Skills of Treatment Goal Setting in Physiotherapy Practices

This article is dedicated to all my little friends, my students who are the aspirant Physiotherapists of tomorrow and the constant source of our learning and motivation.

And also to all my teachers, professional colleagues and friends who have been working hard towards our professional enrichment, development and enhancement.

Have a happy friendships day.

The commonest dilemma we encounter in clinical practise as a physiotherapy student is planning the treatment concept for our patients. Although we know the general line of management, planning the detailed treatment sometimes becomes a challenge. Setting the treatment goal for the patient depends a lot on the patients’ assessment. But even here, the assessment has to be a physiotherapeutic assessment involving the patients’ functional diagnosis rather than purely the medical diagnosis. I don’t mean to say that the medical diagnosis of the patient is not important, but it does not lead us to the physiotherapy treatment. Rather, it helps us understand the red flags and the yellow flags for the patients’ treatment.

E.g., we routinely talk about OA knee, stroke, Grade III B fracture femur, PA shoulder, CABG, ACL reconstruction, TKR, Bronchitis, Spinal cord injury, GBS etc. But as Physios, we do not treat any of these problems. Rather we treat the functional impairments associated with these problems. In fact, many times, the diagnosis is purely functional based, e.g. Low back pain, neck pain, weakness etc. In short, Physiotherapy treatment is more functional impairment driven rather than structural impairment driven. Again, it’s not that we physios don’t manage any structural impairment at all. We do work on the tightness (stiffness) of the muscles, we do mobilise the joints (bread & butter of us manual therapists), we do help in clearing the chest of secretions or working on the consolidated/ fibrosed lungs to reduce the pathology, or reduce swelling (Oedema) or help in accelerating wound healing and in infection control by actinotherapy etc. But these are just a few examples of the application of physiotherapy in structural impairment. At least, to my knowledge, I have never heard of fracture healing, ACL repair, stroke management (of the infarct/ ischemia in the brain), coronary blockage clearance, articular degeneration treatment by physiotherapy.

Thus, the most crucial part is working on the functional aspect of the patient, working on the functional impairments as well as enhancing the activities and participation of the patient. This part cannot be understood without being clear in the International Classification of Functioning (ICF) aspect. ICF deals with a global, holistic approach to the patient. Rather than looking at the assessment on observation, palpation and examination in parts, it unites them together to understand the problems in totality.

E.g. Rather than observing chest movements or swelling, palpating for chest symmetry or type of swelling (pitting or non-pitting), examining for chest expansion or amount of swelling by measuring tape in isolated parts, ICF looks at the Impairment ‘reduced chest mobility’ (functional impairment) confirmed by observing chest movements, palpating for chest symmetry and examining for chest expansion by measuring tape or ‘presence of swelling/ oedema’ (structural impairment) confirmed by observing site of swelling, palpating for type of swelling (pitting or non-pitting) and examining for amount of swelling by measuring tape. This helps in identifying problems faster and planning the treatment goals with more accuracy.

Setting the treatment goals of the patients are often done looking at the patients’ short term goals. But this does not make sense as we need to know the final goal, the treatment end point. For this, the easiest method of treatment planning is the A B C D E method for goal setting:

A – Actor: Describes the patient

B – Behaviour: Describes the need of the patient. It is an important factor as it describes the level of involvement of the patient, whether the patient wants to or does not want to be compliant towards rehab.

C – Condition: Describes the need of the task the patient has to be involved in.

D – Demands of the task: Describes the demands of the task the patient has to be involved in.

E – Event time: Describes the times needed to complete the planned goal.

Example: I may have a 30 year old postman who is from a village and underwent a traumatic trans-tibial amputation on his right leg. Now the final treatment goal of this patient can be:

The patient, a 30 year old male (actor), wants to (behaviour) go back to his job as a postman (condition) and should be able to deliver the letters to all the houses by riding his cycle on the rough village roads (demands of the task) in a period of 4 months (16 weeks) (event time).

HOW????

Treatment Options can be multiple but always rationalise and choose the best possible option including the details of the therapy, dosage etc. Always have an evidence backing for your management with recent literatures from reputed journals. Best possible option means the best and most effective treatment that we can give to our patients in the given possible situation. It may or may not be the most ideal treatment. But it has to be the most practicable and realistic option being offered to the patient.

A] Short term OR Phase I/ Maximum protection phase/ (0 – 4 weeks):

1) Wound care – wound healing by IR (luminous) for 15 minutes x 2times/ day [1-2 weeks cryotherapy for controlling inflammation and pain]

2) Pain relief (VAS was 8/10) – GOAL: Pain should be VAS 2/10 in 4 weeks: TENS at 150 Hz, 4 electrodes, 2 over sciatic nerve course & 2 over L4 – S1 nerve roots on right side [Even a IFT can be used with same arrangement]

3) Strengthening (Strength was grade 3 on MMT) – GOAL: Strength should be grade 4 in 4 weeks: Active resistive exercises [Here calculating the 1RM or the RPE would be very important rather than just 10 reps x 10 count holds which is non-specific to treatment. Also rather than only strength, training for ENDURANCE is more important.]

Left lower limb closed chain strengthening (squats by holding the bed end/ railing) till RPE 6/10 on modified Borg scale.

Bilateral upper limb closed strengthening by scooting/ push ups on the bed till RPE 6/10 on modified Borg scale.

[Initiation of the strength/ endurance training can be done by open chain PRE by calculating the 1RM by dynamometer/ spring balance or calculating RPE and train the patient to 50-60% of it]

4) Range of Motion (Knee flexion was 15 – 65 degrees) – GOAL: ROM should be 0 – 90 in 4 weeks: Active ROM exercises for the knee [in intra articular stiffness/ hypo mobility, manual therapy concept with dosage (grade of mobilisation) and direction of glide to be mentioned]

5) Gait training – with axillary crutches 3 point NWB gait. Start with standing and swing-to gait progressed to swing-through gait.

B] Long term OR Phase II/ Moderate Protection phase (4 – 8 weeks)

1) Stump shaping and conditioning – Weight bearing on the stump, pressure bandaging/ shrinker for compression, bridging exercises for gluteal and back extensor strengthening.

2) Strengthening – GOAL: Strength should be grade 5 in 8 weeks by closed chain exercises till RPE 6/10 on modified Borg scale.

3) Range of motion – GOAL: Full ROM should be obtained. Active ROM exercises for the knee to be done 3-4 times in the day.

4) Pre prosthetic training – GOAL: Should be able to use PTB prosthesis with a SACH foot.

5) Gait training – with temporary prosthesis using a pylon and walker/ crutches

C] Phase III/ Minimum Protection phase (8-12 weeks)

1) Prosthetic training – Gait training with PTB prosthesis for all functional activities

2) Strengthening – Maintenance of strength by closed chain exercises till RPE 6/10 on modified Borg scale. Also focus on endurance training.

3) Proprioception training – For lower limb by single leg stance, eyes closed standing for 10 sec x 5 sets

4) Gait training – walking on even surface in controlled environment. Begin ambulation as per patients’ needs. E.g. Begin with 10 meters progressing to 100 meters in 12 weeks.

D] Return to the work training phase (12-16 weeks)

1) Gait training – uneven surface in real environment

2) Training for cycling on static cycle (12 – 14 weeks) – cycling for ½ hour x 4 times/ day x 5 days/ week

3) Training for cycling on moving cycle on controlled surface (14 – 16 weeks) – cycling for ½ hour x 4 times/ day x 5 days/ week

The treatment goal of being able to ride the cycle on the rough village roads for 8 hours/ day (intermittent) to deliver the letters should be achieved by the end of the 16 weeks. This is only an outline which can be hindered with factors like patient landing with infection/ fever due to reasons other than infection/ got transferred etc. But the minimum time frame and treatment plan is extremely important.

Also treatment has to be realistic in relation to the pathology. E.g. Instead of a Trans tibial, if this patient had a Trans femoral amputation, this above mentioned final outcome will not be possible (considering the limited technology and resources) and alternative treatment options have to be realised by both the therapist and the patient in the final goal and return to work phase.

Similar treatment plan can be done for any condition considering the pathology, healing phase, patients’ age and requirements. The part B, C & D should be based on re-assessment ensuring that the patient participates equally and is well informed of the goals of the treatment and also of the expectations from them in the rehab process. Details of the phase II, III and IV can be based on these re-assessments, but the treatment outline, goals and plan should definitely be ready even before initiation of the 1^st treatment session.

In our professional training we are typically taught the problem solving approach. We are trained to look at what is wrong with the patient and patch it up. Typically like patching the roads with tar which has developed potholes rather than focussing on making a stronger and better road right at the beginning. In ICF, the functional impairments help us formulate our short term goals which are definitely important to make the patient normal again to his pre injury status. I always like to give example of the movies ‘Koi Mil Gaya’ and ‘Krishh’. In KMG, the mentally challenged hero becomes a powerful hero at the movie end. This is typically what we do for our patients. It’s like the patient has become a zero and you are making the patient hero again. But just stopping at this phase is not good as the patient is at a risk of re-injury once again going back to his zero status, maybe with a higher level of disability. In Krishh, the lead actor becomes a superhero from his hero state. This should be the objective from our Phase III treatment onwards. Along with the problem solving approach, we should also perform something called as ‘appreciate enquiry’. We need to know what is good in the patient as well and should enhance these qualities. This will help us take the patient to a level where he learns not just to compensate for his weakness (for which we are treating and training them) but also to reach such a level of fitness and health by which he is never at a risk of landing with the injury again. This can only be obtained by knowing and focussing on the structural and functional integrity of the patient and also on the activities and participation levels of the patient. This can be further enhanced by knowing the contextual factors of the patients, especially the environmental facilitators including the architectural, technological, support systems, family and policies available for health.

We are many times ruled by the treatment protocol in patient treatment. Every protocol is extremely important in patient care as it help us keep in line each and every part of the treatment spectrum. In absence of a protocol, there is always a risk of missing out a crucial treatment link. In the example cited above, it is very important to follow the steps and sequences of the treatment. But we cannot forget the individualisation in the patients’ needs and requirements considering the patients goals. Thus protocols should form the basis of patient treatment, but it should also be individualised using the therapists’ knowledge of the patient, the condition, the pathology, and the sciences of tissue healing and the needs of the patient.

Again, in the example cited above, nowhere are we treating the structural or medical pathologies. We are looking and treating the movement dysfunction, dyskinesia’s, abnormal muscle recruitments, sensory dysfunction, functional loss and loss of involvement in daily life’s situations. Thus, as physiotherapists, we should be more trained in understanding and assessing these problems and managing them rather than conditions and medical diagnosis. There may be surely other views and opinions on the same and they all are respected and welcomed. No way is medical diagnosis lesser important to be learnt and understood. It, many times, helps us in re-assessment or understanding the problem being treated. It also helps us all to speak the same common language of patient care between all the care giving professionals. But as physiotherapists, we should also be focussing more on physiotherapeutic assessment and diagnosis and treatment as well.

Thus, I would again like to say that planning the clients treatment plan is an art, a science and also a commerce as it involves not only the skills of treatments, the evidences and the logics behind it backed by an efficient research methodology and publications but also involves the financial management of treatment expenses, of learning to have a proper documentation of the treatment procedures and also of the financial transactions, payment receipts and bills, legal knowledge of the laws and legislature of the state in relation to Physiotherapy practices, partnering with the professional councils and associations governing profession and the professionals and very important, being accountable and answerable to your clients, your own self and finally to GOD who blessed us all in this noble and honourable profession.

An Alternative Effective Method for Obesity Management in Females – The Modified Suryanamaskar Technique

Introduction:

Overweight and obesity are common health conditions and their prevalence is increasing globally. In developing countries, obesity & sedentary behavior coexists with under nutrition. In India, obesity is highly prevalent in women as compared to men. As the obesity epidemic spreads, there are growing concerns about efficient obesity management. Obesity comes with several causes which makes obesity management more complex. Some evidence suggests that lack of physical activity, rather than caloric intake, is a major determinant of obesity. It is the need of the moment to develop effective & comprehensive strategies which can reduce body weight & obesity related co-morbidities. The current targets should be focused on improving overall physical health rather than only reducing body weight.

Physical activity and/or exercise are commonly included as components of lifestyle interventions for weight loss. There are no specific recommendation mentioned on type & intensity of exercise.  Various studies using aerobic, resistance or combination of both types of exercises have shown to have health benefits. 

Yoga is an ancient Indian form of physical activity which may assist in achieving recommended levels of fitness. Suryanamaskar is a part of yoga. It is a set of sequential yogic postures which are called as asanas. A review by Ross et al suggests that yoga may be equally effective or better than exercise at improving a variety of health-related outcome measures like blood glucose, blood lipids & oxidative stress. Nevertheless, there is a dearth of research in the field of Suryanamaskar and also on its uses as a therapeutic exercise.

In various fitness and weight management centres, ‘aerobics’ involving high impact ballistic movements are incorporated. These forms of exercise are not suitable for obese females, especially those associated with musculoskeletal problems like knee arthritis, back pain and osteoporosis. Thus, an optimal approach is needed for management of obesity and enhancement of physical fitness parameters like cardio respiratory fitness, muscle endurance & flexibility.

Modified Chair Suryanamaskar Technique:

Suryanamaskar or Sun Salutation is the traditional exercise science done with a series of movements or asanas for fitness enhancement. But this technique seems difficult to be done by the population who has knee pain/ back pain or is obese and the protruding ‘tummy’ hinders the steps to be done in Suryanamaskar. The modified Suryanamaskar training (SN) is performed against the wall or with a chair as a modification. Although there are many literatures available on Suryanamaskar technique, no known documented evidence is available for this modified Suryanamaskar chair technique discussed in the present article and establishing the reliability of this procedure itself is an important aspect. Workers in the field of Suryanamaskar suggest that there are more than 1400 different modifications which can be possible in Suryanamaskar itself. This modified chair technique described herein, may be considered as the authors’ innovation to match the needs of the population described. This is performed at a speed of approximately 1 step/ second till the level of fatigue is ‘somewhat hard’.

The modified Suryanamaskar chair technique consists of a total of 12 steps or asanas: (Figures 1-7)

1.           Pranamasana: Stand erect with feet together. Look straight. Pull in knees, thigh muscles. Retract the shoulder girdles. Fold hands with palms pressed against each other to perform namaskar.

Figure 1: Pranamasana

2.             Hastauttanasana: Raise arms above head. Grow taller. Bend the back and stretch abdomen.

Figure 2: Hastauttanasana

3.            Hastapadasana: Bend forward. Don’t bend the knees. Go down and place your hands on the chair. Try to pull the head towards the knees.

Figure 3: Hastapadasana

4.           Ashwasanchalanasana: Take right leg back and stretch it while balancing it on the toe and keep left leg in front of your body aligned with the front legs of the chair. Keep palms straight on the chair and look upwards.

Figure 4: Ashwasanchalanasana

5.             Parvatasana: Take back the left leg as well and keep both the feet together while raising hip from the ground and balancing on all fours. (Hands on the chair & feet on the floor.)

Figure 5: Parvatasana

6.           Chaturnamaskara: Slowly come down and bring your shoulders near your hands. Knees should not touch the ground and waist and hip slightly raised above so that the body is aligned in a straight line.

Figure 6: Chaturnamaskara

7.          Bhujangasana: Arch your back. Lower waist and raise torso, make arms straight and balance. Feel bend of spine and stretch of abdomen.

Figure 7: Bhujangasana

8.             Parvatasana: Same as position 5 

9.             Ashwasanchalanasana: Same as position 4 

10.         Hastapadasana: Same as position 3 

11.         Hastauttanasana: Same as position 2 

12.         Pranamasana: Same as position 1

Discussion:

Lipids are major fuel source to the exercising muscles. Adding resistance to exercise may increase the energy expenditure leading to further fat oxidation. Suryanamaskar lowers the total body fat% by around 3.8% and the visceral fat by 9.3%. Increase in the visceral fat is associated with high risk of cardiovascular diseases & type II diabetes. Aerobic training when combined with resistance training is more effective in stimulating increase in the lean body mass with SN by around 2.2%. Increase in lean body mass caused by exercise can be associated with less reduction in total body weight. Study by Catenacci and Wyatt showed that exercise training improves body composition often independent of weight loss. Hence change in body weight is less reliable as an only outcome.

In sedentary adults, there is decline in muscle tissue by 4 to 6 lbs per decade and muscle efficiency also reduces.  This often leads to a drop in the resting metabolic rate and an increase in body fat. Even 2-3% increase in resting metabolic rate can have the effect of reversing age-related weight and fat gain. Aerobic exercise improves metabolic functions, especially enzymes in the muscles whereas, resistance training improves muscle protein synthesis and hence muscle mass. Aerobic exercise training also helps to maintain or slows down the loss of bone mass whereas resistance training improves bone mass. The modified SN technique may help to improvise this as well. Regular exercise is also associated with changes in muscle morphology and metabolism that correspond to a marked decrease in metabolic risk and increased life expectancy.

The body mechanisms to regulate water content are compromised with increasing age which are further exacerbated with hormonal changes in menopause, medical conditions like hypertension and use of certain medications e.g. diuretics. Body water percentage is an imperative marker of ageing wherein SN training raises the body water % by almost 5.1%.

Physical inactivity coupled with obesity increases the risk of cardiovascular and other obesity related diseases. When assessing the impact of obesity on health status, Cardio Respiratory Function (CRF) evaluation is fundamental part. Large observational studies recommend that CRF is inversely related to morbidity & mortality in obesity.  So, improvement in CRF may be more essential than changes in body weight or BMI in reducing the risk factors for obesity co-morbidities. This CRF is best designated by maximal aerobic capacity i.e. VO₂ max. It reflects the oxygen delivery to the exercising muscles by the cardiovascular & respiratory system. CRF depends on maximal cardiac output and the ability of skeletal muscle to extract oxygen. Hence it enhances the ability to exercise for prolonged duration. VO₂ max based on the Shuttle Walk Run Test performance shows a remarkable improvement with SN by almost 14.1%.

There are tall claims in weight management, but may not offer management of factors like endurance and flexibility which are impaired in obese people in such weight management programs. Increase in mitochondrial size and number and mitochondrial enzymes is mediated by the repetitive contractile activity of the muscle. Also these adaptations are very specific to the type of muscle fibres recruited. Increase in muscle endurance would be because of the metabolic adaptations occurring with training are lower blood lactate levels which delays the development of fatigue and increased fat oxidation. SN improves the upper limb muscle endurance markedly by 51.2% and lower limb muscle endurance by 24.5%. In SN there is repetitive upper limb loading with body weight in specific aasanas like Ashwanasanchalanasana, Chaturnamaskara & Bhujangasana activates various upper limb muscles to maintain the posture in that particular aasana.

Flexibility is the ability to move the joint through its complete Range of Motion. Insufficient ROM increases the risk of injury to the adjacent muscles and joints. Reduced flexibility may be because of various reasons like desk-bound lifestyle, physical inactivity or deposition of fat around the joints restricting complete ROM. Alterations in flexibility can lead to various bio-mechanical changes in joints and altered postures. Hence, flexibility is needed to perform daily activities with ease. Although the modified SN, unlike the traditional SN, does not permit complete movement of the trunk in asanas like the hastapadasan and bhujangasan, it is still an extremely important tool in enhancement of flexibility by almost 12.5%. The different postures in suryanamaskar demands movement till the end ROM which would be the reason of the noteworthy change with SN training.

Thus, employing exercise leads to measurable improvements in overall health status. This improvement is as a result of improvement in metabolic status, more efficient musculoskeletal and the cardiorespiratory system that can lead to a parallel increase in lean tissue and reduction in fat mass. It appears that as long as the increase in energy expenditure is sufficient, low to moderate-intensity endurance exercise is likely to generate beneficial metabolic effects similar to high-intensity exercise.

Clinical Implication:

Any form of exercise is beneficial for fitness enhancement and can be implemented for obesity management. Also, there are different types of benefits by different forms of exercise and no one method is considered superior to other. A normal fitness program requires exercise prescription of approximately 45 – 60 min. But the modified SN training regimes requires a lesser time. Thus we strongly recommend using the modified chair Suryanamaskar technique as a better method for Obesity management, with an added advantage of not requiring any instruments as in circuit training or treadmill in Gyms and also requires less space unlike walking. Hence, SN provides economic & time factor advantages and provides complete provision of fitness enhancement.

Conclusion:

Suryanamaskar training is an effective tool in weight management and improvisation of physical fitness parameters in over weight and obese females, especially in improving Cardio- respiratory fitness, upper limb muscle endurance and body flexibility.

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References:

Available on request.

Dr Komal Jakhotia (PT)

Dr Apurv Shimpi (PT)