Clinical reasoning frameworks for stroke PT
A 65-year-old man, 8 weeks post-stroke. New referral to outpatient PT. Walks with a quad cane, comfortable gait speed 0.51 m/s, FGA 13/30. He says, "I want to walk my granddaughter to school." His wife adds, "He keeps almost falling at home." He scores 4/10 on a brief cognitive screen.
1. Case. A 65-year-old man, 8 weeks post-stroke. New referral to outpatient PT. Walks with a quad cane, comfortable gait speed 0.51 m/s, FGA 13/30. He says, "I want to walk my granddaughter to school." His wife adds, "He keeps almost falling at home." He scores 4/10 on a brief cognitive screen.
2. Framework references. Two complementary tools: the WHO International Classification of Functioning, Disability and Health (ICF; WHO 2001) and the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II; Rothstein JM, Echternach JL, Riddle DL. *Phys Ther*. 2003;83:455–470).
3. Reasoning walkthrough. ICF provides the taxonomy: Body Functions and Structures (paresis, balance impairment), Activity (gait speed, FGA), Participation (school walk), Contextual factors (wife's report, cognitive screen). HOAC II provides the procedure: collect data, generate Patient-Identified Problems (PIPs — granddaughter walk) and Non-Patient-Identified Problems (NPIPs — wife-reported near-falls, cognitive screen), formulate testable hypotheses, set measurable goals tied to each problem, plan and implement, then reassess. NPIPs matter in stroke because aphasia, anosognosia, or cognitive deficits can prevent patients from articulating critical problems. Use both: ICF for what to describe; HOAC II for how to decide.
4. Outcome measure. Pair construct-anchored measures to each ICF level. Body structure/function: FMA-LE, MAS where relevant. Activity: 10MWT, FGA, 5xSTS. Participation: Stroke Impact Scale 16, ABC, or a goal attainment scale.
Two complementary tools: the WHO International Classification of Functioning, Disability and Health (ICF; WHO 2001) and the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II; Rothstein JM, Echternach JL, Riddle DL. *Phys Ther*. 2003;83:455–470).
Get the next article in your inbox
One article a week. No marketing between.