Theinitial examinationprovides data that can be used toaccomplish some or all of the following purposes:(1) perform triage (eg, to determine whether referral to



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another health care professional is needed), (2)describe the movement problem for key tasks that aremeaningful to the patient within a relevant environmen-tal context (eg, walking in the dark; crawling across thecarpet), (3) identify patients resources and impair-ments, (4) test hypotheses from the history and systemsreview, and (5) formulate prognoses (eg, expected

degree of recovery following a stroke, expected develop-mental problems following premature birth). In addi-tion, the examination leads to the ability to provide abasis from which to determine the approach to the planof care and to determine potential outcome measures.

Subsequent re-examinationincludes the following purpos-es: (1) test existing hypotheses, (2) develop and test newclinical hypotheses when the initial hypotheses are notsupported by the patients response to intervention, and(3) obtain specific outcome measurements.

As the clinician proceeds through the examination

process, there is an ongoing synthesis and analysis, asoutlined by the HOAC.1 Information from one set oftests provides guidance regarding the next logicalchoices of tests and measures. This ongoing analysiscomplements, but does not replace, the overall synthesisof findings that occurs in the evaluation.

The strategy and depth of the examination may vary,depending on the purposes. Relevant issues to considerinclude the patients level of function, the purposes ofthe examination (eg, prognosis, plan of care), and theclinicians preferred style. The purposes of the examina-

tion also set specific limits regarding what informationwill be obtained. For example, if the sole purpose is forformulation of a prognosis, the clinician may select aspecific focused examination approach (eg, the Fugl-Meyer examination to predict recovery from stroke,34

the Gross Motor Function Classification to predict func-tion in children with cerebral palsy,35 Glasgow ComaScale to predict outcome after traumatic brain injury36).If the purpose is to develop a plan of care and measureoutcomes, the clinician might chose measures such asthe Unified Parkinsons Disease Rating Scale (UPDRS)37

or functional measures for children such as the Pediatric

Evaluation of Disability Inventory (PEDI) or the GrossMotor Function Measure (GMFM),34,3841 all of whichare sensitive to change.

For purposes of developing a plan of care, the followinginformation should be obtained:

Level of independence or dependence for func-tional activities of greatest importance to thepatient, including level of assistance needed, use ofexternal devices, or environmental modifications;

Analysis of task performance for a variety of func-tional activities under various environmental condi-tions; and

Possible reasons underlying the difficulty or inabil-ity to perform the task, including relevant impair-ments and environmental barriers.

The examination begins by observation of functionalactivities (eg, walking, getting up from a bed or a chair).The clinician decides the order in which the examina-tion data will be obtained. For example, the clinicianmight begin with a detailed task analysis of specificfunctional activities and work backward toward under-lying resources and impairments. Using this approach,the clinician performs the detailed task analysis, devel-ops hypotheses related to likely underlying impairments,and proceeds with the specific tests and measures thatare most likely to identify the presence and severity ofexisting impairments. This detailed task analysis is morespecific and systematic than the task analysis used during

the systems review, as is illustrated below.

The use of task analysis to make judgments during theexamination requires knowledge of the literature link-ing performance and impairments and clinical experi-ence to recognize patterns of performance and theirimplications regarding underlying impairments. There-fore, this strategy may be difficult for the noviceclinician.

Alternatively, the clinician might begin by examiningthose impairments identified during the systems review

as well as those known to occur with the specific under-lying disorder and its sequelae, as well as comorbidconditions. The clinician might proceed next to adetailed analysis of task performance. Using this routeinto the examination process, the clinician works for-ward from impairments to ability to perform functionaltasks.

Whatever examination approach is used, the clinician isjudicious in determining what should be examined sothat the maximum information can be obtained fromthe fewest possible tests and measures. To make judg-

ments, the clinician draws from the patients problemsand goals, the clinicians knowledge of the disorder, andpremorbid and comorbid conditions. In reality, exami-nation often proceeds as a combination of these 2approaches. For clarity, however, these 2 approaches arediscussed as distinct processes beginning with taskanalysis.

Examination at the Level of Task AnalysisTask analysis is a detailed observational analysis of thepatients total body movement patterns during taskperformance.42 Task analysis helps clinicians to deter-




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mine whether the patients movement performance iswithin a range of typical performance and to determinewhere within the performance specific problems occur.

The results of the task analysis shape the plan of care,which typically is focused around improvement offunction.

As movement specialists,43,44 it is incumbent upon phys-ical therapists to analyze movement. Task analysis(Fig. 2) is the route through which the physical therapistcarries out this central aspect of physical therapist prac-tice. Indeed, task analysis is one of the skills that definesthe physical therapist, and therefore synthesizes manyof the skills taught throughout the physical therapycurriculum.

In our framework, we propose a systematic approach totask analysis, based on work of Gentile45 and of Hedmanand colleagues.46,47 These 2 approaches to task analysiswere chosen because they are global in that they areapplicable to any task and because they give a compre-hensive description of task performance that is sufficientfor designing the plan of care. For specific tasks, thisinformation can be augmented by drawing from thegrowing body of available literature focused on move-ment analysis of particular tasks (see Shumway-Cook andWoollacott48 for examples). Specific application of theproposed task analysis is outlined below.

Task and environment. Performance of a task can varysubstantially, depending on the conditions under whichit is performed.49 For this reason, it is important toexamine tasksunder conditions comparable to those in whichthe individual typically functions. Tasks can be described orcategorized in many ways. In the proposed model, thetask and environment are categorized as follows, based

on 4 conditions adapted and simplified from the work ofGentile.45 Two variables are manipulated: the individualand the environment. The 4 task and environmentcategories that we suggest using are:

(1) Stationary individual in a stationary environment(eg, sitting quietly on a treatment mat in a quiettreatment area).

(2) Moving individual in a stationary environment(eg, walking in a quiet treatment area).

(3) Stationary individual in a moving environment

(eg, standing still in a busy clinic environment).

(4) Moving individual in a moving environment(eg, walking in a busy clinic environment).

We suggest that the first step in task analysis, then, is tocategorize the tasks included in the examination into 1of these 4 categories.

Other terms describing task attributes also may be usefulto consider as the clinician performs the systematic taskanalysis. For example, tasks can be categorized as dis-

crete with a recognizable beginning and end (eg, com-ing from a standing position to a sitting position),continuous with no discernable beginning or end(eg, walking), or serial with discrete movements per-formed sequentially (eg, coming from sitting in anarmchair to standing, walking, turning, and sitting at thekitchen table).48(p5)

To categorize tasks using this simplified version ofGentiles taxonomy,45 we consider all of the relevantattributes of the task and the environment that go intothe completion of the task. Included are considerations

such as the support surface (eg, height, compliance),base of support, lighting, use of arms, and assistivedevices. For example, walking on the beach with a caneis very different in terms of environment and taskperformance than walking in the physical therapy gym;the relevant sensory, motor, perceptual, and cognitiveissues must be taken into account.

Categorization of the task and environment as we pro-pose provides critical information regarding the types oftasks and environmental conditions under which apatient may be experiencing difficulty with functional

Figure 2.The elements of task analysis. The environment and temporal sequenceare 2 elements of the task analysis that are applicable to all tasks.Strategies and phases of movement, elements that are task specific, mayadd useful information to the systematic task analysis.



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abilities during daily activities. However, clinicians also

need to identifywherewithin performance of the task thedifficulty occurs. For this purpose, we propose the use ofa temporal sequence to analyze the movements thatcomprise the task as outlined by Hedman and col-leagues.46,47 It is important to note that, as with the workof Gentile,45we are highlighting selective aspects of theirwork.

Temporal sequence. Hedman and colleagues46,47 pro-posed that task analysis can be conducted by consideringthe temporal sequence of movements that comprise thetask. Use of this approach directs clinical decision mak-ing. Applying their concepts to our model, we ask thefollowing questions:

What is the problem with completing the task? Where along the movement continuum does the

problem interfere with function? What are the underlying determinants of the

problem? How do we intervene?

From concepts of Hedman and colleagues,46,47 perfor-mance of any task can be differentiated into the follow-ing 5 stages of movement: initial conditions, prepara-

tion, initiation, execution, and termination (Fig. 3).

Features that influence performance of the tasks aredescribed at these specific points in the temporalsequence (including timing, direction, amplitude, andsmoothness of movement). This observational analysisguides the clinician to specifically target the stageswithin the temporal sequence of the task where themovement is compromised (eg, initial conditions versustermination) and to generate ideas for intervention.Additionally, this observational analysis guides the clini-cian to identify the nature of the problem with move-ment (eg, direction, amplitude) at each stage in thetemporal sequence, further refining decisions regardingthe optimal approach to intervention.

Underlying causes. Identification of the stages of move-ment where problems occur does not, in isolation,provide enough information for treatment planning. Inaddition, at the specific stages within the temporalsequence where problems are observed, the cliniciannext identifies possible underlying causes for the taskdifficulty. Hedman et al46 referred to these causes asdeterminants or clinical components of movement; werefer to them as impairments. These determinants fallunder 3 categories: neurologic (structures and pathwaysthat participate in control of the movement), biome-

Figure 3.The temporal sequence identifies 5 stages of task performance that can be considered during task analysis and the specific features of importancefor each stage. Reprinted with permission of the publisher from: Hedman LD, Rogers MW, Hanke TA. Neurologic professional education: lining thefoundation science of motor control with physical therapy interventions for movement dysfunction. Journal of Neurologic Physical Therapy.1996;20:913.




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chanical (referring to structure and properties of mus-cles, joints, and soft tissue), and behavioral (referring tocognitive, motivational, perceptual, and emotionalaspects). These authors acknowledged that not all deter-minants can be identified by observing the patients taskperformance. However, 2 aspects of the determinantscan be considered as the patient is observed: (1) the

possible underlying sensory, motor, and musculoskeletalimpairments and (2) the synergistic coordination ofgroups of muscles during performance of tasks. These 2aspects are discussed below.

Determinants (impairments) are considered at eachstage in the temporal sequence of the task to guidedecisions regarding which impairments to examine indetail. Identification of the contributing impairmentseventually helps the clinician to determine optimalinterventions. For example, if force production is one ofthe main causes of difficulty with the execution stageduring the sitting-to-standing activity, it may be necessary

to include interventions that improve force production.

Analysis of individual impairments in isolation may onlypartially explain difficulty with task performance. Forexample, just because a muscle can fire, does not meanthat it will fire in the appropriate synergistic combina-tion during performance of a task. Appropriate synergis-tic firing of muscles can be problematic for any patientand can be of particular concern for those with under-lying neurologic dysfunction. For this reason, it can beimportant to examine synergistic coordination of musclegroups.

The coordination of synergistic groups of muscles hassome overlap with Hedman and colleagues concept ofdeterminants of movement,46,47 but goes beyond thoseconcepts. From a kinesiological perspective, purposeful,functional movement is accomplished by coordinationof muscle groups throughout the body. Included areprime movers, secondary movers, synergists (helpingand stabilizing), and whole-body stabilizers.50 With neu-rologic injury, appropriate coordination of these variousmuscle groups is frequently disrupted. At times, individ-uals have the ability to produce adequate force when

muscles are examined in isolation, but they are unable toproduce force in appropriate synergistic combinationsduring functional activities. Conversely, it may be possi-ble to produce force in a muscle group only duringwhole-body movements (or in combination with othermuscle groups) but not during isolated limb or jointmovements. Thus, examination of force production inisolation may not be adequate to fully identify theunderlying causes of movement dysfunction. When pat-terns of movement appear inappropriate or inefficientfor the task, the clinician can use observational andmanual skills to determine which muscles within a

synergistic combination are likely participating andwhich are not. This important part of the analysis ofmovement has not received much attention in recentliterature and, as a consequence, may be overlooked.

The coordination of synergistic activity can be analyzedin a systematic fashion, drawing from principles of

biomechanics and kinesiology, beginning with the abilityto stabilize against gravity, move while in relativelysupported positions (eg, recumbent, sitting), and movewhile in relatively unsupported positions (eg, standing),and progressing to the coordination of complex transi-tional movements (eg, walking, reading). Results of theanalysis of synergistic coordination can guide the clini-cian in making decisions about which aspects of thecoordination of synergistic activity to emphasize withinthe intervention (ie, the ability to stabilize, shift weightwhile remaining stable, shift weight while in less stablepositions, or coordinate complex transitional move-ments). The clinician determines whether problems

with synergistic coordination are observed at only one orat several of the following points in the temporalsequence: initiation, execution, and termination of themovement.

In summary, on completion of this systematic task anal-ysis as we propose, the clinician can identify the task andenvironmental conditions under which the patient hasdifficulty, identify the stages in the temporal sequence ofmovement where the difficulty is most evident, andhypothesize about the underlying determinants of thedifficulty. The underlying determinants may include

impairments (eg, force production, coordination) aswell as coordination of synergistic groups of muscles.This proposed approach to task analysis is generic in thatit can be used with any patient for analyzing perfor-mance of any task.

The clinician can augment this generic analysis of taskperformance by drawing from the extensive body ofliterature that is task specific. This task-specific literaturefocuses around strategies of task performance. The termstrategies refers to those motor patterns that are usedto accomplish the task, including how a person organizes

sensory and perceptual information.48(p123)

Strategiesprovide an overall description of the way the task isperformed. Strategies have been described for a numberof important activities under a variety of environmentaland task conditions. For some of these tasks, strategiesare broken down into component parts or phases(eg, sit to stand,51 reach and grasp52) or into neuro-physiological descriptions.53 The following examples areprovided to illustrate this point, but are by no meanscomprehensive.



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Phases have been described by a number of authors forwhole-body activities (eg, gait,5456 sit to stand51) and forupper-extremity reaching tasks.52 Strategies that are usedby healthy individuals of various ages have beendescribed as typical for getting up from the floor orbed.5759 These and other approaches to stages andstrategies can be used to focus the clinicians observation

and analysis of these specific tasks. As another example,when working with individuals who have balance dys-function associated with vestibular damage, identifica-tion of sensory organization strategies may be critical fordesigning effective interventions.6062 When workingwith an individual after a cerebrovascular accident, itmay be helpful to determine whether the individualtransitions from a sitting position to a standing positionat a fast speed, utilizing momentum (momentum strat-egy), or moves at a slow speed, relying primarily onlower-extremity force (stabilization strategy).63

Examination at the Level of ImpairmentsWhether the clinician begins with task analysis or withimpairment testing, at some point in the examination,the clinician may need to test specific impairments. Aswith the systems review, examination of impairments candraw on a variety of standard tests and measures(eg, reflexes, range of motion, muscle performance,sensory integrity), many of which are well articulated inthe Guide to Physical Therapist Practice.19 Additionally,many resources are available to direct the clinician toexamine specific impairments.64,65

Summary

To summarize, task analysis and impairment testing areused by clinicians to perform the patient examination.Although the clinician can chose either entry point intothe examination, task analysis, in our opinion, is anessential component of the process. Task analysisinforms the general approach to intervention as well asthose specific elements that will be incorporated into theplan of care. This process is further elaborated on in thenext section on evaluation.

EvaluationThe evaluation consists of an interpretation of findings

in order to develop a realistic plan of care. The plan ofcare is based on a synthesis of the information from all ofthe previous steps, including the patients goals andexpectations, task performance, the patients resourcesand impairments, and the medical diagnosis and prog-nosis for the condition. This synthesis results in thefollowing: (1) identification of the most important prob-lems for the patient (including both PIPs and N-PIPs),1

(2) evaluation from both enablement and disablementperspectives, and (3) summary of the movement prob-lem. This information leads to the clinicians ability to:(1) develop a diagnosis and prognosis, (2) develop

realistic goals and selection of appropriate outcomesmeasures, and (3) determine the overall approach tointervention as well as selection of the specific elementsfor the plan of care. Each of these elements is discussedbelow.

One of the first steps to the evaluation is for the clinician

to determine whether the patients goals are realistic andappropriate. If they are inappropriate, it is necessary forthe patient and clinician to negotiate goals that aremeaningful to the patient as well as realistic.

Next, the clinician synthesizes all available informationin relation to the patients main concerns, aspirations,and life circumstances. Included is an evaluation ofrelationships among all findings. This evaluation weighsthe patients resources and impairments and analyzesrelationships among direct and indirect effects of thedisorder.

The plan of care is patient centered and often is focusedaround task performance. Therefore, an important stepin the evaluation process is the analysis and summary ofthe movement problem. This information allows theclinician to design an overall approach to interventionand to determine how to implement the intervention.

Specifically, the analysis of the task and environmentrelationship allows the clinician to determine whetherthe patient has difficulty with all tasks in all environ-ments (eg, cannot even sit unsupported on a stationarymat), has difficulty with only more demanding tasks and

environments (eg, moving in a moving environment), orhas some combination of these difficulties. This analysisguides the clinicians choice of the environment inwhich to work. The nature of the task (eg, discrete versusserial) with which the patient has problems furtherinforms the clinicians decisions regarding the specificplan of care. Identification of where the problem iswithin thetemporal sequenceassists in the determination ofwhether to focus the intervention on initial conditions,initiation, execution, or termination of the task (or somecombination thereof). Finally, the clinicians choicesregarding how best to focus the intervention are guided

by identifying the underlying impairments influencingtask performance.

This overall approach to evaluation flows directly fromthe task analysis and should be fairly consistent acrossphysical therapists. For example, if the movement prob-lem for a patient occurs when the patient moves instationary environments, is most apparent during initia-tion and execution of a specified task, and relates toproblems with postural control, then the overallapproach to intervention should address each of theseissues. The specific treatment techniques that the indi-




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vidual clinicians choose may vary, but the focus must beon the issues identified (ie, execution of tasks within astationary environment, difficulty with postural control).

In summary, at the end of the evaluation of relevant tasksand impairments, the clinician should be able to answerthe following questions:

(1) In what environmental contexts does this individualhave difficulty performing the task(s)?45

(2) Within the environmental context, what other issuesare of importance (eg, height of the chair seat, baseof support, lighting, compliance of the supportsurfaces)?

(3) How does the movement problem manifest itselfwith regard to the temporal sequence of movementsthat comprise the task?46,47

(4) Which key underlying impairments likely affect spe-cific or multiple stages within the temporalsequence of task performance?

(5) Does the patient have difficulty coordinating syner-gistic groups of muscles and under what conditions?

Using these elements of the task analysis, the cliniciandevelops a summary of the movement problem. Twoexamples that illustrate this process follow.

Task Analysis for an Individual Who Sus-tained a Cerebrovascular Accident (CVA)

A patient with a chronic CVA with residual loss ofupper-extremity control seeks physical therapy tobe able to increase the use of the affected upperextremity under a variety of environmental condi-tions. One difficulty that the therapist identifies isdifficulty with the grasp and manipulation phasesof the task of taking a tissue out of box. (Thisdifficulty was environment neutral). The therapistobserves that the initial conditions of the move-ment may not be biomechanically optimal becausethe persons trunk alignment may subsequently

produce abnormal scapular movements. The exe-cution of the task is most affected because theperson does not seem to generate the force pro-duction or the precision of finger movements toremove the tissue. The compensatory trunk move-ments have created a pattern of distal upper-extremity control that interferes with achieving thetask. The therapist identifies initial conditions andexecution as the 2 phases to work on.

Task Analysis for an Individual Who HasUnilateral Vestibular Disorder

A patient 6 weeks after the onset of labrynthitisseeks physical therapy to improve his balance andbe able to resume commuting to work on the bus.The patient appears unstable when walking andclimbing stairs, often holding on to a rail or

touching the wall to maintain balance. Task anal-ysis reveals that the patients primary difficultiesare with execution and termination of movementin standing and walking in all environments, withthe most difficulty when he is moving in a busyenvironment. He is malaligned in standing, whichmay contribute to difficulties with balance. Thepatient appears to have difficulty stabilizing bodysegments, moving within and between postures,and coordinating between postures and move-ments to accomplish functional activities. Impair-ments in flexibility, sensory organization, andmotor control also are likely contributing to his

overall balance problem. He is visually reliant withvery limited use of vestibular inputs for posturalcontrol. The therapist identifies execution andtermination as the 2 phases to concentrate on.

Diagnosis and PrognosisThe diagnosis and prognosis are critical to shaping thefinal plan of care. For example, a patient with a neuro-degenerative disorder may have signs and symptomsquite similar to those of a patient with a nonprogressiveneurologic injury. However, the course of the 2 disor-ders can be quite different, which has a great effect on

appropriate goal setting and the overall plan of care.

Diagnosis, as performed by a physical therapist, refers tothe cluster of signs and symptoms, syndromes, or cate-gories and is used to guide the physical therapist indetermining the most appropriate intervention strategyfor each patient.19 The physical therapy profession hasgrappled for some time with the best means by which tosummarize diagnosis but has not yet reached a consen-sus for individuals with neurologic dysfunction. This hasbeen a source of discussion across the profession and inneurologic physical therapist practice in particular.6668

As a first approach to diagnosis, the clinician can identifythe practice patterns under which this condition falls,using the Guide to Physical Therapist Practice.19 The pre-ferred practice patterns describe the elements of themanagement process for patients with specific medicaldiagnoses as well as strategies for primary preventionand reduction of risk factors. Identification of the prac-tice pattern, however, is not sufficient. As an evolvingapproach to the diagnosis made by the physical thera-pist, one of the important elements is diagnosis of themovement problem.44 Ultimately, given the role of phys-ical therapists as movement specialists, task analysis



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To elaborate on how these roles are performed, inter-vention is organized into 3 categories: (1) remediation,(2) compensation or adaptation, and (3) prevention.The terms remediation, compensation or adapta-tion, and prevention have been used by otherauthors.48(p125) Remediation consists of enhancing skillsand resources or reversing impairments. A remediation

approach assumes that potential for change exists in thesystem and the person (eg, neurologic plasticity, abilityof muscles to become stronger or to lengthen). Use ofbody weightsupported treadmill training for a personwith a stroke80 is an example of remediation. Compensa-tionor adaptationrefers to the alteration of the environ-ment or the task. This intervention approach is takenwhen it is determined that remediation is not possible.Examples include the use of a walker to widen the baseof support for a patient with balance problems, avoidingmultitask activities for patients with motor planningproblems, and the use of prism lenses for patients withvisual deficits. Preventionrefers to the management of

anticipated problems (or N-PIPs in the HOAC model).An example of a preventive intervention related to theintegumentary system in a person with spinal cord injuryis the use of a combined educational program regardingthe need for frequent skin inspection with direct inter-vention for training in ischial weight relief to preventskin breakdown.

Interventions are rendered based on manipulation ofthe environment and principles of exercise and motorlearning. The specific components of the interventionare directly related to the results of the task analysis, in

which tasks, environments, and movement problemswere identified. The therapist uses the task analysisfindings to consider the environmental context underwhich the person should practice the task in order toacquire and generalize the skill. Task-specific traininghas been advocated as the unit of therapy.48,81,82 Learn-ing variables serve as an outline for the specific treat-ment. Therapists select the appropriate schedule ofpractice and type of feedback given the goal and thestate of the learner. The final consideration is dose,which includes frequency, intensity, and duration. Doseis an important variable of therapy and is included in

the framework based on the knowledge that intensivepractice (goal-directed) is an important factor is rehabil-itation.83

A case example is provided to illustrate the process bywhich these models and frameworks are integrated forpatient care. This case example is not intended to becomprehensive, but rather is used to illustrate certainfeatures of the decision-making process, up through thedevelopment of the initial plan of care.

Case Example

History and InterviewMr C was an 88-year-old man who sought physicaltherapy following a diagnosis of PD. He lived in a lifecare community with his wife of 60 years. He was thepresident 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 approxi-mately a year previously and that since that time every-thing has become more difficult for him, takes time, andis just plain slow. He traversed the length of his office(36.6 m [120 ft]) several times daily, and this was a slowprocess. He had severe osteoarthritis, especially of theknees and lumbar spine. Getting up from the seatedposition could be quite painful, and the crepitus wasloud enough to hear from several feet away. Getting inand 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 hasdifficulty with balance control on uneven surfaces andthat, when walking from his apartment to the elevator,he uses the walls for support. He reported frequent nearfalls, which he indicated tended to occur in the morn-ing. He also reported difficulty getting out of the bed inthe morning. Mr Cs goal in seeking treatment was to beable to function more easily, including the ability tocomplete his daily activities more efficiently, with lesspainful knees, and with greater stability.

At present, Mr Cs medical management includedcarbidopa-levodopa for the PD. He reported that hissymptoms did not vary according to time of dosage;therefore, it would not be necessary to plan the inter-vention around his medication schedule. He also hadongoing treatment for the osteoarthritis, including ibu-profen daily and injections of hyaline G-F 20 every 4months.

The clinician summarized Mr Cs history and interviewfrom both enablement and disablement perspectives

(Fig. 5). From the enablement perspective, it was impor-tant to assess his roles, the skills that he needs to fulfillthese roles, and his resources. From the disablementperspective, it was important to assess those factors thatlimited his ability to fulfill his roles and to identifypotential contributing impairments.

Systems ReviewBased on the history and interview, as well as knowledgeof PD, the clinician determined choices and the ratio-nale for the systems review. Two tasks were included: bedmobility and sit to stand. These tasks were chosen both



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because they were problematic for Mr C and becausethey could be used to assess trunk range of motion andlower-extremity strength and for motor planning. TheActivities-specific Balance Confidence (ABC) Scale84wasused to quantify confidence, given his report of instabil-ity, and to identify other areas that would be importantto examine. The Mini-Mental State Exam85 was used to

quantify the cognitive/behavioral system, and theHoehn and Yahr Scale86was used to quantify response toposterior pull. Rationale for choices and results of thesystems review are provided in Table 1.

ExaminationThe examination strategy was based on Mr Cs goals aswell as the findings from the systems review. He reportedfunctional problems due to difficulty with bed mobility,coming from a sitting position to a standing position,and walking. Therefore, the examination strategyfocused on understanding the causes for difficulty withthese functional activities. The clinician chose to beginthe examination using task analysis. The 3 tasks wereanalyzed in detail and under a variety of environmentaland task conditions, which were made progressivelymore difficult to elicit Mr Cs underlying difficulty withfunctional movement. Findings are presented in Table 2.

The task of walking is used to illustrate the application ofthe models and frameworks. Walking first was examinedin a quiet clinic area (stationary environment). The taskthen was made more challenging by asking Mr C to walkin context of a serial task. He was asked to stand up froma seated position and walk to a black mat. Walking also

was made more challenging by asking Mr C to walk in anenvironment in which the surface was moving. This wasaccomplished by having Mr C walk across a black matthat covered large stones and foam (the support surfaceshifted under his weight). Finally, Mr C walked in a busyarea with people passing by quickly and unexpectedly(moving environment). The patients typical perfor-

mance is described below.

Initial conditions revealed that he was consistently inexcessive thoracolumbar flexion, with some asymmetry(lateral flexion to the right).Initiationwas typically in thesagittal plane only, without appropriate movement incoronal plane to initiate gait. Notably, preparationappeared normal, and initiation was not delayed(ie, there was no evidence of akinesia). Executionrevealed the following: amplitude was low (eg, smallsteps, small base of support), direction typically was inthe sagittal plane without shifting of weight from thepelvis and without transverse-plane movement of thethorax relative to the pelvis, and speed was slow. Termi-nationwas stable in less-demanding situations, but he wasunstable in moving environments and when tasks wereperformed serially. Findings from the task analysis forwalking are summarized in Table 2.

The clinician next examined several impairments basedon hypotheses formed during the task analysis andmeasured performance based on functions of impor-tance for Mr C (Tab. 3). The visual analog scale87 wasused to assess knee pain, and the Modified Clinical Testfor Sensory Interaction of Balance (CTSIB)88was used to

Figure 5.The enablement and disablement perspective for Mr C. PDParkinson disease, ROMrange of motion.




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evaluate balance control. Additionally, the UPDRS andthe Modified Hoehn and Yahr Scale37 were used toquantify signs and symptoms specifically associated withPD. Finally, performance-based measures were used toquantify balance, including turning in standing,33 theTimed Up & Go Test,23 and the Six-Minute Walk Test25

(Tab. 3). The rationale is provided for inclusion of eachmeasure. Additionally, the clinician obtained radio-graphs of Mr Cs knees, which demonstrated appropri-

ate contact between the femur and tibia, but bone-on-bone contact between the right patella and femur.

EvaluationFrom the enablement perspective, it was evident thatwork was very important for Mr C and that he greatlyvalued his independence. The plan of care should befocused around helping him to retain his independence(to the extent possible) and his ability to continue to go

Table 1.Systems Review of Mr Ca

Nature ofInformationObtained

SystemReviewed/SpecificTests Rationale Result/Comment

Observation/query Cognitive/behavioral Patient expressed some concernregarding slowing of thought

process; important to begin toestablish ability for independentexercise program

Mini-Mental State Exam85 score29

Confidence Patient expressed concerns about hisstability

Activities-specific Balance ConfidenceScale84 score45/90

Cardiovascular Determine whether system is an assetor liability

Patient self-report that he recently completedan exercise test and is safe to exercise to75% of maximum HR

Vital signsHR Determine cardiac response to

exerciseHR:

Resting: sitting55 bpm, standing61bpm

5-min post-exercise test73 bpmBP Determine cardiac response to

exerciseBP:

Resting: sitting174/70,standing136/70

5-min post-exercise test154/70Integumentary Determine whether system is an asset

or liabilityIntact

Direct examination NeurologicSomatosensory Problems with tandem stance Proprioception: intact

Vibratory sense: impairedResponse to

posterior pullHistory of PD; difficulty with balance

control5 steps; would fall if not caught (Hoehn

and Yahr Scale86 score2.5)Romberg test Report of instability in the home and

office; determine whether problemswith sensorimotor integration exist

Romberg test: stable with eyes open andeyes closed

Sharpened Romberg test: unable to performwith eyes open, falls to left

Task analysis Neurologic/musculoskeletal

Bed mobility Typically, this is a difficult task forpeople with PD

Mr C reports difficulty with this task athome

Use this task to assess axial ROM,organization of motor tasks, andbradykinesia

Performed slowly and with difficulty; utilizesall available ROM, and lack of ROMappears to be the major contributingproblem

Supine to stand: 11.5 sStand to supine: 7.4 s

Sit to stand Mr C reports dif ficulty with this task atall times

Use this task to assess pain, balancecontrol, and lower-extremitystrength, which may be limitedsecondary to PD and osteoarthritis

With hands: slow and laborious; hands onmat to push up, then hands on knees

Without hands: able to complete the taskslowly, indicating lower-extremity strengthof at least F

Findings suggest further examination of

pain and balance is indicateda HRheart rate, BPblood pressure, PDParkinson disease, ROMrange of motion.



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to his office daily. At the same time, the fact that he wasdriving himself to work was of some concern, both

because of his limited mobility and because of his ownreport that his thought processes seemed slower. There-fore, it might be important to discuss driving with Mr Cand with his children as appropriate.

From the disablement perspective, Mr C identified hismain problems as knee pain when getting up from aseated position, slowness during all functional activities,and instability. The physical therapist identified furtherunderlying problems, including substantially impairedaxial range of motion and sensorimotor organization.

Based on the task analysis, Mr Cs move-ment problem was summarized as fol-lows: in stationary environments, Mr Cmoved slowly but was relatively stable;as the task and environmental condi-tions were made more challenging, hehad increasing difficulty with perfor-

mance and stability. Based on the tempo-ral sequence, the clinician observed con-sistent problems with initial conditionsand execution of tasks. Under morechallenging circumstances, problemsalso emerged with initiation and ter-mination. For example, his problemswere more evident with serial tasksthan with discrete tasks and with mov-ing environments compared with sta-tionary environments.

Based on analysis of possible determi-

nants, the clinician hypothesized thatlimited mobility of the spine and result-ing altered alignment were a source ofproblems with initial conditions. Lim-ited spinal mobility, coupled with thepainful right knee, interfered withdirection and smoothness of execution.These impairments, coupled with brady-kinesia resulted in limited amplitude.Together, these impairments affectedstability throughout all phases of thetask. Under more challenging condi-

tions, fatigue, problems with sensori-motor organization, and fear and anx-iety related to the challengingcircumstances further affected perfor-mance, explaining the slow and ineffec-tive initiation and the instability duringtermination of walking.

Diagnosis and PrognosisBased on the Guide to Physical Therapist

Practice,19 the clinician determined that this patientsmain complaint of PD falls under Practice Pattern 5E:

Impaired Motor Function and Sensory Integrity Associated WithProgressive Disorders of the Central Nervous System. However,the osteoarthritis was of sufficient severity to warrantidentification of a second practice patternPractice Pat-tern 4E: Impaired Joint Mobility, Motor Function, MusclePerformance, and Range of Motion Associated With LocalizedInflammation.

Prognosis for this disorder. Parkinson disease is aprogressive disorder with variable rates of progression.89

Pharmacological interventions have not been found toslow the course of neurologic decline. Osteoarthritis,

Table 2.Examination Findings for Mr C: Task Analysis

Task andEnvironment

TemporalSequence Related Impairments

Walking in a stationaryenvironmenta

Initial conditionsPosture

Lack of mobility throughout spine,resulting in excessivethoracolumbar flexion, forward

head, left lateral flexionLack of mobility with hips, knees

in flexionInitiation

DirectionSmoothness

Lack of mobility throughout spine,resulting in inability to shiftweight from pelvisappropriately

Painful right kneeExecution

AmplitudeDirectionSpeedSmoothness

Lack of mobility throughout spinePainful right kneeBradykinesia

Standing up from a

seated position andwalking as acontinuous action ina stationaryenvironment (walkingperformed within aserial task)b

Initiation

TimingExecutionStability

TerminationStability

Difficulty with sequencing multiple

tasksSensorimotor organization

Sensorimotor organization

Walking in a movingenvironment (surface

PreparationAppears impaired

Fear/anxiety

moves beneath feet)c InitiationTiming

Fear/anxietyPainful right kneeSensorimotor organizationPostural alignment

ExecutionStability

Sensorimotor organizationPainful right kneeFear/anxietyPostural alignment

TerminationUnstable

Sensorimotor organizationPostural alignment

a Only significant findings are noted.bAll issues remain that were observed for walking in a stationary environment; only additional issues are

noted.cAll issues remain that were observed standing up from seated position and walking; only additional

issues are noted.




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likewise, is progressive in nature. Interventions such asinjections of hyaline G-F 20 can be beneficial in reducingthe pain associated with the condition. Total kneereplacement most likely is not indicated for this man dueto his age and to the PD. Clinical experience suggests

that patients with PD frequently experience severeincreases in symptoms following surgery.

Prognosis for functional change. Some studies90,91 sug-gest that functional change is possible. Evidence suggeststhat trunk range of motion specifically is limiting tobalance control and can improve.31,33 Mr Cs age, thelength of time that musculoskeletal changes haveexisted, and his questionable commitment and ability tocarry out a home program all may limit the extent offunctional improvement. Evidence also indicates thatchanges can occur with interventions directed towardsensorimotor organization.92 Finally, improved biome-chanics of transitioning from a sitting position to astanding position can diminish the pain that Mr Cexperiences and can slow down further degenerativeprocesses.

A number of investigations have been conducted, spe-cifically examining exercise and PD. Findings of theseinvestigations, most of which had small sample sizes,suggest that balance, gait, and overall function canimprove with a variety of interventions.90,91 The evalua-tion above indicated to the physical therapist that rangeof motion and altered alignment had a major effect on

this patients performance. Therefore, interventionsare specifically indicated that focus directly on theseproblems.

Finally, some studies93,94 provide guidance regarding

intervention directly focused toward osteoarthritis of theknees. These studies demonstrated the effectiveness ofinterventions including fitness walking, aerobic exercise,and strength training as well as mobilization and manip-ulation of the lumbar spine, knee, and ankle.

Goals and Outcome MeasuresThe following were determined to be meaningfulchanges for Mr C: ability to conduct daily functionalactivities with less painful knees, greater stability, and lessfatigue. Goals were set that were focused around theseidentified changes. These goals were deemed to berealistic and achievable within the constraints of thehealth care system (Tab. 4).

Outcome measures were identified that reflected hisgoals and also that reflected the hypothesized steps toachieve those goals. Proposed outcome measures for MrC are shown in Table 4. The first column synthesizes hisgoals and the qualitative indicators of success. Themiddle column summarizes the analysis of necessarychanges to reach these goals and gives insight into thenecessary intervention. The last column lists the quanti-tative indicators of success, which are more specificmeasures that are related to his goals.

Table 3.Examination Findings for Mr C: Impairments and Outcome Measuresa

Measures Rationale Findings

ImpairmentPain (visual analog scale, 010)85 Knee pain may be limiting function, provides baseline

data for future comparisonKnee pain during sit-to-stand

task4Functional axial rotation33 Loss of axial mobility may be limiting function,

provides baseline data for future comparison

Right: X82.5, SD3.5

Left: X87.5, SD3.5Modified CTSIB88 Allows for further evaluation of problems with

balance control, findings will inform approach tointervention

On foam, eyes open20 sOn foam, eyes closedunable

Summary measureUnified Parkinsons Disease Rating Scale37 Reviews impairments and functional limitations

associated with PD (combination of directexamination and self-report), 0no problems

Overall score44.5/124ADL subscale score17/52Motor subscale score27/56Mentation0/16

Performance-based measuresFunctional Reach Test22 Outcome measure for standing balance control 15.2 cm (6 in)360 turn33 Outcome measure chosen due to difficulty associated

with PD in making turns while standingRight: 14 steps, 6.4 sLeft: 14 steps, 6.5 s

Six-Minute Walk Test25 Outcome measure will be interpreted based on

endurance, pain, bradykinesia

175.6 m (576 ft)

Timed Up & Go Test (with hands)23 Outcome measure will be interpreted in context ofbradykinesia, stability, and knee pain; assesses fallrisk

31.6 s

a CTSIBModified Clinical Test for Sensory Interaction of Balance, PDParkinson disease, ADLactivities of daily living.



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Implications for Treatment Planning and theInitial Plan of CareTaking all of this information into account, it wasdeemed important to work with Mr C in progressivelymore demanding environments (moving support sur-faces and people moving around him). It also wouldbe important to use tasks of increasing complexity(eg, serial versus discrete tasks). The focus of these tasksshould be on improving range of motion and posture inorder to improve the initial conditions, execution, andtermination of task performance.

Based on a full analysis of Mr Cs problems, their underly-ing causes, and overall prognosis, a combined interventionapproach was recommended that includes remediation,compensation, and prevention. To provide adequate phys-iological support for function, it would be important toimprove trunk range of motion to the extent possible(remediation) and to assist Mr C to use more biome-chanically favorable strategies for the sitting-to-standingtask (remediation), thereby lessening the demand on hisknees and decreasing the pain. Clinical experiencesuggests that exercises for trunk range of motion shouldbe practiced in stationary environments to allow Mr C to

focus on range of motion. Improved transitioning froma sitting position to a standing position should be practicedfrom higher chair seats with a firm surface initially to workon the organization of the task and moving to progressivelylower seats and less firm surfaces.

Improved sensorimotor organization also was needed toprovide Mr C with greater stability while moving instanding positions (remediation). Sensorimotor organi-zation should be practiced in progressively moredemanding environments (eg, standing on foam witheyes open, then eyes closed; walking across a moving

surface) and with progressively more demanding tasks(eg, walking in the context of serial tasks).

Compensatory strategies also were indicated to assist MrC with his endurance and to protect his knees. Forexample, he should be encouraged to use a cane whilewalking and to obtain an electric tri-cart for locomotionover longer distances (eg, from his apartment to hisparking space). He should be encouraged to have adriver take him to and from his office.

Finally, preventive strategies were important both in

light of the PD and the osteoarthritis. With PD (as well asincreasing age), Mr C was at risk for further loss of rangeof motion. An exercise program was indicated to retardthese further losses. Prevention of further damage to theknees and back is needed (eg, the use of the tri-cart or acane), and general conditioning is important to retainoverall health and wellness.95

Summary of the Framework andIts ApplicationA framework is proposed to guide physical therapistpractice and to provide a structure for teaching clinical

decision making to future clinicians. The frameworkintegrates enablement and disablement perspectives andhypothesis generation and refinement at each step ofpatient care, and it incorporates systematic task analysisfor examination, evaluation, and intervention. The pro-cess is cyclical and iterative. The framework is illustratedusing a case example.

It is important to note that this framework is not meantto be prescriptive in nature. That is, the order andemphasis of application of the elements of the frame-work depend on factors such as the clinicians level of skill,

Table 4.Proposed Outcome Measures for Mr C

Patient-Desired Outcome Hypothesized Necessary Changes Indicators

Sit to stand with less pain, greater speedand stability

Improved stability and speed Timed Up & Go Test, change 10 s

Less pain Visual analog scale for knee pain,change 3

Improved axial mobility and mechanics Functional axial rotation change, 7Anterior excursion of lumbar spine/pelvis

Stable and safe for all tasks Improved balance control No reported loss of balance in morningIncreased capacity for balance controlFunctional Reach Test, change,1.27 cm (0.5 in)

Improved sensory processing Stable on foam, eyes closed 20 sCompensation for loss of vibratory sense,

sensory processingAppropriate use of caneUse of electric tri-cart for distances

Overall physical improvement Adopt and adhere to appropriateexercise program

Self-report of improved well-beingSelf-report of increased exercise habits




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experience, and preferred choices. However, the elementsthat are included are meant to be comprehensive.

Many of the elements of this framework are familiar andused with increasing frequency in both clinical andeducational settings (eg, Guide to Physical Therapist Prac-tice,19 disablement models8,9). This framework differs

from prior work in that we propose that other criticalelements also be included (eg, task analysis, a patient-centered enablement approach, algorithms for makingdecisions). In particular, we propose that task analysisintegrates the entire framework and is critical for effec-tive decision making in the clinic. Such a systematicapproach as we describe should be emphasized in theprocess of educating physical therapists.

It also is important to note that this framework isproposed as a working document. The framework willcontinue to evolve as the scientific basis for movementanalysis and rehabilitation evolves. Additionally, the

framework should be evaluated and refined by applyingit to clinical decision making across a wide variety ofdiagnostic conditions and populations, including thosewith non-neurologic disorders. For example, focusgroups can be used to examine the utility of this approachfor structuring neurologic physical therapist education,and case analyses can be used to test the clarity and utilityof the approach for patient management.

The complete framework, depicted in Figure 1, is arepresentation of actual clinical practice for many expe-rienced clinicians. By building from simple principles to

the entire framework, experienced clinicians and educa-tors can use this framework to assist students and noviceclinicians to better understand and incorporate all aspectsof decision making necessary for effective care of patients.This framework also provides the experienced clinicianwith a structure for articulating intuitive decisions.

References1Echternach JL, Rothstein JM. Hypothesis-oriented algorithms. PhysTher.1989;69:559564.

2Schenkman M, Butler RB. A model for multisystem evaluation,interpretation and treatment of individuals with neurologic dysfunc-tion.Phys Ther. 1989;69:538547.

3Schenkman M, Donovan J, Tsubota J, et al. Management of individ-uals with Parkinsons disease: rationale and case studies. Phys Ther.1989;69:944955.

4Scheets PK, Sahrmann SA, Norton JB. Diagnosis for physical therapyfor patients with neuromuscular conditions. Neurology Report. 1999;23:158169.

5 Schenkman M, Bliss S, Day L, et al. A model for management ofpatients with neurological dysfunction: update and case analysis.Neurology Report. 1999;23:145157.

6Bello-Haas VD. A framework for rehabilitation for neurodegenera-tive diseases: managing progression and maximizing quality of life.Neurology Report. 2002;26:115129.

7Quinn L, Gordon J. Functional Outcomes Documentation for Rehabilita-tion. Philadelphia, Pa: WB Saunders Co; 2003:67.

8International Classification of Impairments, Disabilities, and Handicaps: AManual of Classification Relating to the Consequences of Disease. Geneva,Switzerland: Wor

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