Also known as prior level of function in case you aren’t in to abbreviations. How many times have you written that today? This week? This month? How much thought have you given to what PLOF actually looks like for that patient? Isn’t their PLOF why you are seeing them in the first place? Let’s unpack this…
This past year I have been writing, revising, and editing a chapter for a textbook specific to geriatric considerations in rehabilitation. I was working from an old edition and the phrase “prior level of function” kept showing up. Under every heading, we talked about returning a patient to their prior level of function. Proximal humerous fracture? Return to prior level of function. Vertebral compression fracture? Return to prior level of function. Spinal fusion? Return to prior level of function. But why?
I kept thinking, “Why would I want to return a patient to their prior level of function when that level of function is what lead them to this problem in the first place?” So it was time to change. Instead, I wrote about utilizing proper exercise prescription to rehabilitate a patient to a safe and healthy level of function to prevent further onset of acute medical events or progression of chronic ones. So what does a safe and healthy level of function look like? That’s the tricky part.
Time is the key factor. Setting the time frame of what the “prior level of function” was seems to be an issue of great debate in our profession. The answer to this question isn’t as hard as it seems. When was the patient last not experiencing any medical issues? That would be the prior level of function I would want to target with therapy. I realize that this could have been many years ago, but who is to say that they can’t recover? If they are determined enough and goal-driven, then why not try to get them there?
Why can’t my 85 year old patient with 6 weeks of ICU time for sepsis on 6L of oxygen and a 4pt walker rehab to his prior level of function without oxygen or a device?
Why can’t my patient with a C5 spinal cord injury from cliff diving walk with a cane a year after injury?
Why can’t my patient with COPD return to playing tennis?
Why can’t my patient with a partial knee replacement go back to running 5Ks in 3 weeks?
Why can’t my patient with metastatic lung cancer on high flow oxygen
climb up and down her stairs without desaturating?
If you are listing answers to these questions, like different impairments and limitations, you are really just listing your targets for intervention.
There is plenty of research out there on hip fracture outcomes. Most of this research says that if someone has a fall with a hip fracture, they can really only hope to rehab to one functional level lower than their prior level of function. We need to be thinking about this critically. Is this outcome a limitation of the patient potential? Is this outcome a limitation of the coverage availability? Or is this outcome a limitation of the clinician’s interventions? Maybe this outcome is, itself, creating a limitation on all of these things: the payer’s willingness to pay, the patient’s beliefs in their abilities, and the clinician’s inherent bias toward the patient’s potential. If we can only control what we can control, I’m going to choose to control my role in this scenario.
If a patient has a fall, starts using a walker for a few months, then falls again and ends up with a femoral neck fracture, gets a pinning, goes to rehab, and comes home with a new walker, why do I want her long term goals to be centered around walking safely with the walker? Of course, we have to take in to consideration the healing times frame of boney tissue, but we need to be looking long term. This patient’s prior level of function is not using a walker, it’s whatever their function was before they experienced the decline. And the interventions shouldn’t be only targeting her hip. She got that fracture from a fall so let’s also be working on her balance and gait speed and working toward getting her off the walker!
That patient with sepsis I mentioned above? He was back to fishing and yard work without oxygen and without a device in 8 weeks. That patient with COPD is back to playing tennis. That patient with the C5 cord injury walks with a cane still today. The patient with lung cancer not only climbed her stairs but also walked outside all the way around her home without desaturating. That patient with a partial knee replacement ran his 5K after 3 weeks (against my advice, and yes, he paid for it but he did it. He eventually recovered and was just fine. I was really doubtful on this one but patients can be very driven toward their goals!).
Don’t be the limiting factor in your patient’s recovery by choosing their prior level of function for them. Many people were on the slow decline prior to that event and haven’t been their normal selves in a while. Let their goals guide your understanding of the prior level of function they really want to return to. We are the ones who have the skills to get them back to the lives they want. Mary McMillan saw the future of physical therapists as the purveyors of hope. After all these years, we have the tools to turn hope into reality.
Was there ever a patient who achieved tremendous goals with you? Tell me your story in the comments!
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