PT 201

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To understand the Hypothesis Oriented
Algorithm for Clinicians II process of clinical
decision making.

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 The Hypothesis Orientated Algorithm for Clinicians (HOAC)
– a method for evaluation and treatment planning - was
first published in 1986.
 In 2003 the algorithm was updated to be compatible with
the contemporary physical therapy practice.
 The update was termed the Hypothesis Orientated
Algorithm for Clinicians II (HOAC II).

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 The HOAC II offers a conceptual, patient-centred
framework for physical therapists to use in the
management of any type of patient.
 It addresses the five elements of patient management:
examination, evaluation, diagnosis, prognosis and
intervention.
 Important for contemporary physical therapy, the HOAC II
provides a means to engage in evidence-based practice
and to differentiate between the types of evidence and
science used.
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 Collect Initial Data (Includes the History)
 Generate a PIPs List

 Formulate Examination Strategy

 Conduct the Examination and Analyze the Data

 Add NPIPs to the Problem List

 Justification for Hypotheses

 Generate a Hypothesis (or Hypotheses) as to Why the
Problems Exist
 For Each Anticipated Problem, Identify the Rationale for
Believing Anticipated Problems Are Likely to Occur Unless
Intervention Is Provided
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 Refine Problem List
 For Each Problem, Establish One or More Goals
 Existing problems
 Anticipated problems

 For Each Existing Problem, Establish Testing Criteria

 For Each Anticipated Problem, Establish Predictive

Criteria
 Establish a Plan to Reassess Testing and Predictive
Criteria and Establish a Plan to Assess Problems
and Goals
 Plan Intervention Strategy and Tactics

 Implement Tactics
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 consists of questions that are designed to provide insights
into whether any aspect of patient management is
deficient, including whether the original goals were
viable.
 Examining the Hypothesis for Existing Problems

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 mechanisms relating to tissues –
 tissues injured, nature of injury, stage of healing

 mechanisms relating to pain –

 input (nociceptive, neurogenic), processing (central, cognitive)
 output (motor, sympathetic).

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 Clinical manifestations of the pathobiological
processes, these are the patients main problems at
that time.
 dysfunction - general physical dysfunction as
described by the patient such as limitations in
activity
restriction in participation
 impairment - specific impairments in body
functions and structures identified on examination.
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 The actual anatomical location of the
pathobiological mechanisms.
 What discrete anatomical structure is generating
the primary complaint.

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 Any factor relating to the predisposition, development and
maintenance of the problem
 physical - previous injury, nerve root involvement, pain
provoked by multiple trunk movemements, reduced
muscle control, reduced physical fitness
 Biomechanical

 Psychosocial - yellow flags determine a patients potential

to proceed to chronicity.
 Environmental - Ergonomics, Stress,

 Emotional, Behavioural, Nutritional, Cultural

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 There are 3 primary forces the human body must
dissipate.
 The biomechanical nature of the condition helps the
clinician to determine which of these forces may be the
primary contributor to a patient's symptoms.
 For example: tension overload may be the primary
biomechanical nature of a patient who is experiencing patellar
tendonitis.
 Compression
 Tension
 Shear

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 Forces are moving primarily in an approximating direction
 Compression stimulates bone, cartilage, discogenic tissue,
and often neurological tissue.
 When these tissues are overloaded, this leads to fractures,
in some cases disc damage, or even nerve compression.
 Examples: stress fracture of vertebrae, disc herniation,
cervical radiculopathy, and compartment syndrome.
Insufficient loading may lead to osteoporosis for example.

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 Forces are oriented primarily in opposite directions
 Tension stimulates muscle, tendon, ligament and in some
cases neurological tissue.
 Overload with “tension” leads to sprains, strains and in
some cases peripheral nerve injury.
 Examples: hamstring tear, patellar Tendinopathy, brachial
plexopathy, MCL tear. Insufficient loading leads to muscle
atrophy, and weak ligaments and tendons for example.

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 Forces are NOT moving in opposite or approximating
directions exclusively. This is a COMBINATION of tension
and compression.
 When shear is the primary motion occurring, the body
often lacks sufficient ways to attenuate this stress and
may lead to degenerative changes over time or perhaps
even acute tissue rupture.
 EXAMPLES: This is seen in ACL ruptures and
spondylolisthesis.

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 Biomechanically mediated injuries should be
categorized according to the cause of their
symtpoms in the following way:
 Microtraumatic
 Any repetitive injury over long time
 Macrotraumatic
 Identifiable trauma over short time (example, a slip and fall or
pitching for 6 innings two days in a row, much more than normal
dosage.

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 Patient Identified Problems (PIP)
 Non – Patient Identified Problems (NPIP)
 Anticipated Problems
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 This is essentially a problem list generated by the
clinician.
 This is an ongoing process of evaluation as the
subjective examination and physical examination
is taking place.

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 These are problems that if not addressed, will lead
to PIPs or NPIPs in the future.
 This is based on the clinicians utilization of best
practice as well as there own prognostic skills.

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 The stage of the condition should closely follow the
phases of healing. There is not a consistent language
used across physical therapy literature on how to stage a
condition. Some refer to symptoms lasting >6 weeks as
chronic.
 Acute: Early onset of symptoms. This patient is in the
inflammatory phase of healing.
 Subacute: The inflammatory phase of healing is subsiding
and the patient should be in the reparative/proliferative
phase of healing.
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 Chronic: This patient should have completed the
maturation stage of healing; however, there may be
intrinsic or extrinisc factors limiting the complete recovery
of this patient
 Acute on Chronic: This patient has reinitiated the
inflammatory phase of healing, on a previous chronic
condition that may or may not have completed the
maturation phase of healing.

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 There are basic strategies of physical therapy intervention
that may be employed.
 Stretch

 Soft Tissue Mobilization (STM)

 Joint Mobilization (JM)

 Strengthening/Stabilization

 Re-training/Re-education

 Education

 Offloading

 Pain inhibition

 Modalities/Physical Agents

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 These are the detailed and specific elements of an
intervention. Tactics specify the frequency, duration, and
intensity of interventions.
 In a direct access environment, the therapist decides the
strategy and tactic(s) of the treatment, not the physician.
 In a non-direct access environment, the physician may at
times request a specific strategy; however, they rarely
dictate the tactics employed.
 Therefore, it is the therapists responsibility to prescribe and
modify the tactics implemented.
 The strategy may be to strengthen, but the tactics will specify: i.e.,
quadriceps eccentric load on single leg to maximum tissue failure
for 3 sets, 30 second rest between sets. 3 times per week.
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 Topredict potential improvement identify positive
and negative prognostic indicators. Consider age,
occupation, hobbies, previous treatment
response, stage and stability od condition, general
health, past medical history, pain mechanisms.

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 When is the patient ready for discharge?
 When does optimal care end to address all key NPIP and
PIP. You must also consider anticipated problems and the
need for re-admittance to physical therapy secondary to
inadequate rehabilitation.
 All patients must of course be discharged.

 To prevent re-injury, your D/C criteria may be very specific.

 Consider the discharge criteria your absolute last patient

encounter before they re-enter the general populace
without limitations OR once they have reached their MMI
(maximum medical improvement).
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 The HOAC II was designed to facilitate the use of science
and evidence in practice, and to do so in a manner that is
not intrusive on clinical practice.
 Much of what clinicians to do in the algorithm is already
part of their practice but that it occurs in a less defined
manner and without a context for documentation and
discussions among colleagues.
 Among the differences between this version and the
original HOAC are the mechanisms for justifying prevention
and, more importantly, for developing measurable
outcomes related to prevention as well as defining the time
it will take to achieve reduction of risk factors.
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HOAC II

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