Hypothesis-Oriented Algorithm for Clinicians

A Method for Evaluation and Treatment Planning

JULES M. ROTHSTEIN
and JOHN L. ECHTERNACH

The purpose of this article is to introduce the hypothesis-oriented algorithm for

clinicians (HOAC), which is designed to aid physical therapists in clinical decision
making and patient management. The HOAC consists of two parts. The first part
is a sequential guide to evaluation and treatment planning; the second part
consists of a branching program used for reevaluation and the analysis of
treatment effectiveness. Problem statements used in the HOAC are similar to
those used for problem oriented medical records. The HOAC, however, requires
therapists to state hypotheses about why the problems exist and to generate
criteria that can be used to test the hypotheses. The benefits of the HOAC are
that therapists must 1) clearly state problems in a consistent manner, 2) generate
and list hypotheses and test criteria, 3) develop treatment strategies and methods
based solely on the hypotheses, and 4) systematically review treatment The
rationale for treatment is identified clearly in the algorithm, facilitating the iden-
tification of inappropriate treatments (ie, those not related to the hypotheses). In
addition, the branching program is used to identify where in the treatment process
failures may be occurring and when a therapist needs to make a referral or seek
assistance from a colleague.
Key Words: Patient care management, Physical therapy, Task performance and
analysis.

As the role of the physical therapist The earliest physical therapy evalua- because they usually do not provide in-
changes and as the profession proceeds tions actually consisted of physician-or- formation that may be of concern to
to greater levels of autonomy, the need dered tests. These tests then were used practitioners using a different approach
increases for a conceptual scheme for by the physician who was responsible (eg, the information gathered by Bob-
clinical problem solving that can be used for determining the type of treatment ath-oriented practitioners may differ
in any setting where clinical manage- the patient received. One of the first from that of someone influenced by
ment is planned as a result of a physical physical therapists to generate and pub- Brunnstrom), 2) usually deal only with
therapy evaluation. To be useful, a con- lish an evaluation scheme that could be information considered important in
ceptual scheme must guide the therapist used to guide treatment was Brunn- terms of one specific treatment ap-
in the use of evaluation for treatment strom.1 She viewed the hemiplegic pa- proach (eg, the emphasis on joint mo-
planning and provide the therapist with tient in a unique way and, based on her bility for the manual therapist or on
a logical sequence of activities. To have observations, developed a classification spasticity for the neurodevelopmental
widespread acceptance, this sequence scheme, evaluation methods, and a treatment therapist), and 3) contain in-
must be independent of treatment phi- treatment strategy. Brunnstrom's eval- herent assumptions about causality (eg,
losophies; assist therapists in knowing uation scheme may be contrasted with the implication that spasticity may be
when to seek aidfromother health care
the approach of Michels, who also made causing a functional deficit) but contain
professionals; and guide the processes of
observations of the hemiplegic patient.2 no mechanism for testing the appropri-
treatment planning, evaluation, and
Michels' scheme helped describe the sta- ateness of those assumptions.
modification. The purpose of this article
tus of a patient and made no attempt at In defining the role of the physical
is to introduce the hypothesis-oriented
algorithm for clinicians (HOAC), a con- guiding treatment. The benefit of Mich- therapist, Hoog described the context in
ceptual model that can be used for pa- els' approach is that it is not tied to any which evaluation and treatment must
tient management. one system of patient care. The separa- occur.3 He stated that the therapist has
tion of evaluation methods from treat- five functions: 1) evaluation, 2) treat-
ment schemes, however, places the ment planning, 3) treatment implemen-
responsibility on the therapist for the tation, 4) communication with other
Dr. Rothstein is Assistant Professor, Department
integration of evaluation information health care professionals primarily
of Physical Therapy, School of Allied Health Profes- with treatment planning. Evaluation about the patient, and 5) communica-
sions, Medical College of Virginia, Virginia Com- and treatment may remain independent tion and interaction with the public. The
monwealth University, Richmond, VA 23298
(USA). entities, however, and the possibility ex- HOAC (Figs. 1, 2) serves the first four
Dr. Echternach is Professor and Director, Pro- ists that evaluation may not relate to of these functions. This algorithm is de-
gram in Physical Therapy, and Chairman, Depart-
ment of Community Health Professions, Old Do- treatment. Evaluation approaches that rivedfromthe same logic that underlies
minion University, Norfolk, VA 23508. are tied to specific treatment strategies the problem oriented approach to pa-
This article was submitted December 10, 1984;
was with the authors for revision 32 weeks; and was
may be linked closely with treatment, tient care.4 Although the HOAC is com-
accepted January 31, 1986. but they 1) often lack generalizability patible with existing problem oriented

1388 PHYSICAL THERAPY

 PRACTICE

systems, it differs in several ways. The

primary difference is that the HOAC HYPOTHESIS-ORIENTED ALGORITHM FOR CLINICIANS
places the responsibility with the thera- PART ONE
pist to define goals and to determine
whether they have been met. Continued 1. Collect initial data (eg, interview, history,
management of the patient is mandated chart review, subjective information)
by the HOAC until the goals have been
achieved, although the goals may have
been modified during the course of pa-
tient care. A second major difference is 2. Generate a problem statement
the HOACs emphasis on the therapist
generating hypotheses concerning the
direct underlying cause of functional Establish goals (measurable
deficits (ie, the cause of the problem). and functional with
a temporal element)
Elstein et al have reported that skilled
physicians routinely generate hy-
potheses early in the problem solving
process at the first visit of a patient.5 3. Examination (collection of data)
Based on their observations of 24 in-
ternists who had been rated by other
physicians as being highly skilled, El-
stein et al determined that the physi- Referral to other 4. Generate working hypotheses
cians appeared to abandon some of the practitioner (if about why goals are or cannot be met at
problem solving strategies they were no hypotheses can be the present time (establish testing
generated) criteria for each hypothesis)
taught in medical school. Rather than
waiting until all data had been collected,
as they were taught in medical school,
the physicians found it more functional Ask whether goals are
to generate a series of hypotheses be- viable
forehand, which could be modified as • if no, modify
they proceeded with the patient inter- • if yes, proceed
view and examination. Payton, who
studied 10 physical therapists judged to
be highly skilled by their peers, found a
similar process in use.6 Therefore, a cen- 5. Plan reevaluation methodology
tral element of the HOAC, the genera- (schedule dates for reevaluations)
tion of hypotheses early in the evaluative
process, appears to be highly functional
and is often the strategy used by skilled Consultation, if - 6. Plan treatment strategy based on
physicians and therapists. needed hypotheses (overall treatment approach)
The HOAC consists of two parts. The
first part is a sequential guide to evalu-
ation and treatment planning (Fig. 1). 7. Plan tactics to implement strategy
The second part involves a branching (specifics of treatment plan)
program that anticipates the clinical de-
cisions that must be made (Fig. 2). Suc-
cessful use of the algorithm is dependent 8. Implement tactics
on the therapist's understanding of the (treatment)
terms used in Part One.
Fig. 1. Part One of the hypothesis-oriented algorithm for clinicians: Guidelines for evaluation
and treatment planning.
PART ONE—GUIDELINES FOR
EVALUATION AND TREATMENT lected in the context of the patient's fore, they should be stated in terms of
PLANNING reasons for seeking assistance from the the patient's reasons for seeking help.
therapist. Diagnostic terms and clinical impres-
Initial Data Collection
sions should not be used. For the phys-
The first step in the process involves Problem Statement ical therapy patient, this usually means
the collection of initial data, which con- a statement of a functional loss ex-
sists of recording the patient's medical The second step requires the therapist pressed in the same terms used by the
history (ie, the interview), using avail- to generate a problem statement that patient. When patients are severely ill or
able records, listing the patient's com- can be used to guide the development are unable to communicate, the func-
plaints, and observing any nonverbal of goals. Problems should be described tional loss or the potential loss must be
cues. All of these data should be col- in the problem oriented format.7 There- inferred.

Volume 66 / Number 9, September 1986 1389

 fore, believe that therapists should gen-
HYPOTHESIS-ORIENTED ALGORITHM FOR CLINICIANS erate a working problem list before they
PART TWO intervene and possibly redefine the pa-
tient's problems. We believe that thera-
9. Reassessment: Have goals been met?
pists who best serve their patients' needs
Yes No are aware of this need to remember the
patient's problems and that they ac-
tually begin to generate problem lists
Discharge patient before they examine their patients. The
Are tactics being implemented correctly?
arguments for our sequence are devel-
(Is treatment being implemented as planned?)
oped further in the next section in which
No we advocate developing a tentative goal
Yes
list before the patient is examined phys-
Improve implementation—Go to 8 ically.
Goals
A properly written problem statement
Are tactics appropriate? makes the next step in the algorithm,
Yes No
the generation of goals, relatively easy.
Goals should be stated in behavioral
terms (ie, what the therapist and the
Is strategy correct? Change tactics—Go to 7 patient hope to achieve) and should in-
Yes No clude only problems that can be reme-
died through treatment. As Savander
Are hypotheses viable? has suggested, goals must be stated in
Change strategy—-Go to 6
(ie, if testing criteria terms that are measurable.8 Therefore,
have been met and goals goals must include only terms that the
are not met, new hypotheses therapist can define operationally. For
are needed) example, if a goal is to improve ambu-
No lation, the specific aspect of ambulation
that requires improvement (eg, distance,
a* kinematic element, or the patient's
Generate new hypotheses—Go to 4 subjective report of pain or discomfort)
must be stipulated. All goals must be
Fig. 2. Part Two of the hypothesis-oriented algorithm for clinicians: Branching program. All
numbers less than 9 refer to the steps listed in Figure 1. defined in measurable terms. This proc-
ess requires therapists to define opera-
At times, the problem statements taught, we believe that it is the most tionally, in terms of the patient, every
must be written in terms of "anticipated logical and that it is consistent with ac- term they use. This process may be fa-
problems." For example, the therapist tual practice. Patients seeking physical cilitated if departments maintain lists of
may observe no manifestation of a func- therapy do so because they have a prob- operational definitions that are used in
tional or cosmetic deficit during the in- lem. Similarly, patients are referred to the facility.
itial examinations of the patient, but physical therapists because the referring We emphasize the goals in the HOAC
may find indications that such a deficit professional has determined that a prob- because they are the reason the patient
may develop in the future. The school- lem exists, usually at least partly on the is being treated. Patients are discharged
child examined for scoliosis may not basis of input from the patient. only when all goals have been met. Ini-
demonstrate abnormal spinal curvature, In examining existing problem solv- tial goals, therefore, are tentative and
but the therapist may anticipate the de- ing schemes, it seemed odd to us that in can be modified after the patient is eval-
velopment of such a problem based on a profession as humanistic as physical uated fully. Setting goals before the ther-
the results of the evaluation. Similarly, therapy there could be any question that apist has evaluated the patient and as-
the below-knee amputee may not have the patient's problems are those that are sessed the patient's capabilities might
a knee-flexion contracture, but the ther- identified by the patient—not by the seem unusual but has the following ad-
apist may anticipate the development of therapist. In our experience, problem vantages:
a contracture and, therefore, want to lists generated after physical examina- 1. The therapist is more likely to state
consider this potential deficit in terms tions often have departed from dealing problems and goals in terms that are
of a problem list. Anticipated problems with the patient's problems because they truly in line with the patient's report
frequently will compose a major portion have included clinical impressions, di- (eg, stating that the patient cannot
of a problem list. agnostic information, or professional put on a shirt rather than using the
Many physical therapists may find it jargon (eg, "The problem is that the therapist-oriented statement that the
strange that in this algorithm a problem patient lacks accessory motion at the patient cannot achieve more than
list is generated before the therapist ac- glenohumeral joint"). Such information 100 degrees of shoulder flexion).
tually examines the patient. Although does not describe the patient's problem, 2. The therapist and the patient are
we appreciate that our sequence prob- but instead results in the kinds of hy- more likely to delineate why the pa-
ably is not the sequence commonly potheses that we discuss later. We, there- tient came for treatment, what the

1390 PHYSICAL THERAPY

 PRACTICE

patient expects from treatment, and patient may have a problem with am- ply by determining whether all treat-
what functional problems are most bulation. Specifically, the patient re- ment was based on the hypothesis.
important to the patient. ports having knee pain after walking Because all treatment must be based
3. By fully understanding the patient's long distances. The goal would be for on a hypothesis, we can say logically
expectations in the patient's terms, the patient to be able to walk a specified that when a therapist is unable to gen-
the therapist can treat and advise the distance (based on the patient's needs erate a hypothesis he can administer no
patient more appropriately (eg, the and complaints) without pain. After the treatment. This requirement forces the
patient can be guided to understand examination, the therapist may con- therapist without a hypothesis to seek
what he may reasonably expect from clude that the discomfort in ambulation assistance by consulting either with an-
treatment). is caused by a lack of normal progres- other therapist or with some other
The goals in the HOAC must have a sion from heel-strike to mid-stance be- health care professional. Such consulta-
temporal element (ie, therapists must, cause the patient does not flex his knee tions may be for an additional evalua-
as part of the goal, state when they ex- during this part of the gait cycle. Unless tion or the consultant may generate the
pect that the goal will be achieved). By the therapist believes that this abnor- hypothesis. Clearly, a therapist without
requiring that the goals contain a tem- mality is simply a learned behavior, a hypothesis needs assistance. We
poral element, the HOAC can be used however, that conclusion alone is not should emphasize, however, the require-
to collect data that may reflect the effec- an acceptable hypothesis. The therapist ments of an acceptable HOAC hypoth-
tiveness of a specific type of treatment, must determine why the normal pro- esis. When therapists believe that they
the quality of care given by individual gression is missing. If measurement of have identified the underlying cause of
therapists, and whether therapists can the patient's active range of motion re- a problem, they then have a hypothesis.
set goals realistically in terms of time vealed that he could flex his knee only A hypothesis is really a clinical impres-
and function. In practice, the goals will 15 degrees and that this movement was sion based on an assumption of causal-
be set before the patient is examined, accompanied by pain, then the hypoth- ity. By definition, a hypothesis is a test-
whereas the temporal element, to be esis would be that the functional loss is able idea—a tentative, but best, estimate
realistic, must be added after the patient a result of the gait deviation, which in that only time can prove correct.
has been evaluated. turn is caused by the limitation in pain- Although the algorithm guides thera-
free active ROM. pists in seeking consultation when they
Examination
Multiple hypotheses may be gener- cannot generate a hypothesis, it also re-
After the goals have been established,
ated, which provide the underlying ra- quires consultation under other circum-
the therapist examines and evaluates the
tionale for all treatment that will follow. stances (Figs. 1, 2). If, for example, the
patient and collects data regarding the
No treatment should be administered hypothesis states that the functional def-
patient's health status. Elements that that is not based on a hypothesis. Be- icit is caused by a problem that the
may contribute to the previously de- cause the preceding example involved a therapist is not equipped to treat, then
scribed functional loss are emphasized single hypothesis that dealt with pain- referral is the appropriate action. This
during data collection, which is designed free motion, a treatment plan to include may take the form of referral to another
to minimize expensive and time-con- exercise designed to increase muscle type of health care professional or to a
suming evaluations that may not be di- power would have been inappropriate. therapist with specialized skills. In the
rected at the primary reason the patient If an absence of muscle power had been example described previously, the ther-
is seeking care. Some therapists may be hypothesized as contributing to the loss apist might have hypothesized (based on
regulated by departmental guidelines of motion, however, then exercise would the examination) that the patient had
that prescribe specific evaluative proce- have been an appropriate treatment. septic arthritis. Referral then would
dures for specific types of patients. If have been the appropriate action.
those procedures are in the form of al- By requiring all treatments to relate
gorithms, they may be incorporated in to hypotheses, the HOAC forces thera- Goals must be reconsidered after the
this phase of the HOAC. Similarly, other pists to justify all aspects of treatment hypotheses have been generated. Objec-
therapists may use their own evaluative for all patients. This requirement is de- tive findings may lead the therapist to
sequence or those of other treatment signed to promote the use of appropriate hypothesize that the underlying cause of
philosophies (eg, Brunnstrom, Bobath, treatment protocols and to discourage the functional deficit is one that cannot
McKenzie). the use of treatment regimens simply respond to treatment or that may re-
because they have been prescribed rou- spond only partially to treatment. The
Generation of a Hypothesis tinely in the past. In addition, this re- goals then must be modified, and the
Based on the patient examination re- quirement minimizes the likelihood that modified goals may obviate the need to
sults and the integration of all available therapists will add superfluous treat- proceed with treatment.
data, therapists then must develop a ments to otherwise sound programs. For As has been noted, a hypothesis is a
clinical impression from which they can example, although amputees frequently testable idea. The HOAC requires test-
generate a hypothesis about the causes may need training in weight shifting, a ing of the idea. For each hypothesis, the
of the patient's problem. That is, the patient's functional problems may not therapist must establish at least one test-
hypothesis is the therapist's statement of have anything to do with an inability to ing criterion, and when necessary more
why he believes that the patient does not shift weight. Using the HOAC, this com- than one. In the preceding example, a
meet the treatment goals at the time of mon exercise cannot be added to the lack of active ROM was hypothesized
the initial visit. treatment program of such a patient as the cause of a functional deficit. A
The following example demonstrates unless it is necessary. Inappropriate reasonable testing criterion for the pa-
how a hypothesis may be established. A treatments can be identified readily sim- tient might be the achievement of 60

Volume 66 / Number 9, September 1986 1391

degrees of pain-free active ROM, which Strategy and Tactics der. The sequence requires the therapist
is the excursion needed for normal gait. to ask questions regarding the most con-
If, during the course of treatment, the The next two steps, planning strategy crete items first (ie, questions about im-
patient meets this criterion but still does and planning tactics, are linked closely plementation precede those concerning
not meet the treatment goal, then the and may be considered identical by more conceptual issues, such as the
hypothesis at best was incomplete and some therapists. We, however, believe strategy and hypotheses). This leads the
possibly was totally incorrect. The use that differentiation between the two is therapist through an organized reap-
of testing criteria is a central element of useful. In the HOAC, a strategy is de- praisal of treatment, which eventually
the HOAC, and the algorithm can be fined as the overall approach that will leads to a consideration of whether the
used effectively only when such criteria be adopted, whereas the tactics are the hypothesis was correct, as judged by use
are established before treatment begins. specific means of implementing the of a testing criterion.
These criteria allow for testing of the strategy. Tactics are the treatments, but
When the goals have not been met,
they are not necessarily only the treat-
hypothesis; therefore, the criteria must the therapist first must determine
ment given by the therapist. Tactics may
be measurable. Operational definitions whether the tactics were being imple-
be implemented by physical therapist
may be required if they do not exist mented correctly; that is, was the treat-
assistants, family members, nursing per-
already. ment conducted as planned? For ex-
sonnel, and the patients themselves.
In establishing the testing criteria, the ample, if traction had been part of the
Strategies can be established only by the
therapist must be careful to make them treatment, the therapist might ask: 1)
therapist.
independent from the treatment goals. Was the halter applied properly? 2) Was
The criteria serve only to test whether the angle of traction used the angle that
Implementation of Tactics
the hypothesis was correct. This process was planned? 3) Was the traction force
(Treatment)
serves an educational purpose but, more adequate? The therapist also may want
important, it is a means of determining Treatment, or the implementation of to determine whether the patient under-
when treatment is having an effect (eg, tactics, is prescribed for a finite period stood the purpose of the treatment (eg,
increasing active ROM) but is not effec- of time when the HOAC is used. Re- he may have resisted the traction force).
tive in helping the patient achieve the evaluation must be conducted according When parts of the treatment have been
treatment goal (eg, pain-free walking). to the previously determined schedule. administered by someone other than the
The testing criteria used in the HOAC Because the reevaluation protocol was therapist (the patient, assistants, aides,
may resemble what some therapists now established so that it related to the goals family members, or nursing personnel),
call "short-term goals." We believe that and criteria, the branching program can a review of the tactics must include a
this term should not be used. Changes be used (Fig. 2). determination of whether they were
in active ROM, muscle power, or simi- conducted as prescribed. Compliance
lar elements should serve the achieve- Reevaluation should be determined for all aspects of
ment of goals (function) and should not treatment.
be considered goals in themselves. Reevaluations are conducted on The preceding list is not meant to be
schedule, unless a change in the patient's comprehensive but, rather, is an illustra-
Plan Reevaluation Methodology health status necessitates an earlier re- tion of the type of inquiry therapists
evaluation. When an early reevaluation must engage in before they can proceed
After the goals, hypotheses, and test- is conducted, the change in the patient's
ing criteria have been established, the to the next step. If implementation is
health status may warrant reconsidera- poor, the therapist then deals with that
therapist must outline the procedures tion of the goals and hypotheses. In
that will be used for reevaluation. These problem, establishes a new reevaluation
essence, this reevaluation means starting schedule, and continues treatment. If
reevaluations must include mechanisms over at the beginning of the algorithm.
for testing whether the patient has met the treatment has not been conducted
A patient with rheumatoid arthritis who properly, any of the other questions in
the goals and whether changes have oc- has an exacerbation of the disease dur-
curred in the criteria and related phe- the branching program (Fig. 2) cannot
ing the course of treatment is an exam- be answered. A negative answer to any
nomena. In the example discussed pre- ple of a change requiring an early re-
viously, reevaluation might include not of the questions in the branching pro-
evaluation. gram means that the therapist should
only testing whether pain-free walking
If the goals have been met at the time not continue to ask questions but,
is achieved (the goal), and whether pain-
of reevaluation, the patient is dis- rather, should deal with that problem
free active ROM has increased (the test-
charged. If the goals have not been met, before proceeding to the next step.
ing criteria), but also a gait evaluation
the therapist then uses the branching
to determine whether the progression If the tactics have been implemented
program of the HOAC (Fig. 2), which
from heel-strike to mid-stance has properly, the therapist then must ask
requires him to answer a series of yes-
changed. All procedures to be used for whether the tactics were appropriate and
no questions before determining the
reevaluation should be listed before whether the treatment plan was correct.
next course of action.
treatment begins, and a schedule must For example, was sufficient traction
be established designating when reeval- force used? If the therapist believes, after
PART TWO—BRANCHING reconsideration, that the tactics were
uations will be conducted. When a ther- PROGRAM
apist observes any major change in the correct, he then must consider whether
patient's physical or mental status, how- The branching program of the HOAC the strategy was appropriate.
ever, reevaluation may be conducted be- requires the therapist to perform the For the patient with the limited pain-
fore the scheduled date. previously described steps in reverse or- free active ROM, a reconsideration of

1392 PHYSICAL THERAPY

 PRACTICE

the strategy might involve questioning Discharge ment strategies and to test those as-
whether one type of ROM program sumptions. Use of the HOAC, therefore,
would have been better than another. The HOAC allows for patient dis- has the potential to increase our under-
Passive ROM may have been empha- charge under two clearly defined cir- standing of the scientific basis of prac-
sized when active ROM would have cumstances: 1) when a referral is made, tice. Previously untested assumptions of
been better, or perhaps some form of or 2) when the goals, either original or dysfunctional causality (eg, hypertonic-
manual therapy, rather than just ROM modified, have been achieved. When ity causes a specific deficit) are tested
exercises, would have been part of a the original goals have not been met, or constantly by the therapist using the
better strategy. The HOAC advocates when the patient has been referred else- HOAC.
that therapists who have difficulty gen- where, the therapist must document The impetus for the development of
erating new strategies may need to seek why these actions were taken. The ther- the HOAC came from clinicians' needs;
professional consultation at this stage of apist, therefore, is accountable both for however, the algorithm has other uses.
the algorithm. the reasons the goals were modified and We have described how it can be used
for the management of patients with as a management and peer review tool.
One indication that the strategy might modified goals. The HOAC also can be used to define
need revision is when the rate of change
the therapist's role in independent prac-
in a criterion measure is deemed too DISCUSSION tice, because it identifies the circumstan-
slow. For example, if ROM or muscle
ces under which the therapist must seek
performance levels increase, but not to One of the major strengths of the
testing criteria levels, the therapist consultation and referral. This use of
HOAC as a guide to clinical decision
should determine whether another strat- the algorithm is accomplished in a man-
making is that the algorithm requires
egy would have been more effective. ner that does not allow therapists to pass
the therapist to deal with defined prob-
This slow rate of change, however, may along inappropriate problems to other
lems and to document all actions taken,
indicate that the therapist had unrealis- practitioners because they must state the
in addition to all underlying rationales.
tic expectations of changes (treatment rationale for their referrals when for-
Although therapists may be required to
effects) when the reevaluation schedule mulating their hypotheses. Because the
reevaluate the patient or to reevaluate
was planned. HOAC requires therapists to state the
themselves, they still must use the same
problems they anticipate when they in-
thorough documentation in a logical
By following the branching program, itially examine their patients, the algo-
and consistent format. Therefore, the
we know that when the strategy is rithm mandates a logical justification of
approach to treatment and all modifi-
thought to be correct a treatment plan any screening programs and any subse-
cations of programs can be understood
has been conducted and the plan devel- quent interventions.
by all therapists, regardless of their treat-
oped logically from an idea (ie, the hy- Students, both in the classroom and
ment philosophies. The HOAC, thus,
pothesis). The therapist then must de- in the clinic, can benefit from use of the
provides a generalized approach to
termine whether the idea was correct. If HOAC because it provides a system for
problem solving and record keeping that
the patient meets the testing criteria and patient management that progresses log-
facilitates communication and provides
the goals have not been met, the hypoth- ically from the collection of data,
a mechanism for the identification of
esis was either incorrect or incomplete. through the generation of hypotheses, to
therapists who are unable to meet goals
The patient who had limited pain-free the implementation of treatment. The
within specified time periods.
active ROM may now have 60 degrees logical flow can guide them and help
The HOAC itself does not provide a them integrate theory and practice.
of motion and walk with a normal gait means for determining why therapists
pattern (ie, with a normal progression Clinical supervisors can use the HOAC
may be unable to achieve goals (eg, poor to identify student strengths and weak-
from heel-strike to mid-stance). The pa-
goal setting, unrealistic time expecta- nesses.
tient has met the testing criteria and, if
the hypothesis was correct, should no tions, poor quality of care). By providing
longer have a functional deficit. If the the framework for decision making and SUMMARY
goals have not been met and the prob- documentation, however, the HOAC
lem is persisting, then the therapist must can be used for peer review and quality The HOAC is a method for evalua-
generate a new hypothesis or seek con- assurance programs.7 In addition, it pro- tion and treatment planning that pro-
sultation. vides a mechanism that therapists can vides clinicians with a sequential guide
use to evaluate their own performance. to patient management. The first part
Sometimes, new hypotheses will re- When used by therapists or their super- of the algorithm requires therapists to
quire referral to another practitioner (eg, visors, the HOAC helps to identify identify problems and goals, generate
when an orthosis may be needed or the weaknesses in patient management. An hypotheses, establish testing criteria for
therapist concludes that some other analysis of records maintained using the the hypotheses, and define strategy and
form of intervention, such as surgery, algorithm will demonstrate whether the tactics before treatment begins. All as-
might be needed). Other revised hy- therapist had difficulty in phrasing sumptions underlying treatment must
potheses may demonstrate recognition goals, generating hypotheses, setting be stated and later tested. The second
of conditions that cannot be treated, time limits, determining strategies, or part of the algorithm guides therapists
such as structural anomalies or a per- planning and implementing tactics. through an examination of their own
manent loss of innervation. Goals then We believe that the greatest strength actions when the goals have not been
must be revised accordingly, and the of the HOAC is that it requires thera- achieved. This reconsideration encom-
patient discharged at a lower functional pists to state clearly the assumptions (ie, passes both concrete and theoretical
level than that initially expected. the hypotheses) that underlie their treat- concerns and identifies deficiencies in

Volume 66 / Number 9, September 1986 1393

patient management. The HOAC can bution to our understanding of the 3. Hoog T: Professional standards for quality pa-
tient care. Phys Ther 49:1364-1368, 1969
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Acknowledgments. We thank Dr. 1. Brunnstrom S: Associated reactiohs of the up- clinical note in a physical therapy department.
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