SUPERVISING THE PATIENT DURING TREATMENT

Among the many challenges for the physical therapist assistant (PTA) are supervising the patient during selected interventions, solving problems effectively, and making appropriate decisions. The PTA must recognize that interpersonal communication skills, patient supervision methods, data collection skills, effective problem solving, and responsive clinical decision making must be learned, practiced, and demonstrated to function efficiently and effectively.

Initial contact with a patient establishes a framework of rapport and sets the stage for all future interactions with that individual. The PTA has the opportunity to convey confidence, capability, and sensitivity during the initial introductions by the supervising physical therapist (PT). This leads the patient to trust the PTA and minimizes fear and anxiety in the patient.

The PTA is responsible for carrying out prescribed selected interventions, patient supervision, data collection, and appropriate problem solving and clinical decision making. The American Physical Therapy Association’s Department of Education, Accreditation, and Practice developed the “Problem-Solving Algorithm Utilized by PTAs in Patient/Client Intervention,”¹ which reflects current policies and positions on the problem-solving processes to be utilized by PTAs in the provision of selected interventions (Fig. 1-1). For proper care to be given, the PTA must monitor the patient’s response to selected interventions and accurately and swiftly report changes to the supervising PT. This involves constant patient interaction, observation, data collection, reassessment of initial data, problem solving, and responsive action to clarify and enhance the effectiveness of prescribed selected interventions. Changes in the patient’s status, both positive and negative, can occur throughout the treatment program, whether during a single visit or over the span of multiple treatments. Some of these changes are subtle and require keen awareness of the initial objective data and acute sensitivity to the patient’s subjective reports. Other changes are profound and sudden. In either situation, the PTA observes the patient and collects appropriate data, such as range of motion, strength, pain, balance, coordination, swelling, endurance, or gait deviations. When reported to the supervising PT, these changes dictate and can significantly affect the course of treatment.

Basic Patient Supervision Skills

Communication Skills

The PTA can be most effective if he or she develops an understanding of human behavior and adopts a proactive role in supervising patients. In a proactive role, the PTA does not wait to be placed in a reactive position. Use of appropriate probing questions is a proactive method to use during patient supervision. Questioning patients during treatment can be insightful, rewarding, and helpful for both the supervising PT and the PTA. The format of asking probing questions is critical and strongly influences the responses received (Fig. 1-2). Using open-ended questions invites the patient to share feelings, thoughts, concerns, and opinions.⁹ Examples are as follows:

 “Tell me about your pain.”

 “How does that feel?”

 “What do you think about this exercise?”

These types of questions are generally not answered by “yes” or “no.” They open discussions and prompt the patient to express a wide range of views and opinions.⁹ Open-ended questions for patients have been described as “a good medium for facilitating rapport and, as such, are particularly useful….”⁴ Using open-ended questions promotes personal interactions between the PTA and patient, may allow the patient to give a more in-depth explanation of the problem, and may lead to discussions of what the patient identifies as important. Although this type of questioning does not enable the patient to give precise, clear answers, it is appropriate in situations that require compassion and empathy from the PTA and shared feelings between the PTA and patient.

Closed-ended questions are directed toward finding facts, obtaining specific responses, and filling in details. They can be very helpful in focusing and clarifying essential details of the patient’s condition.⁹ By asking the patient questions such as, “Where is your pain?” “When does your knee feel unstable?” or “Does your back hurt when you bend forward?” the PTA proactively directs the discussion and sequence of questions instead of sifting out pertinent information from among all the data gathered in open-ended questioning.

Summary-type statements check understanding, help the patient clarify thinking, and provide direction for the PTA. Examples include the following: “So your back hurts only at night?” and “Then your knee doesn’t hurt with this exercise.” Using precise closed-ended questions with summary statements elicits information that can lead to an objective assessment of the patient. The approach the PTA takes influences the balance of questioning between open-ended and closed-ended questions.

Behavior

The behavior of the PTA during patient supervision can either reassure the patient and demonstrate appropriate responsive professional care or create a sense of indifference. Four broad categories of behavior are dominance, submission, hostility, and warmth.² Buzzotta and Lefton² define these four categories as follows:

Dominance

Dominance can be defined as exercising control or influence. People who show dominant behavior are forceful, dynamic, and assertive. They push their ideas forward or try to sway the way other people think or behave. They take charge, guide, lead, and move other people to action.

Submission

Submission can be defined as being passive. People who show submissive behavior are willing to take a back seat. They are ready to comply, quick to give in, and reluctant to try to exert influence.

Hostility

Hostility can be defined as being unresponsive or insensitive to others and their needs. People showing hostile behavior tend to care only about themselves; they lack regard for other people’s feelings and ideas. Although anger is a form of hostility, people can be hostile while showing no open anger.

Warmth

Warmth can be defined as being responsive and sensitive to others and their needs. People who show warm behavior are open and caring and have a high regard for other people’s ideas and feelings. This does not mean they automatically gush with affection. A person can be warm without being openly affectionate.

These four categories of behavior are used to describe the extremes of the basic dimensional model (Fig. 1-3, A). Quadrants (Q) are formed and certain patterns of behavior exist when two dimensions are combined, as described in the following:

 Q1: Dominant hostile

 Q2: Submissive hostile

 Q3: Submissive warm

 Q4: Dominant warm

Four patterns, or types, of human behavior come from this (Fig. 1-3, B).

Dominance	Active behavior: leading, controlling, making things happen
Submission	Passive behavior: following, letting things happen, reacting
Hostility	A lack of concern or regard, and unresponsiveness for other people and their position/ideas
Warmth	Concern, regard, and responsiveness for other people and their position/ideas

Applying this model when asking open-ended and closed-ended questions shows such questions to be equally balanced within Quadrant 4 (Q4). The goal of the PTA during supervision of the patient is to consistently demonstrate those qualities found in Q4; for example, being appropriately friendly, attentive, responsive, involved, exploring, analytical, and task oriented.

While supervising patients according to the Q4 model, the PTA must understand the differences between prompting and cueing a patient to perform a specific task. Prompting a patient to perform a task can be viewed as the presentation of a question. For example, when instructing a patient to ambulate with a standard walker, the assistant should prompt the patient by asking, “After you move the walker, what foot do you move next?” Prompting allows patients to decipher information, solve problems, and provide solutions to activities they must overcome during recovery. Cueing can be viewed as a direction. An example is, “After you move the walker, move your injured leg.” Although the solution is provided for the patient, he or she must still demonstrate appropriate follow-through and proper understanding of the command.

MODIFICATIONS DURING TREATMENT

Using attentive Q4 behavior with balanced open-ended and closed-ended questioning of the patient helps the PTA identify and quantify changes in the patient’s condition. After consulting the supervising PT and receiving direction, the PTA can effectively modify a specific intervention in accordance with changes in patient status.

The following example helps to clarify the scope of treatment modifications during postoperative rehabilitation after anterior cruciate ligament (ACL) reconstruction.

Swelling (joint effusion) after knee surgery is common and occurs in about 13% of cases after knee ligament surgery.⁸ Usually the effusion is a hemarthrosis (blood within the joint, which can impair voluntary muscle contraction). In such a case the supervising PT provides baseline evaluation data about the degree of swelling present by making comparative circumferential measurements at midpatella, 2 inches superior to the midpatella, and 2 inches inferior to the midpatella. The PTA maintains daily records of the three comparative circumferential measurements. Because re-education and strengthening of muscle is influenced negatively by postoperative swelling, any increase or decrease in swelling necessitates a modification in the initial program outlined by the supervising PT. Thus the degree of swelling documented influences the adjustment made in the exercise prescription.

As the PTA identifies objective changes in the patient’s status each day, the concept of visual, nonresponsive, and noninteractive supervision is altered to one of appropriate, responsive, and accountable supervision.

Isometric exercises generally are used early in the rehabilitation of acute postoperative knee injuries. Concentric and eccentric exercises are introduced as rehabilitation proceeds. Concentric and eccentric exercises are defined as dynamic, producing work, and creating changes in joint angles and muscle length.⁶ The progression from isometric to dynamic exercise produces an increase in force generated, increases muscle soreness, and causes greater articular stresses.³ If swelling and pain increase as the patient progresses from isometric to concentric and eccentric contractions, the PTA, with direction and input from the supervising PT, can adjust or modify the program back to isometrics or reduce the amount of resistance, joint angle of exercise, volume of exercise, or velocity of movement. The specific sequence or combination of these modifications depends on the patient’s specific needs, the surgical procedure, and the patient’s tolerance to exercise. Usually it is prudent to begin with the least drastic change in exercise prescription and then progress (Box 1-2).

The clinical decision-making process used by the PTA involves recognizing that a problem exists, then taking orderly and specific steps to notify the supervising PT and adjust the program accordingly. Thus the PTA takes an active, participatory role while supervising patients, using his or her training and skills to the fullest extent.

Note that the recognition of changes in patient status does not imply interpretation of objective, measurable data by the PTA. The PTA’s task is to provide information to the supervising PT on a daily basis, keep the supervising PT informed concerning patient status, and provide insightful and meaningful suggestions for modifications.

The objective data supplied to the supervising PT by the PTA may include but is not limited to goniometric measurements, circumferential measurements, manual muscle testing, endurance grading, heart rate, blood pressure, respirations, dynamic balance, and coordination measurements, according to the scope of the assistant’s training.

UNDERSTANDING DIFFERENT PHILOSOPHIES OF PHYSICAL THERAPISTS

Fundamental differences exist among PTs concerning the methods, protocols, and directives they use to treat patients. In addition, just as the PTA is directed by the supervising PT, the PT may at times be directed by the physician. Within a hospital physical therapy department, the PTA may have contact with many supervising PTs, each with different backgrounds, experiences, and education. The PTA sees PTs use various protocols to manage the same pathologic condition. It is not the role of the PTA to change or modify treatment plans or protocols without the supervising PT’s direction and approval. Opinions and controversies exist concerning how best to manage various orthopedic pathologic conditions. Changes in surgery and physical therapy occur because of advanced technology and rigorous research in rehabilitation medicine and orthopedic surgery. New procedures in arthroscopic ACL surgery allow a more rapid return to function, motion, and strength than ever before. Although ideally we presume all surgical procedures and rehabilitation techniques to be universally accepted, in fact the specialties of orthopedics and physical therapy are both art and science; therefore diversity is accepted.

The PTA can be placed in frustrating and confusing situations when dealing with various supervising PTs with different backgrounds and opinions concerning the management of patients. To minimize the confusing array of treatment protocols, the PTA must effectively and efficiently communicate with the supervising PT to clarify differences in patient care, always remembering that the PT has ultimate responsibility for the physical therapy interventions provided. The PTA does not divest interest in the care of any patient because of a disagreement in strategy with the supervising PT. The PTA’s role requires a broader perspective and understanding that there are many ways to effectively manage the same pathology.

Having strong opinions on how to care for orthopedic patients is appropriate and shows passion, interest, and confidence in a certain method or protocol that has demonstrated good results. However, particular experience with the successful management of patients by one supervising PT may in fact conflict with the course of treatment prescribed by another. On the surface this situation may seem particularly frustrating and stressful. To better understand this difference the PTA must identify the key elements of disagreement and seek an appropriate explanation from the supervising PT. This gives each supervising PT the opportunity to teach and explain the rationale for the particular treatment and exposes the PTA to new information. The PTA then can observe and learn new methods that may actually prove equally or more successful than the previous plan of care.

Fully understanding the rationale and purpose of each selected intervention allows for improved delivery of service to the patient. During direct patient supervision the PTA can provide any selected interventions the supervising PT directs him or her to perform so long as allowed by law, and the safety and welfare of the patient are not compromised.

The well-adapted PTA views any apparent roadblocks as learning opportunities. The PTA is advised to take advantage of the broad knowledge and experience of many PTs, constantly inquire about the rationale and scientific basis for a particular program, and establish himself or herself as an eager learning participant who is open to innovative ways of managing various pathologic conditions.