The Right Stuff
Providing the right level of health care.
By F. Mark Amundson, PT, DPT, DSc, MA, ATC, SCS, CSCS
Several expressions are used to describe aims of health care: “The right care, at the right time and place,” evidence-based practice (EBP), and “best practices” are examples of well-known aspirations. Physical therapists should be aware that these objectives correspond to a dramatic shift occurring in health care from being “provider centered” to “patient centered.” To date, the outcome from health care services has been determined primarily by providers. Going forward, patients will contribute more to determining if the health care they receive results in positive outcomes. The probability for achieving these crucial objectives can improve if each patient has received the right level of health care (RLOHC).5,13
“Working in silos” is a common description of health care providers who conduct themselves in a feudalistic system characterized by little if any interaction with other providers.7,8,12 However, the recent health care renaissance finds collaboration being the directive for the breakdown of old silos to achieve the right care at the right time and place; through the use of EBP, resulting in best practices that deliver the RLOHC. During this period of revitalization, physical therapists face a crossroads of either being a commodity or seizing opportunities to be leaders and indispensable members in contemporary health care systems.
Leadership may be secured through the use of a common functional capability-based language for classification of patients/clients along the health wellness continuum. Effective classification facilitates matching health care needs of patients/clients to the RLOHC. A functional capability-based classification system illustrates the valuable role physical therapists possess as health care leaders and providers along the entire length of the continuum.
The World Health Organization (WHO),36 and in turn the American Physical Therapy Association (APTA),15 has adopted a biopsychosocial model for health care. This model represents that health care of a person must incorporate the biological, psychological, and societal implications an injury or illness has on that person. Each component is on a continuum comparing a person’s functional capability level to the degree of difficulty of performing a particular activity. Take for example a female tennis player recovering from a knee injury that has resulted in the knee feeling unstable. The knee injury represents the biological component. Due to the feeling of instability, she is unable to participate in her tennis league. Being unable to play in her league has psychological and societal consequences. Her regular tennis matches allow her to feel good about herself. During and after each match she spends meaningful time socializing with teammates as well as competitors. Returning to her previous functional capability level certainly has biopsychosocial implications.6
What is meant by functional capability level? A level is defined as being “a relative rank on a scale.”32 One definition of scale is “a system of classification in which people or things are ranked according to a specific criterion.”32 In turn a scale is identified as a synonym for continuum. Continuum is defined as “a continuous sequence in which adjacent elements are not perceptibly different from each other, although the extremes are quite distinct.”32 A functional capability continuum ranges from unable to poor to fair to good and ultimately to complex levels. Here the extremes are very different but each successive level along the continuum may not be perceptibly different. By narrowing in on the current functional capability level of a patient/client, a physical therapist can determine the current biopsychosocial status of the individual. They can then level specific interventions—including the best providers for those interventions—and can work toward functional goals while avoiding harm by exceeding current capability, thus achieving the RLOHC. Matching movement capability with the physical stress demands of an activity increases the probability of positive outcomes.18,19,28,29
Movement is an actual change in position that occurs along a continuum of multiple interacting levels. That description forms the basis for the movement continuum theory (MCT)9 that describes levels of movement ranging from micro/molecular to body part to total person to the macro level of the person’s ability to move within society. The cumulative effect will determine the person’s ability to control movement at a preferred functional level. Movement fits into the biopsychosocial model as each level is influenced by physical, social, psychological, and environmental factors. According to MCT, each person has a maximum achievable movement potential (MAMP), current movement capability (CMC), and preferred movement capability (PMC).9 To maximize performance and decrease the risk of injury a person’s CMC needs to match the PMC degree of difficulty. Expectation of others can have an enormous impact on the level of movement attempted by an individual.9 Physical therapists when selecting interventions for a plan of care need to take into consideration that if the demands of the interventions are greater than the person’s CMC there is an increased probability of an injury or other poor outcome.
The movement ability measure (MAM)1,2 provides a standardized measurement to determine the effectiveness of an intervention in improving movement. MAM is a self-report of movement ability based on the MCT. Contained within 24 items, the MAM examines six dimensions of movement: flexibility, strength, accuracy, speed, adaptability, and endurance. Each dimension is measured along a continuum of six levels of ability. The MAM can help physical therapists learn of patients’/clients’ self-perception regarding their ability to move within each dimension along six specific levels for that dimension.1,2 One example of the continuum has at the low end being “unable to move” with “able to move as an athlete or star performer” on the high end. MAM establishes the person’s current and preferred movement capability in the same item.1,2 Knowing the patient’s/client’s movement capabilities aids in learning the RLOHC including the parameters of exercise to use to reach PMC.
Changes in the relative level of physical stress causes a predictable adaptive response in all biological tissue is the basis of the physical stress theory.25 A fundamental principle of the theory is biological tissue has predictable responses to stress that are along a continuum of stress levels: death, atrophy, maintenance, hypertrophy, injury, and death.25 RLOHC exercise prescription utilizes stress levels at the patient/client’s current capability level. To improve capability physical stress needs to be at a maximum threshold level to prompt the body to adapt, increasing the body’s ability to function at a higher stress level. Stress higher or lower than the maximum threshold will result in a poor outcome. To achieve a positive outcome, exercise interventions are at the current and progressed to the preferred capability levels.33,34 RLOHC is dynamic—changing with functional capability.
Function includes all three biopsychosocial components that may be placed along a continuum. WHO developed The International Classification of Functioning, Disability, and Health (ICF),36 which is composed of these interacting components that range from, disability to function of overall health condition, and unable to participate to being able to participate in desired activities. ICF provides a common language for levels of disability to function based on the biopsychosocial model. Accordingly the continuum can be divided into functional levels along a scale from unable at one end to complex on the other end. In between are levels along the continuum that include requiring assistance in daily activities, followed by being able to move about the community without assistance, to the capability for taking part in usual and nonroutine activities.
Individuals have a current and preferred functional capability. A challenge in physical therapy is for current and preferred capabilities to be at the same level.3,4,10,11,14,20,21,22,23,26,27,31,35,37 RLOHC involves matching these capabilities to increase a person’s quality of life while decreasing the risk of injury.16,17,24,30,34 For instance, if current capability is at being able to move about the community, but the preferred capability is sports participation, there will be a high risk of injury if at this point in time the patient/client attempts to take part in sports at a physical stress level higher than current capability.
One component of a physical therapy best practice is physical therapists using EBP for determining the current RLOHC to provide the right care at the right time and place in achieving positive patient-centered functional outcomes. A classification system based on functional capability levels related to biopsychosocial demands of an activity can be used as a guide for physical therapists when determining RLOHC. Current functional capabilities help to ascertain the RLOHC that incorporates the present movement and physical stress levels.18,19,28,29 From this starting point physical therapists can then develop a plan that bridges the gap between current and preferred functional capability. RLOHC interventions are used to ultimately have the current and preferred functional capability at the same level.1,2 Physical therapists can use functional capability-based RLOHC to effectively and efficiently achieve positive patient-centered outcomes.
1. Allen D. Proposing 6 dimensions within construct of movement in the movement continuum theory. Phys Ther. 2007;87:888-898.
2. Allen D. Validity and reliability of the movement ability measure: a self-report instrument proposed for assessing movement across diagnosis and ability levels. Phys Ther. 2007;87:899-916.
3. Arden, CL, et.al. Return to preinjury level of competitive sport after ACL reconstruction surgery. Am J Sports Med. 2011;39:538-543.
4. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after ACL-R. Arthroscopy. 2011;27:1697-1705.
5. Bechtel C, Ness D. If you build it, will they come? Designing truly patient-centered health care. Health Affairs. 2010;29:914-920.
6. Bhagwant, S, et.al. Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther. 2012;92:992-1005.
7. Bircher J. Towards a dynamic definition of health and disease. Med Health Care and Philosophy. 2005;8:335-341.
8. Bircher J, Wehkamp K. Health care needs need to be focused on health. Health. 2011;3:378-382.
9. Cott C, Finch E, Gasner D, et al. The movement continuum theory of physical therapy. Physiotherapy Canada. Spring 1995;47:87-95.
10. Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379-385.
11. Edwards PK, Ackland T, Ebert JR. Clinical rehabilitation guidelines for matrix-induced autologous chondrocyte implantation on tibiofemoral joint. J Orthop. Sports Phys Ther. 2014;44:102-119.
12. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977 April;196:129-136.
13. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Affairs. 8;2010:1489-1495.
14. Grindem, H, et.al. Single-legged hop tests as predictors of self-reported knee function in nonoperatively treated individuals with ACL injury. Am J Sports Med. 2011;39:2347-2354.
15. Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org. Accessed 12/14/14.
16. Hamilton GM, Meeuwisse WH, Emery CA, Shrier I. Subsequent injury definition, classification, and consequence. Clin J Sport Med. 2011;21(6):508-514.
17. Hamilton GM, Meeuwisse WH, Emery CA, et al. Past injury as a risk factor: an illustrative example where appearances are deceiving. Am J Epidemiol. 2011;173(8):941-948.
18. Harris-Hayes M, Sahrmann S, Van Dillen L. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sports Rehabil. 2009 February; 18(1): 60-75.
19. Harris-Hayes M, Van Dillen L. The inter-tester reliability of physical therapists classifying low back pain problems based on the movement system impairment classification system. PMR. 2009 February; 1(2): 117-126. doi:10.1016/j.pmrj.2008.08.001.
20. Hewett T, Di Stasis S, Meyer G. Current concepts in injury prevention in athletes after anterior curciate ligament reconstruction. Am J Sports Med. 2013. January; 41(1): 216-224. doi:10.1177/0363546512459638.
21. Hurd WJ, et.al. The effects of anthropometric scaling parameters on normalized muscle strength in uninjured baseball pitchers. J Sport Rehab. 2011;20:311-320.
22. Logerstedt DS, Snyder-Mackler L, Ritter RC, et al. Orthopedic section of the American Physical Therapy Association, knee stability and movement coordination impairments. J Ortho Sports Phys Ther. 2010 April;40(4):A1-A37.
23. Meuffels D, Poldervaart M, Diercks R, et al. Guidelines on anterior cruciate ligament injury: a multidisciplinary review by the Dutch Orthopedic Association. ACT Ortho 2012: 83(4):379-386. DOI10.3109/17453674.2012.704563.
24. Meyer GD, Schmitt LC, Brent JL, et al. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Ortho Sports Phys Ther. 2011;41(6):337-387.
25. Mueller M, Maluf K. Tissue adaptation to physical stress: proposed “physical stress theory” to guide physical therapist practice, education, and research. 2002;82:383-403.
26. Negrete RJ, Hanney WJ, Kolber MJ, et al. Reliability, minimal detectable change and normative values for tests of upper extremity function and power. J Strength Cond Res, 2101;24:3318-3325.
27. Reiman MP, Lorenz DS. The integration of strength and conditioning into a rehabilitation program. Inter J Sports Phys Ther. 2011; 6:241-254.
28. Sahrman S. Diagnosis and Treatment on Movement Impairment Syndrome. St Louis, MO: Mosby: 2002.
29. Sahrman S. Movement System Impairment Syndromes of the Extremities, Cervical, and Thoracic Spines. St Louis, MO: Mosby: 2010.
30. Schmitt L, Byrnes R, Cherny C, et al. Evidence-based clinical care guidelines for return to activity after lower extremity injury. www.cincinnatichildrens.org/suc/alpha/h/health-policy/otpt.htm. Guideline38, p1-13, 5/24/10.
31. Silbernagel KG. Does one size fit all when it comes to exercise treatment for Achilles tendinopathy? J Ortho Sports Phys Ther. 2014;44:42-44.
32. The Free Dictionary.com. Accessed 11/10/15.
33. Thein Brody L. Effective therapeutic exercise prescription: the right exercise at the right dose. J Hand Ther. 2012;25:220-232.
34. Toscano L, Carroll B. Preventing ACL injuries in females: what physical educators need to know. J Phys Ed Rec Dance. 2015 January;86:40-46.
35. Van der Wees PJ, Moore AP, Powers CM, et al. Development of clinical guidelines in physical therapy: perspective for international collaboration. Phys Ther. 2011; 91:1551-1563.
36. World Health Organization. How to use the ICF: a practical manual for using the International Classification of Functioning, Disability, and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO.
37. Yenchak AJ, Wilk KE, Arrigo CA. Criteria-based management of an acute multistructure knee injury in a professional football player: a case report. J Ortho Sports Phys Ther. 2011;41(9):675-686.
F. Mark Amundson, PT, DPT, DSc, MA, ATC, SCS, CSCS, is a PPS member, clinician, and Chief Clinical Officer for Twin Boro Physical Therapy in New Jersey. He may be reached at email@example.com.