HYPOTHESIS-ORIENTED ALGORITHM FOR CLINICIANS

 Hypothesis-oriented algorithm for clinicians (HOAC) is designed to aid physical

therapists in clinical decision making and patient management.
 The HOAC consists of two parts.
o The first part is a sequential guide to evaluation and treatment planning.
o The second part consists of a branching program used for re-evaluation and
the analysis of treatment effectiveness.
 The benefits of the HOAC are that therapists must :
o Clearly state problems in a consistent manner
o Generate and list hypotheses and test criteria
o Develop treatment strategies and methods based solely on the hypotheses
o Systematically review treatment
 HOAC serves the following functions:
o Evaluation
o Treatment planning
o Treatment implementation
o Communication with other health care professionals primarily about the
patient
 Though the HOAC is compatible with existing problem oriented systems but it
differs in several ways.
o The HOAC places the responsibility with the therapist to define goals and
continued management of the patient is mandated until the goals have
been achieved.
o HOAC emphasizes on the hypothesis generated by the therapist concerned
with the direct underlying cause of the functional deficits.

PART ONE: guidelines for evaluation and treatment planning

1. Initial data collection :

It involves the collection of initial data, which consists of recording the patient’s
medical history using available records, listing the patient’s complaints and observing
any non-verbal cues.

2. Problem statement :
 This step requires the therapist to generate a problem statement that can be
used to guide the development of goals.
 Problems should be described in the problem oriented format.
 Diagnostic terms and clinical impressions should not be used and it should be
expressed in the same terms used by the patient as this usually means a
statement of a functional loss. In case of severely ill patient the functional loss
must be inferred.
 Sometimes the problem statements must be written in terms of "anticipated
problem as the therapist may observe no manifestation of a functional or cosmetic
deficit during the initial examinations of the patient, but may find indications that
such a deficit may develop in the future. E.g. the schoolchild examined for scoliosis
may not demonstrate abnormal spinal curvature, but the therapist may anticipate
the development of such a problem based on the results of the evaluation.
Similarly, the below-knee amputee may not have a knee-flexion contracture, but
the therapist may anticipate the development of a contracture and, therefore,
want to consider this potential deficit in terms of a problem list.
 Anticipated problems frequently will compose a major portion of a problem list.

3. Goals:
 A properly written problem statement makes the next step in the algorithm, the
generation of goals, relatively easy.
 Goals should be stated in behavioural terms (i.e. what the therapist and the patient
hope to achieve) and should include only problems that can be remedied through
treatment.
 Goals must be stated in terms that are measurable. Therefore, goals must include
only terms that the therapist can define operationally. For example, if a goal is to
improve ambulation, the specific aspect of ambulation that requires improvement
must be stipulated. All goals must be defined in measurable terms. This process
requires therapists to define operationally.
 The goals in the HOAC are emphasized because they are the reason the patient is
being treated. Patients are discharged only when all goals have been met. Initial
goals, therefore, are tentative and can be modified after the patient is evaluated
fully. Setting goals before the therapist has evaluated the patient and assessed the
patient's capabilities might seem unusual but has the following advantages:
 The therapist is more likely to state problems and goals in terms that are
truly in line with the patient's report.
 The therapist and the patient are more likely to describe why the patient
came for treatment, what the patient expects from treatment, and what
functional problems are most important to the patient.
 By fully understanding the patient's expectations in the patient's terms,
the therapist can treat and advise the patient more appropriately
4. Examination:
 After the goals have been established, the therapist examines and evaluates the
patient and collects data regarding the patient's health status. Elements that may
contribute to the previously described functional loss are emphasized during data
collection, which is designed to minimize expensive and time-consuming
evaluations that may not be directed at the primary reason the patient is seeking
care.
 Some therapists may be regulated by departmental guidelines that prescribe
specific evaluative procedures for specific types of patients. Therapists may use
their own evaluative sequence or those of other treatment philosophies (e.g.
Brunnstrom, Bobath, and McKenzie).
5. Generation of a Hypothesis:
 Based on the patient examination results and the integration of all available data,
therapists then must develop a clinical impression from which they can generate a
hypothesis about the causes of the patient's problem. That is, the hypothesis is the
therapist's statement of why he believes that the patient does not meet the
treatment goals at the time of the initial visit.
 For e.g. a patient may have a problem with ambulation. Specifically, the patient
reports having knee pain after walking long distances. The goal would be for the
patient to be able to walk a specified distance (based on the patient's needs and
complaints) without pain. After the examination, the therapist may conclude that
the discomfort in ambulation is caused by a lack of normal progression from heel-
strike to mid-stance because the patient does not flex his knee during this part of
the gait cycle. Unless the therapist believes that this abnormality is simply a learned
behaviour, however, that conclusion alone is not an acceptable hypothesis. The
therapist must determine why the normal progression is missing. If measurement
of the patient's active range of motion revealed that he could flex his knee only 15
degrees and that this movement was accompanied by pain, then the hypothesis
would be that the functional loss is a result of the gait deviation, which in turn is
caused by the limitation in pain-free active ROM.
 Multiple hypotheses may be generated, which provide the underlying rationale for
all treatment that will follow.
 No treatment should be administered that is not based on a hypothesis.
 By requiring all treatments to relate to hypotheses, the HOAC forces therapists to
justify all aspects of treatment for all patients. This requirement is designed to
promote the use of appropriate treatment protocols and to discourage the use of
treatment regimens simply because they have been prescribed routinely in the
 past. In addition, this requirement minimizes the likelihood that therapists will add
superfluous treatments to otherwise sound programs.
 Because all treatment must be based on a hypothesis, we can say logically that
when a therapist is unable to generate a hypothesis he can administer no
treatment. This requirement forces the therapist without a hypothesis to seek
assistance by consulting either with another therapist or with some other health
care professional. Such consultations may be for an additional evaluation or the
consultant may generate the hypothesis. Clearly, a therapist without a hypothesis
needs assistance. We should emphasize, however, the requirements of an
acceptable HOAC hypothesis.
 When therapists believe that they have identified the underlying cause of a
problem, they then have a hypothesis. A hypothesis is really a clinical impression
based on an assumption of causality.
 Goals must be reconsidered after the hypothesis have been generated. Objective
findings may lead the therapist to hypothesize that the underlying cause of the
functional deficit is one that cannot respond to treatment or that may respond only
partially to treatment. The goals then must be modified, and the modified goals
may obviate the need to proceed with treatment.
 The testing criteria used in the HOAC may resemble what some therapists now call
"short-term goals." We believe that this term should not be used. Changes in active
ROM, muscle power, or similar elements should serve the achievement of goals
(function) and should not be considered goals in themselves.
6. Plan Re-evaluation Methodology:
 After the goals, hypotheses, and testing criteria have been established, the
therapist must outline the procedures that will be used for re-evaluation. These re-
evaluations must include mechanisms for testing whether the patient has met the
goals and whether changes have occurred in the criteria and related phenomena.
 All procedures to be used for re-evaluation should be listed before treatment
begins, and a schedule must be established designating when re-evaluations will
be conducted. When a therapist observes any major change in the patient's
physical or mental status, however, re-evaluation may be conducted before the
scheduled date.
7. Strategy and Tactics:
 The next two steps, planning strategy and planning tactics, are linked closely and
may be considered identical by some therapists.
 In the HOAC, a strategy is defined as the overall approach that will be adopted,
whereas the tactics are the specific means of implementing the strategy.
 Tactics are the treatments, but they are not necessarily only the treatment given
by the therapist.
 Tactics may be implemented by physical therapist assistants, family members,
nursing personnel, and the patients themselves.
 Strategies can be established only by the therapist.
 Treatment, or the implementation of tactics, is prescribed for a finite period of time
when the HOAC is used. Re-evaluation must be conducted according to the
previously determined schedule.
8. Re-evaluation:
 Re-evaluations are conducted on schedule, unless a change in the patient's health
status necessitates an earlier re-evaluation.
 When an early re-evaluation is conducted, the change in the patient's health status
may warrant reconsideration of the goals and hypotheses. In essence, this re-
evaluation means starting over at the beginning of the algorithm.
PART TWO—BRANCHING PROGRAM
 The branching program of the HOAC requires the therapist to perform the
previously described steps in reverse order.
 The sequence requires the therapist to ask questions regarding the most
concrete items first. This leads the therapist through an organized way of
treatment, which eventually leads to a consideration of whether the hypothesis
was correct, as judged by use of a testing criterion.
 When the goals have not been met, the therapist first must determine whether
the tactics were being implemented correctly i.e. was the treatment conducted
as planned?
 The preceding list is not meant to be comprehensive but, rather, is an
illustration of the type of inquiry therapists must engage in before they can
proceed to the next step. If implementation is poor, the therapist then deals
with that problem, establishes a new re-evaluation schedule, and continues
treatment. If the treatment has not been conducted properly, any of the other
questions in the branching program cannot be answered.
 If the tactics have been implemented properly, the therapist then must ask
whether the tactics were appropriate and whether the treatment plan was
correct.
 By following the branching program, we know that when the strategy is thought
to be correct a treatment plan has been conducted and the plan developed
logically from an idea (i.e. the hypothesis).
  The therapist then must determine whether the idea was correct. If the patient
meets the testing criteria and the goals have not been met, the hypothesis was
either incorrect or incomplete.
 The patient has met the testing criteria and, if the hypothesis was correct,
should no longer have a functional deficit. If the goals have not been met and
the problem is persisting, then the therapist must generate a new hypothesis
or seek consultation.
 Sometimes, new hypotheses will require referral to another practitioner.
 Other revised hypotheses may demonstrate recognition of conditions that
cannot be treated, such as structural anomalies or a permanent loss of
innervation. Goals then must be revised accordingly, and the patient discharged
at a lower functional level than that initially expected.
Discharge
 The HOAC allows for patient discharge under two clearly defined circumstances:
o When a referral is made
o When the goals, either original or modified, have been achieved.
 When the original goals have not been met, or when the patient has been referred
elsewhere, the therapist must document why these actions were taken. The
therapist, therefore, is accountable both for the reasons the goals were modified
and for the management of patients with modified goals.

Girijashankar khuntia
Elective - Ortho