Discharge Testing and Return to Activity: Letting the Patient be the Guide

The ever-changing landscape of healthcare can be difficult to navigate. The entrenched biomedical model has been scrutinized because of its focus on treating the disease rather than the person. This model is slowly being replaced by the biopsychosocial model that allows care to be guided by each patient’s specific case.

“It is much better to treat the person with a disease rather than treat the disease a person has.” –Hippocrates

Focusing on the patient is not a new concept. The challenge is finding a comprehensive, standardized evaluation and treatment approach while maintaining the flexibility to modify or adapt the approach to each patient. This is especially clear in the test selection, justification, and implementation issues surrounding initial evaluations and return to activity assessment. Let’s briefly talk about these issues and how to potentially overcome them.

1. Why do traditional impairment measures fall short?

Impairment measures (goniometric measurements, manual muscle testing, etc.) are valuable, but we need to understand their limitations in providing a full picture of physical function. While side-to-side asymmetries of range of motion and strength can be predictive of injury, the concern is that these measures do not aid clinicians in making diagnoses or decisions about a patient’s ability to perform more dynamic tasks.

For example, a recent study noted that force output during manual muscle testing of arm elevation at 90° in subjects with shoulder symptoms did not differ between the involved and uninvolved arm.¹ The inability of manual muscle testing to discriminate between the involved and non-involved extremity suggests that static testing may not have robust value as an individual evaluation tool for musculoskeletal injury.

This is not advocating for the elimination of manual muscle testing from physical examinations. When looking at the history of manual muscle testing, the maneuvers were originally used to assess the strength ability of patients with paralytic conditions.² If one wants to assess the presence of nerve injury or neurological dysfunction, then manual muscle testing may have clinical value.

If single component measurements do not necessarily translate to a patient’s ability to perform a highly-skilled dynamic task^3,4 then a clinician should assess a patient’s ability to perform the specific task(s) necessary to participate in the activity.

2. Which tests/maneuvers best suit my diverse patient population?

This is one of the biggest challenges we face in the clinical setting. There is no standardized regimen that is taught or recommended for clinicians to use. The best approach to balancing the demanding maneuvers/tasks that allow clinicians to adequately judge return to activity and activity specific tests has yet to be discovered. There is no “one size fits all” solution.

Current literature suggests that a battery of tests may assist clinicians in making informed clinical decisions about return to activity.^5,6 This is especially true when looking at diverse patient populations (athletes, manual laborers, sedentary individuals, etc.). To individualize treatment for each of these populations, we should use assessment tools that are reliable, predictive of injury, discriminatory and modifiable.

3. Can we customize a pre-injury baseline?

Clinicians have begun using physical performance measures in a cross-sectional approach as screening tools to predict injury risk.^7-9 However, these measures are often not used to create a baseline to be referred to after treatment concludes. Considering the goal is to return a patient to pre-injury activity levels, it would be prudent to have a personalized “pre-injury” baseline specific to each patient.

This concept is more feasible in athletes because of the common practice of a pre-participation physical examination. For non-athletes, care is typically sought only after an injury. Thus, the traditional clinical setting may struggle to obtain true pre-injury information. That should not dissuade clinicians from employing a comprehensive screening to gain a complete picture of each individual patient.

Individualized Care in the Clinic

Working in the clinic is both an art and science. Appreciating the complexity of the rehabilitation process and individuality of each patient is crucial in diagnosing the impairment and underlying causes. An approach that goes beyond traditional impairment measures to include clinically valuable physical performance measures can help optimize outcomes. This comprehensive, patient-specific approach is a practical example of evidence-based medicine where patient values, clinical experience, and the best available evidence are all accounted for.