revisiting hoac ii for determining the physical therapy

REVISITING HOAC II FOR DETERMINING THE PHYSICAL

THERAPY COURSE OF TREATMENT FOR A PATIENT

WITH UPPER EXTREMITY PARESTHESIA

Kaitlyn E. Canterbury, SPT

MAY 14, 2018 MARYMOUNT UNIVERSITY PHYSICAL THERAPY DEPARTMENT

Arlington, VA Case Advisor: Diana Venskus, PT, PhD

Abstract

Background: Accountability among physical therapists is increasingly essential to ensure

patients achieve optimal functional outcomes, maximize quality and efficiency of care, and

establish the value of physical therapy as a profession within the spectrum of health care. The

Hypothesis-Oriented Algorithm for Clinicians (HOAC) II is a decision-making tool that can

enhance clinical accountability.

Purpose: The purpose of this case report is to describe the retrospective application of the

Hypothesis-Oriented Algorithm for Clinicians II (HOAC II) to reflect on a student’s clinical

reasoning for a patient with insidious onset upper extremity paresthesia.

Discussion: This case report demonstrates that the HOAC II can be used retrospectively to

outline the treatment and decision-making process which resulted in achievement of the patient’s

goals.

Conclusion: The HOAC II guides the clinical reasoning process to include formulating a clear

intervention strategy mapped to both patient identified and clinically identified problems. To

advance practice standards, clinicians must analyze the intervention effectiveness. The HOAC II

establishes an ongoing treatment framework built on continuous evaluation of results.

Introduction

Background

Accountability among physical therapists is increasingly essential to ensure patients

achieve optimal functional outcomes, maximize quality and efficiency of care, and establish the

value of physical therapy as a profession within the spectrum of health care. Examples of

accountability in practice include responding to patient specific goals and needs, accepting the

consequences of decisions and actions, assuming responsibility for learning and change, and

communicating decisions and actions to others involved in patient care.1 The Hypothesis-

Oriented Algorithm for Clinicians II (HOAC II) is a decision-making guide developed by

physical therapists for use across practice sites and patient populations. The sequential format of

the HOAC II assists with the reasoning process to determine the patient management strategies

that will optimize treatment outcome and enhance clinical practice accountability. The model

was designed to facilitate the use of evidence in clinical decision making.2,3 A recent critique of

the literature suggests that published scientific evidence is underutilized in physical therapy

practice.4 One possible reason is that a majority of randomized controlled trials lack external

validity. External validity relies on a complete, comprehendible clinical reasoning process.

Some publications suggest that clinical reasoning is incomplete, which potentially compromises

diagnostic accuracy and best outcomes.4 Others emphasize the importance of clinical reasoning

because independent decision making is vital for an autonomous profession.5 The HOAC II

assists physical therapists in the clinical reasoning process by providing a systematic decision-

making algorithm.

Purpose

The purpose of this case report is to describe the retrospective application of the

Hypothesis Oriented Algorithm for Clinicians II (HOAC II) to reflect on a student’s clinical

reasoning for a patient with insidious onset upper extremity paresthesia.

Case Description

Initial Data Collection

The patient was a 58-year-old, right hand dominant, female referred to physical therapy

by her primary care physician with the diagnosis of right arm paresthesia (ICD-10: R20.2). The

order specified physical therapy evaluation and treatment. The patient complained of numbness

and tingling around the lateral aspect of the right shoulder and on the palmar side of her thumb

and first two digits. Initial onset was early November 2017. She stated that there was no

mechanism of injury nor other known precipitating causes. She reported noticing the tingling

one morning upon awakening. It was very minimal so she proceeded with her day as usual.

Throughout the next several weeks, the symptoms seemed randomly intermittent, but progressed

in intensity and frequency. Her discomfort woke her up at night, yet was not severe enough to

prohibit her from returning to sleep. Thinking her bed may be to blame, she purchased a new

mattress. Unfortunately, the new mattress did not make a difference. She reported that she

began feeling clumsy when using her right arm, as if she might drop things. She insisted,

however, that there were no strength deficits. She was employed as an administrative assistant

requiring computer work and writing. The clumsiness and discomfort caused her productivity to

decline. Further complicating matters, she was unable to recognize positions or activities that

improved or worsened her symptoms. She reported constant tingling to an extent, but felt the

fluctuations in intensity were random. Her past medical history consisted of infrequent

migraines since the age of 17 and skin cancer which was removed from her left foot 7 years ago.

She reported no history of cardiovascular issues nor diabetes.

Patient Identified Problems (PIPs) List

According to HOAC II, Patient-Identified Problems (PIPs) represent subjective

complaints and functional limitations reported by the patient.2,3,6 This helps the clinician

recognize what activities are meaningful to the patient, therefore the PIP list is particularly useful

for generating patient-oriented goals. According to this patient, feelings of paresthesia limited

her ability to use her right upper extremity during work-related tasks, self-grooming, and

household chores such as cooking or reaching an overhead shelf (Figure 1). One of her primary

complaints was interrupted sleep. She reported frequently awakening in the middle of the night

with discomfort in her upper extremity. She was concerned that if the problem was not

remedied, the symptoms would progress in intensity and functional limitations. The HOAC II

classifies this as an “anticipated problem” to differentiate it from the existing problems.2,3

Initial DataFemale, 58 years oldRight hand dominant

Employed as administrative assistant Married, no kids

Referral Source:primary care physicianICD-10:Arm paresthesia, right (R20.2)

Order:PT eval and treat

Patient-Identified Problems (PIPs)Limitations:

Work-related duties-typing and writingHousehold tasks-cooking or cleaningReaching shelf above shoulder-height

Styling hairUninterrupted sleep

Examination Strategy/ObjectivesRule in/out arterial and/or venous compromise

Test dermatomes to assess sensory involvementAssess UE strength to determine muscular involvement

Triangulate most proximal area of involvementAssess for any adverse neural tension

Hypotheses

Non-PIPs

Poor Desk Ergonomics

Functional

Asymmetries

Altered

Neurodynamics

Decreased

Strength

Decreased Range

of Motion

Carpal Tunnel

Syndrome

Arthrokinematic DysfunctionScapular Dyskinesis

Habitual Postural Abnormalities

Figure 1. HOAC II – Part 1: Data Collection

Initial Examination

Planning the Examination

Based on the initial data collection and PIPs, the HOAC II prompts the formation of a

plan regarding the strategies and objectives for the examination. Description of the hypothetico-

deductive reasoning used to developed the examination plan is crucial for initiation of the

clinical reasoning process.4,5 Paresthesia is due to vascular or neural compromise. To determine

the pathoanatomy of paresthesia, the type of structure affected (arterial, venous, or neural) needs

to be differentiated in addition to the etiology.7–10 Such distinctions are necessary to determine if

the patient’s needs are outside the physical therapist’s personal or professional scope of practice,

thereby warranting consultation or referral to the appropriate practitioner.11 For instance,

dysfunctions of musculoskeletal origin are within the physical therapy scope of practice.

Treating the secondary complications of autoimmune or endocrine disorders is also within the

scope; however, if an undiagnosed systemic disorder was suspected, referral to a specialist would

be needed. An underlying cardiac pathology would be suspected if examination findings

indicated the paresthesia was vascular in origin, thus justifying a consult for additional testing.

There are several points in the HOAC II diagram acknowledging the possible need for

consultation, further exhibiting how its use facilitates optimal treatment outcomes.

Examination Findings

Blood pressure, heart rate, oxygen saturation, and capillary refill were all within normal

limits. This information, in conjunction with a visual inspection revealing no abnormalities of

skin coloration or texture, served to rule out arterial or venous compromise. Sensory tests of

dermatomes C2-T2 were all normal, ruling out significant disruption of cutaneous peripheral

nerves. Notable findings of active range of motion (AROM) goniometric measurement and

manual muscle testing (MMT) of upper extremity strength were provocation of the patient’s

signs and symptoms (sxs) during active right shoulder abduction, resisted right shoulder flexion,

and resisted right elbow flexion. Upper limb tension tests were positive for radial and median

neural tension. These findings suggested that the paresthesia was of neural origin, whether it be

compression, traction, or other restrictions in the mechanical interface. To determine the

location causing the mobility restriction, several special tests were performed. For optimal

efficiency, testing was performed proximal to distal. To assess the cervical spine, the axial

manual traction test and Spurling’s maneuver were conducted. Both tests were negative,

effectively ruling out cervical radiculopathy.12,13

Thoracic outlet syndrome (TOS) results from compression of the neurovascular bundle in

the clavicular region, causing upper extremity paresthesia.8,10 The thoracic outlet is the

passageway between the clavicle and first rib. The brachial plexus, subclavian artery, and

subclavian vein travel through the outlet. Each structure is individually susceptible to

compression and irritation, thereby delineating TOS into arterial, venous, or neurogenic types.

Neurogenic TOS is the most prevalent form of the disorder and commonly affects middle-aged

women.10 Not only is this parallel to the patient’s demographics, it is also consistent with the

previous examination findings that ruled out vascular compromise in favor of neural compromise

as the most plausible cause of paresthesia. Manual assessment revealed the patient’s right first

rib was elevated. First rib elevation would subsequently narrow the thoracic outlet. Hence, TOS

was preserved as an acceptable hypothesis.

Per patient report, the paresthesia in her hand was confined to the palmer aspect of her

thumb and first two digits. This distribution of paresthesia is consistent with the area affected by

carpal tunnel syndrome (CTS). The carpal tunnel refers to a space in the wrist confined by the

carpal bones and flexor retinaculum through which the median nerve plus the nine extrinsic

finger flexor tendons travel to reach the hand. CTS occurs when the pressure inside the tunnel

increases, compromising the mobility of the median nerve.14 CTS is more prevalent among

women, typically affects those who do a lot of typing or writing, and is reported to be the most

common neuropathy due to peripheral nerve entrapment.14–16 Despite CTS being a very viable

hypothesis, the patient’s symptoms were not provoked by the carpal compression test. However,

the sensitivity of the carpal compression test is only 52.5%, therefore CTS was not yet ruled

out.17 Because the median nerve innervates the abductor pollicis brevis, opponens pollicis, and

flexor pollicis brevis, it is not uncommon to see thenar atrophy in patients with severe or chronic

CTS.16 For this reason, grip strength and Phalen’s tests were conducted in addition to visual

inspection and palpation of the thenar eminence muscle bulk, all of which were normal.

Non-Patient Identified Problem (NPIP) List

The Non-Patient Identified Problems (NPIP) list is a compilation of problems identified

by anyone other than the patient, primarily the treating therapist (Figure 1). While PIPs are

subjective reports, NPIPs are based on objective measures. The NPIP list is developed through

consideration of the physical limitations and other notable findings from the examination along

with the plausibility of their relation to the patient’s functional disabilities and subjective

complaints.

Tracking the HOAC II framework, the therapist also is prompted to identify and include

the factors that increase the patient’s risk of reoccurrence or continuation of their disability in the

NPIPs list.2,3,6 As in the PIP list, these are termed “anticipated problems”. This patient’s job

required deskwork, which increases her risk for poor postural habits and incorrect desk

ergonomics. Postural dysfunction could cause muscular imbalances beginning at the head and

neck with effects along the entire kinetic chain. These imbalances increase the risk of

neuromuscular compression or restriction. Although the special tests indicated that the patient

did not have carpal tunnel syndrome (CTS), the possibility of future occurrence was not

discounted. The nature of her work significantly increases her risk. Research shows cumulative

keyboard use is an independent predictor of CTS among employees working at a data processing

unit.15 As such, CTS was placed on the anticipated problem list.

The Hypotheses

Central to HOAC II is establishment of a hypothesis for guiding interventions, and the continual

reflection on and validation of the hypothesis.2,3 The hypothesis may, but does not need to be, a

specific medical diagnosis. Instead, the hypothesis can be a functional deficit that links

identified impairments and relevant contributing factors. In the context of this case, there was

not enough evidence to make a definite medical diagnosis of either TOS or CTS. In this case, it

was hypothesized that impaired arthrokinematics of the shoulder complex was the primary cause

of the patient’s signs and symptoms. This hypothesis was supported by the following: initial

presentation of symptoms began in the arm, limitations were noted in shoulder range of motion

and strength, upper limb tension tests were positive, and her right first rib was elevated

(Figure 1).

The shoulder complex consists of four joints/articulations (glenohumeral,

scapulothoracic, acromioclavicular, and sternoclavicular). It is important to note that these

structures do not function in isolation. Improper mechanics at any of these joints affects the

others, and all four must function appropriately for full, pain-free overhead motion.

Furthermore, prolonged arthrokinematic dysfunction results in maladaptive changes in the soft

tissue and vice versa. In theory, this patient’s symptoms could directly be due to soft tissue

restrictions and/or muscular tension that occurred consequent to arthrokinematic dysfunction.

Refined Problem List

The Refined Problem List is an amalgam of reported PIPs and therapist-identified

problems, or NPIPs (Figure 2). Decreased right shoulder flexion and abduction AROM,

subjective reports, and symptom provocation were combined to construct the first problem

statement, “pain with limited range of motion preventing right upper extremity elevation above

shoulder height”. The next problem, “decreased ability to lift an object overhead with right

upper extremity”, reflects information from the subjective intake questionnaire in addition to the

strength deficits noted in the objective examination. The third problem, “abnormal sensation in

hands and fingers during work activities”, acknowledges the patient’s primary concern while

supporting the need for treatment to prevent CTS. The final problem, “waking up at night”, was

included on the refined list because it was a frequent occurrence and very disruptive according to

verbal subjective reports.

Goals

Goals should reflect the patient’s personal needs as they relate to improved functional

ability. Focus on Therapeutic Outcomes (FOTO) is an outcomes management system used in the

clinic that provided physical therapist services to this patient.18 FOTO measures provide risk-

Problem List

Implementation

Outcomes Measures Patient report questionnaire and Focus On

Therapeutic Outcomes (FOTO) score

Intervention Strategy

1. Decreased ability to raise R UE to shoulder height

2. Decreased ability to lift an object overhead with R UE

3. Abnormal sensation in hands and fingers during work activities

1. Reach a shelf at shoulder height with no difficulty

2. Place gallon of milk on overhead shelf with no difficulty

3. Place a 25 lb. box on overhead shelf with little difficulty

4. Waking up at night

1. Mobilize neural interface 3. Joint mobilizations 4. Postural reeducation2. Relax overactive muscles

Nerve glides Soft tissue mobilizationSpinal CPAs/UPAsGH capsule mobs

Scapular mobs

Patient educationNeuromuscular reeducation

Tactile, verbal, & visual cueing

Figure 2. HOAC II – Part 1 Cont.: Refined Problem List

adjusted, benchmarked reporting and quality management. FOTO precisely measures patient

functional status using Computer Adaptive Testing (CAT). Data captured in FOTO for this

client included pain complaints, limitations, fear avoidance, and complexity level of the injury.18

FOTO uses risk adjustment analytics to estimate discharge and predict patient outcomes. It is an

effective guide for patient-centered goal setting and care management throughout the plan of

care.

After information from this patient’s case was put in the HOAC II framework (Figure 2),

it became apparent that the documented goals did not fully reflect the problem list. Per direction

of the clinic manager, the goals to be documented were derived directly from the FOTO

questionnaire report. Because the survey had no questions pertaining to paresthesia, two items

on the problem list, “abnormal sensations in hands and fingers during work activities” and

“waking up at night”, were not officially documented as goals. This exemplifies how the HOAC

II ensures no oversight of information.

Testing Criteria / Outcome Measures

At this point, the model requires establishment of outcome measures used to objectify

current status and change in status (Figure 2). In this way, outcome measures are important to

accountability because they give clinicians the ability to analyze treatment effectiveness. The

patient’s progress, and therefore treatment effectiveness, was determined primarily by the

patient’s subjective reports.

At the beginning of each treatment session she was asked to describe the current status of

her symptoms in addition to her recent activity and functional abilities. The subjective reports

were recorded in the daily notes so comparison across sessions could occur. Ideally, when the

daily notes reflected positive changes the intervention strategies and tactics would be continued

and progressed. Conversely, when the reports reflected negative changes or no changes, new

intervention strategies and/or tactics would be implemented.

Interventions/Treatment

Intervention Strategies and Tactics

Strategies are general categories of the type of intervention needed. The tactics are more

specific, detailed descriptions of each strategy. To justify the treatment selection, each strategy

should correspond with at least one goal. Since physiological adaptations do not occur as

isolated events, the goals, strategies, and tactics may all be interrelated. In this case, all goals

overlapped with one another, therefore each chosen strategy would potentially affect every goal.

Also, some strategies were directly dependent on one another, thereby sharing the same tactics.

This intricacy can be visualized in Figure 3.

Figure 3. Relationship of the Goals, Strategies, and Tactics

Goals Strategies Tactics

Patient will reach a shelf at

shoulder height with no

difficulty

Patient will place a gallon of

milk on overhead shelf with no

difficulty

Mobilization of the

neural interface

Relaxation of

overactive

muscles

Nerve glides and soft tissue

mobilizations (pec major/

minor, levator scap, scalenes)

Cervicothoracic CPAs/UPAs

Glenohumeral posterior capsule

mobilizations

Scapular mobilizations in all

directions emphasizing retraction

and depression

Place a 25-lb box on overhead

shelf with little difficulty.

Joint

mobilizations

Postural

reeducation

Combat forward head, rounded/

elevated shoulders via:

Patient education

Neuromuscular reeducation

Tactile, visual, and verbal cueing

Reassessment and Outcomes

HOAC II guides continual decision-making analyses throughout intervention and re-evaluation

for analyzing effectiveness of the strategies and tactics that are applied, theoretically eliminating

overuse of inconsequential interventions. On the patient’s twelfth visit, a formal re-evaluation

was performed. The re-evaluation consisted of retesting the notable objective findings from the

initial evaluation, other relevant tests/measures, and administration of the subjective

questionnaire. The patient’s function had improved significantly as indicated by subjective

reports, verbally and via FOTO questionnaire. Objective improvements in shoulder strength and

active range of motion were also achieved.

As indicated by the check-marks in Figure 4, all three of the documented goals were met.

To an outside payer, meeting all goals should be indicative of problem resolution. Therefore it

would be reasonable to deny coverage for continued therapy services. However, the two

problems without documented goals were still present. Thankfully, these problems were not

entirely excluded in the documentation, often expressed in the daily notes subjective reports.

These reports also provided record that both problems steadily improved. For this reason, the

decision to continue with physical therapy was justifiable to the patient’s insurance provider.

Secondary to the positive therapeutic outcomes, session frequency was decreased from 2–3 times

per week to 1–2 times per week.

In other reports demonstrating application of the HOAC II, the patients were discharged

after reevaluation.2,6 By continuing with treatment, this case report provides unique insight to

clinical application of the HOAC II. Since the remaining problems did not have written goals,

Part 1 of the model was revisited to reflect the updated status (Figure 5). Following the HOAC

II requirements retrospectively, new goals were written and the intervention strategies and tactics

were updated. The new strategies and tactics lead to successful resolution of the patient’s

problems, as illustrated in Figure 6.

Re-evaluation of Goals

Medical Patient Process

1. Reach a shelf at shoulder height with no

difficulty

2. Place gallon of milk on overhead shelf with no

difficulty

3. Place a 25 lb. box on overhead shelf with

little difficulty







Reduce myofascial restrictionsPatient empowerment with

education

Deep friction techniqueDynamic stretching

3. Participate in work-related, recreational, ADLs, & IADLs with normal sensory feedback

4. Sleep through the night without interruption


Outcomes MeasurePatient report

Soft tissue mobilization Self-management & prevention

3. Abnormal sensation in hands and fingers during

work activities4. Waking up at night




Figure 4. HOAC II – Part 2: Re-Evaluation

Re-evaluation of Hypotheses



difficulty


difficulty


little difficulty








education











Re-evaluation of Hypotheses




difficulty


difficulty


little difficulty








education












Figure 5. HOAC II – Part 1: Updated Refined Problem List

Figure 6. HOAC II – Part 2: Re-Evaluation of Updated Goals

Discussion

This case report demonstrates that the HOAC II can be used retrospectively to outline the

treatment and decision-making process which resulted in achievement of the patient’s goals.

Due to scheduling issues, clinicians other than the case therapist saw this patient for several

treatment sessions. In retrospect, it is evident that inadequate communication between therapists

resulted in overuse of ineffective strategies and tactics. For instance, neither spinal nor

glenohumeral capsular mobilizations produced a change in the patient’s symptoms, yet these

interventions were performed in multiple sessions. The hierarchical decision-making format

used in the HOAC II for each patient encounter results in accurate clinical reasoning that

matches presenting symptoms with effective treatment planning. In this way, the HOAC II

eliminates overuse of inconsequential interventions. The HOAC II establishes an ongoing

treatment framework built on continuous evaluation of results. The key is that this continuous

analysis is explicitly outlined, thus improving external validity through explanation of the

complete clinical reasoning process. This is necessary to advance practice standards by linking

the evidence to the clinical setting.

Conclusion

HOAC II supports the “right” treatment at the “right” time while spending the “right”

amount of resources for best patient outcomes. It is a detailed, structured process that may be

used to guide differential diagnosis and evaluate patient management strategies to optimize

treatment outcomes. By prompting construction of the patient-identified problems list prior to

the objective examination, the HOAC II emphasizes a patient-centered approach to care.

Furthermore, documentation guided by the HOAC II framework facilitates communications that

guide consistency in clinical reasoning for coordinating patient management across multiple

practitioners.

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revisiting hoac ii for determining the physical therapy

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