How Physical Therapists can Individualize Treatment?

Physical therapists are being challenged to provide better services in less time under shrinking reimbursements.  Clinical Practice Guidelines are being developed based on the best available evidence to “reduce unwarranted variations in care”1. However, the client desires the warranted and necessary variations in our care that allow for efficacious and efficient service.  The Gray Institute wants to empower physical therapists and all movement practitioners with the ability to identify the patient’s specific needs and to create an individualized treatment program.

 Everyone is an Individual

One of the primary Principles of Applied Functional Science R is “everyone is an individual,” and therefore their specific needs are different. In order to offer individualized treatment services to each patient, physical therapists must first utilize an examination scheme that is not pre-scripted.

Individualized Treatment & Exam

The foundational movements/tests that the client is taken through must be flexible enough to respond to the individuals’ movement capabilities.

Subsequent movements are chosen based on quantity and quality of the examination movements combined with subjective comments from the patient.

Additional movements are selected based on the specific activities that the person needs to do (walking, work, caretaking, activities of daily living) and wants to do (gardening, running, golf).

Finally a specific goal will influence the examination strategy (strength, flexibility, balance, endurance).

What About Isolated Exam Techniques?

Why focus on global movements instead of isolated joint examination?  An editorial in the Journal of Sports and Physical Therapy stated that “… physical therapists treat movement-related impairments rather than structural anatomical abnormalities”.2

Although isolated examination techniques are still part of any evaluation, the need for a small number of global movements, pertinent to all function that challenge the entire body is obvious.

3DMAPS & Global Movements

The Gray Institute developed the 3D Movement Analysis and Performance SystemR (3DMAPS).

3DMAPS R   is a system for analysis (examination) and performance training (treatment) that utilizes the arms and legs to create 6 global movements in all three planes.  It allows the practitioner to see the influence of one part of the body on another (well beyond regional interdependence3 ).  The quantity and the quality of the movements are assessed.  The focus is on the amount of movement throughout the entire body and the ability to control that movement.

Relative Success Code

One important maxim at the Gray Institute is “success begets success”.  So the examination emphasizes which movements are executed successfully just as much as movements that provide evidence of difficulty.  3DMAPS Analysis provides a Relative Success Code that serves as a template for starting and sequencing rehabilitation and training interventions based on the success that each specific client demonstrates.

In addition to the 3DMAPS Analysis, the practitioner must then consider what specific activities this patient needs and want to perform successfully.  Based on the functional biomechanics of these activities, additional global movements are designed to mimic the requirements of those activities.  The number of repetitions, the speed of the movement, and whether any loads are used during the analysis will be altered to match any specific goals for that particular client.  Local examination, both isolated and integrated, complement the global movements.  Only after such an individualized examination, can a treatment program specific to that person be designed.

“Success begets success” is only true when a client works at the threshold of their success. Practitioners of Applied Functional Science R know that tweaking a successful movement is the “secret” to rapid progression in the rehab and training program.

Just like the examination, any program can not be determined ahead of time, but instead is adjusted based on the progress of the individual.  Global movements that are tweaked based on the Relative Success Code and the performance variables will direct intervention at the causes of the movement dysfunction rather than just the symptoms.

The tweaks (progressions) of any program can not be random. They must be based on an individualized strategy created from the Principles of AFS.  Certification in Applied Functional Science (CAFS) teaches the logic behind the individual strategies.  The same diagnosis in different clients is likely to have very different causes.  If these different causes are not identified by the analysis and targeted by the intervention using strategies specific to that individual, then the service provided to each individual will be less that optimal.

Resources

1. Clinical Practice Guidelines (CPGs), APTA website. http://www.apta.org/EvidenceResearch/ImplementingEBP/CPGs/
2. Ludewig PM, et al. J Orthop Sports Phys Ther. 2013; 43(5): 280-283
3. .Wannier RS, et al. J Orthop Sports Phys Ther. 2007; 37(11): 658-660