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Toni Talks about PT Today

How Do You Define Functional?

Published August 7, 2012 2:45 PM by Toni Patt

I'm having a debate with the PTA I work with. We can't agree on the definition of functional. I want to use it to describe activities, as in they are functional. She wants to use it to describe actions as functional, such as in functional ROM or strength. Her position is that a person can perform a functional activity without functional measurements.

Now this would be a great discussion for a roundtable panel or debate. We could argue for hours where the line is between functional and non-functional. Our problem is more basic. I write treatment plans to develop functional mobility such as gait and transfers. She works to increase ROM and strength. I agree there must be adequate ROM and strength to perform mobility. I just don't think entire treatments should be devoted to obtaining them.

I've lost count of the number of conversations we've had concerning tight hamstrings. Every patient she works with has tight hamstrings. That can be a problem. But to me, inability to ambulate is a bigger one. They were probably tight before whatever brought them to therapy.

Contractures are another sore spot. Contracture management really isn't skilled therapy. It can be managed by splinting and positioning. My PTA wants to keep patients on caseload to stretch out long-standing contractures. These are ambulatory patients who lack full hip and knee extension but are generally independent.

I feel like I'm always the bad guy because I keep asking why. My first question is always about the patient's functional status. My second is, "Why do you think it will help?" I admit my treatment ideology is very neuro-oriented. We never strengthen for strength, only for function; the same with stretching. Gait doesn't have to be symmetrical if its energy efficient, safe and functional. I just can't believe a few more degrees of hamstring length will make that big of a difference.

I've talked to her. I've talked to the rehab manager. I don't know how to bridge this ideological gap.


Do you know from where the PTA's perspective stems?

I'm going to be posting a link to a pre-test for a tech training program. One of the questions touches on this topic.

The program is taught by the physical therapist who developed the program. I looked up the definition to "functional limitation". It surprised me. I would say a functional limitation is the "the inability to ambulate". The definition says the functional limitation is "tight hamstrings".

If your PTA was taught from this PT's framework, then her perspective makes sense. It may be as simple as developing and defining your own terminology.

Janey Goude August 17, 2012 10:56 PM

I agree with you, Toni. I set goals such as "Patient will be able to comb own hair" or "Patient will be able to don/doff own footwear". At which point I look at is there sufficient strength, coordination, ROM, or sensation to perform the task.

Working with predominantly older adults whose kyphotic spines, osteoporosis, arthritis, which almost always prevents achieving full range of any given joint, I don't care if Mrs Smith only has 120 degrees of shoulder flexion. Can she fasten her bra? Brush her teeth? Take the rollers out of her hair? To me that is function.

This actually ties in nicely with Jason's post about the woman willing to work on the way to Bingo. Goals have to have meaning to the patient. To simply "improve your range of motion" is not meaningful or inspiring on its own. Things like "get to Bingo""comb over your bald spot" or "Dance at your granddaughter's wedding" now that's meaningful and functional!

Good topic. Thanks.

Dean Metz August 9, 2012 1:33 PM

I think it depends on the patient and whether they are going home after therapy.  A TKA may want to get down and garden.  Without the ROM and strength they may not get back up.  

I agree functional skills are more apparent and needed when treating in a SNF.  The strength will come as their function increases.  

Some patients may need a restorative plan for strength AND therapy to improve their functional activity.  Sounds like the PTA is in a rut and may not be comfortable with the functional aspects of therapeutic proceedures.  Set a goal on the Tinetti or Berg Balance and see what happens.  

Jason Marketti August 9, 2012 1:08 AM

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