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Introduction

This chapter presents an overview of the decisionmaking process used in developing treatment plans and modality selection based on the best available evidence. A case study is used to help reinforce the problem-solving approach presented in this chapter.

• The problem-solving approach (PSA) is a logic-based technique that uses the clinical examination findings, the patient's long-term goals (including the resolution of participation restrictions), and the best available evidence to develop an intervention strategy. We practice logical thinking as a part of our daily routine, involving basic skills such as getting dressed in the morning or more complicated tasks such as finding your way around an unfamiliar city. The PSA extends this logical thinking to the care of the patient.

This text began by explaining that therapeutic modalities are used to create the proper environment for healing to occur. The components of the injury response process are interrelated. For example, swelling causes pain, pain causes spasm, and spasm causes pain (Fig. 3-1). Although pain may be the patient's primary complaint, simply focusing the treatments on pain relief does little to resolve the underlying cause of the discomfort and the associated dysfunction. Approaching the patient's problems on a purely symptomatic basis often produces short-term benefits but unsatisfactory long-term results.

Figure 3-1.

The Pain-Spasm-Pain Cycle. This represents a self-perpetuating process in which pain causes muscle spasm and muscle spasm produces pain. This cycle continues until either pain or muscle spasm is resolved.

Treatment and rehabilitation (collectively known as "intervention") program planning is among the most complex skills that must be mastered. This process integrates clinical examination skills, knowledge of pathology, and identification of the patient's level of function and participation restrictions with knowledge of the physiological effects of therapeutic techniques, goal setting, and patient motivation and education. The body of knowledge is continuously progressing, and the efficacy of interventions is being established or refuted.

✱ Practical Evidence

Obtaining a correct diagnosis is important for identifying the current indications and contraindications • to a specific treatment. Intervention planning depends on the patient's goal (level of activity) and must address those impairments that limit activity.2,125

International Classification of Function

The result of injury or disease often focuses on what the patient is unable to do—disability. In 2002 the World Health Organization (WHO) implemented a new classification system that emphasizes what the patient is able to do, the International Classification of Functioning, Disability and Health (ICF).125 This model synthesizes parts of two disability models: the medical model and the social model. The medical model centers on resolution of the pathology. The social model focuses on the impact of the condition on the patient's quality of life. Termed a biopsychological model, the ICF system integrates the biological, ...

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