Problem Solving and Scope of Practice

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Problem Solving and Scope of Practice
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NAGI grid
Problem Goal
Treatment Impairment Functional
Limitation Disability
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Problem Solving

• Impairment
• Any measurable loss or abnormality of
  psychological, physiological, anatomical
  structure or function
• Examples ROM, strength, tone, swelling,
  hypermobility, hypomobility, flexibility or pain

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Problem Solving

• Functional Limitation
• Any restriction or lack of full function
  resulting from an impairment of ability to
  perform an activity in the manner or within the
  range considered normal for a human being.
• Examples Squatting, walking, running, sitting
  reaching, writing, bathing, eating, combing hair

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Problem Solving

• Disability
• A disadvantage for a given individual resulting
  from an impairment or disability that limits or
  prevents the fulfillment of a role that is normal
  for that individual.
• Examples work limitations, recreational (or
  sports) limitations, community locomotion, social
  limitations

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Stages of Rehabilitation

• Stage 1 Pain Control
• Addresses management of pain through passive
  afferent treatment and biomechanical counseling.
  Objective is to avoid further irritation of the
  lesion, decrease pain and restore pain free ROM.
• Biomechanical Counseling is the education of the
  patient in daily activities on how to avoid
  destructive forces to the lesion.

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Stage 1 Pain Control

• Stabilization
• Preventing movement at the lesion site.
• Recruitment of controllers or deep stabilizers
  (TA and Multifidus) which are type I fibers that
  contract isometrically around the lesioned joint
  or segment

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Stage 1 Pain Control

• Disassociation
• Isolation of movement at a desired joint distal
  or proximal to the site of the lesion.
• Shifts the aggravating force from the site of the
  lesion.

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Stage 2 Begin Non-Destructive Movement

• Restoration of movement with focus on restoring
  lost ROM secondary to injury.
• Begins after control is established statically
• Lesion often the result of instability or poor
  joint proprioception
• Instability often accompanied by neighboring
  hypomobility
• Hypomobility can be due to capsular restrictions
  but often due to poor motor planning

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Stage 2 Begin Non-Destructive Movement

• Incorporate assistance to reduce shear and
  facilitate successful movement that supports
  joints structures and soft tissues
• Use of assistance is crucial and must not be too
  aggressive or premature with mobilization
• Improve outcome by choosing right degree of
  assistance and modification

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Stage 3 Begin Proprioceptive Training in
Protected Range

• Dynamic Stabilization challenges newly acquired
  ROM against gravity, resistance and in movements
  requiring proprioception and balance
• Challenges control of static trunk
• Prepares patient for return to function
• Elite movers require greater challenges than
  sedentary
• Continuum from mobilization by decreasing
  assistance
• Focus on control in all functional planes of
  motion

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Stage 3 Begin Proprioceptive Training in
Protected Range

• Dynamic Stabilization
• Requires appropriate recruitment of Type I
  Slow-twitch Stabilizers (TA, Multifidus, Internal
  Oblique, and pelvic floor musculature)

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Stage 3 Begin Proprioceptive Training in
Protected Range

• Functional Re-education faulty movement patterns
  must be broken down prior to re-education of new
  patterns
• Foreign Environment perform bio-mechanically
  correct exercises in an unfamiliar orientation to
  gravity
• Familiar Environment once comfortable with new
  movement in unfamiliar orientation to gravity,
  they are ready to progress to the task originally
  identified in the initial evaluation as the
  movement desired. (familiar orientation to
  gravity)

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Stage 4 Set Limits

• Limitations are set pertaining to movements,
  load, positions and frequencies
• Polestar modifies this by looking within to set
  limits
• Teach patient to recognize fatigue, illness, poor
  diet, emotional distress and early onset of pain
  signals or triggers
• Places responsibility on patient for their
  actions are relieves the practitioner of blame
  for potential flare-ups

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Stages of Rehabilitation

• Stage 1
• Control of static neutral lumbo-pelvic postures
  incorporation of motor skill into static spine
  postures.
• Stage 2
• Lumbo-pelvic control during trunk movements with
  assistance requires activation of deep muscles
  to provide segmental control in synergy with the
  global muscles providing trunk movement.
• Stage 3
• Control of neutral lumbo-pelvic postures under
  dynamic limb loading lumbo-pelvic control during
  trunk movements against resistance or gravity

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Spectrum of Movement

• Passive
• Assistive
• Gravity Eliminated
• Movement Against Gravity
• Resistive

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Treatment Planning

• A. Identify appropriate stage of rehabilitation
• Make appropriate modifications to
  exercises
• Choose appropriate number of repetitions
• Provide enough assistance to complete the
  repetitions successfully

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Treatment Planning

• B. Give Responsibility to Patient
• Select most productive movements for Home
  Exercise Program
• Design program with reasonable demands
• Educate patient to monitor progress
• Exercise follow-up is the practitioners
  responsibility

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Treatment Planning

• C. Progress at Appropriate rate
• Avoid stagnation by frequently progressing
  program in clinic and home
• Do not continue exercises that have been
  replaced
• Remember principles of neurological
  inhibition and excitation
• Avoid traditional philosophy of building
  muscle strength through strength training