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Models of Patient Management

1.) The disablement model
2.) Enablement models
3.) The guide to PT practice

Biomedical model

1.) Pathology or mechanical change exists
2.) Promotes physiological healing
3.) Does Not take into consideration other aspects of healing

Biopsychosocial adaptation

1.) Identifies functional impairments in peoples abilities to adapt to the problem
2.) The role of clinician is to empower patient to manage symptoms
3.) Set goals with the patient and family members

Example of biopsychosocial adaptation


Disablement model 4 parts

1.) Pathology
2.) Impairments
3.) Functional Limitations
4.) Disability


-"Disease or Disorder"
-Medical Diagnosis
-What occurs at the cellular level
-May be due to a single onset or from adaptation from a previous injury/episode

Examples of pathology

Rheumatoid arthritis
ACL tear


-What are the consequences of the pathological process or lesions
-Indicated by signs and symptoms

Examples of impairments

Loss of muscle strength, abnormal range of motion, pain

As PT's we try to

"Treat the impairments" -Not the pathology
We also quantify the impairments and make judgements about the effectiveness of treatment

Functional limitations

-As a result of the impairments the patient is not able to perform a task as efficiently or as safely
-Limitations in their abilities to perform ADLs

Examples of functional limitations

Patient is limited in the ability to reach over head, unable to climb a ladder, reach behind their back, carry greater than 10 pounds


-Inability to carry out typical roles in the community including work or leisure, school, home
-The functional limitations are severe enough to limit "normal" role performance


Unable to perform tasks of a painter

Three perspectives of disability

1.) Person's reaction to his/her own situation
2.) How others react to/define the person's condition
3.) Person's environment may represent barriers

Things to note

Functional limitations do not always lead to a disability. You might be able to perform all work related tasks but still have problems with activities of daily living
Having a disability does not always mean you have a functional limitation. People adapt to situations quite well

Enablement model

Change of focus and wording from one of disablement to one of enablement

What is the benefit of the enablement model

The end results can be the same but there is benefit to considering the value of different models that may improve client-centered care

Enablement model structure

Start with assessment of roles and participation
1.) Roles
2.) Skills
3.) Resources
4.) Recovery

Disablement model structure

Typically assessed for intervention starting with pathology or impairments
Functional Limitations

Side-by-Side terminology

Activity-Functional Limitation
Body Function/Structure-Impairment
Health-Active pathology

Why was the guide to PT practice created

1.) Describe PT practice
2.) Describe the roles of PT
3.) Describe the settings in which PTs practice
4.) Standardize terminology
5.) Delineate tests, measures, and interventions
6.) Delineate preferred practice patterns

Building blocks of the guide

1.) Nagi disablement model
2.) Contemporary definition of physical therapy and scope of practice
3.) Key elements of patient/client management that incorporate the nagi disablement model

Preferred practice patterns

1.) Improve quality of care
2.) Enhance positive outcomes
3.) Enhance patient/client satisfaction
4.) Promote appropriate utilization of health care services
5.) Diminish economic burden of disablement through prevention, wellness, fitness
6.) educate "outsiders"

Practice patterns systems


Pattern A

Prevention and risk reduction
Each pattern is a summary statement of physical therapy diagnostic categories

Patient/Client management

1.) Examination and Evaluation
2.) Diagnosis
3.) Prognosis
4.) Intervention
5.) Outcomes

Basics of Examination and Evaluation

What is the reason for referral to PT?
Functional status/limitations

What is reason for referral to PT?

Establish a diagnosis
Medical History
What is patients history of disability and social history

Examination and Evaluation fundamental question

Is physical therapy appropriate for this patient
If yes-treat appropriately or treat and refer
If no-refer or no treatment

Disablement model in exam and eval

The examination and evaluation involves determining the disability, the functional limitations that create the disability, and the impairments that are linked to the functional limitations

Parts of the examination

1.) Medical Screening
2.) Inspection of body's systems to determine presence or absence of pathology
3.) Data collection

Medical screening

Determine need for
Prevention services
Further examination
Consultation with another physical therapist
Referral to another health care professional

Data collection

1.) Chart review
2.) Subjective information
3.) Objective information

Chart review

1.) Admission information
2.) Medical histories
3.) Surgical or special procedures
4.) laboratory findings
5.) Evaluations by other professionals
6.) discharge summaries from past admissions

Subjective data

Reflects patient's perception and cannot be externally verified
PT establishes role
Establish rapport
Series of questions about the patient's condition
Listen effectively

Objective data

1.) Observations and testing
2.) Cognitive/Affect/Communication
3.) Baseline status of systems
4.) Selective tests based on history, subjective reports and initial tests

Medical screening characteristics

-Identify comorbidities
-Involves a systems review

Differential diagnosis

Diagnoses impairments/limitations
At times may differentially diagnose a medical pathology


1.) Your assessment of the findings from examination
2.) PT diagnosis: descriptive summary from the guide
3.) Develop a problem list
4.) Problem list should be prioritized


Interpretation of the examination-render your personal judgement
Fluid and ongoing process throughout process of working with the patient
The assessment does not end the first day

Essentialistic diagnosis

1.) Know the pathology involved
2.) Technology can give us a proof positive test that diagnosis exists

Examples of essentialistic diagnosis

MS, Stroke, fracture, ligament, tear


1.) Classified by a cluster of symptoms
2.) Do not know the underlying pathology
3.) No "proof positive"

Examples of nominalistic

fibromyalgia, cervical strain, patellofemoral pain syndrome

Prognosis Goals

Develop a set of functional goals
Need to be made with the patient
Goals are written in short and long terms and must be measurable

Types of goals

Disability goals: regain social roles
Functional goals: Regain activity potential
Impairment goals: Restore body structure and function

PT prognosis

What is your expected outcome for the patient
What is the patients potential to meet the goals
Different variables that contribute to patient potential


1.) Treatment plan developed with the patient
2.) Informed consent-patient agrees with the treatment
3.) Does another health care provider need to be included?
4.) Continually reassessing/reevaluating for effectiveness
5.) Is progress being exhibited?
6.) Involves prevention

Three parts of intervention

Coordination/communication-with physicians or health care providers
Patient and family members instruction and education
Procedural interventions


What is the impact of PT intervention on impairments, functional limitations, and disability
Patient/Client satisfaction
"Health related quality of life" questionnaires or other tools to measure outcomes

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