CH 5 Clinical Decision-Making

OBM clinical decision-making process  (OBM P.109)

Goals

1.  Describe 4 phases of OBM clinical decision making process
1. Evaluation phase
2. Treatment planning phase
3. Treatment phase
4. Discharge phase
2. List impairment that clinicians can treat with massage techniques and the outcomes that they can achieve by doing so
3. Identify the process by which clinicians use the findings from the client examination and re-examinations to develop the plan of care and then modify, refine, and progress interventions
4. Describe how to identify the client's discharge needs, plan for discharge and discharge a client
5. Describe thee relationships between OBM clinical decision-making, evidence-based practice, and the therapeutic relationship 

This decision-making process is a guide through the evaluation, treatment planning, treatment, and discharge phase of clinical care

Phases

Evaluation phase

Therapist clarifies the client’s clinical problem and identifies the client’s relevant impairments and functional limitations

This evaluation is used for identification and treatment planning

Treatment planning phase

Treatment phase

Discharge phase

Wellness VS Medical massage 

Wellness massage

Client does not present with impairment in body structures and function that are secondary to a clinical condition

Client has several body structures and functions that are free from impairment and goals for wellness

Medical massage

Impairment can be any loss or abnormality of the client’s body structures or function that occur as a result of the pathophysiology of a clinical condition

Purpose is to reduce the impairments associated with clinical condition

STEP1 & STEP2

Observe client, Select tests and measures, Examine the client

Review treatment reason and conduct subjective and objective client examination

Collect information, History taking

Subjective examination

Generate preliminary (= Introductory) clinical hypothesis 

• Generate A few possible hypothesis 
• Have less than 3 hypothesis so that you can use a focused set of tests and measures
• Avoid making hypotheses very general so that they will fit inconsistent findings
• Include both objective data and info on the client’s perception of their clinical condition and functional limitations
• Be selective in the collected data
• Be flexible and depart from a standard examination framework
• Stay focused on the main clinical hypothesis
• Avoid exaggerating findings to justify an existing hypothesis
• Be willing to acknowledge that an existing hypothesis is incorrect and seek a new hypothesis

STEP3: Analyze findings and confirm the client’s presenting issue

• Confirm clinical hypothesis
• Summarize pertinent clinical findings
• Determine appropriateness of treatment: Legal right to treat, Ethical right to treat

STEP4: Treatment planning

Identify client problems/wellness goals and specify relevant outcomes

Identify functional outcomes

1. Client’s current and prior level of function
2. Severity, complexity, stability, and acuity of t he client’s condition
3. Client’s discharge destination (Setting the Goal)
4. Literature on the prognosis for an individual with that condition
5. Therapist’s judgement, from clinical experience, of what the client has the potential to achieve

Identify treatable impairments and relevant outcomes

1. Which impairments need to be treated to facilitate the achievement of the functional outcomes?
2. Which of these impairments are amenable to active treatment?
3. Which impairment require compensations because they are not amenable to active treatment?
4. Impairment-related outcome for each impairment that she will treat

STEP5:

Select appropriate treatment techniques and Create plan of care

This phase include the identification off those impairments that are most appropriate for the application of massage techniques

Possible options 

1. Direct effect on the impairment
2. Secondary effect on the impairment
3. No effect on the impairment

Impairment and Treatment plan have to match to justify OBM

Select treatment techniques

1. Match of expected outcome, related to impairments, of the massage technique to the clients’ impairment
2. Identification of contraindication or caution in the application of that technique given the client’s clinical condition
3. The therapist’s legal right an competence to use the technique
4. Generate plan of care an document the details such as type of exercise, how many sets, how frequent, caution, etc.

*Contraindications and cautions are indicated at the end

STEP6: Select treatment and re-examination technique

• Gauge the client’s treatment tolerance and to ascertain whether the treatment technique can affect the client’s impairment
• Document which technique has the most positive response to client’s impairment
• Less intense treatment for acute condition
• Do not introduce too many techniques at once because that will make it difficult to identify which technique works the best for the client

STEP7: Conduct client re-examination and modify treatment 

• Palpation and the massage techniques themselves can provide information on the client's response to the technique the the therapist is applying and to the intervention as a whole
• Once the client has reached a point at which the therapist can reasonably expect a measurable clinical change, the therapist carries out a more formal re-examination using the test and measures she selected for this purpose
• Re-examination focuses on the identification and measurement of changes in the client’s impairments and functional level from the baseline established at the initial examination. This rate-examination can also be used to determine whether to modify the plan of care or the identified outcomes

If there is no positive prognosis...

Possible cause is an incorrect clinical hypothesis, an inappropriate treatment technique or an incorrect application of a technique

STEP8: Identify client’s discharge needs and formulate discharge plan 

No exact formula to use for determining when to initiate the discharge process

Consider Client’s characteristics, progress with their functional outcomes, physiological and educational readiness for discharge

In some cases, discharge plan could be formulated as early as the first treatment

Initiate post discharge education and referrals

STEP9: Determine readiness for discharge

Finalize discharge plans and review home program 
Special discharge issues

Ongoing care

1. Paediatric clients with developmental disabilities
2. Chronic, terminal conditions who are at risk for deterioration of health status
3. Geriatric clients who are at risk for falls or deterioration of health status
4. Ongoing disability and health-care needs as a result of spinal cord injury, head injury, amputation, or other traumatic injury
5. Clients who are receiving wellness interventions

Therapeutic process

Trust relationship that occurs between the therapist and client in the context within which therapist provide OBM

1. Building trust
2. Exploring sensation
3. Healthy closure

Ch.4 Client examination for Outcome-Based Massage

Objectives

1. Distinguish "Outcome based massage" vs "Wellness massage"

2. Identify elements of the client interview that are relevant to the assessment of soft tissue dysfunction

3. Identify the components of the objective examination for massage including MSK, psychoneuroimmunologic, multisystem, neurologic, cardiopulmonary, and functional components

4. Discuss how to perform palpation and identify the impairments that can be assessed using palpation

5. Describe a variety of nonpalpatory approaches to assessing the impairments that are relevant to massage