By David, Kurihara, DPT, OCS, SCS, FAAOMPT
One of the more challenging things we do as a clinicians involves our clinical reasoning and how it guides the prioritization of treatment. In other words, making sense of the information we gather in our examination and implementing an effective and logical intervention plan.
To this day, I still have cases where I fall off the track or get lost in the plethora of information. When that happens, the picture becomes muddled and the case complexity automatically doubles.
To keep me on the right path, I like to use a very useful tool adapted by Phil Page and Clare Frank called the Functional Management Progression (FMP). I have it in my head constantly and it guides me in terms of progressing and prioritizing appropriate interventions. The pyramid is broken down into four main categories.
1) Normalization of dysfunctional structures (base of pyramid)
2) Correction of muscle/movement balance (mid-bottom pyramid)
3) Increasing proprioception and facilitate subcortical pathways (mid-top pyramid)
4) Improving endurance in coordinated movement (top of pyramid)
*within each category are specific impairments
Functional Management Progression - adapted from Phil Page and Clare Frank
This is a powerful tool and there are many ways to utilize it. For most cases, my personal preference is to use it like a ‘ladder’. I will try to climb the pyramid all the way to the top where ‘skill/functional activity’ is sitting (which is usually the goal). As I climb each level, I’ll try to address any impairment the patient might have within that specific level. I usually won’t advance levels until the impairment at the current level is resolved.
This is especially helpful when you have what I like to call “impairment overload”. It’s when you gather so much data in the subjective/objective exam that you don’t know what to do with it or where to start. The easy way out is to have a “shotgun” approach to blindly treat every impairment. That approach may sometimes produce results, however, there is no “progress control” and the reasoning of what helped or not is lacking. It’s always nice to have a system in place.
PATIENT EXAMPLE:
KEY SUBJECTIVE FINDINGS:
13 year-old female with chief complaints of:
1) Right lateral hip clicking/pain with every step x 4 years. Insidious onset.
2) Left anterior- posterior hip pain (“locking/weird feeling”) x 4 years. Insidious onset. Has episodes every 1-2 months until 1 month ago got 3 episodes in a span of 2 weeks. Symptoms occur with putting on pants, getting in/out of car, turning while feet planted. Pain lasts 3 days. Plays judo and golf regularly for years.
.
KEY OBJECTIVE FINDINGS:
1) Posture: BL pes planus (functional), BL genu valgus, BL femoral IR (worse on left)
2) Gait: excessive femoral IR worse on right (with clicking laterally in left hip)
3) PROM: hyperflexible all joints (especially hips)
4) Wobbly/incoordinated SL squat on left > right
5) Golf swing: over-rotation with shoulder, trunk and hips
5) MMT: 3/5 (inhibited--poor initiation) BL glute max, ER and medius
IMPRESSION:
13 year-old female with BL hip pain secondary to multidirectional excessive mobility driven from inherent joint laxity and poor phasic muscle stability.
Day 1
It would have been fair (and obvious to most) to start strengthening her hips due to the glaring strength deficit. However, using the FMP, I started on the bottom of the pyramid and opted to normalize her faulty posture and pain deficits (as much as possible).
Posture re-ed: Neutral legs in standing (tripod foot position), sitting (no crossing legs), sleeping on side (pillow)
Postural Re-Education in standing, sitting, sleeping
Gait re-ed: Verbal cueing for reducing right femoral IR during gait resolved her right hip clicking
Gait Re-Education out of excess Femoral IR
Day 2
Patient experienced no clicking in the right hip with “mindful” hip position and no symptoms in left hip with putting on pants, twisting in closed chain or getting in/out of car. Patient was “mindful” about centration of joints with sleeping, sitting, standing and walking and often catches herself in bad positions, but quickly re-corrects.
*** Addressing the static postural deficits proved to be helpful as she was standing, sitting and sleeping in poor positions and creating a ‘stretch weakness’ within her muscles and de-centration of joint position. If that was not corrected, strengthening exercises may not have been as successful.
Furthermore, her words of being more “mindful” was a huge positive in that it told me that she was understanding the building blocks of motor control/awareness, which is a nice prerequisite for creating muscle balance.
Continuing to climb up the pyramid, there was no need to address her joint mobility or muscle length as she was hypermobile and flexible. Those levels were skipped and we advanced to motor function/proprioception activities (with an overlapping of ‘muscle performance’). I wanted to dial-up her “phasic” motor chain to increase stability in her joints.
Illustration of clinical reasoning using the FMP for Day 2
Brügger band squat, sidestep and leg opening, SL with TB
Top line: Brügger band squat// Bottom left: Brügger band sidestepping// Bottom middle: Brügger leg opening// Bottom right: Single leg stance with TB
*** The faster I can get a patient off the table, the better. It would have been fine to start her in open chain exercises but it was a clinical decision I made to get her in closed chain immediately. I felt that her motor awareness was excellent and the exercises we put her in could facilitate the right muscles even better than in open chain.
Day 3
Still no symptoms with all aggravating factors and able to return to full Judo and Golf without problems. She liked the exercises as it helped her feel “good” in her legs.
We now arrived at the top of the pyramid and addressed the functional activities and skills she’d been doing regularly (judo/golf). I could tell she felt a difference in her body with the exercises so I decided to advance her to a more functionally difficult regimen (specifically, dynamic single leg stability and closed chain hip rotation control to mimic judo and golf mechanics)
Illustration of clinical reasoning using the FMP for Day 3
SL squat with TB, SL airplanes
Left: Single leg Squat with TB// Right: Single Leg Airplanes
***. We also tightened up her golf swing with leg and trunk positional cues to not over rotate (skill).
Again, you can utilize the pyramid to your liking based on your patient case or preferred way of thinking. It’s probably better if you do, that way you know you’re thinking criticallyJ
David Kurihara is a board-certified specialist in Orthopedic Physical Therapy (OCS) and Sports Physical Therapy (SCS) and a fellow in the American Academy of Orthopedic Manual Physical Therapy (FAAOMPT).
He completed the Southern California Kaiser Permanente Orthopedic Residency Program in 2005, Manual Therapy Fellowship in 2006, Sports Residency in 2007 and Movement Science Fellowship in 2009.
David served on the clinical faculty for Kaiser Orthopedic Residency (2010-15), and Sports Fellowship (2008-15) and has been instructing various continuing education and residency classes since 2009. He currently resides in Honolulu and is part of Queen's Medical Center Sports Medicine team.
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