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GGuideuide ttoo TTherapyherapy PPrescriptionrescription WWritingriting GGautamautam MMalhotra,alhotra, JamesJames F.F. Wyss,Wyss, andand AmrishAmrish D.D. PatelPatel

INTRODUCTION: A FAREWELL TO “PLEASE options are considered and to streamline the delivery of a EVALUATE AND TREAT” prescription. However, in their experience, therapists do not respond as well to long lists that are not individualized When “please evaluate and treat” is the entire prescription, to the patient’s particular situation. Patients do not recover it puts the entire responsibility of developing a treatment or rehabilitate productively with this approach either. plan on the therapist. Although some therapists have grown to enjoy the autonomy that this type of practice has engen- dered, in the end, this situation results in the patient losing APPROACH TO THERAPY PRESCRIPTION the benefi ts of an interdisciplinary approach to care. In the WRITING authors’ experiences the answer is quite clear: If you were to ask any patient whether they would prefer to be treated In addition to the thoughts above, here are some specifi c by multiple separate clinicians (multidisciplinary approach) thoughts to consider as you work to individualize your or a team of clinicians who work together on developing a prescriptions: diagnosis and treatment plan (interdisciplinary approach), they would prefer the interdisciplinary team approach. ■ You will prescribe therapy much like you would Like many residents and fellows, the authors quickly a medication. You have to know the patient, the realized that they would never be equally profi cient to a ther- problem that you are addressing, concurrent apist at delivering hands-on modalities, functional training, or problems that could affect your prescription, and exercise education. Also, the therapist tends to spend hours most important, what the goal is with the patient while their interactions with patients are ■ Use therapy like it’s your bag of tricks to much shorter and less frequent encounters. As the prescribing accomplish treatment goals. The prescription clinicians, this was a humbling realization and has resulted in requires a thoughtful goal-oriented approach rather the practice of genuinely seeking and honoring the feedback, than a mindless cookbook recipe approach. (Do not advice, evaluations, and outcomes delivered by therapists. just copy and paste) This in turn builds respect and lines of communication from ■ It is helpful to think about the following questions: the therapist back to the prescribing physician. In the end, the What therapeutic modalities are safe and benefi cial patient reaps a more comprehensive yet expeditious experi- for my patient? ence derived from such an interdisciplinary team approach. What types of manual therapy techniques would be If you are reading this book, it means you are a benefi cial? clinician who is interested in taking an active role in the What structures are weak and need to be rehabilitation of your patients. Whether you are a physiat- strengthened? What structures are tight and need rist, family physician, sports medicine specialist, rheuma- to be stretched or lengthened? tologist, internist, or surgeon, this book is an attempt to What movements are poorly coordinated or have bridge some of the gaps between the prescribing physician biomechanical faults that need to be retrained and the therapist. It is not meant to be a cookbook with and corrected? recipes for a dogmatic cookie-cutter approach to prescrip- What other impairments (e.g., poor balance, tions. Templates can be useful starting points to ensure all impaired proprioception) exist?

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What activities or positions should be avoided due to Problem List (Optional) their detrimental effects versus what activities or positions should be encouraged to promote recovery? This section provides an additional way to communicate What educational training and resources would be mechanical and functional defi cits that may be contribut- helpful for my patient? ing factors to the development of the diagnosis or that may ■ Some components of the prescription may require lead to delayed rehabilitation of the condition if not properly detailed specifi city to ensure that the therapist addressed. An example would include decreased passive and understands it to be important in your thought active ankle dorsifl exion following acute lateral ankle sprain. process. Flexibility in other components of the Failure to restore this range of motion (ROM) may lead to prescription will be appreciated by your therapist incomplete functional recovery or recurrent ankle sprains. as it will allow some personalization at the time of therapy. So be careful to consider every word in your prescriptions in order to avoid over-writing as well. Precautions The balance of writing enough but not too much is more like an art that takes years of experience Spend time detailing precautions for the patient’s therapy pro- with the therapists and patient populations in your gram; examples include weight bearing restrictions, ROM community restrictions, and specifi c exercises to avoid. Precautions will be dictated by information elicited on history and physical examination. Does the patient have a history of falls or are COMPONENTS OF A THERAPY they at signifi cant risk of future falls? Cardiac or pulmonary PRESCRIPTION disease? Seizures? Is there a history of severe osteoporosis necessitating fracture risk precautions? Are they insensate The prescription may incorporate the following fi elds in areas that may burn if heat is used or develop pressure (see sample Rx at the end of the chapter). ulcers if unchecked? Do they have any breaks or openings in the skin? Are there issues that need to be resolved/clari- fi ed/cleared by other physicians (e.g., surgeon, cardiologist, Identifying Information internist) before therapy can be initiated?

Including the patient’s name, date of birth, medical record numbers etc… along with the date the prescription was Frequency of Visits written. Most prescriptions are written “2-3x/week,” but please take the time to consider the needs of the specifi c patient. An Discipline athletic patient with good body awareness may adequately progress with weekly visits and a daily home exercise pro- Indicate physical therapy (PT) or occupational therapy gram. Whereas patients with acute injuries or postsurgical (OT). Although these are the main disciplines consid- cases may initially require more frequent visits. The burdens ered in this textbook other disciplines may need to be of being a sole caregiver, sole provider, or diffi culty with included as well: athletic training, exercise physiology, travel or fi nancial limitations may play a part in the decision massage therapy, recreational therapy, even speech and on frequency of treatment. Every effort must be made to language pathology. consider these practical impediments to participation.

Diagnosis Duration of Treatment

Begin with your primary diagnosis, then secondary diagno- The most common length of treatment is 4 to 6 weeks, ses if relevant. Identify contributing factors to the diagno- but take the time to individualize the duration as well. sis (e.g., tight hamstrings in the setting of mechanical low Based on known natural history or acuity of the condi- back pain). Also identify relevant past medical and surgical tion, shorter (1–2 weeks) or longer (> 6 weeks) may be history to effectively communicate with the therapist. anticipated for improvement or resolution.

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Treatment Upper body ergometry (UBE), treadmill, upright or recumbent stationary bike, or ambulation training with This part of the Rx is the most challenging and may or without assistive devices (e.g., parallel bars) be overwhelming the fi rst time you do it. It is useful to approach it systematically with the list in the text box and by applying the concepts or questions discussed in Specialized Treatments the “approach to therapy prescription writing” section. ■ Some examples include the use of aquatic therapy or kinesiology taping Therapeutic Modalities ■ Other examples include analysis of the kinetic chain, functional movement screen, or even a running ■ Thermotherapy: analysis could be considered here ● Cryotherapy: (ice pack, ice bath, ice massage) for ■ The prescribing physician may also request a infl ammation/swelling/pain specifi c therapeutic approach in this section, such ● Superfi cial heat therapy: (hot packs, warm bath, as mechanical diagnosis and therapy (MDT), also paraffi n, fl uidotherapy, whirlpool, contrast baths) known as the McKenzie method for pain relief and to enhance recovery ■ Other examples are related to task specifi c functions, ● Deep heat therapy: ultrasound, short wave such as: diathermy, laser therapy ● Mobility training: kinetic chain or biomechanical ■ Phototherapy: laser therapy, UV light analysis and training, gait analysis and training, ■ Electrical stimulation: transcutaneous electrical transfer training, postural analysis and training nerve stimulation (TENS), interferential current ● Activities of Daily Living (ADL) training: Personal (IFC), functional electrical stimulation (FES), care activities with or without adaptive equipment neuromuscular stimulation (NMES), Iontophoresis such as dressing, eating, or personal hygiene ● Instrumental ADL: These activities are related to independent living but not necessary for Manual Therapy fundamental functioning (e.g., food preparation, accounting, housework, etc.) ■ Massage, joint mobilization, myofascial release ● Equipment: Use of specifi c supportive or assistive (MFR), soft-tissue mobilization, acupressure, devices, orthotic training, and durable medical transverse friction massage, positional release or equipment to aid in all of the above categories counter-strain, traction (manual, mechanical) are some techniques to consider for your patient Patient Education

Therapeutic Exercise Patient education is provided to the patient and possibly their family in the form of verbal, visual, and written instruction; ■ ROM exercises: passive, active assisted, active or digital media. Examples of patient education include an ■ Stretching: self-stretching, therapist-assisted explanation of their specifi c condition and associated prog- stretching, contract-relax stretching nosis, home exercise program, and postural education. Joint ■ Strengthening: generalized strengthening or identify protection and energy conservation techniques are other the need to strengthen specifi c muscle groups, isotonic examples. In addition, all of the therapeutic exercises dis- (eccentric/concentric) versus isometric, closed versus cussed above have an educational component and require open kinetic chain progressive resistive exercise carryover by the patient to change posture, correct move- (PRE), core strengthening or stabilization programs ment patterns, and eliminate causative factors of pain. ■ Balance/proprioceptive training, neuromuscular reeducation ■ Conditioning exercises: this may be indicated as general Reevaluation conditioning exercises (GCEs) or if necessary, specifi c programs with a warm-up/cool down, duration and Time until physician reevaluation should be clearly commu- type of exercise may be considered. Examples include: nicated with the patient and the therapist. Communicating

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with the providing therapist is crucial. Therapists vary in SAMPLE THERAPY PRESCRIPTION their training, experience, skill sets, biases, philosophies on healthcare delivery, and even bedside manner, just as phy- sicians do. We recommend getting to know the therapists Name with identifying factors: (e.g., DOB) at your hospital and in your local community. Knowing Date: their strengths and weaknesses in these fi elds will be a crucial step in correctly pairing patients and therapists to Discipline: PT, OT, or other successfully obtain favorable outcomes. In addition, you Diagnosis or diagnoses: will need to communicate (written or verbally) with the therapist to make sure they are following the therapeutic Problem list: program you have prescribed and what the outcomes have Precautions: been, just as you would with a nurse regarding a prescribed medication. Frequency of visits: such as 2 to 3x/week. We recommend requesting formal feedback on patient Duration of treatment: such as 3 to 4 weeks; progress to help guide your reevaluation. Read the thera- or 8 to 12 total visits used at the therapist’s pist’s notes or call them to clarify the patient’s progress and discretion tolerance to the therapeutic program. Their feedback is vital when reassessing the patient’s condition, when deciding to Treatment: continue or discontinue your patient’s therapy program, and 1. Therapeutic modalities: such as heat or cold when deciding if additional diagnostic studies or treatments packs, electrical stimulation are necessary. If therapy is to be continued, the prescription should change at follow-up to incorporate the progress and/ 2. Manual therapy: such as MFR, massage, or or changes in symptomatology. joint mobilization 3. Therapeutic exercise: such as active, active SUMMARY assisted, and passive range of motion (A/ AA/PROM), stretching, strengthening/ PREs, balance/proprioceptive training, Therapy prescription writing is more of an art neuromuscular reeducation, or conditioning than a science. If you invest time and effort into exercises this part of your practice we do believe it will infl uence patient outcomes. In this chapter, we have 4. Specialized treatments: kinesiology presented a “guide to therapy prescription writing” taping, aquatic therapy, or kinetic chain that can be utilized for the overall framework, analysis concepts, and systematic approach. As you become 5. Patient education: such as written home more comfortable with your practice and develop exercise program relationships with therapists at your hospital and in your community, your style of writing will evolve, Goals: such as decrease pain and swelling, restore but always remember to utilize it to establish a team ROM/fl exibility then strength, or safely return approach to care that provides all the necessary to functional activities (e.g., sport, hobbies, and medical information to the treating therapist and work) treatment recommendations that are evidence based Reevaluation: such as 3 to 4 weeks by referring and individualized to your patient. physician.

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