Guidelines to Physical Therapist Practice APTA [1]

Guidelines to Physical Therapist Practice

Expanded Academic ASAP Print

Page 1 of 2

What Is Physical Therapy?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p21. (560 words)

Full Text:COPYRIGHT 2001 American Physical Therapy Association, Inc.

Physical therapy is a dynamic profession with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function. For more than 750,000 people every day in the United States, physical therapists: * Diagnose and manage movement dysfunction and enhance physical and functional abilities. * Restore, maintain, and promote not only optimal physical function but optimal wellness and fitness and optimal quality, of life as it relates to movement and health. * Prevent the onset, symptoms, and progression of impairments, functional limitations, and disabilities that may result from diseases, disorders, conditions, or injuries. The terms "physical therapy" and "physiotherapy," and the terms "physical therapist" and "physiotherapist," are synonymous. As essential participants in the health care delivery system, physical therapists assume leadership roles in rehabilitation; in prevention, health maintenance, and programs that promote health, wellness, and fitness; and in professional and community organizations. Physical therapists also play important roles both in developing standards for physical therapist practice and in developing health care policy to ensure availability, accessibility, and optimal delivery of physical therapy services. Physical therapy is covered by federal, state, and private insurance plans. The positive impact of physical therapists' services on health-related quality of life is well accepted. As clinicians, physical therapists engage in an examination process that includes taking the patient/client history, conducting a systems review, and performing tests and measures to identify potential and existing problems. To establish diagnoses, prognoses, and plans of care, physical therapists perform evaluations, synthesizing the examination data and determining whether the problems to be addressed are within the scope of physical therapist practice. Based on their judgments about diagnoses and prognoses and based on patient/client goals, physical therapists provide interventions (the interactions and procedures used in managing and instructing patients/clients), conduct reexaminations, modify interventions as necessary to achieve anticipated goals and expected outcomes, and develop and implement discharge plans. The American Physical Therapy Association (APTA), the national membership organization representing and promoting the profession of physical therapy, believes it is critically important for those outside the profession to understand the role of physical therapists in the health care delivery system and the unique services that physical therapists provide. APTA is committed to informing consumers, other health care professionals, federal and state governments, and thirdparty payers about the benefits of physical therapy--and, more specifically, about the relationship between health status and the services that are provided by physical therapists. APTA actively supports outcomes research and strongly endorses all efforts to develop appropriate systems to

http://find.galegroup.com/itx/printdoc.do?contentSet=IAC-Documents&docType=IAC&i... 11/21/2008


Page 2 of 2

measure the results of patient/client management that is provided by physical therapists. The patient/client management elements of examination, evaluation, diagnosis, and prognosis should be represented and reimbursed as physical therapy only when they are performed by a physical therapist. Physical therapists are the only professionals who provide physical therapy examinations, evaluations, diagnoses, prognoses, and interventions. Physical therapist assistants, under the direction and supervision of physical therapists, are the only paraprofessionals who assist in the provision of physical therapy interventions. Intervention should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist. APTA recommends that federal and state government agencies and other third-party payers require physical therapy to be provided only by physical therapists or under the direction and supervision of physical therapists.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"What Is Physical Therapy?." Physical Therapy 81.1 (Jan 2001): 21. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .

Gale Document Number:A70453287 Disclaimer: This information is not a tool for self-diagnosis or a substitute for professional care.

© 2008 Gale, Cengage Learning.



Page 1 of 2

Preface to the First Edition November 1997.(Guide to Physical Therapist Practice).Marilyn Moffat, Andrew Guccione and Jayne Snyder. Physical Therapy 81.1 (Jan 2001): p12. (297 words)


All health care professions are accountable to the various publics that they serve. The American Physical Therapy Association (APTA) has developed Guide to Physical Therapist Practice ("the Guide") to help physical therapists analyze their patient/client management and describe the scope of their practice. The Guide is necessary not only to daily practice but to preparation of students. It was used as a primary resource by the Commission on Accreditation in Physical Therapy Education (CAPTE) during its revision of evaluative criteria for physical therapist professional education programs and is an essential companion document to The Normative Model of Physical Therapist Professional Education, Version 97. Specifically, the Guide is designed to help physical therapists (1) enhance quality of care, (2) improve patient/client satisfaction, (3) promote appropriate utilization of health care services, (4) increase efficiency and reduce unwarranted variation in the provision of services, and (5) promote cost reduction through prevention and wellness initiatives. The Guide also provides a framework for physical therapist clinicians and researchers as they refine outcomes data collection and analysis and develop questions for clinical research. Groups other than physical therapists are important users of the Guide. Health care policymakers and administrators can use the Guide in making informed decisions about health care service delivery. Third-party payers and managed care providers can use the Guide in making informed decisions about reasonableness of care and appropriate reimbursement. Health care and other professionals can use the Guide to coordinate care with physical therapist colleagues more efficiently. As the Guide is disseminated throughout the profession and to other groups, the process of revision and refinement will begin. We thank our colleagues who helped us make the Guide a reality. Marilyn Moffat, PT, PhD, FAPTA (APTA President, 1991-1997) Andrew Guccione, PT, PhD Jayne Snyder, PT, MA APTA Board Oversight Committee

Named Works: Guide to Physical Therapist Practice (Book) Source Citation:Moffat, Marilyn, Andrew Guccione, and Jayne Snyder. "Preface to the First Edition November 1997." Physical Therapy 81.1 (Jan 2001): 12. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .



Page 2 of 2





Page 1 of 1

Foreword to the Second Edition January 2001.(Guide to Physical Therapist Practice).Ben F Massey Jr. Physical Therapy 81.1 (Jan 2001): p13. (264 words)


The Guide to Physical Therapist Practice ("the Guide"), Parts One and Two, has represented a living document, with a life that has already spanned more than 8 years. The first edition of the Guide was the result of the expertise contributed by almost 1,000 physical therapist members of the American Physical Therapy Association. Each individual shared not only his or her knowledge and skills, but also time, energy, and commitment to a document that has dramatically affected the practice environment. The Guide has been used in ways and by people we never had imagined-becoming an invaluable resource to clinicians, educators, administrators, legislators, and payers throughout the health care community. This second edition is a testament to its evolutionary nature. In reviewing the pages of this edition, you will know that its strengths have been shaped by its users--all of whose comments and questions received serious consideration. Hundreds of members have worked to respond to those suggestions and to the demands of a changing practice environment, thereby ensuring that the Guide encompasses the full scope of current physical therapist practice. To all of them, I extend the deep appreciation of our profession and its Association. The Guide will continue to grow and be revised based on research evidence and on changes in examination and intervention strategies within practice. I invite you to be a part of its life by bringing to the Association your questions, comments, and suggestions. Our united participation in this evolutionary process will keep the Guide at the forefront of the profession. Ben F Massey, Jr, PT President American Physical Therapy Association

Named Works: Guide to Physical Therapist Practice (Book) Source Citation:Massey, Ben F Jr. "Foreword to the Second Edition January 2001." Physical Therapy 81.1 (Jan 2001): 13. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 3

On the Second Edition of the Guide.(Guide to Physical Therapist Practice).Jules M Rothstein. Physical Therapy 81.1 (Jan 2001): p6. (1458 words)


We begin the year with something different from the Journal's usual content--the second edition of the Guide to Physical Therapist Practice. This document was developed by APTA to encourage a uniform approach to physical therapist practice and to explain to the world the nature of that practice. This document has been in development for almost a decade. (See box on page 8 for an outline of the process used to develop the Guide; further description is given in the Guide's Introduction.) As the document itself emphasizes, the Guide is not a set of clinical guidelines, nor is it a set of protocols or a listing of approved tests or interventions. The Guide forms a framework for describing and implementing practice. The patient/client management model put forth by the Guide appears to be widely used and has provided physical therapists with a common conceptual approach to patient care, and in this way the Guide has proven that it could be an invaluable adjunct to our literature. The second edition contains expanded sections on such topics as diagnosis by physical therapists and the disablement model. As with the first edition, much of what appears in the second edition will be helpful to physical therapists in all areas of practice. And, as with the first edition, for both practical and philosophical reasons, preferred practice patterns are supplied for a limited number of conditions. If the Guide is to continue playing a salutary role in our profession, physical therapists need to understand what this new edition is--and what it is not. As indicated in the Guide's Introduction, the Guide initially was developed in response to requests from legislative bodies. Given the nature of that impetus, a process was developed and used to generate the Guide. I believe that the process was credible and resulted in an important document that has helped to shape physical therapy as it now exists. The process was not a peer-review process such as that used by scholarly journals, and it did not result in the development of clinical guidelines that are in line with current expectations of evidence-based practice. That was not the Guide's purpose. Clinical guidelines are the product of intense scrutiny of the literature, and they are developed using methods that are applied by experts with publication records who have knowledge in guideline development. The distinctions between clinical guidelines and the Guide were understood by the Association's leadership and the Guide's developers and are acknowledged in the Guide. The process used to generate both the first and second editions of the Guide resulted in the description of what are called "preferred practice patterns for selected patient/client diagnostic groups." Whether these patterns will give rise over time to clinical guidelines that have a more scholarly foundation or research support is up to the profession and our clinical researchers. But we need to keep in mind that what we now have in the Guide are the opinions of our colleagues on how to manage our patients and clients--and that is very different from evidence for practice.



Page 2 of 3

Both the document and the discussion that led to its creation have benefited the profession, and all those who worked on the Guide editions deserve our appreciation. The Guide, however, is a work in progress, and I hope that the next edition will appear soon--one that will be created not because of political necessity but because of our need to codify a growing body of scientific knowledge. Given APTA's Clinical Research Agenda for Physical Therapy (Phys Ther. 2000;80:499-513), it is clear that we need more data, and we should share pride in a profession that is willing to recognize its limitations and its responsibilities. The Guide can be viewed as an attempt to develop the best possible document from a body of clinical literature that still contains too many unanswered questions. Too often in the development of the Guide, personal opinions were necessary because of the paucity of data. We should look forward to a third edition that relies less on personal views and more on the evidence that becomes available in the public arena, evidence that deals directly with clinical practice and that has been published in peer-reviewed literature. Again, we see the importance of the Clinical Research Agenda and the necessity of supporting the Foundation for Physical Therapy. There were six purposes for creating the Guide (page S16). Every reader should consider to what extent those purposes were met and to what extent they could be met. For instance, I believe that the process used to develop the Guide could never achieve the stated goal of "standardizing terminology used in and related to physical therapist practice." I believe that the Guide instead contains an official or semi-official version of how terms should be used. As a peer-reviewed journal, therefore, Physical Therapy will continue to depend on the preponderance of scientific literature for the evolution of terms and definitions. The Guide was designed to "delineate" tests, interventions, and preferred practice patterns. If we use the traditional definition of delineate, the Guide should accurately convey what the tests, interventions, and preferred practice patterns are. In other words, the Guide should provide lists, which it does--and I believe that is good, because the structure of the Guide does not allow for critical evaluation of tests and interventions. Nonetheless, value judgments are expressed when it comes to a listing of preferred practice patterns. By listing what is preferred, the developers have made an assertion that the Guide describes what is thought to be best. We should be reminded, however, that preferring something is not the same as having evidence that something is better than something else. Here again we have the basic difference between clinical guidelines and the preferred practice patterns. Guidelines should be developed based on evidence that speaks to the benefits of a form of intervention, whereas the preferred practice patterns are patterns that are considered by the Guide developers to be the most commonly used or the most appropriate. Because of the extraordinary effort of many people, the Journal this month is publishing something that can greatly enhance practice--when it is properly used. If the Guide is viewed as containing immutable truths, however, we will be using it incorrectly. My hope is that the next edition of the Guide will be based primarily on evidence--and that physical therapists will use that evidence. Guide to Physical Therapist Practice, Second Edition In the August 1995 issue of Physical Therapy, the American Physical Therapy Association (APFA) published A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management. Development continued with the addition of Volume II to delineate preferred practice patterns. Volumes I and II were combined to become Parts One and Two of a single document--Guide to Physical Therapist Practice--which was published in the Journal in November



Page 3 of 3

1997. Revisions were made to the Guide based on input from both the general membership and the leadership of APTA and based on changes in APTA House of Delegates policies. These revisions were published in the June 1999 and November 1999 issues of Physical Therapy. Throughout 1999 and 2000, a Board-appointed Project Advisory Group revised Parts One and Two of the Guide to further refine and clarify terminology and definitions used in the Guide. The result--the second edition of the Guide (Parts One and Two)--is being published in this issue of the Journal. In 1998, APTA began development of Part Three of the Guide to catalog the tests and measures that are used by physical therapists in the examination of patients/clients and in the documentation of patient/client management outcomes. (This part of the Guide, intended as a reference work, will be available on CD-ROM only.) One task force was charged by APTA's Board to examine the available literature pertaining to tests and measures that are used in the assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. Another task force was charged to examine the available literature on tests and measures of health status, health-related quality of life, and patient/client satisfaction. Field reviews were conducted, using APTA's Board, all APTA components (sections and state chapters), a sample of clinical specialists certified by the American Board of Physical Therapy Specialties (ABPTS), and APTA's general membership. Presentations of the work-in-progress were made at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1999 and 2000. The Part Three task forces also developed a template for documenting the history and systems review components of examination and for documenting intervention, based on the essential data elements of patient/client management described in the Guide. The template (Appendix 6 of the Guide) were reviewed by all APTA components (sections and state chapters), a sample of certified clinical specialists, and APTA's general membership. Jules M Rothstein, PT, PhD, FAPTA Editor

Named Works: Guide to Physical Therapist Practice (Book) Source Citation:Rothstein, Jules M. "On the Second Edition of the Guide." Physical Therapy 81.1 (Jan 2001): 6. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 13

Guide to Physical Therapist Practice: Revisions.Physical Therapy 79.6 (June 1999): p623. (3424 words)


In November 1997, Physical Therapy published APTA's Guide to Physical Therapist Practice (Guide). As explained in its introduction, the Guide "represents expert consensus and contains preferred practice patterns describing common sets of management strategies used by physical therapists for selected patient/client diagnostic groups." The Guide is an evolving document. In April 1999, APTA published a revised edition that contains ICD-9-CM code corrections and clarifications of terms. Parts Three and Four of the Guide, scheduled for publication in 2000, will focus on a minimum data set for physical therapist examination and on the reliability and validity of measurements obtained using specific tests and measures. The following pages list revisions that have been made to the Guide since 1997. PDF versions of some of the revised Guide pages are available at APTA's Web site (http://www.apta.org). For more information about the Guide, contact APTA's Department of Practice at 800/999-2782, ext 3176, or write to GUIDE, Division of Practice and Research, d, 1111 North Fairfax Street, Alexandria, VA 22314-1488. The revised Guide is available through APTA's Service Center, ext 3395 or via e-mail at [email protected]. If you use the version of the Guide that was published in the November 1997 issue of Physical Therapy or the book version of the Guide that was published in 1997, please note the following changes (in shaded text): Musculoskeletal Practice Patterns Pattern E: Impaired Joint Mobility Muscle Performance, and Range of Motion Associated With Ligament or Other Connective Tissue Disorders Page 4E-2 ICD-9-CM code 729 was incorrectly worded. It has been changed to: 729 Other disorders of soft tissues 729.9 Other and unspecified disorders of soft tissue Imbalance of posture Pattern F: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation Page 4F-2 ICD-9-Cm code 726.6 was incomplete. It has been change to: 726.6 Enthesopathy of knee Bursitis of knee, not otherwise specific



726.60

Page 2 of 13

Enthesopathy of knee, unspecified

Pattern G: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, or Reflex Integrity Secondary to Spinal Disorders Page 4G-2 ICD-9-CM codes 723.0 and 724.0 were incorrectly worded. They have been changed to: 723.0 Spinal stenosis in cervical region 424.0 Spinal stenosis, other than cervical Pattern H: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With Fracture Page 4H-2 ICD-9-CM codes 715 and 821 were incorrectly worded. They have been changed to: 715 Osteoarthrosis and allied disorders 821 Fracture of other and unspecified parts of femur Cardiopulmonary Practice Patterns Pattern C: Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity Associated With Airway Clearance Dysfunction Page 6C-2 ICD-9-CM code 507.0 was incorrectly identified as 507.7 and has been changed to: 507.0 Due to inhalation of food or vomitus Aspiration pneumonia Pattern G: Impaired Ventilation With Mechanical Ventilation Secondary to Ventilatory Pump Dysfunction Page 6G-2 ICD-9-CM codes 518 and 786.9 were incorrectly worded. They have been changed to: 518 786.9

Other diseases of lung 518.8 Other diseases of lung Other symptoms involving respiratory system and chest

Pattern H: Impaired Ventilation and respiration (Gas Exchange) With Potential for Respiratory Failure Page 6H-2 ICD-9-CM procedures code 54 was incorrectly worded. It has been changed to: 54 Other operations on abdominal region Pattern I: Impaired Ventilation and Respiration (Gas Exchange) With Mechanical Ventilation Secondary to Respiratory Failure



Page 3 of 13

Page 6I-2 ICD-9-CM code 507.0 was incorrectly identified as 507 and has been changed to: 507.0 Due to inhalation of food or vomitus Aspiration pneumonia Integumentary Practice Patterns Pattern A: Primary Prevention/Risk Factor Reduction for Integumentary Disorders Page 7A-3 Added to the ICD-9-CM codes: 995 Certain adverse effects not elsewhere classified Pattern C: Impaired Integumentary Integrity Secondary to Partial-Thickness Skin Involvement and Scar Formation Page 7C-3 ICD-9-CM code 943.2 was incorrectly worded. It has been changed to: 943.2 Blisters, epidermal loss[ second degree] Appendix Page Appendix 2-1 APTA's Standards of Practice for Physical Theraphy and the Criteria was updated to the version approved by the APTA Board of Directors in March 1997, which can be found in the January 1999 issue of the Journal. Numerical Index to ICD-9-CM Codes [Pneumonitis] Due to inhalation of food or vomitus was incorrectly identified as ICD-9-CM code 507 it has been changed to 507.0. ICD-9-Cm code 719.8 Other specified disorders of joint is now listed as appearing in the following patterns only: 4A, 4D, 4G, 4H, 4I. Alphabetical Index to ICD-9-CM Codes Atherosclerosis (440) is now listed as appearing in the following patterns only: 6D, 6E, 7A, 7E. Burn of lower limb(s) (945) is now listed as appearing in the following patterns only: 6G, 7B, 7C, 7D The following codes have been deleted from Burn of lower limb(s) (945): Deep necrosis of uynderlying tissues [deep third degree] with loss of a body part (945.2) Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body (945.4)



Page 4 of 13

Chronic airway obstruction, not elsewhere classified has been deleted. Complications of procedures, not elsewhere classified, other (998) is now listed as appearing in patterns 4D and (not 7F). [Pneumonitis] Due to inhalation of food or vomitus was incorrectly identified as ICD-9-CM code 507.1 and has been corrected to 507.0. Pulmonary embolism and infarction (415.1) is now listed as appearing in pattern 61 (not 6E). Rheumatoid arthritis and other inflammatory polyarthropathies (714) is now listed as appearing in the following patterns only: 4A, 4C, 4D, 41, 6B. If you use the Guide that was published in the November 1997 issue of Physical Therapy, the book version of the Guide that was published in 1997, the second printing (1998) of the Guide, or CD-ROM version 1998 of the Guide, please note the following changes (in shaded text): Some Important Global Changes "Represented and Reimbursed as Physical Therapy" In Part One of the Guide, the statement intended specifically for payers ("an examination, evaluation, or intervention-unless performed by a physical therapist or under the direction and supervision of a physical therapist--is not physical therapy, nor should it be represented or reimbursed as such") was clarified and expanded: Examination, evaluation, diagnosis, and prognosis are physical therapy--and should be represented and reimbursed as physical therapy--only when they are performed by a physical therapist. Intervention is physical therapy--and should be represented and reimbursed as physical therapy--only when performed by a physical therapist or under the direction, delegation, and supervision of a physical therapist. From "Desired Outcomes" to "Expected Outcomes" To emphasize that outcomes of patient/client management can and should be expected in a profession that is based in science, desired outcomes has been changed to expected outcomes. Discharge The definition of discharge has has been clarified: Discharged occurs at the end of an episode of care and is the end of physical therapy services that have been provided during that episode. The primary criterion for discharge: The anticipated goals and the expected outcomes have been achieved. In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. Discharge does not occur with transfer, that is, when a patient is moved from one site to another site within the same setting or across settings during a single episode of care; however, ther may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services as the patient moves between sites or across settings during that episode of care ...



Page 5 of 13

A new term, discontinuation of physical therapy services, has been added: Discontinuation of physical therapy services occurs when (1) the patient/client, caregiver, or legal guardian declines to continue intervention, (2) the patient/client is unable to continue to progress toward goals because of medical or psychosocial complications or because financial/insurance resources have been expended, or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy.... Tumor versus Neoplasm Based on preferred usage in the current health care literature, neoplasm has replaced tumor in most instances. Other New or Revised Definitions Airway Clearance Techniques The definition of airway clearance techniques has been clarified to include: a broad group of activities used to manage or prevent consequences of acute and chronic lung diseases and impairment, including those associated with surgery. impaired mucociliary transport or impaired cough. Airway clearance techniques may be used with therapeutic exercise, manual therapy techniques, or mechanical modalities to improve airway protection, ventilation, and respiration. Episode of Care The definition of episode of care has been expanded: All patient/client management activities provided, directed, or supervised by the physical therapist, from initial contact through discharge. Episode of physical therapy care: Physical therapy services provided in an unbroken sequence and related to physical therapist intervention for a given condition or problem or related to a request from the patient/client, family, or other health care provider. May include transfers between sites within or across settings or reclassification of the patient/client diagnostic group. Reclassification may alter the expected range of number of visits and therefore may shorten or lengthen the episode of care. If reclassification involves a condition, problem, or request that is not related to the initial episode of care. a new episode of care may be initiated. Episode of physical therapy maintenance: A series of occasional clinical, educational, and administrative services related to maintenance of current function. Episode of physical therapy prevention: A series of occasional clinical, educational, and administrative services related to primary and secondary prevention, wellness, health promotion, and preservation of optimal function. Manual Therapy Techniques, Manipulation, and Mobilization The definitions of manual therapy techniques, manipulation, and mobilization have been clarified: Manipulation



Page 6 of 13

A skilled passive hand movement that usually is performed with a small amplitude at a high velocity at the end of the available range of motion. Manual Therapy Techniques A broad group of skilled hand movements, including but not limited to mobilization and manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints for the purpose of modulating pain; increasing range of motion; reducing or eliminating soil tissue swelling, inflammation, or restriction; inducing relaxation; improving contractile and noncontractile tissue extensibility; and improving pulmonary function. Mobilization A skilled passive hand movement at the end of the available range of motion that can be performed with variable speeds. Manipulation is one type of mobilization. Physical Therapist Assistant To be consistent with APTA policy (Direction, Delegation and Supervision in Physical Therapy Services, HOD 06-96-30-42), the definition has been changed: The physical therapist assistant is a technically educated health care provider who assists the physical therapist in the provision of physical therapy. The physical therapist assistant is a graduate of a physical therapist assistant associate degree program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). Visit The following definition has been added: All encounters with a patient/client in a 24-hour period are summed as "one visit." Range of visits: All visits within a single episode of care. The range may be adjusted based on factors that may require a new episode of care or that may modify frequency of and duration of episode. The following items were defined within the Guide but were not included in the original Glossary. They have been added to the Glossary as an aid to payers: Goals Goals generally relate to the remediation (to the extent possible) of impairments. Respiration Primarily, the exchange of oxygen and carbon dioxide across a membrane into and out of the lungs and at the cellular level. Ventilation The movement of a volume of gas into and out of the lungs. Musculoskeletal Practice Patterns



Page 7 of 13

Pattern 4C: Impaired Muscle Performance Page 4C-1 Upper and lower motor neuron disease has been deleted from the patient/client diagnostic group exclusions. Page 4C-2 Deleted from the ICD-9-CM codes: 781.0 Abnormal involuntary movements Pattern 4G: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, or Reflex Integrity Secondary to Spinal Disorders Page 4G-2 Added to the ICD-9-CM codes: 724.3 Sciatica Neuromuscular Practice Patterns Pattern 5A: Impaired Motor Function and Sensory Integrity Associated With Congenital or Acquired Disorders of the Central Nervous System in Infancy, Childhood, and Adolescence Page 5A-1 Nonprogressive neoplasm has been added to the list of patient/client diagnostic group inclusions. Progressive neoplasm has been added to the list of exclusions. Page 5A-2 Deleted from 331 Other 331.3 331.4

the ICD-9-CM codes: cerebral degenerations Communicating hydrocephalus Obstructive hydrocephalus

Added to the ICD-9-CM codes: 742.3 Congenital hydrocephalus Pattern B: Impaired Motor Function and Sensory Integrity Associated With Acquired Nonprogressive Disorders of the Central Nervous System in Adulthood Page 5B-1 Nonprogressive neoplasm and central vestibular disorders have been added to the list of patient/client diagnostic group inclusions. Progressive neoplasm has been added to the list of exclusions. Page 5B-2 Several ICD-9-CM codes have been added:



Page 8 of 13

049 Other non-arthropod-borne viral diseases of the central nervous system 049.9 Unspecified non-arthropod-borne viral diseases of the central nervous system Viral encephalitis, not otherwise specified 225 Benign neoplasm of brain and other parts of nervous system 320 Bacterial meningitis system 320.9 Meningitis due to unspecified bacterium 321 Meningitis due to other organisms 321.8 Meningititis due to other nonbacterial organisms classified elsewhere 322 Meningitis of unspecified cause 322.9 Meningitis, unspecified 323 Encephalitis, myelitis, and encephalomyelitis 323.4 Other encephalitis due to intection classified elsewhere 323.5 Encephalitis following immunization procedures 323.6 Postintectious encephalitis 323.8 Other causes of encephalitis 323.9 Unspecified cause of encephalitis 331 Other cerebral degenerations 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 342 Hemiplegia and hemiparesis 343 Infantile cerebral palsy 345 Epilepsy 345.1 Generalized convulsive epilepsy 345.2 Petit mal status 345.3 Grand mal status 345.4 Partial epilepsy, with impairment of consciousness Epilepsy: partial: secondarily generalized 345.5 Partial epilepsy, without mention of impairment of consciousness Epilepsy: sensory-induced 345.9 Epilepsy, unspecified 348 Other conditions of brain 348.0 Cerebral cysts 348.1 Anoxic brain damage 348.3 Encephalopathy, unspecified 386 Vertiginous syndromes and other disorders of vestibular system 386.5 Labyrinthine dystunction 431 Intracerebral hemorrhage 433 Occlusion and stenosis of precerebral arteries 434 Occlusion of cerebral arteries 435 Transient cerebral ischemia 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 442 Other aneurysm 442.8 Of other specified artery 444 Arterial embolism and thrombosis 444.9 Of unspecified artery 447 Other disorders of arteries and arterioles



Page 9 of 13

447.1 Stricture of artery 741 Spina bifida 742 Other congenital anomalies of nervous system 747 Other congenital anomalies of circulatory system 747.8 Other specified anomalies of circulatory system 756 Other congenital musculoskeletal anomalies 756.1 Anomalies of spine 765 Discorders relating to short gestation and unspecified low birthweight 767 Birth trauma 767.0 Subdural and cerebral hemorrhage 767.9 Birth trauma unspecified 768 Intrauterine hypoxia and birth asphyxia 768.5 Severe birth asphyxia 768.6 Mild or moderate birth asphyxia 768.9 Unspecified birth asphyxia in liveborn infant 771 Infections specific to the perinatal period 771.2 Other congenital infections Congenital toxoplasmosis 780 General symptoms 780.3 Convulsions 781 Symptoms involving nervous and musculoskeletalsystems 781.2 Abnormality of gait Gait: ataxic 781.3 Lack of coordination Ataxia, not otherwise specified 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 800 Fracture of vault of skull 801 Fracture of base of skull 803 Other and unqualified skull fractures 804 Multiple fractures involving skull or face with other bones 850 Consussion 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage following injury 853 Other and unspecified intracranial hemorrhagefollowing injury 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drowning and nonfatal submersion Pattern 5C: Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System in Adulthood Page 5C- 1 Malignant brain tumor has been deleted from the list of patient/client diagnostic group inclusions. Progressive neoplasm has been added to the list of exclusions. Page 5C-2 Several ICD-9-CM codes have been added: 042 Human immunodeficiency virus (HIV) disease 191 Malignant neoplasm of brain



Page 10 of 13

192 Malignant neoplasm of other and unspecified parts of nervous system 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 331 Other cerebral degenerations 331.0 Alzheimer's disease 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.0 Other degenerative diseases of the basal ganglia 333.3 Tics of organic origin 333.4 Huntington's chorea 333.9 Other and unspecified extrapyramidal disease and abdominal movement disorders 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 334.3 Other cerebellar ataxia 334.8 Other spinocerebellar diseases 335 Anterior horn cell disease 335.2 Motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 341 Other demyelinating diseases of central nervous system 341.8 Other demyelinating diseases of central nervous system Central demyelination of corpus callosum 341.9 Demyelinating disease of central nervous system, unspecified 345 Epilepsy 345.4 Partial epilepsy, with impairment of consciousness Epilepsy: partial: secondarily generalized 345.5 Partial epilepsy, without mention of impairment of consciousness Epilepsy: sensory-induced 348 Other conditions of brain 348.9 Unspecified condition of brain 780 General symptoms 780.3 Convulsions 781 Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait Gait: ataxic 781.3 Lack of coordination Ataxia, not otherwise specified Pattern 5D: Impaired Motor Function and Sensory Integrity Associated With Peripheral Nerve Injury Page 5D-1 Peripheral vestibular disorders (eg, labyrinthitis, parozysmal positional vertigo) has been added to the list of patient/client diagnostic group inclusions. Page 5D-2



Page 11 of 13

Several ICD-9-CM codes have been added: 225 Benign neoplasm of brain and other parts of nervous system 225.1 Cranial nerves 350 Trigeminal nerve disorders 350.1 Trigeminal neuralgia 352 Disorders of other cranial nerves 352.4 Disorders of accessory (11 th) nerve 352.5 Disorders of hypoglossal (12th) nerve 352.9 Unspecified disorder of cranial nerves 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.6 Phantom limb (syndrome) 354 Mononeuritis of upper limb and mononeuritis multiplex 354.2 Lesion of ulnar nerve 354.3 Lesion of radial nerve 355 Mononeuritis of lower limb and unspecified site 357 Inflammatory and toxic neuropathy 357.1 Polyneuropathy in collagen vascular disease 386 Vertiginous syndromes and other disorders of the vestibular system 386.0 Meniere's disease 386.03 Active Meniere's disease, vestibular 386.1 Other and unspecified peripheral vertigo 386.3 Labyrinthitis Pattern 5E: Impaired Motor Function and Sensory Integrity Associated With Acute or Chronic Polyneuropathies Page 5E-2 Added to the ICD-9-CM codes: 357.0 Acute infective polyneuritis (Guillain-Barre syndrome) Pattern 5F: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Spinal Cord Page 5F-2 Deleted from the ICD-9-CM codes: 192

198

Malignant neoplasm of other and unspecified parts of nervous system 192.2 Spinal cord Cauda eguina Secondary malignant neoplasm of other specified sites 198.3 Brain and spinal cord

Cardiopulmonary Practice Patterns Pattern 6H: Impaired Ventilation and Respiration (Gas Exchange) With Potential for Respiratory Failure Page 6H-2



Page 12 of 13

Deleted from the ICD-9-CM codes: 770

Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory disease arising in the perinatal period Bronchopulmonary dysplasia

Pattern 6I: Impaired Ventilation and Respiration (Gas Exchange) With Mechanical Ventilation Secondary to Respiratory Failure Page 6I-1 Immediate posttransplant (heart of lung or both), multisystem trauma, and sepsis have been added to the list of patient/client diagnostic group inclusions. Page 6I-2 Deleted from the ICD-9-CM codes: 770

Other respiratory conditions of fetus and newborn 770.4 Primary atelactasis 770.7 Chronic respiratory diseases arising in the perinatal period Bronchopulmonary dysplasia

Integumentary Practice Patterns Pattern 7A: Primary Prevention/Risk Factor Reduction for Integumentary Disorders Page 7A-1 Break in skin integrity has been added to the list of patient/client diagnostic group exclusions. Page 7A-6 Total body surface area (TBSA) of burn has been deleted from the list of "Factors That May Modify Frequency of Visits." Pattern B: Impaired Integumentary Integrity Secondary to Superficial Skin Involvement Page 7B-1 Any break in skin integrity has been deleted from the list of patient/client diagnostic group exclusions. Pattern 7E: Impaired Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone Page 7E-1 The title of this pattern has been corrected to "Impaired Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone ans Scar Formation."



Page 13 of 13

Page 7F: Impaired Anthropometric Dimensions Secondary to Lymphatic System Disorders Page 7F-8 Under "specific direct interventions for "Physical Agents and Mechanical Modalities," the following items have been deleted: Compression therapies (eg, all compression devices, compression bandaging, compression garments) Continuous passive motion (CPM) Appendixes Guidelines for Physical Therapy Documentation has been updated to the version approved by APTA's Board of Directors in November 1998. Guide for Professional Conduct has been updated to the version approved by APTA's Ethics and Judicial Committee in January 1999. These updated versions can be obtained through APTA's Service Center, 800/999-2782, ext 3395, or [email protected]. Numerical and Alphebetical Indexes to ICD-9-CM Codes All of the above changes have been reflected in the Indexes. In addition, the following corrections have been made: Enthesopathy of knee, unspesified 726.60.... 4F has been added. Viral encephalitis is listed under Infectious and parasitic diseases, other and unspecified.

Named Works: Guide to Physical Therapist Practice (Book) Analysis Source Citation:"Guide to Physical Therapist Practice: Revisions." Physical Therapy 79.6 (June 1999): 623. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 5

How and Why Was the Guide Developed?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p23. (1665 words)


During the early 1990s, state legislative bodies began to request that health care professionals develop practice parameters. In February 1992, at the request of one of the American Physical Therapy Association's (APTA) state components, APTA's Board of Directors embarked on a process to determine whether practice parameters could be delineated for the profession of physical therapy. The Board initiated development of a document that would describe physical therapist practice-content and processes--both for members of the physical therapy profession and for health care policy makers and third-party payers. The initial foundation for the document was laid by the Board-appointed Task Force on Practice Parameters, whose work led to the appointment of the Task Force to Review Practice Parameters and Taxonomy. The deliberations of these task forces and the materials that they produced resulted in the Board's development of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management ("Volume I").[1] This document was approved in March 1995 by the Board. In June 1995, APTA's House of Delegates approved the conceptual framework on which Volume I was based and endorsed the Board's plan to develop Volume II using a process of expert consensus. Volume I was published in the August 1995 issue of Physical Therapy. Volume II was to be "composed of descriptions of preferred physical therapist practice for patient groupings defined by common physical therapist management:" [Report to the 1997 House of Delegates, Processes to Describe Physical Therapy Care for Specific Patient Conditions, RC 3295] A Board-appointed Project Advisory Group and a Board Oversight Committee were charged to lead the Volume II project. The members of the Project Advisory Group were chosen on the basis of the following criteria: * Broad knowledge of physical therapy * Understanding of clinical policy development * Familiarity with research in physical therapy * Recognized decision-making abilities In June 1995, the Project Advisory Group and the Board Oversight Committee met to refine the project design. That September, the Committee selected 24 physical therapists to serve on one: of four panels: cardiopulmonary, integumentary, musculoskeletal, and neuromuscular. Each Project Advisory Group member was assigned as a liaison to one of the panels. Criteria for selection of panel members included the following: * Experience in the subject area



Page 2 of 5

* Knowledge of physical therapy literature * Understanding of research and the use of data * Expertise in documentation * Experience in peer review * Knowledge of broad areas of physical therapy * Recognized ability to work with groups and reach a consensus * Openness to a variety of treatment philosophies * Willingness to commit to the entire project Consideration also was given to creating panels whose collective clinical experience would represent a wide range of patient/client age groups and practice settings. Between October 1995 and September 1996, the panels developed preferred practice patterns that were subsequently reviewed by more than 200 select reviewers. In addition, each pattern was reviewed by APTA's Risk Management Committee, by physical therapists with reimbursement expertise, by APTA's Reimbursement Department, and by APTA's legal counsel. In December 1996, revised drafts of the patterns were sent for broad-based review to more than 600 reviewers, to APTA chapter and section presidents, to APTA members with risk management and reimbursement expertise, and to other select reviewers. Input from the general membership was obtained during open forums at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1996 and 1997. In early 1997, Volume I and Volume II became Part One and Part Two of a single document ("the Guide"). Revisions were made to Part One to reflect Part Two. In March 1997, the Board of Directors approved the draft of Part Two; in June 1997, the House of Delegates approved the conceptual framework on which Part Two is based. The first edition of the Guide was published in the November 1997 issue of Physical Therapy.[2] In 1998 and 1999, revisions were made to the Guide based on (1) input from both the general membership and the leadership of APTA and (2) changes in House of Delegates policies. These revisions were published in Physical Therapy.[3,4] During this period, the Association developed forms (Appendix 6) to be used in clinical practice (both inpatient and outpatient settings) for documenting the five elements of patient/client management that are described in the Guide: examination, evaluation, diagnosis, prognosis (including plan of care), and interventions. In addition, a patient/client satisfaction assessment was developed for inclusion in the Guide (Appendix 7).[5] In 1998, APTA began development of Part Three of the Guide to catalog the armamentarium of tests and measures that are used by physical therapists in the examination of patients/clients and in the documentation of patient/client management outcomes. (This part of the Guide, intended as a reference work, is available on CD-ROM only.) One task force was charged by APTA's Board to examine the available literature pertaining to tests and measures that are used in the assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. Another task force was charged to retrieve and review the available literature on tests and measures of health status, health-related quality of life, and patient/client satisfaction.



Page 3 of 5

The two task forces met throughout 1999 and 2000 to search the peer-reviewed literature and develop a comprehensive list of tests and measures that are used in physical therapist practice. Field reviews were conducted, using APTA's Board, all APTA components (sections and state chapters), a sample of clinical specialists certified by the American Board of Physical Therapy Specialties (ABPTS), and APTA's general membership. Presentations of the work-in-progress were made at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1999 and 2000. To complete their charge to catalog the armamentarium of tests and measures that are used in physical therapist practice, the two task forces refined the template for documenting the history and systems review components of examination and for documenting intervention, based on the essential data elements of patient/client management described in the Guide. The template (Appendix 6) was reviewed by all APTA components (sections and state chapters), a sample of clinical specialists certified by ABPTS, and APTA's general membership. Also throughout 1999 and 2000, Board-appointed Project Editors revised Part One and Part Two of the Guide to reflect input from the general membership, the Task Force on Development of Part Three of the Guide to Physical Therapist Practice (Second Edition), and the leadership of APTA and to refine and clarify terminology and definitions used in the Guide. Purposes of the Guide APTA developed the Guide to Physical Therapist Practice as a resource not only for physical therapist clinicians, educators, researchers, and students, but for health care policy makers, administrators, managed care providers, third-party payers, and other professionals. The Guide serves the following purposes: 1. To describe physical therapist practice in general, using the disablement model as the basis. 2. To describe the roles of physical therapists in primary, secondary, and tertiary care; in prevention; and in the promotion of health, wellness, and fitness. 3. To describe the settings in which physical therapists practice. 4. To standardize terminology used in and related to physical therapist practice. 5. To delineate the tests and measures and the interventions that are used in physical therapist practice. 6. To delineate preferred practice patterns that will help physical therapists (a) improve quality of care, (b) enhance the positive outcomes of physical therapy services, (c) enhance patient/client satisfaction, (d) promote appropriate utilization of health care services, (e) increase efficiency and reduce unwarranted variation in the provision of services, and (f) diminish the economic burden of disablement through prevention and the promotion of health, wellness, and fitness initiatives. The Guide does not provide specific protocols for treatments, nor are the practice patterns contained in the Guide intended to serve as clinical guidelines. Clinical guidelines usually are based on a comprehensive search and systematic evaluation of peer-reviewed literature. The Institute of Medicine has defined clinical guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [emphasis added]."[6,7] The Guide was developed using expert consensus to



Page 4 of 5

identify common features of patient/client management for selected patient/client diagnostic groups. The Guide is a first step toward the development of clinical guidelines in that it provides patient/client diagnostic classifications and identities the array of current options for care. The preferred practice patterns identify the breadth of physical therapist practice. They are the boundaries within which the physical therapist may select and implement any of a number of clinical alternatives based on consideration of a wide variety of factors, including individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. The Guide is not intended to set forth the standard of care for which a physical therapist may be legally responsible in any specific case. Future Development of the Guide The Guide to Physical Therapist Practice is an evolving document that will be systematically revised as the physical therapy profession's knowledge base, scientific literature, and outcomes research develop and as examination and intervention strategies change. The Guide is the structure on which scientific evidence will be fastened, and, in turn, the evidence will reshape the structure. Notification of revisions will be published annually in Physical Therapy and will be posted on APTA's Web site (www.apta.org). [TABULAR DATA NOT REPRODUCIBLE IN ASCII] References [1] A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management. Plays Ther. 1995;75:707-764. [2] Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650. [3] Guide to Physical Therapist Practice. Revisions. Phys Ther. 1999;623-629. [4] Guide to Physical Therapist Practice. Revisions. Phys Ther. 1999;1078-1081. [5] Goldstein MS, Elliott SD, Guccione AA. The development of an instrument to measure satisfaction with physical therapy. Phys Ther. 2000;80:853-863. [6] Field M, Lohr K, eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: Institute of Medicine, National Academy Press; 1990. [7] Field M, Lohr K, eds. Guidelines for Clinical Practice: From Development to Use. Washington, DC: Institute of Medicine, National Academy Press; 1992.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"How and Why Was the Guide Developed?." Physical Therapy 81.1 (Jan 2001): 23. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .



Page 5 of 5





Page 1 of 9

On What Concepts Is the Guide Based?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p27. (3448 words)


Three key concepts serve as the building blocks of the Guide and as the foundation of physical therapist practice: * The disablement model typifies physical therapist practice and is the model for understanding and organizing practice. * Physical therapist practice addresses the needs of both patients and clients through a continuum of service across all delivery settings--in critical and intensive care units, outpatient clinics, longterm care facilities, school systems, and the workplace--by identifying health improvement opportunities, providing interventions for existing and emerging problems, preventing or reducing the risk of additional complications, and promoting wellness and fitness to enhance human performance as it relates to movement and health. Patients are recipients of physical therapist examination, evaluation, diagnosis, prognosis, and intervention and have a disease, disorder, condition, impairment, functional limitation, or disability; clients engage the services of a physical therapist and can benefit from the physical therapist's consultation, interventions, professional advice, prevention services, or services promoting health, wellness, and fitness. * Physical therapist practice includes the five essential elements of patient/client management (examination; evaluation; diagnosis; prognosis, including the plan of care; and intervention), which incorporate the principles of the disablement model. The Disablement Model The concept of disablement refers to the "various impact(s) of chronic and acute conditions on the functioning of specific body systems, on basic human performance, and on people's functioning in necessary, usual, expected, and personally desired roles in society."[1,2] Thus, the disablement model is used to delineate the consequences of disease and injury both at the level of the person and at the level of society. The disablement model provides the conceptual basis for all elements of patient/client management that are provided by physical therapists. The Guide uses an expanded disablement model[3,4] that provides both the theoretical framework for understanding physical therapist practice and the classification scheme by which physical therapists make diagnoses. A number of disablement models have emerged during the past 3 decades; three models are shown in Figure 1. All of the disablement models attempt to better delineate the interrelationships among disease, impairments, functional limitations, disabilities, handicaps, and the "effects of the interaction of the person with the environment,"[5] though the effects themselves may be defined differently from model to model. Nagi, a sociologist, was among the first to begin to challenge the appropriateness of the traditional medical classification of disease for understanding the genesis of disability. He put forth a



Page 2 of 9

theoretical formulation based on the concepts of disease or active pathology, impairment, functional limitation, and disability? Based on Nagi's model, active pathology is the interruption of or interference with normal processes and the simultaneous efforts of the organism to restore itself to a normal state by mobilizing the body's defense and coping mechanisms; impairment is any loss or abnormality of anatomical, physiological, mental, or psychological structure or function; functional limitation is the restriction of the ability to perform a physical action, task, or activity in an efficient, typically expected, or competent manner at the level of the whole organism or person; and disability is the inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles that are customary for the individual or expected for the person's status or role in a specific sociocultural context and physical environment. In 1980, the World Health Organization (WHO) developed an alternative disablement model. In WHO's International Classification of Impairments, Disabilities, and Handicaps (ICIDH),[9] disease was defined as a pathological change that manifests itself as a health condition that is an alteration or attribute of an individual's health status and that may lead to distress, interference with daily activities, or contact with health services. Impairment was defined as abnormal changes at the molecular, cellular, and tissue levels through abnormal structure or function at the organ level; disability, as the restriction in or lack of ability to perform common activities in a manner or within a range considered normal; and handicap, as the inability to function at the person-toperson level or person-to-environment level. Handicap indicated the social disadvantages related to impairment or disability that limit or prevent fulfillment of a normal role. WHO is revising its original formulation of the disablement model and in December 2000 released a pre-final version, entitled ICIDH-2: International Classification of Functioning, Disability, and Health.[10]

In 1992, the National Center for Medical Rehabilitation and Research (NCMRR) published a



Page 3 of 9

disablement model that was derived from both the Nagi and WHO models and that used the classifications of pathophysiology, impairment, functional limitation, disability, and societal limitation." The NCMRR model rejected the negative connotation of the term "handicap" and suggested replacing it with the term "societal limitations" to account for the restrictions--imposed by society--that limit people's ability to participate independently in tasks, activities, and roles. In 1991, the Institute of Medicine (IOM) put forth its own disablement model to emphasize prevention, suggesting that disability may be prevented through the control of physical and social environmental risk factors in addition to biological and lifestyle risk factors.[12] Although the various disablement models may seem to be quite different, the concepts in each of them can be "cross-walked" to describe an entire spectrum of experience of illness and disablement. Guide Terminology The terminology selected for the Guide framework is based on the disablement terms developed initially by Nagi (pathology/pathophysiology, impairment, functional limitation, disability) and incorporates the broadest possible interpretation of those terms. Figure 2 shows the scope of physical therapist practice both within the context of the Nagi model and within the continuum of health care services.[4] Pathology/Pathophysiology (Disease, Disorder, or Condition) Pathology/pathophysiology (disease, disorder, or condition) refers to an ongoing pathological/pathophysiological state that is (1) characterized by a particular cluster of signs and symptoms and (2) recognized by either the patient/client or the practitioner as "abnormal." Pathology/pathophysiology (disease, disorder, or condition) is primarily identified at the cellular level and usually is the physician's medical diagnosis. Disease may be the result of infection, trauma, metabolic imbalance, degenerative processes, or other etiologies. Any single disorder may disrupt the anatomical structures and physiological processes of one or more systems. The Guide uses a broad definition of pathology/pathophysiology to include the interruption of normal processes and to include other health threats, injury, and conditions produced by pathological or pathophysiological states. Many of the signs and symptoms that are important to the physical therapist--and many of the conditions that affect a person's ability to function--are not associated with a single active pathology/pathophysiology, nor are they always found to have an impact exclusively on a single system or the system of origin. For example, a patient may have a medical diagnosis that indicates the presence of fixed lesions from previous insults to a body part or organ, but these lesions may not be associated with any current active pathological/pathophysiologic processes. Signs and symptoms also may exist as long-term adaptations to the original disorder or injury. Using the disablement model as a theoretical framework to describe physical therapist practice does not negate the importance of the traditional medical diagnosis (eg, pathology/pathophysiology, injury) in patient/client management by physical therapists. In fact, changes at the cellular, tissue, and organ levels that are associated with disease and injury often may predict the range and severity of impairments at the system level. The diagnosis of multiple sclerosis, for instance, typically requires that the physical therapist understand the fatigue factors that may be associated with the disease and how those factors must be addressed both in examining the patient/client and in providing interventions. A diagnosis of multiple sclerosis by itself, however, tells the physical therapist nothing about the impairments, functional limitations, or disabilities that would be the focus of physical therapy intervention.



Page 4 of 9

Contrast two cases involving a diagnosis of multiple sclerosis. A 79-year-old woman who needs only a posterior splint to walk efficiently and who is able to carry out all activities of daffy living (ADL) and instrumental activities of daily living (IADL) with total independence has very different needs from a 36-year-old woman who is postpartum and wheelchair dependent and who is unable to take care of her family as a result of severe generalized weakness. Both patients/clients have the same medical diagnosis, but the severity of impairments, functional limitations, and disabilities are sharply different. The examination, evaluation, and subsequent diagnosis of those impairments, functional limitations, and disabilities are the key contributions of the physical therapist. The complexity of interconnections among the four components of the disablement model is indicative of the knowledge of pathology and pathophysiology that each physical therapist must bring to bear in addressing impairments, functional limitations, and disabilities. In the case of a patient/client who is referred to a physical therapist with a general diagnosis of "shoulder pain with activity," for instance, the physical therapist has to perform an examination to differentiate among several possible conditions in order to accurately manage the patient. It therefore is important for the physical therapist to understand the many possible underlying causes for the pain. The physical therapist's knowledge that different clusters of signs and symptoms are consistent with underlying conditions--such as angina, osteoarthritis, or prior fracture--is incorporated into the examination, evaluation, and intervention processes. If the clinical findings on examination suggest a pathological or pathophysiological condition that is inconsistent with the referring practitioner's diagnosis, or if the physical therapist notes an underlying pathology or pathophysiology that was not previously identified, the therapist responds appropriately, including returning the patient to the original referring practitioner or making a referral to another practitioner. When the underlying cause is not identified, however, the physical therapist proceeds with the examination by continually testing the signs and symptoms and by providing interventions that are justified by changes in patient/client status. Impairments Impairments typically are the consequence of disease, pathological processes, or lesions. They may be defined as alterations in anatomical, physiological, or psychological structures or functions that both (1) result from underlying changes in the normal state and (2) contribute to illness. Impairments occur at the tissue, organ, and system level, and they are indicated by signs and symptoms. The Guide's diagnostic classification scheme uses the definition "abnormality of structure or function" for its impairment classification. Physical therapists most often quantify and qualify the signs and symptoms of impairment that are associated with movement. Alterations of structure and function, such as abnormal muscle strength, range of motion, or gait, would be classified and diagnosed as impairments by physical therapists.



Page 5 of 9

The origin of some impairments is often' unclear. Poor posture, for example, is neither a disease nor a pathological state; however, the muscle shortening and capsular tightness associated with poor posture are still clinically significant. The physical therapist would diagnose them as impairments that may be remedied by physical therapy intervention. In the physical therapist's examination, impairments typically are measured using noninvasive procedures--even those impairments that are associated with disease, disorders, and medical conditions--and may predict risk for functional limitation or disability. Functional Limitations Functional limitations occur when impairments result in a restriction of the ability to perform a physical action, task, or activity in an efficient, typically expected, or competent manner. In other words, functional limitations occur as a result of the inability to perform the actions, tasks, and activities that constitute the "usual activities" for a given individual, such as reaching for a box on an overhead shelf. Functional limitations are measured by testing the performance of physical and mental behaviors at the level of the person and should not be confused with diseases, disorders, conditions, or impairments involving specific tissue, organ, or system abnormalities that result in signs and symptoms. The concept of functional limitations is based on a consensus about what is "normal." The Guide uses the broad definition of functional limitations to look at the actions, tasks, or activities of that whole person during his or her usual activities. Functional limitations include sensorimotor performance in the execution of particular actions, tasks, and activities (eg, rolling, getting out of bed, transferring, walking, climbing, bending, lifting, carrying). These sensorimotor functional abilities underlie the daily, fundamental organized patterns of behaviors that are classified as basic activities of daily living (ADL) (eg, feeding, dressing, bathing, grooming, toileting). The more complex tasks associated with independent community living (eg, use of public transportation, grocery shopping) are categorized as instrumental activities of daily living (IADL). Successful performance of complex physical functional activities, such as personal hygiene and housekeeping, typically requires integration of cognitive and affective abilities as well as physical ones. Although physical therapists are chiefly concerned with physical function, the effects of physical therapy may go beyond improvement in physical function. For instance, physical therapists may assess patient/client mental function, including a range of such cognitive activities as telling time and calculating money transactions. Attention, concentration, memory, and judgment also may be assessed. Disability The Guide defines disability broadly as the inability or restricted ability to perform actions, tasks, and activities related to required self-care, home management, work (job/school/play), community, and leisure roles in the individual's sociocultural context and physical environment. Disability refers to patterns of behavior that have emerged over periods of time during which functional limitations are severe enough that they cannot be overcome to maintain "normal" role performance. Thus, the concept of disability includes deficits in the performance of ADL and IADL that are broadly pertinent to many social roles. If a person has limited range of motion at the shoulder but bathes independently by using a shower mitt and applies the available range of motion at other joints to best mechanical advantage, that person is not "disabled," even though



Page 6 of 9

functional performance may be extremely limited without the use of an assistive device and altered movement patterns.

Disability is characterized by discordance between actual performance in a particular role and the expectations of the community regarding what are "normal" behaviors in that role. Labeling a person as "disabled" requires a judgment, usually by a professional, that an individual's behaviors are somehow inadequate, based on that professional's understanding of community expectations about how a given activity should be accomplished (eg, in ways that are typical for a person's age, sex, and cultural and social environment). Disability depends on both the capacities of the individual and the expectations that are imposed on the individual by those in the immediate social environment, most often family and caregivers. Changing the expectations of a patient, family, or caregiver in a social context--for example, the physical therapist explaining to family members the level of assistance that is needed for an elder following stroke--may help to diminish disability as much as supplying the patient with assistive devices or increasing the patient's physical ability to use them. Interrelationships Among Disease, Impairments, Functional Limitations, and Disability When the physical therapist has determined which impairments are related to the patient's functional limitations, the therapist must determine which impairments may be remedied by physical therapy intervention. If they cannot be remedied, the physical therapist can help the patient compensate by using other abilities to accomplish the intended goal. The task or the environment also may be modified so that the task can be performed within the restrictions that the patient's condition imposes. These two approaches focus on "enablement" rather than remediation of "disablement," and they may be characterized as the classical physical therapist response to the disablement process.[3,13-17] Disablement models have always included the concept of preventing progression toward disability. "Unidirectional" causal progression--from disease to impairment to functional limitation to disability, handicap, or societal limitation--"inexorably ... without the possibility of reversal"-should not be assumed.[5] In 1997, IOM revised its disablement model to show both the interactions of the person with the environment and the "potential effects of rehabilitation and the `enabling process'" (Fig. 3). The model suggests a bidirectional interaction among the components, in which improvement in one component has an effect on the development or progression of a preceding component. Disability was not included in the model because disability "is not inherent in the individual but, rather, a function of the interaction of the individual and the environment."[5] The "enabling-disabling process," therefore, recognizes that functional limitations and disability may be reversed.[5] Prevention and the Promotion of Health, Wellness, and Fitness in the Context of Disablement Progression from a healthy state to pathology--or from pathology or impairment to disability--does



Page 7 of 9

not have to be inevitable. The physical therapist may prevent impairments, functional limitations, or disabilities by identifying disablement risk factors during the diagnostic process and by buffering the disablement process (Fig. 4). The patient/client management described in the Guide includes three types of prevention:

* Primary prevention. Prevention of disease in a susceptible or potentially susceptible population through specific measures such as general health promotion efforts. * Secondary prevention. Efforts to decrease duration of illness, severity of disease, and sequelae through early diagnosis and prompt intervention. * Tertiary prevention. Efforts to decrease the degree of disability and promote rehabilitation and restoration of function in patients with chronic and irreversible diseases. In the diagnostic process, physical therapists identify risk factors for disability that may be independent of the disease or pathology. The Individual, the Environment, and Health-Related Quality-of-Life Factors Many factors may have an impact on the disablement process (Fig. 4). These factors may include individual and environmental factors that predispose or interact to create a person's disability.[2,5] Individual factors include biological factors (eg, congenital conditions, genetic predispositions) and demographic factors (eg, age, sex, education, income). Comorbidity, health habits, personal behaviors, lifestyles, psychological traits (eg, motivation, coping), and social interactions and relationships also influence the process of disablement. Furthermore, environmental factors--such as available medical or rehabilitation care, medications and other therapies, and the physical and social environment--may influence the process of disablement. Each of these factors may be modified by prevention and the promotion of health, wellness, and fitness. Health-related quality of life (HRQL) can be said to represent the total effect of individual and environmental factors on function and health status. Three major dimensions of HRQL have been described in the literature: the physical function component, which includes basic activities of daffy living (ADL) (eg, bathing) and instrumental activities of daily living (IADL) (eg, shopping); the psychological component, that is, the "various cognitive, perceptual, and personality traits" of a person; and the social component, which involves the interaction of the person "within a larger social context or structure."[18] As shown in Figure 5, the broad concept of HRQL encompasses the disablement model. Other "non-health" factors that typically are not included in definitions of functional limitation or disability contribute to an individual's sense of well being--and to both overall quality of life and health-related quality of life. Such factors include economic status, individual expectations and achievements, personal satisfaction with choices in life, and sense of personal safety. References [1] Jette AM. Physical disablement concepts for physical therapy research and practice. Phys



Page 8 of 9

Ther. 1994;74:380-386. [2] Verbrugge L, Jette A. The disablement process. Soc Sci Med. 1994;38:1-14. [3] Guccione AA. Arthritis and the process of disablement. Phys Ther. 1994;74:408414. [4] Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991;71:499-504. [5] Brandt EN Jr, Pope AM, eds. Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, DC: Institute of Medicine, National Academy Press; 1997:62-80. [6] Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965:100-113.

[7] Nagi S. Disability and Rehabilitation. Columbus, Ohio: Ohio State University Press; 1969. [8] Nagi S. Disability concepts revisited: implications for prevention. In: Pope A, Tarlov A, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: Institute of Medicine, National Academy Press; 1991. [9] ICIDH: International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland: World Health Organization; 1980. [10] ICIDH-2: International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organization; 2000. [11] National Advisory Board on Medical Rehabilitation Research, Draft V: Report and Plan for Medical Rehabilitation Research. Bethesda, Md: National Institutes of Health; 1992. [12] Disability in America: Toward a National Agenda for Prevention. Washington, DC: Institute of Medicine, National Academy Press; 1991. [13] Craik RL. Disability following hip fracture. Phys Ther. 1994;74:387-398. [14] Duncan PW. Stroke disability. Phys Ther. 1994;74:399-407. [15] Delitto A. Are measures of function and disability important in low back care? Phys Ther. 1994;74:452-462.



Page 9 of 9

[16] Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998;78:248-258. [17] Gill-Body KM, Beninato M, Krebs DE. Relationship among balance impairments, functional performance, and disability in people with peripheral vestibular hypofunction. Phys Ther. 2000;80:748-758. [18] Jette AM. Using health-related quality of life measures in physical therapy outcomes research. Phys Ther. 1993;73:528-537.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"On What Concepts Is the Guide Based?." Physical Therapy 81.1 (Jan 2001): 27. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 3

What Does the Guide Contain?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p35. (651 words)


The Guide has five major components: the Introduction, which defines physical therapy, outlines the Guide's development, and describes the concepts that underlie the Guide; Part One, which delineates the physical therapist's scope of practice and describes the patient/client management that is provided by physical therapists; Part Two, which delineates preferred practice patterns; Part Three, available only on CD-ROM (June 2001), which catalogs the tests and measures that are used in physical therapist practice; and the Appendixes, which include the core documents of the American Physical Therapy Association and Guide-based documentation templates. The Guide does not contain specific treatment protocols, does not provide clinical guidelines, and does not set forth the standard of care for which a physical therapist may be legally responsible in any specific case. "Part One: A Description of Patient/Client Management" Part One is an overview of physical therapists as health care professionals and their approach to patient/client management, specifically: * Physical therapist qualifications, roles, and practice settings * The five elements of patient/client management (examination; evaluation; diagnosis; prognosis, including plan of care; and intervention) provided by physical therapists * Tests and measures that physical therapists frequently use, clinical indications that may prompt the use of the tests and measures, tools that may be used to gather data, and types of data that may be generated * Interventions that physical therapists frequently provide, clinical considerations that may prompt the selection of interventions, and anticipated goals and expected outcomes of intervention "Part Two: Preferred Practice Patterns" Part Two describes the boundaries within which the physical therapist may design and implement plans of care for patients/clients who are classified into specific practice patterns. The patterns are grouped under four categories of conditions: musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary. Some patients/clients may be best managed through classification in more than one pattern. Each practice pattern describes the following: * The specific patient/client diagnostic classification, including examples of (1) examination findings that may support inclusion of patients/clients in the pattern or exclusion of patients/clients



Page 2 of 3

from the pattern and (2) examination findings that may require classification of patients/clients in a different pattern or in more than one pattern * The five elements of patient/client management for each pattern: examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis (including plan of care and expected range of number of visits), and interventions (including anticipated goals and expected outcomes) * Reexamination * Global outcomes (impact on pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, and disabilities; risk reduction/ prevention; impact on health, wellness, and fitness; impact on societal resources; patient/client satisfaction) * Criteria for termination of physical therapy services In addition, each pattern lists relevant ICD-9-CM codes. (These lists are intended as general information and are not to be used for coding purposes.) "Part Three: Specific Tests Used in Physical Therapist Practice" Part Three (available on CD-ROM only) contains a listing of tests and measures used in the assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and a listing of tests and measures of health status, health-related quality of life, and patient/client satisfaction. Citations in the peer-reviewed literature regarding the reliability and validity of specific tests are included. Appendixes Appendix I contains the Guide glossary. Appendixes 2 through 4 contain the APTA core documents on which physical therapist practice is based: Standards of Practice for Physical Therapy and the Criteria (Appendix 2); Code of Ethics and Guide for Professional Conduct (Appendix 3); and Standards of Ethical Conduct for the Physical Therapist Assistant and Guide for Conduct of the Affiliate Member (Appendix 4). Appendix 5 contains Guidelines for Physical Therapy Documentation. (Note: APTA documents are revised on a regular basis. For the most recent versions of these documents, contact APTA's Service Center, [email protected].) Appendix 6 contains the "Documentation Templates for Physical Therapist Patient/Client Management"; Appendix 7, the "Patient/Client Satisfaction Questionnaire." Indexes Both numerical and alphabetical indexes of the ICD-9-CM codes cited in the Guide are provided.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"What Does the Guide Contain?." Physical Therapy 81.1 (Jan 2001): 35. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .

Gale Document Number:A70453290



Page 3 of 3

Disclaimer: This information is not a tool for self-diagnosis or a substitute for professional care.




Page 1 of 17

Who Are Physical Therapists, and What Do They Do?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p39. (7255 words)


Education and Qualifications Physical therapists are professionally educated at the0 college or university level and are required to be licensed in the state or states in which they practice. Graduates from 1926 to 1959 completed physical therapy curricula approved by appropriate accreditation bodies. Graduates from 1960 to the present have successfully completed professional physical therapist education programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). As of January 2002, CAPTE accreditation is limited to only those professional education programs that award the postbaccalaureate degree. Physical therapists also may be certified as clinical specialists through the American Board of Physical Therapy Specialties (ABPTS). Practice Settings Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings, including the following: * Hospitals (eg, critical care, intensive care, acute care, and subacute care settings) * Outpatient clinics or offices * Rehabilitation facilities * Skilled nursing, extended care, or subacute facilities * Homes * Education or research centers * Schools and playgrounds (preschool, primary, and secondary) * Hospices * Corporate or industrial health centers * Industrial, workplace, or other occupational environments * Athletic facilities (collegiate, amateur, and professional) * Fitness centers and sports training facilities



Page 2 of 17

Patients and Clients Physical therapists are committed to providing necessary and high-quality services to both patients and clients. Patients are individuals who are the recipients of physical therapy examination, evaluation, diagnosis, prognosis, and intervention and who have a disease, disorder, condition, impairment, functional limitation, or disability. Clients are individuals who engage the services of a physical therapist and who can benefit from the physical therapist's consultation, interventions, professional advice, prevention services, or services promoting health, wellness, and fitness. Clients also are businesses, school systems, and others to whom physical therapists provide services. The generally accepted elements of patient/client management typically apply to both patients and clients. Scope of Practice Physical therapy is defined as the care and services provided by or under the direction and supervision of a physical therapist. Physical therapists are the only professionals who provide physical therapy. Physical therapist assistants--under the direction and supervision of the physical therapist--are the only paraprofessionals who assist in the provision of physical therapy interventions. APTA therefore recommends that federal and state government agencies and other third-party payers require physical therapy to be provided only by a physical therapist or under the direction and supervision of a physical therapist. Examination, evaluation, diagnosis, and prognosis should be represented and reimbursed as physical therapy only when they are performed by a physical therapist. Intervention should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist. Physical therapists: * Provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. In the context of the model of disablement[1-4] on which this Guide is based, impairment is defined as loss or abnormality of anatomical, physiological, mental, or psychological structure or function; functional limitation is defined as restriction of the ability to perform, at the level of the whole person, a physical action, task, or activity in an efficient, typically expected, or competent manner; and disability is defined as the inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles that are customary for the individual or expected for the person's status or role in a specific sociocultural context and physical environment. * Interact and practice in collaboration with a variety of professionals. The collaboration may be with physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, audiologists, and any other personnel involved with the patient/client. Physical therapists acknowledge the need to educate and inform other professionals, government agencies, third-party payers, and other health care consumers about the cost-efficient and clinically effective services that physical therapists provide. * Address risk. Physical therapists identify risk factors and behaviors that may impede optimal functioning. * Provide prevention and promote health, wellness, and fitness. Physical therapists provide prevention services that forestall or prevent functional decline and the need for more intense care. Through timely and appropriate screening, examination, evaluation, diagnosis, prognosis, and intervention, physical therapists frequently reduce or eliminate the need for costlier forms of care and also may shorten or even eliminate institutional stays. Physical therapists also are involved in promoting health, wellness, and fitness initiatives, including education and service provision, that stimulate the public to engage in healthy behaviors.



Page 3 of 17

* Consult, educate, engage in critical inquiry, and administrate. Physical therapists provide consultative services to health facilities, colleagues, businesses, and community organizations and agencies. They provide education to patients/clients, students, facility staff, communities, and organizations and agencies. Physical therapists also engage in research activities, particularly those related to substantiating the outcomes of service provision. They provide administrative services in many different types of practice, research, and education settings. * Direct and supervise the physical therapy service, including support personnel. Physical therapists oversee all aspects of the physical therapy service. They supervise the physical therapist assistant (PTA) when PTAs provide physical therapy interventions as selected by the physical therapist. Physical therapists also supervise any support personnel as they perform designated tasks related to the operation of the physical therapy service. Roles in Primary Care Physical therapists have a major role to play in the provision of primary care, which has been defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community.[5] APTA has endorsed the concepts of primary care set forth by the Institute of Medicine's Committee on the Future of Primary Care,[5] including the following: * Primary care can encompass myriad needs that go well beyond the capabilities and competencies of individual caregivers and that require the involvement and interaction of varied practitioners. * Primary care is not limited to the "first contact" or point of entry into the health care system. * The primary care program is a comprehensive one. On a daily basis, physical therapists practicing across acute, rehabilitative, and chronic stages of care assist patients/clients in restoring health, alleviating pain, and examining, evaluating, and diagnosing impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Intervention, prevention, and the promotion of health, wellness, and fitness are a vital part of the practice of physical therapists. As clinicians, physical therapists are well positioned to provide services as members of primary care teams. For acute musculoskeletal and neuromuscular conditions, triage and initial examination are appropriate physical therapist responsibilities. The primary care team may function more efficiently when it includes physical therapists, who can recognize musculoskeletal and neuromuscular disorders, perform examinations and evaluations, establish a diagnosis and prognosis, and intervene without delay. For patients/clients with low back pain, for example, physical therapists can provide immediate pain reduction through programs for pain modification, strengthening, flexibility, endurance, and postural alignment; instruction in activities of daily living (ADL); and work modification. Physical therapy intervention may result not only in more efficient and effective patient care but also in more appropriate utilization of other members of the primary care team. With physical therapists functioning in a primary care role and delivering early intervention for work-related musculoskeletal injuries, time and productivity loss due to injuries may be dramatically reduced. For certain chronic conditions, physical therapists should be recognized as the principal providers of care



Page 4 of 17

within the collaborative primary care team. Physical therapists are well prepared to coordinate care related to loss of physical function as a result of musculoskeletal, neuromuscular, cardiovascular/pulmonary, or integumentary disorders. Through community-based agencies and school systems, physical therapists coordinate and integrate provision of services to patients/clients with chronic disorders. Physical therapists also provide primary care in industrial or workplace settings, in which they manage the occupational health services provided to employees and help prevent injury by designing or redesigning the work environment. These services focus both on the individual and on the environment to ensure comprehensive and appropriate intervention. Roles in Secondary and Tertiary Care Physical therapists play major roles in secondary and tertiary care. Patients with musculoskeletal, neuromuscular, cardiovascular/pulmonary, or integumentary conditions may be treated initially by another practitioner and then referred to physical therapists for secondary care. Physical therapists provide secondary care in a wide range of settings, including acute care and rehabilitation hospitals, outpatient clinics, home health, and school systems. Tertiary care is provided by physical therapists in highly specialized, complex, and technology-based settings (eg, heart and lung transplant services, burn units) or in response to other health care practitioners' requests for consultation and specialized services (eg, for patients with spinal cord lesions or closed-head trauma). Roles in Prevention and in the Promotion of Health, Wellness, and Fitness Physical therapists are involved in prevention; in promoting health, wellness, and fitness; and in performing screening activities. These initiatives decrease costs by helping patients/clients (1) achieve and restore optimal functional capacity; (2) minimize impairments, functional limitations, and disabilities related to congenital and acquired conditions; (3) maintain health (thereby preventing further deterioration or future illness); and (4) create appropriate environmental adaptations to enhance independent function. There are three types of prevention in which physical therapists are involved: * Primary prevention. Preventing a target condition in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts. * Secondary prevention. Decreasing duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention. * Tertiary prevention. Limiting the degree of disability and promoting rehabilitation and restoration of function in patients with chronic and irreversible diseases. Physical therapists conduct screenings to determine the need for (1) primary, secondary, or tertiary prevention services; (2) further examination, intervention, or consultation by a physical therapist; or (3) referral to another practitioner. Candidates for screening generally are not patients/clients currently receiving physical therapy services. Screening is based on a problem-focused, systematic collection and analysis of data. Examples of the prevention screening activities in which physical therapists engage include: * Identification of lifestyle factors (eg, amount of exercise, stress, weight) that may lead to increased risk



Page 5 of 17

for serious health problems * Identification of children who may need an examination for idiopathic scoliosis * Identification of elderly individuals in a community center or nursing home who are at high risk for falls * Identification of risk factors for neuromusculoskeletal injuries in the workplace * Pre-performance testing of individuals who are active in sports Examples of prevention activities and health, wellness, and fitness promotion activities in which physical therapists engage include: * Back schools, workplace redesign, strengthening, stretching, endurance exercise programs, and postural training to prevent and manage low back pain * Ergonomic redesign; strengthening, stretching, and endurance exercise programs; postural training to prevent job-related disabilities, including trauma and repetitive stress injuries * Exercise programs, including weight bearing and weight training, to increase bone mass and bone density (especially in older adults with osteoporosis) * Exercise programs, gait training, and balance and coordination activities to reduce the risk of falls--and the risk of fractures from falls--in older adults * Exercise programs and instruction in ADL (self-care, communication, and mobility skills required for independence in daily living) and instrumental activities of daily living (IADL) (activities that are important components of maintaining independent living, such as shopping and cooking) to decrease utilization of health care services and enhance function in patients with cardiovascular/pulmonary disorders * Exercise programs, cardiovascular conditioning, postural training, and instruction in ADL and IADL to prevent disability and dysfunction in women who are pregnant * Broad-based consumer education and advocacy programs to prevent problems (eg, prevent head injury by promoting the use of helmets, prevent pulmonary disease by encouraging smoking cessation) * Exercise programs to prevent or reduce the development of sequelae in individuals with life-long conditions The Five Elements of Patient/Client Management The physical therapist integrates the five elements of patient/client management--examination, evaluation, diagnosis, prognosis, and intervention--in a manner designed to optimize outcomes (Fig. 1). Appendix 6 contains a template for documenting the five elements of patient/client management. Examination, evaluation, and the establishment of a diagnosis and a prognosis are all part of the process that helps the physical therapist determine the most appropriate intervention(s) to address the outcomes that are desired by the patient/client. Examination



Page 6 of 17

Examination is required prior to the initial intervention and is performed for all patients/clients. The initial examination is a comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner. The examination has three components: the patient/client history, the systems review, and tests and measures. History. The history is a systematic gathering of data--from both the past and the present--related to why the patient/client is seeking the services of the physical therapist. The data that are obtained (eg, through interview, through review of the patient/client record, or from other sources) include demographic information, social history, employment and work (job/school/play), growth and development, living environment, general health status, social and health habits (past and current), family history, medical/surgical history, current conditions or chief complaints, functional status and activity level, medications, and other clinical tests. While taking the history, the physical therapist also identifies health restoration and prevention needs and coexisting health problems that may have implications for intervention. This history typically is obtained through the gathering of data from the patient/client, family, significant others, caregivers, and other interested individuals (eg, rehabilitation counselor, teacher, workers' compensation claims manager, employer); through consultation with other members of the team; and through review of the patient/client record. Figure 2 lists the types of data that may be generated from the history. Data from the history (Fig. 2) provide the initial information that the physical therapist uses to hypothesize about the existence and origin of impairments or functional limitations that are commonly related to medical conditions, sociodemographic factors, or personal characteristics. For example, in the case of a 78-year-old woman who has a medical diagnosis of Parkinson disease and who lives alone, the medical diagnosis would suggest the possibility of the following impairments: loss of motor control, range ofmotion deficits, faulty posture, and decreased endurance for functional activities. Epidemiologic research that is available about functional limitations of older women, however, suggests that performance of IADL also may be problematic for that age group. Consequently, in this case, the physical therapist may use the information obtained during the history as well as the epidemiological information to create a "hypothesis" that would require further, in-depth examination during the tests-and-measures portion of the examination. Systems review. After organizing the available history information, the physical therapist begins the "hands-on" component of the examination. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient. The physical therapist especially notes how each of these last five components affects the ability to initiate, sustain, and modify purposeful movement for performance of an action, task, or activity that is pertinent to function. The systems review includes the following: * For the cardiovascular/pulmonary system, the assessment of heart rate, respiratory rate, blood pressure, and edema * For the integumentary system, the assessment of skin integrity, skin color, and presence of scar formation * For the musculoskeletal system, the assessment of gross symmetry, gross range of motion, gross strength, height, and weight



Page 7 of 17

* For the neuromuscular system, a general assessment of gross coordinated movement (eg, balance, locomotion, transfers, and transitions) * For communication ability, affect, cognition, language, and learning style, the assessment of the ability to make needs known; consciousness; orientation (person, place, and time); expected emotional/behavioral responses; and learning preferences (eg, learning barriers, education needs) The systems review also assists the physical therapist in identifying possible problems that require consultation with or referral to another provider.

Tests and measures. Tests and measures are the means of gathering data about the patient/client. From the comprehensive identification and questioning processes of the history and systems review, the physical therapist determines patient/client needs and generates diagnostic hypotheses that may be further investigated by selecting specific tests and measures. These tests and measures are used to rule in or rule out causes of impairment and functional limitations; to establish a diagnosis, prognosis, and plan of care; and to select interventions. The tests and measures that are performed as part of an initial examination should be only those that are necessary to (1) confirm or reject a hypothesis about the factors that contribute to making the current level of patient/client function less than optimal and (2) support the physical therapist's clinical judgments about appropriate interventions, anticipated goals, and expected outcomes. Before, during, and after administering the tests and measures, physical therapists gauge responses, assess physical status, and obtain a more specific understanding of the condition and the diagnostic and therapeutic requirements. There are 24 tests and measures that are commonly performed by physical therapists. These tests and measures, tools used to gather data, and types of data generated are discussed in detail in Chapter 2. The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination, based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision-making process. As the examination progresses, the physical therapist may identify additional problems that were not uncovered by the history and systems review and may conclude that other specific tests and measures or portions of other specific tests and measures are required to obtain sufficient data to perform an evaluation, establish a diagnosis and a prognosis, and select interventions. The examination therefore may be as brief or as lengthy as necessary. The physical therapist may decide that a full examination is



Page 8 of 17

necessary and then select appropriate tests and measures. Conversely, the physical therapist may conclude from the history and systems review that further examination and intervention are not required, that the patient/client should be referred to another practitioner, or both. Tests and measures vary in the precision of their measurements; however, useful data may be generated through various means. For instance, data generated from either a gross muscle test of a group of muscles or from a very precise manual muscle test could be used to reject the hypothesis that muscle performance is contributing to a functional deficit. Similarly, even though a functional assessment instrument may quantify a large number of ADL or IADL, it may fail to detect the inability to perform a particular task and activity that is most important to the patient. The tests and measures that are selected by the physical therapist should yield data that are sufficiently accurate and precise to allow the therapist to make a correct inference about the patient's/client's condition. The selection of specific tests and measures and the depth of the examination vary based on the age of the patient/client; severity of the problem; stage of recovery (acute, subacute, or chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. Evaluation Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the examination. They synthesize all of the findings from the history, systems review, and tests and measures to establish the diagnosis, prognosis, and plan of care. Factors that influence the complexity of the evaluation process include the clinical findings, the extent of loss of function, social considerations, and overall physical function and health status. The evaluation reflects the chronicity or severity of the current problem, the possibility of multisite or multisystem involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the severity and complexity of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; potential discharge destinations; and social support. Diagnosis Diagnostic labels may be used to describe multiple dimensions of the patient/client, ranging from the most basic cellular level to the highest level of functioning--as a person in society. Although physicians typically use labels that identify disease, disorder, or condition at the level of the cell, tissue, organ, or system, physical therapists use labels that identify the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person. The assigning of a diagnostic label through the classification of a patient/client within a specific practice pattern is a decision reached as a result of a systematic process. This process includes integrating and evaluating the data that are obtained during the examination (history, systems review, and tests and measures) to describe the patient/client condition in terms that will guide the physical therapist in determining the prognosis, plan of care, and intervention strategies. Thus the diagnostic label indicates the primary dysfunctions toward which the physical therapist directs interventions. The diagnostic process enables the physical therapist to verify the individual needs of each patient/client relative to similar individuals who are classified in the same pattern while also capturing the unique concerns of the patient/client in meeting those needs in a particular sociocultural and physical environment. If the diagnostic process does not yield an identifiable cluster (eg, of signs or symptoms, impairments, functional limitations, or disabilities), syndrome, or category, the physical therapist may administer interventions for the alleviation of symptoms and remediation of impairments. As in all other cases, the physical therapist is guided by patient/client responses to those interventions and may determine that a



Page 9 of 17

reexamination is in order and proceed accordingly. The objective of the physical therapist's diagnostic process is the identification of discrepancies that exist between the level of function that is desired by the patient/client and the capacity of the patient/client to achieve that level. In carrying out the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other professionals. In addition, as the diagnostic process continues, physical therapists may identify findings that should be shared with other professionals (including referral sources) to ensure optimal care. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist refers the patient/client to an appropriate practitioner. Making a diagnosis requires the clinician to collect and sort data into categories according to a classification scheme relevant to the clinician who is making the diagnosis. These classification schemes should meet the following criteria:[6] 1. Classification schemes must be consistent with the boundaries placed on the profession by law (which may regulate the application of certain types of diagnostic categories) and by society (which grants approval for managing specific types of problems and conditions). 2. The tests and measures necessary for confirming the diagnosis must be within the legal purview of the health care professional. 3. The label used to categorize a condition should describe the problem in a way that directs the selection of interventions toward those interventions that are within the legal purview of the health care professional who is making the diagnosis. The preferred practice patterns in Part Two of the Guide describe the management of patients who are grouped by clusters of impairments that commonly occur together, some of which are associated with health conditions that impede optimal function. Each pattern represents a diagnostic classification. The pattern title therefore reflects the diagnosis--or impairment classification--made by the physical therapist. The diagnosis may or may not be associated with a health condition for patients/clients who are classified into that pattern. The physical therapist uses the classification scheme of the preferred practice patterns to complete a diagnostic process that begins with the collection of data (examination), proceeds through the organization and interpretation of data (evaluation), and culminates in the application of a label (diagnosis). Prognosis (Including the Plan of Care) Once the diagnosis has been established, the physical therapist determines the prognosis and develops the plan of care. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level, and also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. The plan of care consists of statements that specify the anticipated goals and the expected outcomes, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions that are required to reach the anticipated goals and expected outcomes. The plan of care therefore describes the specific patient/client management and the timing for patient/client management for the episode of physical therapy care. The plan of care is the culmination of the examination, diagnostic, and prognostic processes. It is



Page 10 of 17

established in collaboration with the patient/client and is based on the data gathered from the history, systems review, and tests and measures and on the diagnosis determined by the physical therapist. In designing the plan of care, the physical therapist analyzes and integrates the clinical implications of the severity, complexity, and acuity of the pathology/pathophysiology (disease, disorder, or condition), the impairments, the functional limitations, and the disabilities to establish the prognosis and predictions about the likelihood of achieving the anticipated goals and expected outcomes. The plan of care identifies anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. (If required, the anticipated goals and expected outcomes may be expressed as short-term and long-term goals.) Anticipated goals and expected outcomes are the intended results of patient/client management and indicate the changes in impairments, functional limitations, and disabilities and the changes in health, wellness, and fitness needs that are expected as the result of implementing the plan of care. The anticipated goals and expected outcomes also address risk reduction, prevention, impact on societal resources, and patient/client satisfaction. The anticipated goals and expected outcomes in the plan should be measurable and time limited. The plan of care includes the anticipated discharge plans. In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge is the achievement of the anticipated goals and expected outcomes. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Note: In the course of examining the patient/client and establishing the diagnosis and the prognosis, the physical therapist may find evidence of physical abuse or domestic violence. Universal screening for domestic violence is increasingly becoming a statutory requirement. Intervention Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Physical therapist interventions consist of the following components: * Coordination, communication, and documentation * Patient/client-related instruction * Procedural interventions, including - therapeutic exercise - functional training in self-care and home management (including ADL and IADL) - functional training in work (job/school/play), community, and leisure integration and reintegration (including IADL, work hardening, and work conditioning) manual therapy techniques (including mobilization/manipulation) - prescription, application, and, as appropriate, fabrication of devices and equipment (assistive, adaptive,



Page 11 of 17

orthotic, protective, supportive, and prosthetic) - airway clearance techniques - integumentary repair and protection techniques - electrotherapeutic modalities - physical agents and mechanical modalities Coordination, communication, and documentation. These administrative and supportive processes are intended to ensure that patients/clients receive appropriate, comprehensive, efficient, and effective quality of care from admission through discharge. Coordination is the working together of all parties involved with the patient/client. Communication is the exchange of information. Documentation is any entry into the patient/client record--such as consultation reports, initial examination reports, progress notes, flow sheets, checklists, reexamination reports, or summations of care--that identifies the care or service provided. Physical therapists are responsible for coordination, communication, and documentation across all settings for all patients/clients. Administrative and support processes may include addressing required functions, such as advanced care directives, individualized educational plans (IEPs) or individualized family service plans (IFSPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting); admission and discharge planning; case management; collaboration and coordination with agencies; communication across settings; cost-effective resource utilization; data collection, analysis, and reporting; documentation across settings; interdisciplinary teamwork; and referrals to other professionals or resources. Documentation should follow APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Patient/client-related instruction. The process of informing, educating, or training patients/clients, families, significant others, and caregivers is intended to promote and optimize physical therapy services. Instruction may be related to the current condition; specific impairments, functional limitations, or disabilities; plan of care; need for enhanced performance; transition to a different role or setting; risk factors for developing a problem or dysfunction; or need for health, wellness, or fitness programs. Physical therapists are responsible for patient/client-related instruction across all settings for all patients/clients. Procedural interventions. The physical therapist selects, applies, or modifies these interventions (listed above) based on examination data, the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient in a specific patient/client practice pattern. Based on patient/client response to interventions, the physical therapist may decide that reexamination is necessary, a decision that may lead to the use of different interventions or, alternatively, the discontinuation of care. Chapter 3 details the types of procedural interventions commonly selected by the physical therapist. Forming the core of most physical therapy plans of care are: therapeutic exercise, including aerobic conditioning; functional training in self-care and home management activities, including ADL and IADL; and functional training in work (job/school/play), community, and leisure integration or reintegration, including IADL, work hardening, and work conditioning. Factors that influence the complexity, frequency, and duration of the intervention and the decision-making process may include the following: accessibility and availability of resources; adherence to the intervention program; age; anatomical and physiological changes related to growth and development;



Page 12 of 17

caregiver consistency or expertise; chronicity or severity of the current condition; cognitive status; comorbidities, complications, or secondary impairments; concurrent medical, surgical, and therapeutic interventions; decline in functional independence; level of impairment; level of physical function; living environment; multisite or multisystem involvement; nutritional status; overall health status; potential discharge destinations; premorbid conditions; probability of prolonged impairment, functional limitation, or disability; psychosocial and socioeconomic factors; psychomotor abilities; social support; and stability of the condition. Reexamination Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions. Outcomes Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. Beginning with the history, the physical therapist identifies patient/client expectations, perceived need for physical therapy services, personal goals, and desired outcomes. The physical therapist then considers whether these goals and outcomes are realistic in the context of the examination data and the evaluation. In establishing a diagnosis and a prognosis and selecting interventions, the physical therapist asks the question, "What outcome is likely, given the diagnosis?" The physical therapist may use reexamination to determine whether predicted outcomes are reasonable and then modify them as necessary. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions on the following domains: * Pathology/pathophysiology (disease, disorder, or condition) * Impairments * Functional limitations * Disabilities * Risk reduction/prevention * Health, wellness, and fitness * Societal resources * Patient/client satisfaction The physical therapist engages in outcomes data collection and analysis-that is, the systematic review of outcomes of care in relation to selected variables (eg, age, sex, diagnosis, interventions performed)--and develops statistical reports for internal or external use.



Page 13 of 17

Episode of Care, Maintenance, or Prevention An episode of physical therapy care consists of all physical therapy services that are (1) provided by a physical therapist, (2) provided in an unbroken sequence, and (3) related to the physical therapy interventions for a given condition or problem or related to a request from the patient/client, family, or other provider. A defined number or identified range of number of visits will be established for an episode of care. A visit consists of all physical therapy services provided in a 24-hour period. The episode of care may include transfers between sites within or across settings or reclassification of the patient/client from one preferred practice pattern to another. Reclassification may alter the expected range of number of visits and therefore may shorten or lengthen the episode of care. If reclassification involves a condition, problem, or request that is not related to the initial episode of care, a new episode of care may be initiated. A single episode of care should not be confused with multiple episodes of care that may be required by certain individuals who are classified in particular patterns. For these patients/clients, periodic follow-up is needed over a lifetime to ensure optimal function and safety following changes in physical status, caregivers, the environment, or task demands. An episode of physical therapy maintenance is a series of occasional clinical, educational, and administrative services related to maintenance of current function. No defined number or range of number of visits is established for this type of episode. An episode of physical therapy prevention is a series of occasional clinical, educational, and administrative services related to prevention, to the promotion of health, wellness, and fitness, and to the preservation of optimal function. Prevention services; programs that promote health, wellness, and fitness; and programs for maintenance of function are a vital part of the practice of physical therapy. No defined number or range of number of visits is established for this type of episode. Criteria for Termination of Physical Therapy Services Two processes are used for terminating physical therapy services: discharge and discontinuation. Discharge Discharge is the process of ending physical therapy services that have been provided during a single episode of care, when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer, that is when the patient is moved from one site to another site within the same setting or across settings during a single episode of care. There may be facility-specific or payerspecific requirements for documentation regarding the conclusion of physical therapy services as the patient moves between sites or across settings during the episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral. Discontinuation Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue



Page 14 of 17

intervention; (2) the patient/client is unable to continue to progress toward anticipated goals and expected outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When termination of physical therapy service occurs prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for discontinuation are documented. In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discontinuation and provides for appropriate follow-up or referral. Other Professional Roles of the Physical Therapist Consultation Consultation is the rendering of professional or expert opinion or advice by a physical therapist. The consulting physical therapist applies highly specialized knowledge and skills to identify problems, recommend solutions, or produce a specified outcome or product in a given amount of time on behalf of a patient/client. Patient-related consultation is a service provided by a physical therapist at the request of a patient, another practitioner, or an organization either to recommend physical therapy services that are needed or to evaluate the quality of physical therapy services being provided. Such consultation usually does not involve actual intervention. Client-related consultation is a service provided by a physical therapist at the request of an individual, business, school, government agency, or other organization. Examples of consultation activities in which physical therapists may engage include: * Advising a referring practitioner about the indications for intervention * Advising employers about the requirements of the Americans with Disabilities Act (ADA) * Conducting a program to determine the suitability of employees for specific job assignments * Developing programs that evaluate the effectiveness of an intervention plan in reducing work-related injuries * Educating other health care practitioners (eg, in injury prevention) * Examining school environments and recommending changes to improve accessibility for students with disabilities * Instructing employers about job preplacement in accordance with provisions of the ADA * Participating at the local, state, and federal levels in policymaking for physical therapy services * Performing environmental assessments to minimize the risk of falls * Providing peer review and utilization review services * Responding to a request for a second opinion



Page 15 of 17

* Serving as an expert witness in legal proceedings * Working with employees, labor unions, and government agencies to develop injury reduction and safety programs Education Education is the process of imparting information or skills and instructing by precept, example, and experience so that individuals acquire knowledge, master skills, or develop competence. In addition to instructing patients/clients as an element of intervention, physical therapists may engage in education activities such as the following: * Planning and conducting academic education, clinical education, and continuing education programs for physical therapists, other providers, and students * Planning and conducting education programs for local, state, and federal agencies * Planning and conducting programs for the public to increase awareness of issues in which physical therapists have expertise Critical Inquiry Critical inquiry is the process of applying the principles of scientific methods to read and interpret professional literature; participate in, plan, and conduct research; evaluate outcomes data; and assess new concepts and technologies. Examples of critical inquiry activities in which physical therapists may engage include: * Analyzing and applying research findings to physical therapy practice and education * Disseminating the results of research * Evaluating the efficacy and effectiveness of both new and established interventions and technologies * Participating in, planning, and conducting clinical, basic, or applied research Administration Administration is the skilled process of planning, directing, organizing, and managing human, technical, environmental, and financial resources effectively and efficiently. Administration includes the management, by individual physical therapists, of resources for patient/client management and for organizational operations. Examples of administration activities in which physical therapists engage include: * Ensuring fiscally sound reimbursement for services rendered * Budgeting for physical therapy services * Managing staff resources, including the acquisition and development of clinical expertise and leadership abilities



Page 16 of 17

* Monitoring quality of care and clinical productivity * Negotiating and managing contracts * Supervising physical therapist assistants, physical therapy aides, and other support personnel The Physical Therapy Service: Direction and Supervision of Personnel Direction and supervision are essential to the provision of high-quality physical therapy. The degree of direction and supervision necessary for ensuring high-quality physical therapy depends on many factors, including the education, experience, and responsibilities of the parties involved; the organizational structure in which the physical therapy is provided; and applicable state law. In any case, supervision should be readily available to the individual being supervised. The director of a physical therapy service is a physical therapist who has demonstrated qualifications based on education and experience in the field of physical therapy and who has accepted the inherent responsibilities of the role. The director of a physical therapy service must: * Establish guidelines and procedures that will delineate the functions and responsibilities of all levels of physical therapy personnel in the service and the supervisory relationships inherent to the functions of the service and the organization * Ensure that the objectives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization and in accordance with safe physical therapist practice * Interpret administrative policies * Act as a liaison between line staff and administration * Foster the professional growth of the staff Written practice and performance criteria should be available for all levels of physical therapy personnel in a physical therapy service. Regularly scheduled performance appraisals should be conducted by the supervisor based on applicable standards of practice and performance criteria. Responsibilities should be commensurate with the qualifications--including experience, education, and training--of the individuals to whom the responsibilities are assigned. When the physical therapist of record directs physical therapist assistants to perform specific components of physical therapy interventions, that physical therapist remains responsible for supervision of the plan of care. Regardless of the setting in which the services are given, the following responsibilities must be borne solely by the physical therapist: * Interpretation of referrals when available * Initial examination, evaluation, diagnosis, and prognosis * Development or modification of a plan of care that is based on the initial examination or the reexamination and that includes physical therapy anticipated goals and expected outcomes * Determination of (1) when the expertise and decision making capability of the physical therapist requires the physical therapist to personally render physical therapy interventions and (2) when it may be appropriate to utilize the physical therapist assistant. A physical therapist determines the most appropriate utilization of the physical therapist assistant that will ensure the delivery of service that is safe, effective,



Page 17 of 17

and efficient. * Provision of physical therapy interventions * Reexamination of the patient/client in light of the anticipated goals and expected outcomes, and revision of the plan of care when indicated * Establishment of the discharge plan and documentation of discharge summary/status * Oversight of all documentation for services rendered to each patient References [1] Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965: 100-113. [2] Nagi S. Disability and Rehabilitation. Columbus, Ohio: Ohio State University Press; 1969. [3] Nagi S. Disability concepts revisited: implications for prevention. In: Pope A, Tarlov A, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: Institute of Medicine, National Academy Press; 1991. [4] Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991;71:499-504. [5] Defining Primary Care:An Interim Report. Washington, DC: Institute of Medicine, National Academy Press; 1995. [6] Guccione AA. Geriatric Physical Therapy, 2nd ed. St Louis, Mo: Mosby; 2000.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"Who Are Physical Therapists, and What Do They Do?." Physical Therapy 81.1 (Jan 2001): 39. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 82

What Types of Tests and Measures Do Physical Therapists Use?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p51. (21248 words)


Introduction Test and measures are the means of gathering information about the patient/client. Depending on the data generated during the history and systems review, the physical therapist may use one or more tests and measures, in whole or in part: * To help identify and characterize signs and symptoms of pathology/pathophysiology, impairments, functional limitations, and disabilities * To establish the diagnosis and the prognosis, to select interventions, and to document changes in patient/client status * To indicate achievement of the outcomes that are the end points of care and thereby ensure timely and appropriate discharge. Physical therapists may perform more than one test or obtain more than one measurement at a time. Physical therapists individualize the selection of tests and measures based on the history they take and systems review they perform, rather than basing their selection on a previously determined medical diagnosis. When examining a patient/client with impairments, functional limitations, or disabilities resulting from brain injury, for instance, the physical therapist may decide to perform part or all of several tests and measures, based on the signs and symptoms of that particular patient. What Is Measurement? Obtaining measurements is an everyday part of physical therapist practice. APTA's Standards for Tests and Measurements in Physical Therapy Practice[1] state that a measurement is the "numeral assigned to an object, event, or person or the class (category) to which an object, event, or person is assigned according to rules." Physical therapists obtain many different types of measurements. Assessing the magnitude of a patient's report of pain, quantifying muscle performance or range of motion, describing the various characteristics of a patient's gait pattern, categorizing the assistance that a patient requires to dress--all of these are measurements. The physical therapist collects data through many different methods, such as interviewing; observation; questionnaires; palpation; auscultation; conducting performance based assessments; electrophysiological testing; taking photographs and making other videographic recordings; recording data using scales, indexes, and inventories; obtaining data through the use of technology-assisted devices; administering patient/client self-assessment tests; and reviewing patient/client diaries and logs. Physical therapists use tests and measures to obtain measurements, which they then interpret to identify:



Page 2 of 82

* Signs and symptoms of pathology/pathophysiology (disease, disorder, or condition), such as joint tenderness, pain, elevated blood pressure with activity, numbness and tingling, and edema * Impairments, such as aerobic capacity; anthropometric characteristics; arousal, attention, and cognition; circulation; cranial and peripheral nerve integrity; ergonomics and body mechanics; gait, locomotion, and balance; integumentary integrity; joint integrity and mobility; motor function; muscle performance; neuromotor development and sensory integration; posture; range of motion; reflex integrity; sensory integrity; and ventilation and respiration/gas exchange * Functional limitations, such as work (job/school/ play), community, and leisure integration or reintegration (including instrumental activities of daily living), ergonomics and body mechanics, and self-care and home management (including activities of daily living and instrumental activities of daily living) * Disabilities, such as inability to engage in community, leisure, social, and work roles * Device and equipment need and use, such as assistive and adaptive devices; orthotic, protective, and supportive devices; and prosthetic devices * Barriers, such as environmental, home, and work (job/school/play) barriers In the evaluation process, the physical therapist synthesizes the examination data to establish the diagnosis and prognosis (including the plan of care). The data gathered through the use of tests and measures during initial examination provide information used for determining anticipated goals and expected outcomes. These data may indicate initial abilities in performing actions, tasks, and activities; establish criteria for placement decisions; and identify level of safety in performing a particular task or risk of injury with continued performance with or without devices and equipment. Reexamination at regular intervals during an episode of care enables the physical therapist to measure and document changes in patient/client status and the progress that the patient/client is making toward the anticipated goals and expected outcomes. Whenever possible, physical therapists should use measurements whose reliability and validity have been documented in the peer-reviewed literature. Reliable and valid measurements enable physical therapists to gauge the certainty of their examination data and the appropriate scope of inferences that may be drawn from those data. Reliability and validity are properties of a measurement, not the test or measure that is used to obtain the measurement. A measurement is reliable only under certain conditions and for certain types of patients/clients and is valid only for a particular purpose. Reliability and validity have not yet been reported for every measurement used by physical therapists. Use of measurements without established reliability and validity may be appropriate, however, especially when there are no alternatives-and provided that the physical therapist is aware that those measurements may be prone to error and that, therefore, decisions made using those measurements may be less certain. Reliability of Measurements Assessing a measurement's reliability is an attempt to identify sources of error.[2(p73-74)] A measurement is said to be reliable when it is consistent time after time, with as little variation as possible. Because all measurements have some error, however, the clinician must determine whether a measurement is useful or whether there is so much error that the measurement is rendered useless for a particular purpose.



Page 3 of 82

Two major types of reliability--test-retest and intratester/intertester--help determine how much error exists in a measurement. Test-retest reliability is the consistency of repeated measurements that are separated in time when there is no change in what is being measured; test-retest reliability indicates the stability of a measurement. Intrarater reliability indicates the degree to which measurements that are obtained by the same physical therapist at different times will be consistent. Interrater reliability indicates the degree to which measurements obtained by multiple therapists will be consistent.[1] Interrater reliability is especially important-if different physical therapists obtain different measurements when measuring the same phenomenon, the usefulness of the measurements is limited. There are two other forms of reliability: parallel-form reliability, which relates to measurements that are obtained by using different versions of the same test or measure, and internal consistency, or homogeneity, which relates to measurements that are obtained by using tests or measures with multiple items or parts, where each part is supposed to measure one, and only one, concept.[1] Validity of Measurements Validity is the "degree to which a useful (meaningful) interpretation can be inferred from a measurement."[1] There are many forms of validity, including face validity, content validity, construct validity, concurrent validity, and predictive validity. Face validity exists when the measurement seems to reflect what is supposed to be measured-but it does not depend on evidence. Goniometric measurements, for instance, have face validity as measurements of joint position. Content validity establishes the degree to which a measurement reflects the domain of interest. For example, an instrument that is used to assess joint pain might generate data only regarding pain on motion, not pain at rest or factors that aggravate or alleviate pain. Construct validity is a theoretical form of validity that is established on the basis of evidence that a measurement represents the underlying concept of what is to be measured.[1] For example, the overall concept of "motor function" is the construct that underlies any particular test or measure of motor function. There are no direct tests of construct validity. Theoretical evidence of construct validity is often provided by demonstrating convergence if tests or measures believed to represent the same construct are highly related. For example, a test of motor function, based on a particular concept of what "motor function" means, should correlate highly with other tests or measures based on similar conceptions of "motor function" or on concepts that are closely related to "motor function," such as "dexterity" and "coordination." Evidence of construct validity is also found when there is a low association, or divergence, between a test or measure of one particular construct and other tests or measures reflecting distinctly different, or even unrelated, constructs. For example, there should be a low association between a test or measure of "motor function" and tests and measures that are based on the concepts of "aerobic conditioning" or "range of motion." Concurrent validity exists when "an inferred interpretation is justified by comparing a measurement with supporting evidence that was obtained at approximately the same time as the measurement being validated."[1] The developers of a new balance test might compare the measurements obtained using the new test to those obtained using an established balance test involving one legged stance. The comparative method of establishing concurrent validity is particularly relevant



Page 4 of 82

for self-assessment instruments. Predictive validity exists when "an inferred interpretation is justified by comparing a measurement with supporting evidence that is obtained at a later point in time" and "examines the justification of using a measurement to say something about future events or conditions."[1] The predictive validity of a measurement of functional capacity might be established by verifying whether the measurement indicates the likelihood of return to work. Knowing the predictive validity of a measurement may facilitate the identification of achievable outcomes and increase the efficiency of discharge planning. Predictive validity also may provide the physical therapist with several kinds of information about the value of selecting particular tests or measures for the examination. The sensitivity of a measurement indicates the proportion of individuals with a positive finding who already have or will have a particular characteristic or outcome.[1,3,4] In other words, sensitivity is the positive predictive validity of the measurement. In contrast, the specificity of a measurement indicates the proportion of people who have a negative finding on a test or measure who truly do not or will not have a particular characteristic or outcome.[1,3,4] Thus, specificity is the negative predictive validity of the test or measure. Clinical Utility In addition to reliability and validity of the measurements obtained with a given test or measure, a physical therapist considers the clinical utility of the test or measure for a particular purpose. Physical therapists should consider the precision of the data yielded by a test or measure and whether it will meet the needs of the situation. Some measurements are only gross measurements. Gross measurements may be useful for a population screen but may not be useful for identifying a small change in patient/client status after intervention. The measurements used by the physical therapist should always be sensitive enough to detect the degree of change expected as a result of intervention. The physical therapist also should consider the time involved in administering a test or measure, the cost of administering it, and such patient/client factors as tolerance of testing positions and suitability of the test or measure to a particular population. Guide Categories for Tests and Measures This chapter contains 24 categories of tests and measures (Figure) that the physical therapist may decide to use during an examination. Tests and measures are listed in alphabetical order. In Part Two, each preferred practice pattern contains a list of tests and measures that are used in the examination of patients/clients who are classified in the diagnostic group for that pattern. Part Three of the Guide, available on CD-ROM, provides available information on tests and measures used by physical therapists, including the reliability and validity of measurements that are obtained using those tests and measures. Physical therapists may decide to use other tests and measures that are not described in the Guide, following the principles stated in the Standards for, Tests and Measurements in Physical Therapy Practice.[1] Figure Guide Categories for Tests and Measures Aerobic Capacity/Endurance Anthropometric Characteristics Arousal, Attention, and Cognition Assistive and Adaptive Devices Circulation (Arterial, Venous, Lymphatic)



Page 5 of 82

Cranial and Peripheral Nerve Integrity Environmental, Home, and Work (Job/School/Play) Barriers Ergonomics and Body Mechanics Gait, Locomotion, and Balance Integumentary Integrity Joint Integrity and Mobility Motor Function (Motor Control and Motor Learning) Muscle Performance (Including Strength, Power, and Endurance) Neuromotor Development and Sensory Integration Orthotic, Protective, and Supportive Devices Pain Posture Prosthetic Requirements Range of Motion (Including Muscle Length) Reflex Integrity Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living) Sensory Integrity Ventilation and Respiration/Gas Exchange Work (Job/School/Play), Community, and Leisure Integrity or Reintegration (Including Instrumental Activities of Daily Living) * General definition and purpose of the test and measure. A definition and purpose of the test and measure is provided. All tests and measures produce information used to identify the possible or actual causes of difficulties during performance of essential everyday activities, work tasks, and leisure pursuits. Selection of tests and measures depends on the findings of the history and systems review. The examination findings may indicate, for instance, that tests should be conducted while the patient/client performs specific activities. In all cases, the purpose of tests and measures is to ensure the gathering of information that will lead to evaluation, diagnosis, prognosis, and selection of appropriate interventions. * Clinical indications. Examples of clinical indications that are identified during the history and systems review are provided to indicate the use of tests and measures. Special requirements may prompt the physical therapist to perform tests and measures. All tests and measures are appropriate in the presence of: - impairment, functional limitation, disability, developmental delay, injury, or suspected or identified pathology that prevents or alters performance of daily activities, including self-care, home management, work (job/school/play), community, and leisure actions, tasks, or activities - requirements of employment that specify minimum capacity for performance - identified risk factors - need to initiate programs that promote health, wellness, or fitness * Tests and measures (methods and techniques). Examples of specific tests and measures are provided. * Tools used for gathering data. A listing of tools used for collecting data is provided. * Data generated. Types of data that may be generated from the tests and measures are listed.



Page 6 of 82

Other information that may be required for the examination includes findings of other professionals; results of diagnostic imaging, clinical laboratory, and electrophysiological studies; federal, state, and local work surveillance and safety reports and announcements; and the reported observations of family members, significant others, caregivers, and other interested people. Physical therapists are the only professionals who provide physical therapy. Physical therapist assistants--under the direction and supervision of the physical therapist-are the only paraprofessionals who assist in the provision of physical therapy interventions. APTA recommends that federal and state government agencies and other third-party payers require physical therapy to be provided only by a physical therapist or under the direction and supervision of a physical therapist. Examination, evaluation, diagnosis, and prognosis should be represented and reimbursed as physical therapy only when performed by a physical therapist. Intervention should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist. Note: The terms "physical therapy" and "physiotherapy," and the terms "physical therapist" and "physiotherapist," are synonymous. References [1] American Physical Therapy Association. Standards for Tests and Measurements in Physical Therapy Practice. Phys Ther. 1991;71:589-622. [2] Rothstein JM, Echternach JL. Primer on Measurement: An Introductory Guide to Measurement Issues. Alexandria, Va: American Physical Therapy Association; 1993. [3] Jaeschke R, Guyatt GH, Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and how will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA. 1994;271:703-707. [4] Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone Inc; 2000. Tests and Measures Aerobic Capacity/Endurance Aerobic capacity/endurance is the ability to perform work or participate in activity over time using the body's oxygen uptake, delivery, and energy release mechanisms. During activity, the physical therapist uses tests and measures ranging from simple measurements to complex calculations to determine the appropriateness of patient/client responses to increased oxygen demand. Responses that are monitored both at rest and during and after activity may indicate the degree of severity of the impairment, functional limitation, or disability. Results of tests and measures of aerobic capacity/endurance are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications



Page 7 of 82

Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of aerobic capacity/endurance. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, coronary artery disease, peripheral vascular disease) - endocrine/metabolic (eg, osteoporosis) multiple systems (eg,AIDS, trauma) - musculoskeletal (eg, arthritis) - neuromuscular (eg, cerebral palsy, Parkinson disease) - pulmonary (eg, emphysema, pulmonary fibrosis) * Impairments in the following categories: - circulation (eg, abnormal heart rate, rhythm, blood pressure) - muscle performance (eg, generalized muscle weakness, decreased muscle endurance) - posture (eg, abnormal body alignment) - range of motion (eg, asymmetrical chest wall motion, thorax tightness) - ventilation and respiration/gas exchange (eg, abnormal respiratory pattern, rate, rhythm) * Functional limitations in the ability to perform actions, tasks, and activities in the following categories: - self-care (eg, inability to perform shower or overhead activities because of shortness of breath) - home management (eg, inability to vacuum or make the bed because of chest discomfort) - work (job/school/play) (eg, inability to keep up with peers during recess, inability as a parent to carry a child up the stairs because of increasing sense of fatigue, inability to perform overhead lifting tasks because of shortness of breath) - community/leisure (eg, inability to walk to religious activities because of shortness of breath, difficulty with gardening because of chest discomfort) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:



Page 8 of 82

- self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired aerobic capacity: - family history of cardiovascular or pulmonary disease - obesity - sedentary lifestyle - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, submaximal oxygen uptake for age and sex, submaximal running efficiency for sprint) - health and wellness (eg, incomplete understanding of role of aerobic capacity/endurance during activities) Tests and Measures Tests and measures may include those that characterize or quantify: * Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations) * Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests) * Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry) * Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; and ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests) Tools Used for Gathering Data Tools for gathering data may include: * Devices for gas analysis



Page 9 of 82

* Electrocardiographs * Ergometers * Force meters * Indexes * Measured walkways * Nomograms * Observations * Palpation * Pulse oximeters * Scales * Sphygmomanometers * Spirometers * Steps * Stethoscopes * Stop watches * Treadmills Data Generated Data are used in providing documentation and may include: * Cardiovascular and pulmonary signs, symptoms, and responses per unit of work * Gas volume, concentration, and flow per unit of work * Heart rate, rhythm, and sounds per unit of work * Oxygen uptake during functional activity * Oxygen uptake, time and distance walked or bicycled, and maximum aerobic performance * Peripheral vascular responses per unit of work * Respiratory rate, rhythm, pattern, and breath sounds per unit of work



Page 10 of 82

Anthropometric Characteristics Anthropometric characteristics are those traits that describe body dimensions, such as height, weight, girth, and body fat composition. The physical therapist uses tests and measures to quantify these traits. Results of tests and measures of anthropometric characteristics are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for tests and measures are predicated on the history and systems review findings (egg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of anthropometric characteristics. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, ascites, lymphedema) genitourinary (eg, pregnancy) multiple systems (eg,AIDS, cancer) - musculoskeletal (eg, amputation, muscular dystrophy) - neuromuscular (eg, prematurity, spinal cord injury) - pulmonary (eg, cystic fibrosis) * Impairments in the following categories: - circulation (eg, abnormal blood pressure, abnormal fluid distribution) - muscle performance (eg, generalized muscle weakness) - neuromotor development (eg, abnormal growth rate) - range of motion (eg, abnormal fluid distribution) - ventilation and respiration (eg, abnormal rate and rhythm) * Functional limitations in the ability to perform actions, tasks, or fixed activities in the following categories: - self-care (eg, inability to dress and reach because of abnormal fat or fluid distribution) - home management (eg, inability to get down on knees to clean floor because of weight



Page 11 of 82

abnormality) - work (job/school/play) (eg, inability to assume parenting role because of impaired fluid distribution from pregnancy, inability to gain access to classroom environment because of delayed growth, inability to perform filing tasks because of decreased range of motion and muscle weakness) - community/leisure (eg,inability to fish because of generalized muscle weakness, inability to participate in amateur sports because of edema, inability to participate in social activities because of perceived body image as a result of impaired fluid distribution) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired anthropometric characteristics: - anorexia - obesity * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inefficient sprinting because of excess body fat, limited endurance for long-distance hiking because of inappropriate body composition) - health and wellness (eg, incomplete understanding of the relationship between nutrition and body composition) Tests and Measures Tests and measures may include those that characterize or quantify: * Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) * Body dimensions (eg, body mass index, girth measurement, length measurement) * Edema (eg, girth measurement, palpation, scales, volume measurement) Tools Used for Gathering Data Fools for gathering data may include: * Body mass index



Page 12 of 82

* Calipers * Cameras and photographs * Impedance devices * Nomograms * Palpation * Rulers * Scales * Tape measures * Volumometers * Weight scales Data Generated Data are used in providing documentation and may include: * Height and weight * Presence and severity of abnormal body fluid distribution Arousal, Attention, and Cognition Arousal is a state of responsiveness to stimulation or action or of physiological readiness for activity. Attention is the selective awareness of the environment or selective responsiveness to stimuli. Cognition is the act or process of knowing, including both awareness and judgment. The physical therapist uses tests and measures to characterize the patient's/client's responsiveness. Results of tests and measures of arousal, attention, and cognition are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of arousal, attention, and cognition. Clinical indications for these tests and measures may include:



Page 13 of 82

* Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, malignant hypertension, cerebral vascular accident) - multiple systems (eg, Down syndrome) - neuromuscular (eg, hydrocephalus, traumatic brain injury) - pulmonary (eg, end-stage chronic obstructive pulmonary disease) * Impairments in the following categories: - arousal (eg, lack of response to stimulation) - circulation (eg, abnormal blood pressure in shock) - cognition (eg, inability to follow instructions) - motor function (eg, inability to plan and carry out movement) - ventilation and respiration (eg, hypoventilation, somnolence) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to perform bathroom transfers because of lack of safety awareness) - home management (eg, decreased environmental mobility in the home because of lack of safety awareness) - work (job/school/play) (eg, inability to perform bricklaying because of inability to recall steps of task, inability to play at age-appropriate level because of lack of internal desire to move) - community/leisure (eg, inability to participate as volunteer at child's school because of inattention, inability to participate in routine exercise program because of lack of interest) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired arousal, attention, and cognition - inability to manage stress



Page 14 of 82

- lack of motivation - poor attitude * Health, wellness, and fitness needs: - fitness, including physical performance (eg, impaired judgment during workout, ineffective attention and recall for complete training regimen) - health and wellness (eg, incomplete understanding of the role of attention to safety during activities) Tests and Measures Tests and measures may include those that characterize or quantify: * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) * Consciousness, including agitation and coma (eg, scales) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) Tools Use for Data Collection Tools for gathering data may include: * Adaptability tests * Attention tests * Indexes * Interviews * Inventories * Observations * Profiles



Page 15 of 82

* Questionnaires * Safety checklists * Scales * Screening tests Data Generated Data are used in providing documentation and may include: * Descriptions of short-term and long-term memory * Presence and severity of: - cognitive impairment - coma - communication deficits depression or impaired motivation impaired consciousness * Quantifications or characterization of: - ability to attend to task or to - participate - ability to recognize time, person, place, and situation Assistive and Adaptive Devices Assistive and adaptive devices are implements and equipment used to aid patients/clients in performing tasks or movements. Assistive devices include crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, percussors, static and dynamic splints, and vibrators. Adaptive devices include raised toilet seats, seating systems, and environmental controls. The physical therapist uses tests and measures to determine whether a patient/client might benefit from such a device or, when such a device already is in use, to assess how well the patient/client performs with it. Results of tests and measures of assistive and adaptive devices are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which indudes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may



Page 16 of 82

indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of assistive and adaptive devices. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, coronary artery disease) - endocrine/metabolic (eg, diabetes) - integumentary (eg, surgical wound, vascular ulcer) - multiple systems (eg, sarcoidosis, trauma) - musculoskeletal (eg, arthritis, sprain, strain) - neuromuscular (eg, cerebral palsy, spina bifida, spinal cord injury) - pulmonary (eg, amyotrophic lateral sclerosis, respiratory failure) * Impairments in the following categories: - aerobic capacity (eg, decreased endurance) - gait, locomotion, and balance (eg, frequent falls) - motor function (eg, inability to sit) - muscle performance (eg, weakness) - range of motion (eg, pain on reaching) * Functional limitations in the ability to perform actions, tasks, or activities in following categories: - self-care (eg, inability to dress because of difficulty with sitting) - home management (eg, inability to remove items from closet shelf because of limited range of motion) - work (job/school/play) (eg, difficulty with keyboarding because of pain, inability to attend school because of lack of endurance, inability to get to work because of distance that must be traveled to work site) - community/leisure (eg, inability to walk on uneven surfaces because of altered balance) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care



Page 17 of 82

- home management - work (job/school/play) - community/leisure * Risk factor for improper use or lack of use of assistive and adaptive devices - inactivity * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to participate in wheelchair sports, poor wheelchair tolerance because of inadequate fit) - health and wellness (eg, in adequate knowledge of how to regularly assess devices) Tests and Measures Tests and measures may include those that characterize or quantify: * Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily living [ADL], functional scales, instrumental activities of daily living [IADL] scales, interviews, observations) * Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) * Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) * Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports) Tools Used for Gathering Data Tools for gathering data may include: * Activity status indexes * Aerobic capacity tests * Diaries * Functional performance inventories * Health assessment questionnaires * Interviews



Page 18 of 82

* Logs * Observations * Pressure-sensing devices * Reports * Scales * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions of: - alignment and fit of devices and equipment - ability to use and care for devices and equipment - components of assistive and adaptive devices and equipment level of safety with devices and equipment - practicality of devices and equipment - remediation of impairment, functional limitation, or disability with devices and equipment * Quantifications of: - movement patterns with or without devices and equipment - physiological and functional effect and benefit of devices and equipment Circulation (Arterial, Venous, Lymphatic) Circulation is the movement of blood through organs and tissues to deliver oxygen and to remove carbon dioxide and the passive movement (drainage) of lymph through channels, organs, and tissues for removal of cellular byproducts and inflammatory wastes. The physical therapist uses the results of circulation tests and measures to determine whether the patient/client has adequate cardiovascular pump, circulation, oxygen delivery, and lymphatic drainage systems to meet the body's demands at rest and with activity. Results of tests and measures of circulation (arterial, venous, lymphatic) are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications



Page 19 of 82

Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records).The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of circulation (arterial, venous, lymphatic). Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, atherosclerosis, coronary artery bypass graft, lymphedema) - endocrine/metabolic (eg, diabetes, reflex sympathetic dystrophy) - genitourinary (eg, renal failure) - integumentary (eg, cellulitis, lymphadenitis) - multiple systems (eg, cancer, trauma) - musculoskeletal (eg, fracture) - neuromuscular (eg, multiple sclerosis, spinal cord injury) * Impairments in the following categories: - aerobic capacity (eg, shortness of breath) - circulation (eg, swollen feet) - gait, locomotion, and balance (eg, dizziness on rising from sitting to standing position) - muscle performance (eg, palpitations on stair climb) - ventilation and respiration (eg, shortness of breath at night) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with eating because of indigestion) - home management (eg, inability to mow lawn because of leg cramps) - work (job/school/play) (eg, difficulty with loading cargo because of shortness of breath, inability to support family financially because of shortness of breath with manual labor) - community/leisure (eg, inability to play tennis because of chest and shoulder pain, inability to walk to the senior center because of leg pain) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of



Page 20 of 82

required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired circulation: - obesity - positive family history of cardiovascular disease - sedentary lifestyle - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate circulation for cross-country skiing, inadequate protection of extremities during extended activities in cold weather ) - health and wellness (eg, incomplete understanding of importance of motion to circulation) Tests and Measures Tests and measures may include those that characterize or quantify: * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) Tools Used for Gathering Data Tools for gathering data may include: * Doppler ultrasonographs * Electrocardiographs * Observations



Page 21 of 82

* Palpation * Scales * Sphygmomanometers * Stethoscopes * Tape measures * Thermographs * Tilt tables Data Generated Data are used in providing documentation and may include: * Characterizations of: - central pressure and volume - intracranial pressure responses - physiological responses to position change * Descriptions of: - peripheral arterial circulation - peripheral lymphatic circulation - peripheral venous circulation - skin color - nail changes * Presence of bruits * Presence and severity of: - abnormal heart sounds - abnormal heart rate or rhythm at rest - cardiovascular signs and symptoms - edema



Page 22 of 82

* Quantifications of cardiovascular pump demand * Vital signs at rest Cranial and Peripheral Nerve Integrity Cranial nerve integrity is the intactness of the twelve pairs of nerves connected with the brain, including their somatic, visceral, and afferent and efferent components. Peripheral nerve integrity is the intactness of the spinal nerves, including their afferent and efferent components. The physical therapist uses tests and measures to assess the cranial and peripheral nerves. Results of tests and measures of cranial and peripheral nerve integrity are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of cranial and peripheral nerve integrity. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident) - endocrine/metabolic (eg, Meniere disease, viral encephalitis) - integumentary disease/disorder (eg, neuropathic ulcer) - multiple systems (eg, Guillain-Barre syndrome) - neuromuscular (eg, Erb palsy, labyrinthitis) - pulmonary (eg, amyotrophic lateral sclerosis) * Impairments in the following categories: - cranial nerve and peripheral nerve integrity (eg, numb and tingling fingers) - gait, locomotion, and balance (eg, staggering gait) - motor function (eg, numbness of foot leading to falls) - muscle performance (eg, weakness of upper extremity)



Page 23 of 82

- ventilation (eg, decreased expansion and excursion) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with eating because of swallowing difficulties) - home management (eg, decreased environmental mobility in the home because of unsteadiness) - work (job/school/play) (eg, inability to perform activities as a stuntperson because of difficulty with coordination, inability to perform electrical wiring and circuitry because of numbness of fingers) - community/leisure (eg, inability to play cards because of proprioceptive deficit, inability to sing in choir because of inadequate phonation control) * Disability-that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context-in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired cranial and peripheral nerve integrity. - habitual suboptimal posture - increased risk for falls * Health, wellness, and fitness needs.' - fitness, including physical performance (eg, inadequate hand control in school child, limited neuromuscular control of jumping) - health and wellness (eg, incomplete comprehension of value of sensation in gross motor activities) Tests and Measures Tests and measures may include those that characterize or quantify: * Electrophysiological integrity (eg, electroneuromyography) * Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) * Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations,



Page 24 of 82

thoracic outlet tests) * Response to neural provocation (eg, tension tests, vertebral artery compression tests) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation tests) * Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) * Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests) Tools Used for Gathering Data Tools for gathering data may include: * Dynamometers * Electroneuromyographs * Muscle tests * Observations * Palpation * Provocation tests * Scales * Sensory tests Data Generated Data are used in providing documentation and may include: * Descriptions and quantification of: - sensory responses to provocation of cranial and peripheral nerves - vestibular responses * Descriptions of ability to swallow * Presence or absence of gag reflex * Quantifications of electrophysiological response to stimulation * Response to neural provocation



Page 25 of 82

Environmental, Home, and Work (Job/School/Play) Barriers Environmental, home, and work (job/school/play) barriers are the physical impediments that keep patients/clients from functioning optimally in their surroundings. The physical therapist uses the results of tests and measures to identify any of a variety of possible impediments, including safety hazards (eg, throw rugs, slippery surfaces), access problems (eg, narrow doors, thresholds, high steps, absence of power doors or elevators), and home or office design barriers (eg, excessive distances to negotiate, multistory environments, sinks, bathrooms,counters, placement of controls or switches). The physical therapist also uses the results to suggest modifications to the environment(eg, grab bars in the shower, ramps, raised toilet seats, increased lighting) that will allow the patient/client to improve functioning in the home, workplace, and other settings. Results of tests and measures of environmental, home, and work (job/school/play) barriers are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of environmental, home, and work (job/school/play) barriers. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, congestive heart failure) - multiple systems (eg, trauma) - musculoskeletal (eg, amputation, joint replacement, muscular dystrophy) - neuromuscular (eg, cerebral palsy, multiple sclerosis, traumatic brain injury) - pulmonary (eg, chronic obstructive pulmonary disease) * Impairments in the following categories. - circulation (eg, calf cramps with walking) - gait, locomotion, and balance (eg, ataxic gait) - muscle performance (eg, decreased muscle strength and endurance) - ventilation (eg, increased respiratory rate)



Page 26 of 82

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to get into bathtub because of decreased muscle strength) - home management (eg, inability to climb stairs to bathroom because of decreased muscle endurance) - work (job/school/play) (eg, inability as a student to gain wheelchair access to science station in school because of station height, inability to enter building because no ramp is available) - community/leisure (eg, inability to join friends on sailboat because of dock instability, inability to walk on beach because of ataxic gait) * Disability-that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context-in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for environmental, home, and work barriers. - decreased accessibility to home, work (job/school/play), community, and leisure environments - increased risk for falls - lack of emergency evacuation plan * Health, wellness, and fitness needs.' - fitness, including physical performance (eg, inability to negotiate uneven terrains, limited ability to gain access to outdoor trails) - health and wellness (eg, incomplete understanding of how to assess terrains for more efficient functioning) Tests and Measures Tests and measures may include those that characterize or quantify: * Current and potential barriers (eg, checklists, interviews, observations, questionnaires) * Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, technology-assisted assessments, videographic assessments)



Page 27 of 82

Tools Used for Gathering Data Tools for gathering data include: * Cameras and photographs * Checklists * Interviews * Observations * Questionnaires * Structural specifications * Technology-assisted analysis systems * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions of: - barriers - environment * Documentation and description of compliance with regulatory standards * Observations of environment * Quantifications of physical space Ergonomics and Body Mechanics Ergonomics is the relationship among the worker; the work that is done; the actions, tasks, or activities inherent in that work (job/school/play); and the environment in which the work (job/school/play) is performed. Ergonomics uses scientific and engineering principles to improve safety, efficiency, and quality of movement involved in work (job/school/play). Body mechanics are the interrelationships of the muscles and joints as they maintain or adjust posture in response to forces placed on or generated by the body. The physical therapist uses these tests and measures in examining both the worker and the work (job/school/play) environment and in determining the potential for trauma or repetitive stress injuries from inappropriate workplace design. These tests and measures may be conducted after a work injury or as a preventive step. The physical therapist may conduct tests and measures as part of work hardening or work conditioning programs and may use the results of tests and measures to develop such programs. Results of tests and measures of ergonomics and body mechanics are integrated with the history



Page 28 of 82

and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of ergonomics and body mechanics. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, coronary artery disease) - endocrine/metabolic (eg, pregnancy) - multiple systems (eg, deconditioning) - musculoskeletal (eg, repetitive strain injury, scoliosis, spinal stenosis) - neuromuscular (eg, paroxysmal positional vertigo, spina bifida) - pulmonary (eg, ventilatory pump disorders) * Impairments in the following categories: - aerobic capacity (eg, decreased endurance and shortness of breath) - circulation (eg, abnormal heart rate and rhythm) - gait, locomotion, and balance (eg, dizziness) - muscle performance (eg, decreased power) - range of motion (eg, decreased range of motion) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories. - home management (eg, inability to lift laundry basket because of decreased range of motion) - community/leisure (eg, inability to bowl because of decreased muscle power, inability to deliver meals-onwheels because of poor sitting tolerance)



Page 29 of 82

- self-care (eg, inability to tie shoes because of dizziness) - work (job/school/play) (eg, inability to carry school back pack because of pain, inability to rotate trunk at assembly line because of pain) * Disablity--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context-in the following categories: - self-care - home management - work (job/school/play) - community/leisure Risk factors for inefficient ergonomics and impaired body mechanics: - habitual suboptimal posture - hazardous work environment - lack of safety awareness in all environments - risk-prone behaviors (eg, lack of use of safety gear, performance of tasks requiring repetitive motion) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to perform all workplace tasks, use of inappropriate body mechanics for pushing) - health and wellness (incomplete understanding of importance of correct body mechanics during work tasks) Tests and Measures Tests and measures may include those that characterize or quantify: Ergonomics * Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) * Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests,force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology assisted assessments, videographic assessments, work analyses) * Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)



Page 30 of 82

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists) * Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics * Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, activities of daily living [ADL] and instrumental activities of daily living [IADL] scales, observations, photographic assessments, technology-assisted assessments, videographic assessments) Tools Used for Gathering Data Tools for gathering data may include: * Accelerometers * Cameras and photographs * Checklists for exposure standards, hazards, lifting standards * Dynamometers * Electroneuromyographs * Environmental tests * Force platforms * Functional capacity evaluations * Goniometers * Hand function tests * Indexes * Interviews * Muscle tests * Observations * Physical capacity and endurance tests * Postural loading tests * Questionnaires



Page 31 of 82

* Scales * Screenings * Technology-assisted analysis systems * Video cameras and videotapes * Work analyses Data Generated Data are used in providing documentation and may include: Ergonomics * Characterizations of efficiency and effectiveness of use of tools, devices, and workstations * Characterizations of environmental hazards, health risks, and safety risks * Descriptions of tools, devices, equipment, and workstations * Descriptions and quantification of: - abnormal movement patterns associated with work actions, tasks, or activities - dexterity and coordination - functional capacity - repetition and work/rest cycle in - work actions, tasks, or activities - work actions, tasks, or activities * Presence or absence of actual, potential,or repetitive trauma in the work environment Body mechanics * Characterizations of abnormal or unsafe body mechanics * Descriptions and quantification of limitations in self-care, home management, work, community, and leisure actions, tasks, or activities Gait, Locomotion, and Balance Gait is the manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed. Locomotion is the ability to move from one place to another. Balance is the ability to maintain the body in equilibrium with gravity both statically (ie, while stationary) and dynamically (ie, while moving). The physical therapist uses these tests and measures to assess disturbances in gait, locomotion, and balance and assess the risk for falling. The physical therapist also uses these tests and measures to determine whether the patient/client is a candidate for assistive,



Page 32 of 82

adaptive, orthotic, protective, supportive, or prosthetic devices or equipment. Gait, locomotion, and balance problems often involve difficulty in integrating sensory, motor, and neural processes. Results of tests and measures of gait, locomotion, and balance are integrated with the history and systems review fmdings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of gait, locomotion, and balance. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, peripheral vascular disease) - endocrine/metabolic (eg, cellulitis) - multiple systems (eg, Down syndrome) - musculoskeletal (eg, arthropathy; disorders of muscle, ligament, and fascia; osteoarthrosis) - neuromuscular (eg, central vestibular disorders, peripheral neuropathy) - pulmonary (eg, emphysema) * Impairments in the following categories: - circulation (eg, claudication pain) - joint integrity and mobility (eg, hip pain with mobility) - motor function (eg, abnormal movement pattern) - muscle performance (eg, decreased power and endurance) - range of motion (eg, abnormal range with gait) - ventilation (eg, paradoxical breathing pattern on ambulation) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories:



Page 33 of 82

- self-care (eg, difficulty with dressing because of abnormal sitting balance) - home management (eg, inability to perform yardwork because of decreased power) - work (job/school/play) (eg, inability to do shopping as household manager because of painful ambulation, inability as a parent to climb the stairs carrying a child because of decreased power) - community/leisure (eg, inability to coach a Little League team because of hip pain, inability to play shuffleboard because of dizziness) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired gait, locomotion, and balance: - increased risk for falls - risk-prone behaviors (eg, scatter rugs, unclearly marked steps) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate dynamic balance for climbing, limited leg strength for squatting) - health and wellness (eg, incomplete understanding of need for dynamic balance in all functional actions) Tests and Measures Tests and measures may include those that characterize or quantify: * Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, activities of daily living [ADL] scales, instrumental activities of dally living [IADL] scales, observations, videographic assessments) * Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) * Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait indexes,



Page 34 of 82

IADL scales, mobility skill profiles, observations, videographic assessments) * Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait indexes, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) * Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports) Tools Used for Gathering Data Tools for gathering data may include: * Batteries of tests * Cameras and photographs * Diaries * Dynamometers * Electroneuromyographs * Force platforms * Goniometers * Indexes * Inventories * Logs * Motion analysis systems * Observations * Postural control tests * Profiles * Rating scales * Reports * Scales * Technology-assisted analysis systems



Page 35 of 82

* Video cameras and videotapes Data Generated Data are used in providing documentation and may include: Descriptions of: - gait and locomotion - gait, locomotion, and balance characteristics with or without use of devices or equipment - gait, locomotion, and balance on and in different physical environments - level of safety during gait, locomotion, and balance - static and dynamic balance - wheelchair maneuverability and mobility Integumentary Integrity Integumentary integrity is the intactness of the skin, including the ability of the skin to serve as a barrier to environmental threats (eg, bacteria, parasites). The physical therapist uses these tests and measures to assess the effects of a wide variety of disorders that result in skin and subcutaneous changes, including pressure and vascular, venous, arterial, diabetic, and necropathic ulcers; burns and other traumas; and a number of diseases (eg, soft tissue disorders). Results of tests and measures of integumentary integrity are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of integumentary integrity. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, deep vein thrombosis, peripheral vascular disease) - endocrine/metabolic (eg, diabetes, frostbite)



Page 36 of 82

- integumentary (eg, burn, frostbite, laceration, surgical wound) - multiple systems (eg, trauma) - musculoskeletal (eg, fracture, osteomyelitis) - neuromuscular (eg, coma, spinal cord injury) - pulmonary (eg, respiratory failure) * Impairments in the following categories: - aerobic capacity (eg, deconditioning) - circulation (eg, abnormal fluid distribution) - integumentary integrity (eg, burn eschar) - sensory integrity (eg, loss of sensation) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to bathe because of burn) - home management (eg, inability to wash dishes because of hand blisters) - work (job/school/play) (eg, inability to do construction work because of lower-extremity cellulitis, inability to hold a job because of pressure sore) - community/leisure (eg, inability to play organ at religious center because of loss of finger sensation, inability to skate because of frostbite) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired integumentary integrity: - obesity - risk-prone behaviors (eg, excessive exposure to sun or cold)



Page 37 of 82

- sedentary lifestyle - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate protection from sun during outdoor activities) - health and wellness (eg, limited comprehension of value of skin monitoring and protection) Tests and Measures Tests and measures may include those that characterize or quantify: Associated skin * Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales) * Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) * Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility; nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography) Wound * Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps) * Burn (body charting, planimetry) * Signs of infection (eg, cultures, observations, palpation) * Wound characteristics, including bleeding, contraction, depth, drainage, exposed anatomical structures, location, odor, pigment, shape, size, staging and progression, tunneling, and undermining (eg, digital and grid measurement, grading of sores and ulcers, observations, palpation, photographic assessments, wound tracing) * Wound scar tissue characteristics, including banding, pliability, sensation, and texture (eg, observations, scarrating scales) Tools Used for Gathering Data Tools for gathering data may include: * Cameras and photographs



Page 38 of 82

* Charts * Culture kits * Grids * Observations * Palpation * Planimeters * Pressure-sensing devices * Rulers * Scales * Thermographs * Tracings, maps, graphs Data Generated Data are used in providing documentation and may include: Associated skin * Descriptions of activities and postures that aggravate or relieve skin trauma * Descriptions and quantifications of skin characteristics * Descriptions of: - blister - devices and equipment that may produce skin trauma - hair pattern - skin color and continuity Wound * Descriptions of activities and postures that aggravate or relieve wound or scar trauma * Descriptions of signs of infection * Descriptions and quantifications of:



Page 39 of 82

- burn (eg, size, type, depth) - wound characteristics - wound scar tissue characteristics Joint Integrity and Mobility Joint integrity is the intactness of the structure and shape of the joint, including its osteokinematic and arthrokinematic characteristics. The tests and measures of joint integrity assess the anatomic and biomechanical components of the joint. Joint mobility is the capacity of the joint to be moved passively, taking into account the structure and shape of the joint surface in addition to characteristics of the tissue surrounding the joint. The tests and measures of joint mobility assess the performance of accessory joint movements, which are not under voluntary control. The physical therapist uses these tests and measures to assess whether there is excessive motion (hypermobility) or limited motion (hypomobility) of the joint. Results of tests and measures of joint integrity and mobility are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of joint integrity and mobility. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - endocrine/metabolic (eg, gout, osteoporosis) - multiple systems (eg, vehicular trauma) - musculoskeletal (eg, fracture, osteoarthritis, rheumatoid arthritis, sprain) - neuromuscular (eg, cerebral palsy, Parkinson disease) - pulmonary (eg, restrictive lung disease) * Impairments in the following categories: - anthropometric characteristics (eg, abnormal girth of limb at the knee) - ergonomics and body mechanics (eg, decreased dexterity and coordination)



Page 40 of 82

- gait, locomotion, and balance (eg, uneven step length) - posture (eg, abnormal spinal alignment) - range of motion (eg, decreased muscle length) - ventilation (eg, abnormal breathing pattern) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to fasten garments because of limited range of motion) - home management (eg, inability to sew on a button because of Finger joint pain) - work (job/school/play) (eg, inability to clean teeth as a dental hygienist because of joint stiffness, inability to climb a ladder because of joint tightness) - community/leisure (eg, inability as a student to attend driver's education because of limited range of motion in neck, inability to play golf because of shoulder joint pain) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired joint integrity and mobility: - increased risk for falls - performance of tasks requiring repetitive motion * Health, wellness, and fitness needs: - fitness, including physical performance (eg, reduced shoulder mobility for weight lifting) - health and wellness (eg, insufficient awareness of impact of mobility exercises on ability to lift weight) Tests and Measures Tests and measures may include those that characterize or quantify: * Joint integrity and mobility (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry; palpation)



Page 41 of 82

* Joint play movements, including end feel (all joints of the axial and appendicular skeletal system) (eg, palpation) * Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry) Tools Used for Gathering Data Tools for gathering data may include: * Arthrometers * Apprehension tests * Compression and distraction tests * Drawer tests * Glide tests * Impingement tests * Palpation * Shear tests * Valgus/varus stress tests Data Generated Data are used in providing documentation and may include: * Descriptions of: - accessory motion - bony and soft tissue restrictions during movement * Descriptions or quantifications of joint hypomobility or hypermobility * Presence of: - apprehension - joint impingement * Presence and severity of abnormal joint articulation Motor Function (Motor Control and Motor Learning)



Page 42 of 82

Motor function is the ability to learn or demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns. The physical therapist uses these tests and measures in the assessment of weakness, paralysis, dysfunctional movement patterns, abnormal timing, poor coordination, clumsiness, atypical movements, or dysfunctional postures. Results of tests and measures of motor function (motor control and motor learning) are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of motor function (motor control and motor learning). Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, congenital heart anomalies) - multiple systems (eg, encephalitis, meningitis, seizures) - musculoskeletal (eg, muscular dystrophy) - neuromuscular (eg, cerebral palsy, multiple sclerosis, Parkinson disease, spinal cord injury, traumatic brain injury, vestibular disorders) - pulmonary (eg, hyaline membrane disease) * Impairments in the following categories: - circulation (eg, increased heart rate with activities) - motor function (eg, irregular movement pattern) - muscle performance (eg, weakness) - orthotic, protective, and supportive devices (eg, dropfoot requiring an ankle-foot orthosis) - range of motion (eg, limited) - sensory integrity (eg, altered position sense) * Functional limitations in the ability to perform actions, tasks, or activities in the following



Page 43 of 82

categories: - self-care (eg, difficulty with combing hair because of weakness) - home management (eg, inability to clean the shower because of dysfunctional movement pattern) - work (job/school/play) (eg, inability to perform functions as toll collector because of dizziness, inability to sort mail because of clumsiness) - community/leisure (eg, inability to play softball because of poor coordination, inability to serve as greeter at senior citizen center because of muscle weakness and decreased endurance) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories.' - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired motor function: - increased risk for falls - lack of safety in all environments * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to control throwing motion, inadequate eyehand coordination in sports) - health and wellness (eg, incomplete understanding of importance of value of motor planning and practice in task performance) Tests and Measures Tests and measures may include those that characterize or quantify: * Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) * Electrophysiological integrity (eg, electroneuromyography) * Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity



Page 44 of 82

indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments) Tools Used for Gathering Data Tools for gathering data may include: * Batteries of tests * Dexterity tests * Electroneuromyographs * Function tests * Hand manipulation tests * Indexes * Motor performance tests * Observations * Postural challenge tests * Profiles * Scales * Screens * Tilt boards * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions and quantifications of: - dexterity, coordination, and agility - hand movements - head, trunk, and limb movements - sensorimotor integration



Page 45 of 82

- voluntary, age-appropriate postures and movement patterns * Observations and descriptions of atypical movements * Quantifications of electrophysiological responses to stimulation Muscle Performance (Including Strength, Power, and Endurance) Muscle performance is the capacity of a muscle or a group of muscles to generate forces. Strength is the muscle force exerted by a muscle or a group of muscles to overcome a resistance under a specific set of circumstances. Power is the work produced per unit of time or the product of strength and speed. Endurance is the ability of muscle to sustain forces repeatedly or to generate forces over a period of time. The muscle force that can be measured depends on the interrelationships among such factors as the length of the muscle, the velocity of the muscle contraction, and the mechanical advantage. Recruitment of motor units, fuel storage, and fuel delivery, in addition to balance, timing, and sequencing of contraction, mediate integrated muscle performance. The physical therapist uses these tests and measures to determine the ability to produce, maintain, sustain, and modify movements that are prerequisite to functional activity. Results of tests and measures of muscle performance (including strength, power, and endurance) are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of muscle performance (including strength, power, and endurance). Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, congestive heart failure, vascular insufficiency) - endocrine/metabolic (eg, diabetes, Down syndrome, osteoporosis) - integumentary (eg, post-mastectomy lymphedema, scar) - multiple systems (eg, AIDS) - musculoskeletal (eg, amputation, muscular dystrophy, osteoarthritis, spinal stenosis, synovitis, tenosynovitis) - neuromuscular (eg, cerebral palsy, Guillain-Barre, multiple sclerosis)



Page 46 of 82

- pulmonary (eg, cystic fibrosis, emphysema, pneumonia) * Impairments in the following categories: - aerobic capacity (eg, decreased endurance) - gait, locomotion, and balance (eg, frequent falls, decreased stance phase) - muscle performance (eg, decreased gross strength, generalized muscle weakness) - posture (eg, abnormal body alignment) - ventilation (eg, abnormal breathing pattern) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to don and doff clothing because of proximal instability) - home management (eg, inability to squat to pick up laundry because of muscle weakness) - work (job/school/play) (eg, inability as an airline baggage handler to handle baggage because of inability to lift heavy objects, inability to carry objects because of decreased muscle endurance, inability to keep up with peers on playground because of decreased muscle endurance) - community/leisure (eg, inability to hike because of ankle weakness) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired muscle performance: - increased risk for falls - sedentary lifestyle * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate muscle strength for aquatic sports, insufficient muscle endurance for long distance running) - health and wellness (eg, incomplete understanding of the need for strength before power)



Page 47 of 82

Tests and Measures Tests and measures may include those that characterize or quantify: * Electrophysiological integrity (eg, electroneuromyography) * Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted assessments, timed activity tests) * Muscle strength, power, and endurance during functional activities (eg, activities of daily living [ADL] scales, functional muscle tests, instrumental activities of daily living [IADL] scales, observations, videographic assessments) * Muscle tension (eg, palpation) Tools Used for Gathering Data Tools for gathering data may include: * Dynamometers * Electroneuromyographs * Functional muscle tests * Manual muscle tests * Muscle performance tests * Observations * Palpation * Physical capacity tests * Scales * Sphygmomanometers * Technology-assisted analysis systems * Timed activity tests * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Characterizations of:



Page 48 of 82

- electrophysiological responses to stimulation - muscle strength, power, and endurance * Presence and severity of pelvic-floor muscle weakness * Quantifications of: - levels of excitability of muscle - muscle strength, work, and power Neuromotor Development and Sensory Integration Neuromotor development is the acquisition and evolution of movement skills throughout the life span. Sensory integration is the ability to integrate information that is derived from the environment and that relates to movement. The physical therapist uses tests and measures to characterize movement skills in infants, children, and adults. The physical therapist also uses tests and measures to assess mobility; achievement of motor milestones; postural control; voluntary and involuntary movement; balance; righting and equilibrium reactions; eye-hand coordination; and other movement skills. Results of tests and measures of neuromotor development and sensory integration are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of neuromotor development and sensory integration. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems.' - cardiovascular (eg, cardiac or associated vessel disorders) - endocrine/metabolic (eg, fetal alcohol syndrome, lead poisoning) - multiple systems (eg, autism, birth prematurity, seizure disorder) - musculoskeletal (eg, congenital amputation) - neuromuscular (eg, hearing loss, visual deficit)



Page 49 of 82

- pulmonary (eg, anoxia, hypoxia) * Impairments in the following categories: - circulation (eg, abnormal heart rhythm) - gait, locomotion, and balance (eg, poor sitting posture) - motor function (eg, presence of involuntary movements) - muscle performance (eg, muscle weakness) - neuromotor development (eg, delayed motor skills) - posture (eg, lack of postural control) - prosthetic requirements (eg, poor balance with prosthesis) - ventilation (eg, asymmetrical expansion) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories.' - self-care (eg, inability to grasp bottle for feeding because of weakness) - home management (eg, inability to dust because of poor sensory integration) - work (job/school/play) (eg, inability to do assembly piecework because of poor eye-hand coordination, inability to play with peers in day care because of inability to crawl) - community/leisure (eg, inability to knit because of poor movement initiation, inability to vote in standing ballot booth because of inability to stand) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired neuromotor development and sensory integration: - increased risk for falls - poor nutritional status during gestation



Page 50 of 82

- substance abuse * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inappropriate timing or sequencing for skipping, limited ability to participate in organized play programs) - health and wellness (eg, lack of understanding of need for developmental screening) Tests and Measures Tests and measures may include those that characterize or quantify: * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) * Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, observations, postural challenge tests, reflex tests, sensory profiles, visual perceptual skill tests) Tools Used for Gathering Data Tools for gathering data may include: * Batteries of tests * Behavioral assessment scales * Electrophysiological tests * Indexes * Interviews * Inventories * Motor assessment tests * Motor function tests * Neuromotor assessments * Observations * Postural challenge tests * Proficiency assessments



Page 51 of 82

* Profiles * Questionnaires * Reflex tests * Scales * Screens * Skill tests * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions and quantifications of: - behavioral response to stimulation - dexterity, coordination, and agility - movement skills, including age-appropriate development, gross and - fine motor skills, reflex development - oral motor function, phonation, and speech production - sensorimotor integration, including postural, equilibrium, and righting reactions * Observations and description of atypical movement Orthotic, Protective, and Supportive Devices Orthotic, protective, and supportive devices are implements and equipment used to support or protect weak or ineffective joints or muscles and serve to enhance performance. Orthotic devices include braces, casts, shoe inserts, and splints. Protective devices include braces, cushions, helmets, and protective taping. Supportive devices include compression garments, corsets, elastic wraps, mechanical ventilators, neck collars, serial casts, slings, supplemental oxygen, and supportive taping. The physical therapist uses these tests and measures to assess the need for devices in patients/clients not currently using them and to evaluate the appropriateness and fit of those devices already in use. Results of tests and measures of orthotic, protective, and supportive devices are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications



Page 52 of 82

Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of orthotic, protective, and supportive devices. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, congestive heart failure, peripheral vascular disease) - endocrine/metabolic (eg, rheumatological disease) - multiple systems (eg, AIDS, trauma) - musculoskeletal (eg, amputation, status post joint replacement) - neuromuscular (eg, cerebellar ataxia, cerebral palsy) - pulmonary (eg, asthma, cystic fibrosis, reactive airways disease) * Impairments in the following categories: - anthropometric characteristics (eg, girth, height) - gait, locomotion, and balance (eg, impaired motor function) - integumentary integrity (eg, impaired sensation) - joint integrity and mobility (eg, joint hypermobility) - muscle performance (eg, weakness) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories.' - self-care (eg, inability to wash hair because of upper-extremity lymphedema) - home management (eg, inability to walk on uneven terrain because of ankle instability) - work (job/school/play) (eg, inability as a factory worker to lift repetitively on assembly line because of pain, inability to maintain head position in classroom because of poor motor function, inability to stand because of low back pain) - community/leisure (eg, inability to bowl because of wrist pain and weakness) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:



Page 53 of 82

- self-care - home management - work (job/school/play) - community/leisure * Risk factor for improper use or lack of use of orthotic, protective, and supportive devices: - lack of safety awareness - lack of use of adequate protective devices during activity * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate control of skis without orthotic device for ski boot) - health and wellness (eg, incomplete understanding of importance of orthotic evaluation and compliance with program) Tests and Measures Tests and measures may include those that characterize or quantify: * Components, alignment, fit, and ability to care for the orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) * Orthotic, protective, and supportive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daily living [IADL] scales, interviews, observations, profiles) * Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, LADL scales, pain scales, play scales, videographic assessments) * Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports) Tools Used for Gathering Data Tools for gathering data may include: * Aerobic capacity tests * Diaries * Indexes



Page 54 of 82

* Interviews * Inventories * Logs * Observations * Play scales * Pressure-sensing devices * Profiles * Questionnaires * Reports * Scales * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions of: - ability to use and care for devices and equipment - alignment and fit of the devices and equipment - components of orthotic, protective, or supportive devices and equipment - level of safety with devices and equipment - practicality of devices and equipment - remediation of impairment, functional limitation, or disability with devices and equipment * Quantifications of: - movement patterns with or without devices - physiological and functional effect and benefit of devices and equipment Pain Pain is a disturbed sensation that causes suffering or distress. The physical therapist uses these tests and measures to determine a cause or a mechanism for the pain and to assess the intensity,



Page 55 of 82

quality, and temporal and physical characteristics of any pain that is important to the patient and that may result in impairments, functional limitations, or disabilities. Results of tests and measures of pain are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of pain. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems.' - cardiovascular (eg, coronary artery disease, myocardial infarction) - endocrine/metabolic (eg, osteoporosis, rheumatological disease) - integumentary (eg, burn, incision, ulcer, wound) - multiple systems (eg, vehicular trauma) - musculoskeletal (eg, amputation, cumulative trauma, fracture, spinal stenosis, temporomandibular joint dysfunction) - neuromuscular (eg, nerve compression, spinal cord injury) - pulmonary (eg, lung cancer, status post thoracotomy) * Impairments in the following categories.' - circulation (eg, decreased ability to walk because of chest discomfort) - integumentary (eg, limited range of motion because of painful rash) - joint integrity (eg, decreased range of motion because of finger ache) - muscle performance (eg, weakness because of muscle burning) - pain (eg, decreased movement of spine because of stabbing back pain) - posture (eg, forward head position because of upper-back discomfort) - ventilation (eg, decreased expansion because of splinting of painful chest wall)



Page 56 of 82

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories.' - sell-care (eg, difficulty with eating because of jaw pain) - home management (eg, inability to shovel snow because of shoulder soreness) - work (job/school/play) (eg, inability as a parent to carry infant because of shooting knee pain, inability to mop floor because of chest pressure) - community/leisure (eg, inability to canoe because of backache, inability to keep up with grandchildren because legs ache while walking) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - sell-care - home management - work (job/school/play) - community/leisure * Risk factors for pain: - habitual suboptimal posture - risk-prone behaviors (eg, lack of use of safety gear, performance of tasks requiring repetitive motion) - sedentary lifestyle - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, decreased ability to tolerate strength training because of pain, limited participation in leisure sports because of pain) - health and wellness (eg, limited information about living with pain) Tests and Measures Tests and measures may include those that characterize or quantify: * Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) * Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)



Page 57 of 82

Tools Used for Gathering Data Tools for gathering data may include: * Descriptor tests (verbal and pictorial) * Discrimination tests * Indexes * Pain drawings and maps * Provocation and structural provocation tests * Questionnaires * Scales Data Generated Data are used in providing documentation and may include: * Characterizations of activities or postures that aggravate or relieve pain * Descriptions and quantifications of pain according to specific body part * Localization of pain * Sensory and temporal qualities of pain * Severity of pain, soreness, and discomfort * Somatic distribution of pain Posture Posture is the alignment and positioning of the body in relation to gravity, center of mass, or base of support. The physical therapist uses these tests and measures to assess structural alignment. Good posture is a state of musculoskeletal balance that protects the supporting structures of the body against injury or progressive deformity. Results of tests and measures of posture are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the



Page 58 of 82

systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of posture. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems.' - cardiovascular (eg, cerebral vascular accident) - endocrine/metabolic (eg, rheumatological disease) - genitourinary (eg, pelvic floor dysfunction, pregnancy) - multiple systems (eg, trauma) - musculoskeletal (eg, amputation, intervertebral disk disorders, scoliosis, joint replacement) - neuromuscular (eg, cerebral palsy, neurofibromatosis, spina bifida) - pulmonary (eg, pneumonectomy, restrictive lung disease) * Impairments in the following categories: - circulation (eg, decreased endurance) - orthotic, protective, and supportive devices (eg, swollen malaligned knee) - muscle performance (eg, weakness, imbalance) - pain (eg, decreased range of motion of lumbar spine) - posture (eg, leg length discrepancies) - range of motion (eg, decreased cervical range of motion) - ventilation (eg, asymmetrical expansion) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with donning and doffing shoes and socks because of limited painful spinal range of motion) - home management (eg, inability to do laundry because of shortness of breath) - work (job/school/play) (eg, inability to bake because of painful upper-extremity postures, inability to compete on soccer team because of scoliosis)



Page 59 of 82

- community/leisure (eg, inability as a scout leader to camp and hike because of hip pain, inability to walk dog because of leg pain) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories.' - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired posture: - habitual suboptimal posture - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to serve tennis ball with required speed, poor posture that limits time at computer workstation) - health and wellness (eg, inadequate information about need for posture stretching) Tests and Measures Tests and measures may include those that characterize or quantify: * Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted assessments, videographic assessments) * Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) * Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests) Tools Used for Gathering Data Tools for gathering data may include: * Angle assessments * Cameras and photographs * Goniometers * Grids



Page 60 of 82

* Observations * Palpation * Positional tests * Plumb lines * Tape measures * Technology-assisted analysis systems * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Quantifications of: - dynamic alignment, symmetry, and deviation during movement - postural alignment using posture grids - static alignment, symmetry, and deviation Prosthetic Requirements Prosthetic requirements are the biomechanical elements necessitated by the loss of a body part. A prosthesis is an artificial device used to replace a missing part of the body. The physical therapist uses these tests and measures to assess the effects and benefits, components, alignment and fit, and safe use of the prosthesis. Results of tests and measures of prosthetic requirements are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of prosthetic requirements. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems:



Page 61 of 82

- cardiovascular (eg, peripheral vascular disease) - endocrine/metabolic (eg, diabetes) - integumentary (eg, burn, frostbite) - multiple systems (eg, congenital anomalies, gangrene) - musculoskeletal (eg, amputation, compartment syndrome) * Impairments in the following categories: - aerobic capacity (eg, decreased endurance) - circulation (eg, decreased ankle motion) - gait, locomotion, and balance (eg, altered stride length) - muscle performance (eg, decreased muscle endurance) - pain (eg, claudication) - prosthetic requirements (eg, residual limb pain) Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to put on shoes because of edema) - home management (eg, inability to climb stairs because of leg pain) - work (job/school/play) (eg, inability to use a keyboard because of loss of fingers, inability to walk child to school because of distal limb ache) - community/leisure (eg, inability to engage in bird watching because of residual limb discomfort on uneven terrain, inability to ride bicycle to school because of poor prosthetic fit) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for improper use or lack of use of prosthesis:



Page 62 of 82

- obesity - risk of skin breakdown - sedentary lifestyle * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to participate in endurance activities with current prosthesis, inadequate prosthetic components or fit for running) - health and wellness (eg, inadequate knowledge about importance of prosthetic fit) Tests and Measures Tests and measures may include those that characterize or quantify: * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Prosthetic device use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daily living [IADL] scales, interviews, observations) * Remediation of impairments, functional limitations, or disabilities with use of the prosthetic device (eg, aerobic capacity tests, activity status indexes, ADL scales, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, technologyassisted assessments, videographic assessments) * Residual limb or adjacent segment, including edema, range of motion, skin integrity, and strength (eg, goniometry, muscle tests, observations, palpation, photographic assessments, skin integrity tests, technology-assisted assessments, videographic assessments, volume measurement) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) Tools Used for Gathering Data Tools for gathering data may include: * Aerobic capacity tests * Cameras and photographs * Diaries * Goniometers * Indexes * Interviews



Page 63 of 82

* Inventories * Logs * Muscle tests * Observations * Palpation * Pressure-sensing devices * Profiles * Questionnaires * Reports * Scales * Skin integrity tests * Technology-assisted analysis systems * Video cameras and videotapes * Volumometers Data Generated Data are used in providing documentation and may include: * Descriptions and quantifications of: - ability to use and care for device and practicality of device - components of prosthetic devices - level of safety with device - residual limb or adjacent segment * Descriptions and quantifications of: - alignment and fit of the device - remediation of impairment, functional limitation, or disability with device * Quantifications of:



Page 64 of 82

- movement patterns with or without device - physiological and functional effects and benefits of device Range of Motion (Including Muscle Length) Range of motion (ROM) is the are through which movement occurs at a joint or a series of joints. Muscle length is the maximum extensibility of a muscle-tendon unit. Muscle length, in conjunction with joint integrity and soft tissue extensibility, determines flexibility. The physical therapist uses these tests and measures to assess the range of motion of a joint. Results of tests and measures of range of motion (including muscle length) are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records).The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of range of motion (including muscle length). Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - endocrine/metabolic (eg, rheumatological disease) - genitourinary (eg, pregnancy) - multiple systems (eg, trauma) - musculoskeletal (eg, avulsion of tendon; disorders of muscle, ligament, and fascia; fracture; osteoarthritis; scoliosis; spinal stenosis; sprain; strain) - neuromuscular (eg, Parkinson disease) - ventilation (eg, restrictive lung disease) * Impairments in the following categories: - assistive and adaptive devices (eg, swollen knee) - cranial and peripheral nerve integrity (eg, radiating leg pain) - gait, locomotion, and balance (eg, limp)



Page 65 of 82

- muscle performance (eg, muscle weakness) - range of motion (eg, limited elbow range of motion) - ventilation (eg, shortness of breath) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to put on stockings because of weakness) - home management (eg, inability to load dishwasher because of difficulty bending) - work (job/school/play) (eg, inability to cut hair because of painful swollen fingers, inability as a professional dancer to assume en pointe position because of painful arch) - community/leisure (eg, inability to roller blade because of ankle swelling, inability to serve as volunteer in hospital gift shop because of pain on standing) * Disability--that is, the inability or the restricted ability toperform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired range of motion: - increased risk for falls - habitual suboptimal posture - smoking history * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate flexibility to participate in gymnastics, limited range of motion in shoulders for mural painting) - health and wellness (eg, incomplete understanding of relationship between mobility and painfree functional activities) Tests and Measures Tests and measures may include those that characterize or quantify: * Functional ROM (eg, observations, squat testing, toe touch tests)



Page 66 of 82

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, technology-assisted assessments, videographic assessments) * Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation) Tools Used for Gathering Data Tools for gathering data may include: * Back ROM devices * Camera and photographs * Cervical protractors * Flexible rulers * Functional tests * Goniometers * Inclinometers * Ligamentous stress tests * Multisegment flexibility tests * Observations * Palpation * Scoliometers * Tape measures * Technology-assisted analysis systems * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions of muscle, joint, and soft tissue characteristics * Observations and descriptions of functional or multisegmental movement * Quantifications of:



Page 67 of 82

- musculotendinous extensibility ROM Reflex Integrity Reflex integrity is the intactness of the neural path involved in a reflex. A reflex is a stereotypic, involuntary reaction to any of a variety of sensory stimuli. The physical therapist uses these tests and measures to determine the excitability of the nervous system and the integrity of the neuromuscular system. Results of tests and measures of reflex integrity are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of reflex integrity. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident) - multiple systems (eg, Guillain-Barre syndrome) - neuromuscular (eg, amyotrophic lateral sclerosis, cerebral palsy, coma, prematurity, traumatic brain injury) - pulmonary (eg, anoxia) * Impairments in the following categories: - assistive and adaptive devices (eg, limited mobility) - gait, locomotion, and balance (eg, poor balance) - integumentary integrity (eg, pressure sore) - motor function (eg, poor coordination) - muscle performance (eg, weakness) - neuromotor development and sensory integration (eg, delayed gross motor skills)



Page 68 of 82

- posture (eg, asymmetrical alignmen0 - range of motion (eg, hypermobility) * Functional limitations in the ability to perform actions, tasks, and activities in the following categories: - self-care (eg, difficulty with eating because of jaw pain with chewing) - home management (eg, inability to take trash cans out because of poor coordination) - work (job/school/play) (eg, inability to reach to restock shelves because of poor coordination) - community/leisure (eg, inability to hike with friends because of poor coordination and weakness, inability to obtain driver's license because of startle reflex, inability to run because of hypermobility) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired reflex integrity: - habitual suboptimal posture increased risk for falls * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inability to participate in leisure activities that involve jumping and hopping, inadequate knowledge of proper stretch techniques for sports participation) - health and wellness (eg, inadequate knowledge of relaxation) Tests and Measures Tests and measures may include those that characterize or quantify: * Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) * Electrophysiological integrity (eg, electroneuromyography) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) * Primitive reflexes and reactions, including developmental (eg, reflex profiles, screening tests)



Page 69 of 82

* Resistance to passive stretch (eg, tone scales) * Superficial reflexes and reactions (eg, observations, provocation tests) Tools Used for Gathering Data Tools for gathering data may include: * Electroneuromyographs * Myotatic reflex scales * Observations * Postural challenge tests * Provocation tests * Reflex profiles * Reflex tests * Scales * Screens * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Characterizations and quantifications of: - age-appropriate reflexes - deep reflexes - electrophysiological responses to stimulation - postural reflexes and righting reactions - superficial reflexes Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living) Self-care management is the ability to perform activities of daily living (ADL), such as bed mobility, transfers, dressing, grooming, bathing, eating, and toileting. Home management is the ability to perform the more complex instrumental activities of daily living (IADL), such as structured play (for



Page 70 of 82

infants and children), maintaining a home, shopping, performing household chores, caring for dependents, and performing yard work. The physical therapist uses the results of these tests and measures to assess the level of performance of tasks necessary for independent living; the need for assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment; and the need for body mechanics training, organized functional training programs, or therapeutic exercise. Results of tests and measures of self-care and home management (including ADL and IADL) are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of self-care and home management (including ADL and IADL). Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, congestive heart failure, peripheral vascular disease) - endocrine/metabolic (eg, rheumatological disease) - genitourinary (eg, pelvic floor dysfunction) - multiple systems (eg, AIDS, trauma) - musculoskeletal (eg, amputation, joint replacement, spinal stenosis, spinal surgery) - neuromuscular (eg, cerebellar ataxia, cerebral palsy, multiple sclerosis, post-polio syndrome, spinal cord injury, traumatic brain injury) - pulmonary (eg, asthma, chronic obstructive pulmonary disease, cystic fibrosis, reactive airways disease) * Impairments in the following categories: - aerobic capacity (eg, decreased endurance, shortness of breath) - arousal, attention, cognition (eg, lack of safety awareness) - circulation (eg, abnormal heart rate and rhythm) - gait, locomotion, and balance (eg, falls)



Page 71 of 82

- muscle performance (eg, decreased power) - neuromotor development (eg, abnormal movement patterns) - orthotic, protective, and supportive devices (eg, wearing a corset) - posture (eg, severe kyphosis) - prosthetic requirements (eg, use of prosthesis) - range of motion (eg, decreased muscle length) - ventilation (eg, accessory muscle use) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to dress because of abnormal range of motion, inability to tie shoes as a first grader because of poor coordination) - home management (eg, inability to shop because of decreased endurance) - community/leisure (eg, inability to garden because of shortness of breath, inability to travel to visit relatives because of lack of safety awareness) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for limitations in self, are and home management: - habitual suboptimal posture - lack of safety awareness in all environments - risk-prone behaviors (eg, performance of tasks requiring repetitive motion, lack of use of safety gear) - sedentary lifestyle * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate endurance to perform heavy chores)



Page 72 of 82

- health and wellness (eg, limited knowledge of adaptations to allow independent function) Tests and Measures Tests and measures may include those that characterize or quantify: * Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) * Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) * Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments) Tools Used for Gathering Data Tools for gathering data may include: * Aerobic capacity tests * Barrier identification checklists * Diaries * Fall scales * Indexes * Interviews * Inventories * Logs * Observations * Physical performance tests * Profiles * Reports * Questionnaires * Scales * Video cameras and videotapes



Page 73 of 82

Data Generated Data are used in providing documentation and may include: * Descriptions and quantifications of: - ability to participate in variety of environments - functional capacity - level of safety in self-care and home management activities - need for devices or equipment - physiological responses to activity Sensory Integrity Sensory integrity is the intactness of cortical sensory processing, including proprioception, pallesthesia, stereognosis, and topognosis. Proprioception is the reception of stimuli from within the body (eg, from muscles and tendons) and includes position sense (the awareness of joint position) and kinesthesia (the awareness of movement). Pallesthesia is the ability to sense mechanical vibration. Stereognosis is the ability to perceive, recognize, and name familiar objects. Topognosis is the ability to localize exactly a cutaneous sensation. The physical therapist uses the results of tests and measures to determine the integrity of the sensory, perceptual, and somatosensory processes. Results of tests and measures of sensory integrity are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of sensory integrity. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems.' - cardiovascular (eg, cerebral vascular accident, peripheral vascular disease) - endocrine/metabolic (eg, diabetes, rheumatological disease) - integumentary (eg, burn, frostbite, lymphedema)



Page 74 of 82

- multiple systems (eg,AIDS, Guillain-Barre syndrome, trauma) - musculoskeletal (eg, derangement of joint; disorders of bursa, synovia, and tendon) - neuromuscular (eg, cerebral palsy, developmental delay, spinal cord injury, traumatic brain injury) - pulmonary (eg, respiratory failure, ventilatory pump failure) * Impairments in the following categories: - circulation (eg, numb feet) - integumentary integrity (eg, redness under orthotic) - muscle performance (eg, decreased grip strength) - orthotic, protective, and supportive devices (eg, wears ankle foot orthosis) - posture (eg, forward head) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to put on trousers while standing because of loss of feeling in foot) - home management (eg, difficulty with sorting change because of numbness) - work (job/school/play) (eg, inability as a day care provider to change child's diaper because of loss of finger sensation, inability to operate cash register because of clumsiness) - community/leisure (eg, inability to drive car because of loss of spatial awareness, inability to play guitar because of hyperesthesia) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired sensory integrity: - lack of safety awareness in all environments - risk-prone behaviors (eg, working without protective gloves)



Page 75 of 82

- smoking history - substance abuse * Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate balance to compete in dancing competition, limited perception of arms and legs in space during ballroom dancing) - health and wellness (eg, inadequate understanding of role of proprioception in balance) Tests and Measures Tests and measures may include those that characterize or quantify: * Combined/cortical sensations (eg, stereognosis tests, tactile discrimination tests) * Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) * Electrophysiological integrity (eg, electroneuromyography) Tools Used for Gathering Data Tools for gathering data may include: * Cameras and photographs * Esthesiometers * Electroneuromyographs * Filaments * Kinesthesiometers * Observations * Palpation * Pressure scales * Sensory tests * Tuning forks Data Generated Data are used in providing documentation and may include:



Page 76 of 82

* Characterizations and quantifications of: - electrophysiological responses to stimulation - position and movement sense - sensory processing - sensory responses to provocation Ventilation and Respiration/Gas Exchange Ventilation is the movement of a volume of gas into and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide across a membrane either in the lungs or at the cellular level. The physical therapist uses these tests and measures to determine whether the patient has an adequate ventilatory pump and oxygen uptake/carbon dioxide elimination system to meet the oxygen demands at rest, during aerobic exercise, and during the performance of activities of daily living. Results of tests and measures of ventilation and respiration/gas exchange are integrated with the history and systems review findings and the results of other tests and measures. All of these data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of ventilation and respiration/gas exchange. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, congestive heart failure, coronary artery disease) - endocrine/metabolic (eg, diabetes, rheumatological disease) - genitourinary (eg, pelvic floor dysfunction) - multiple systems (eg,AIDS, deconditioning, trauma) - musculoskeletal (eg, kyphoscoliosis, muscular dystrophy) - neuromuscular (eg, coma, cerebral palsy, Parkinson disease, spinal cord injury, traumatic brain injury) - pulmonary (eg, asthma, cystic fibrosis, chronic obstructive pulmonary disease, hyaline



Page 77 of 82

membrane disease, pneumonia, pulmonary edema, reactive airways disease, respiratory failure, restrictive lung disease, status post thoracotomy) * Impairments in the following categories: - aerobic capacity (eg, shortness of breath) - anthropometric characteristics (eg, pedal edema) - circulation (eg, abnormal heart rate, calf cramps with walking) - muscle performance (eg, decreased endurance) - posture (eg, scoliosis) - prosthetic requirements (eg, dyspnea on exertion while wearing prosthesis) - ventilation (eg, accessory muscle use) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to put on socks because of shortness of breath) - home management (eg, inability to do yard work because of decreased power) - work (job/school/play) (eg, inability to preach sermons because of uncontrolled breathing pattern, inability to suck as neonate because of rapid respiratory rate) - community/leisure (eg, inability to participate in community gardening events because of dyspnea on exertion, inability to swim because of dyspnea and chest tightness) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - self-care - home management - work (job/school/play) - community/leisure * Risk factors for impaired ventilation and respiration/gas exchange: - risk-prone behaviors (eg, exercise in high-pollution environments, lack of understanding of the need for flu shot) - sedentary lifestyle - smoking history



Page 78 of 82

* Health, wellness, and fitness needs: - fitness, including physical performance (eg, inadequate oxygen consumption for participating in marathon running, inadequate peripheral response for running) - health and wellness (eg, incomplete understanding of necessity for paced breathing during activity) Tests and Measures Tests and measures may include those that characterize or quantify: * Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) * Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests) * Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales) Tools Used for Gathering Data Tools for gathering data may include: * Airway clearance tests * Force meters * Gas analyses * Indexes * Observations * Palpation * Pulse oximeters * Spirometers * Stethoscopes Data Generated Data are used in providing documentation and may include: * Descriptions and characterization of: - breath and voice sounds



Page 79 of 82

- chest wall and related structures - phonation - pulmonary-related symptoms - pulmonary vital signs - thoracoabdominal ventilatory patterns * Observations and descriptions of nail beds * Presence and level of cyanosis * Quantifications of: - ability to dear and protect airway - gas exchange and oxygen transport - pulmonary function and ventilatory mechanics Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living) Work (job/school/play) integration or reintegration is the process of assuming or resuming roles and functions at work (job/school/play), such as negotiating school environments, gaining access to work (job/school/play) environments and workstations, and participating in age-appropriate play activities. Community integration or reintegration is the process of assuming or resuming roles and functions in the community, such as gaining access to transportation (eg, driving a car, boarding a bus, negotiating a neighborhood), to community businesses and services (eg, bank, shops, parks), and to public facilities (eg, attending theaters, town hal meetings, and places of worship). Leisure integration or reintegration is the process of assuming or resuming roles and functions of avocational and enjoyable pastimes, such as recreational activities (eg, playing a sport) and ageappropriate hobbies (eg, collecting antiques, gardening, or making crafts). The physical therapist uses the results of work, community, and leisure integration or reintegration tests and measures to (1) make judgments as to whether a patient/client is currently prepared to assume or resume community or work (job/school/play) roles, including all instrumental activities of daily living (IADL), (2) determine when and how such integration or reintegration might occur, or (3) assess the need for assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment. The physical therapist also uses the results of these tests and measures to determine whether the patient/client is a candidate for a work hardening or work conditioning program. Results of tests and measures of work (job/school/play), community, and leisure integration or reintegration are integrated with the history and systems review findings and the results of other tests and measures. All of the data are then synthesized during the evaluation process to establish the diagnosis, the prognosis, and the plan of care, which includes the selection of interventions. The results of these tests and measures may indicate the need to use or recommend other tests and measures or the need to consult with, or refer the patient/client to, another professional. Clinical Indications



Page 80 of 82

Clinical indications for the use of tests and measures are predicated on the history and systems review findings (eg, information provided by the patient/client, family, significant other, or caregiver; symptoms described by the patient/client; signs observed and documented during the systems review; and information derived from other sources and records). The findings may indicate the presence of or risk for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities that require a more definitive examination through the selection of tests and measures of work (job/school/play), community, and leisure integration or reintegration. Clinical indications for these tests and measures may include: * Pathology/pathophysiology (disease, disorder, or condition) in the following systems: - cardiovascular (eg, cerebral vascular accident, peripheral vascular disease) - endocrine/metabolic (eg, rheumatological disease) - genitourinary (eg, pelvic floor dysfunction) - multiple systems (eg,AIDS, trauma) - musculoskeletal (eg, amputation, status post joint replacement) - neuromuscular (eg, cerebellar ataxia, cerebral palsy) - pulmonary (eg, asthma, cystic fibrosis) * Impairments in the following categories: - circulation (eg, calf cramps with walking) - muscle performance (eg, decreased strength) - neuromotor development (eg, abnormal movement control) - posture (eg, pain on sitting) - range of motion (eg, decreased muscle length) - ventilation (eg, abnormal breathing pattern) * Functional limitations in the ability to perform actions, tasks, and activities in the following categories: - work (job/school/play) (eg, inability to sit at desk because of pain) - community/leisure (eg, inability to attend a concert because of incontinence, inability to board a bus because of muscle weakness, inability to gain access to recreational facilities because of abnormal movement control, inability to visit friends in neighborhood because of decreased endurance) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:



Page 81 of 82

- self-care - home management - work (job/school/play) - community/leisure * Risk factors for limitations in work Gob/school/play), community, and leisure integration and reintegration: - lack of safety awareness in all environments * Health, wellness, and fitness needs.' - fitness, including physical performance (eg, inadequate motor skill to perform repeated lifting activities as part of job, inadequate muscle strength for lifting boxes to and from shelves) - health and wellness (eg, incomplete understanding of need for community support during reintegration) Tests and Measures Tests and measures may include those that characterize or quantify: * Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests) * Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) * Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments) Tools Used for Gathering Data Tools for gathering data may include: * Diaries * Indexes * Interviews * Logs * Observations * Physical capacity tests



Page 82 of 82

* Profiles * Questionnaires * Transportation assessments * Scales * Video cameras and videotapes Data Generated Data are used in providing documentation and may include: * Descriptions of: - level of safety in work (job/school/ play), community, and leisure activities - physiological responses to activity * Quantifications of: - ability to participate in variety of environments - functional capacity - need for devices or equipment

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"What Types of Tests and Measures Do Physical Therapists Use?." Physical Therapy 81.1 (Jan 2001): 51. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 63

What Types of Interventions Do Physical Therapists Provide?(A Guide to Physical Therapist Practice).Physical Therapy 81.1 (Jan 2001): p105. (14732 words)


Introduction In its broadest sense, intervention is the purposeful interaction of the physical therapist with the patient/client--and, when appropriate, with other individuals involved in patient/client care--using various methods and techniques to produce changes that are consistent with the examination and reexamination findings, the evaluation, the diagnosis, and the prognosis. Decisions about intervention are contingent on the timely monitoring of patient/client responses to interventions and on the progress made toward anticipated goals and expected outcomes. Physical therapist intervention consists of three major components (Figure): * Coordination, communication, and documentation * Patient/client-related instruction * Procedural interventions Coordination, communication, and documentation and patient/client-related instruction are provided as part of intervention for all patients/clients. The use of procedural interventions varies, however, because those interventions are selected, applied, or modified according to examination and reexamination findings and the anticipated goals and expected outcomes for a particular patient/client in a specific diagnostic group. Physical therapist intervention encourages functional independence, emphasizes patient/clientrelated instruction, and promotes proactive, wellness-oriented lifestyles. Through appropriate education and instruction, the patient/client is encouraged to develop habits that will maintain or improve function, prevent recurrence of problems, and promote health, wellness, and fitness. Selection of Procedural Interventions Physical therapists select interventions based, on the complexity and severity of the clinical problems. In determining the prognosis, the interventions to be used, and the likelihood of an intervention's success, physical therapists also must consider the differences between the highest level of function of which the individual is capable and the highest level of function that is likely to be habitual for that individual. Patients/clients are more likely to achieve the anticipated goals and expected outcomes that are determined with the physical therapist if they perceive a need to function at the highest level of their ability--and if they are motivated to function habitually at that level. Thus understanding the difference between what a person currently does and what that person potentially could do is essential in making a prognosis and identifying realistic, achievable goals and outcomes. Physical therapists ultimately must abide by the decisions of the patient/client regarding actions, tasks, and activities that will be incorporated into a daily routine



Page 2 of 63

and regarding what constitutes a meaningful level of function. The physical therapist's selection of procedural interventions should be based on: * Examination findings (including those of the history, systems review, and tests and measures), an evaluation, and a diagnosis that supports physical therapy intervention * A prognosis that is associated with improved or maintained health status through risk reduction; health, wellness, and fitness programs; or the remediation of impairments, functional limitations, or disabilities * A plan of care designed to improve, enhance, and maximize function through interventions of appropriate intensity, frequency, and duration to achieve anticipated goals and expected outcomes efficiently using available resources The physical therapist selects, applies, or modifies one or more procedural interventions based on anticipated goals and expected outcomes that have been developed with the patient/client. Anticipated goals and expected outcomes relate to specific impairments, functional limitations, or disabilities; signs or symptoms; risk reduction/prevention; and health, wellness, or fitness needs. The anticipated goals and expected outcomes listed in the plan of care should be measurable and time-specific. In conjunction with coordination, communication, and documentation and patient/client-related instruction, three categories of procedural interventions form the core of most physical therapy plans of care: therapeutic exercise, functional training in self-care and home management, and functional training in work (job/school/play), community, and leisure integration or reintegration. The other categories of procedural interventions may be used when the examination, evaluation, diagnosis, and prognosis indicate their necessity. Factors that influence the complexity of both the examination process and the selection of interventions may include chronicity or severity of current condition; level of current impairment and probability of prolonged impairment, functional limitation, or disability; living environment; multisite or multisystem involvement; overall physical function and health status; potential discharge destinations; preexisting systemic conditions or diseases; social supports; and stability of the condition.



Page 3 of 63

Through routine monitoring and reexamination, the physical therapist determines the need for any alteration in an intervention or in the plan of care. The interventions used, including their frequency and duration, are consistent with patient/client needs and physiological and cognitive status, anticipated goals and expected outcomes, and resource constraints. The independent performance of the procedure or technique by the patient/client (or significant other, family, or caregiver) is encouraged following instruction in safe and effective application. Failing to intervene appropriately to prevent illness or to habilitate or rehabilitate patients/clients with impairments, functional limitations, and disabilities leads to greater costs for both the person and society. The Guide provides administrators and policy makers with the information they need to make decisions about the cost-effectiveness of physical therapist intervention. Criteria for Termination of Physical Therapy Services Discharge and discontinuation are the two processes used for terminating physical therapy services. Discharge is the process of ending physical therapy services that have been provided during a single episode of care when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (that is, when the patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral. Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward anticipated goals and expected outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy.



Page 4 of 63

In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discontinuation and provides for appropriate follow-up or referral. In this chapter, each component of physical therapist intervention--coordination, communication, and documentation; patient/client-related instruction; and procedural interventions--is described, including: * General definitions. General definitions of each category of intervention are provided. * Clinical considerations. Clinical considerations for selection of interventions are provided. For procedural interventions, examples are given of the types of examination and diagnostic findings that may indicate that a procedural intervention may be appropriate for a given patient/client. Findings may include pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/prevention needs; and health, wellness, and fitness needs. * Interventions. Examples of methods, procedures, or techniques that may be used are provided. * Anticipated goals and expected outcomes. Anticipated goals and expected outcomes are categorized according to a procedural intervention's impact on pathology/ pathophysiology; impairments; functional limitations; disabilities; risk reduction/prevention; health, wellness, and fitness; impact on societal resources; and patient/client satisfaction. Coordination, Communication, and Documentation Coordination, communication, and documentation are administrative and supportive processes that are intended to ensure that patients/clients receive appropriate, comprehensive, efficient, effective, and high-quality care from admission through discharge. Coordination is the working together of all parties involved with the patient/client. Communication is the exchange of information. Documentation is any entry into the patient/client record--such as consultation reports, initial examination reports, progress notes, flow sheets, checklists, reexamination reports, or summations of care--that identifies the care or service provided. Administrative and support processes may include the addressing of such required functions as advance directives, individualized education plans (IEPs), individualized family service plans (IFSPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting); admission and discharge planning; case management; collaboration and coordination with agencies; communication across settings; cost-effective resource utilization; data collection, analysis, and reporting; documentation across settings; interdisciplinary teamwork; and referrals to other professionals or resources. Physical therapists are responsible for coordination, communication, and documentation across all settings for all patients/clients. Clinical Considerations Considerations that may direct the type and specificity of interventions for coordination, communication, and documentation may include: * Patient/client seeks physical therapy services.



Page 5 of 63

* Patient/client is referred to physical therapy services. * Patient/client condition indicates need for referral to physical therapy services. * Patient/client requires referral from the physical therapist to another service or provider. * Physical therapist obtains informed consent from patient/client in accordance with jurisdictional law. * Patient/client has signs or symptoms of physical abuse that must be reported in accordance with jurisdictional law. * Patient/client is admitted to or transferred across patient care settings. * Physical therapy services are terminated (through discharge or discontinuation). * Patient/client experiences changes in pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, disabilities, or overall health status. * Patient/client is managed by interdisciplinary team. * Physical therapist's plan of care for patient/client requires coordination of resources. * Patient/client, family, significant other, or caregiver requests physical therapist participation in coordination, communication, and documentation activities. * Physical therapist is contacted by internal communities or external agencies related to patient/client. Interventions Coordination, communication, and documentation may include: * Addressing required functions - advance directives - IFSPs or IEPs - informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) * Admission and discharge planning * Case management * Collaboration and coordination with agencies, including: - equipment suppliers



Page 6 of 63

- home care agencies - payer groups - schools - transportation agencies * Communication across settings, including: - case conferences - documentation - education plans * Cost-effective resource utilization * Data collection, analysis, and reporting - outcome data - peer review findings - record reviews * Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: - changes in impairments, functional limitations, and disabilities - changes in interventions - elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) - outcomes of intervention * Interdisciplinary teamwork - case conferences - patient care rounds - patient/client family meetings * Referrals to other professionals or resources Anticipated Goals and Expected Outcomes



Page 7 of 63

Anticipated goals and expected outcomes related to interventions for coordination, communication, and documentation may include: * Accountability for services is increased. * Admission data and discharge planning are completed. * Advance directives, IFSPs or IEPs, informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant other, caregiver, and other professionals. * Case is managed throughout the episode of care. * Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and trarisportation agencies. * Communication enhances risk reduction and prevention. * Communication occurs across settings through case conferences, education plans, and documentation. * Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews. * Decision making is enhanced regarding health, wellness, and fitness needs. * Decision making is enhanced regarding patient/client health and the use of health care resources by patient/client, family, significant others, and caregivers. * Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). * Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings. * Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. * Placement needs are determined. * Referrals are made to other professionals or resources whenever necessary and appropriate. * Resources are utilized in a cost-effective way. Patient/Client-Related Instruction Patient/client-related instruction is the process of informing, educating, or training patients/clients,



Page 8 of 63

families, significant others, and caregivers with the intent to promote and optimize physical therapy services. Instruction may be related to the current condition (eg, specific impairments, functional limitations, or disabilities); the plan of care; the need to enhance performance; transition to a different role or setting; risk factors for developing a problem or dysfunction; or the need for health, wellness, and fitness programs. Physical therapists are responsible for patient/client-related instruction across all settings for all patients/clients. Clinical Considerations Considerations that may direct the type and specificity of interventions for patient/client-related instruction may include: * Patient/client requires instruction to optimize interventions that are designed to decrease impairments, functional limitations, or disabilities. * Patient/client requires instruction to reduce risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities. * Patient/client requires instruction that is appropriate for impaired arousal, attention, and cognition that may have an impact on learning and memory. * Patient/client requires instruction that is appropriate for sensory impairment (eg, vision, hearing) that may affect learning and skill acquisition. * Patient/client requires instructional or educational assistive technology (eg, large print cards) or environmental accommodations or modifications (eg, enhanced lighting, signage) that may be required for effective learning and skill acquisition. * Physical therapist identifies potential learning barriers (eg, beliefs, cultural expectations, and language) that must be addressed prior to and throughout patient/client-related instruction and education. * Physical therapist identifies patient/client impairments, functional limitations, or disabilities that indicate assistance (eg, caregiver, family member, equipment) is required for effective learning and skill acquisition. * Physical therapist provides instruction and education to patient/client and patient/client support system regarding the plan of care. * Physical therapist provides instruction when patient/client has identified personal goals for enhanced performance. * Physical therapist provides instruction when patient/client is transitioning across care settings or performing in a new role that will require an increased or decreased level of service. * Physical therapist provides instruction when patient/client will benefit from health, wellness, and fitness programs. Interventions



Page 9 of 63

Patient/client-related instruction may include: * Instruction, education, and training of patients/clients and caregivers regarding - current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities) - enhancement of performance - health, wellness, and fitness programs - plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities - transitions across settings - transitions to new roles Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to patient/client-related instruction may include: * Ability to perform physical actions, tasks, or activities is improved. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding patient/client health and the use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Health status is improved. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in self-care, home management, work (job/school/play), community or



Page 10 of 63

leisure actions, tasks, or activities are improved. * Physical function is improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairment is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is increased. * Utilization and cost of health care services are decreased. Therapeutic Exercise Therapeutic exercise is the systematic performance or execution of planned physical movements, postures, or activities intended to enable the patient/client to (1) remediate or prevent impairments, (2) enhance function, (3) reduce risk, (4) optimize overall health, and (5) enhance fitness and well-being. Therapeutic exercise may include aerobic and endurance conditioning and reconditioning; agility training; balance training, both static and dynamic; body mechanics training; breathing exercises; coordination exercises; developmental activities training; gait and locomotion training; motor training; muscle lengthening; movement pattern training; neuromotor development activities training; neuromuscular education or reeducation; perceptual training; postural stabilization and training; range-of-motion exercises and soft tissue stretching; relaxation exercises; and strength, power, and endurance exercises. Physical therapists select, prescribe, and implement exercise activities when the examination findings, diagnosis, and prognosis indicate the use of therapeutic exercise to enhance bone density; enhance breathing; enhance or maintain physical performance; enhance performance in activities of daily living (Al)L) and instrumental activities of daily living (IADL); improve safety; increase aerobic capacity/endurance; increase muscle strength, power, and endurance; enhance postural control and relaxation; increase sensory awareness; increase tolerance to activity; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; enhance health, wellness, and fitness; reduce complications, pain, restriction, and swelling; or reduce risk and increase safety during activity performance. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary



Page 11 of 63

- integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - aerobic capacity/endurance (eg, decreased walk distance) - anthropometric characteristics (eg, increased body mass index) - arousal, attention, and cognition (eg, decreased motivation to participate in fitness activities) - circulation (eg, abnormal elevation in heart rate with activity) - cranial and peripheral nerve integrity (eg, difficulty with swallowing, risk of aspiration, positive neural provocation response) - ergonomics and body mechanics (eg, inability to squat because of weakness in gluteus maximus and quadriceps femoris muscles) - gait, locomotion, and balance (eg, inability to perform ankle dorsiflexion) - integumentary integrity (eg, limited finger flexion as a result of dorsal burn scar) - joint integrity and mobility (eg, limited range of motion in the shoulder) - motor function (eg, uncoordinated limb movements) - muscle performance (eg, weakness of lumbar stabilizers) - neuromotor development and sensory integration (eg, delayed development) - posture (eg, forward head, kyphosis) - range of motion (eg, increased laxity in patellofemoral joint) - reflex integrity (eg, poor balance in standing) - sensory integrity (eg, lack of position sense) - ventilation and respiration/gas exchange (eg, abnormal breathing patterns) * Functional limitations in the ability to perform actions, tasks, and activities in the following categories:



Page 12 of 63

- self-care (eg, difficulty with dressing, bathing) - home management (eg, difficulty with raking, shoveling, making bed) - work (job/school/play) (eg, difficulty with keyboarding, pushing, or pulling, difficulty with play activities) - community/leisure (eg, inability to negotiate steps and curbs) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to assume parenting role, inability to care for elderly relatives, inability to return to work as a police officer) - community/leisure (eg, difficulty with jogging or playing golf, inability to attend religious services) * Risk reduction/prevention in the following areas: - risk factors (eg, need to decrease body fat composition) - recurrence of condition (eg, need to increase mobility and postural control for work [job/school/play] actions, tasks, and activities) - secondary impairments (eg, need to improve strength and balance for fall risk reduction) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to improve golf-swing timing, need to maximize gymnastic performance, need to maximize pelvic-floor muscle function) - health and wellness (eg, need to improve balance for recreation, need to increase muscle strength to help maintain bone density) Interventions Therapeutic exercise may include: * Aerobic capacity/endurance conditioning or reconditioning - aquatic programs - gait and locomotor training - increased workload over time - movement efficiency and energy conservation training - walking and wheelchair propulsion programs * Balance, coordination, and agility training



Page 13 of 63

- developmental activities training - motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation - perceptual training - posture awareness training - sensory training or retraining - standardized, programmatic, complementary - exercise approaches - task-specific performance training - vestibular training * Body mechanics and postural stabilization - body mechanics training - postural control training - postural stabilization activities - posture awareness training * Flexibility exercises - muscle lengthening - range of motion - stretching * Gait and locomotion training - developmental activities training - gait training - implement and device training - perceptual training - standardized, programmatic, complementary



Page 14 of 63

- exercise approaches - wheelchair training * Neuromotor development training - developmental activities training - motor training - movement pattern training - neuromuscular education or reeducation * Relaxation - breathing strategies - movement strategies - relaxation techniques - standardized, programmatic, complementary - exercise approaches * Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles - active assistive, active, and resistive exercises (including concentric, dynamic/ isotonic, eccentric, isokinetic, isometric, and plyometric) - aquatic programs - standardized, programmatic, complementary exercise approaches - task-specific performance training Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to therapeutic exercise may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Joint swelling, inflammation, or restriction is reduced. - Nutrient delivery to tissue is increased.



Page 15 of 63

- Osteogenic effects of exercise are maximized. - Pain is decreased. - Physiological response to increased oxygen demand is improved. - Soft tissue swelling, inflammation, or restriction is reduced. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Aerobic capacity is increased. - Airway clearance is improved. - Balance is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. - Ventilation and respiration/gas exchange are improved. - Weight-bearing status is improved. - Work of breathing is decreased.



Page 16 of 63

* Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in ADL and IADL with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Preoperative and postoperative complications are reduced. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client.



Page 17 of 63

- Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Functional Training in Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living) Functional training in self-care and home management is the education and training of patients/clients in activities of daffy living (ADL) and instrumental activities of daffy living (IADL). Functional training in self-care and home management is intended to improve the ability to perform physical actions, tasks, or activities in an efficient, typically expected, or competent manner. Self-care includes ADL such as bed mobility, transfers, dressing, grooming, bathing, eating, and toileting. Home management includes more complex IADL, such as caring for dependents, maintaining a home, performing household chores and yard work, shopping, and structured play (for infants and children). Activities may include accommodation to or modification of environmental and home barriers; ADL and IADL training; guidance and instruction in injury prevention or reduction; functional training programs; training in the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment during self-care and home management activities; task simulation and adaptation; and travel training. Physical therapists select, prescribe, and implement specific training activities when the examination findings, diagnosis, and prognosis indicate the use of functional training in self-care and home management to enhance health, wellness, and fitness; enhance musculoskeletal, neuromuscular, and cardiovascular/pulmonary capabilities; improve body mechanics; increase assumption or resumption of self-care or home management in a safe and efficient manner; increase postural awareness; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk and increase safety during activity performance. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular



Page 18 of 63

- endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments that have an impact on function in self-care and home management actions, tasks, and activities in the following categories: - aerobic capacity/endurance (eg, shortness of breath interferes with raking, shoveling, mopping) - anthropometric characteristics (eg, swollen arm interferes with grooming) - arousal, attention and cognition (eg, inability to recall sequence of daily routine interferes with dressing) - circulation (eg, heart rate increases during hair drying) - cranial and peripheral nerve integrity (eg, paresthesia interferes with bathing) - ergonomics and body mechanics (eg, pain increases during vacuuming) - gait, locomotion, and balance (eg, dizziness interferes with climbing stairs into home) - integumentary integrity (eg, decreased sensation as a result of second degree burns of hand interferes with personal hygiene) - joint integrity and mobility (eg, hip and knee pain interferes with taking out trash) - motor function (eg, loss of finger dexterity interferes with use of utensils) - muscle performance (eg, decreased lower-extremity strength interferes with bathroom transfers) - neuromotor development and sensory integration (eg, delayed development interferes with selfcare) - posture (eg, cervical posture interferes with desk work) - range of motion (eg, decreased shoulder range of motion interferes with reaching behind the back to fasten buttons) - reflex integrity (eg, primitive reflexes interfere with positioning for feeding)



Page 19 of 63

- sensory integrity (eg, altered proprioception interferes with yard work) - ventilation and respiration (eg, decreased oxygen saturation interferes with showering) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, inability to bottle feed independently, inability to dress and bathe) - home management (eg, inability to perform meal preparation tasks) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to assume parenting roles) - community/leisure (eg, inability to serve as volunteer in hospital coffee shop) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to learn correct biomechanics of lifting for daily activities) - recurrence of condition (eg, need to use assistive device or equipment to perform tasks that are likely to cause rein jury) - secondary impairments (eg, need to relearn adaptive skills for self-care and home management) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to increase endurance to complete self-care tasks, need to maximize independence in self-care, need to maximize safety in home management) - health and wellness (eg, need to improve physical ability to paint landscapes, need to increase ability to travel) Interventions Functional training in self-care and home management may include: * ADL training - bathing - bed mobility and transfer training - developmental activities - dressing - eating



Page 20 of 63

- grooming - toileting * Barrier accommodations or modifications * Device and equipment use and training - assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during self


Page 21 of 63

management may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Pain is decreased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. * Impact on impairments - Balance is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Sensory awareness is increased. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care and home management is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in ADL and IADL with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care and home management roles is improved. * Risk reduction/prevention - Risk factors are reduced.



Page 22 of 63

- Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living, Work Hardening, and Work Conditioning) Functional training in work Gob/school/play), community, and leisure integration or reintegration is the education and training of patients/clients in assumption and resumption of roles and functions in the work environment, in the community, and during leisure activities so that (1) the physical actions or activities required for these roles and functions are performed in an efficient, typically



Page 23 of 63

expected, or competent manner and (2) the expectations of work (job/school/play), community, and leisure roles are fulfilled. Work integration or reintegration into roles may include functions such as gaining access to work (job/school/play) environments and workstations, participating in work hardening or work conditioning programs, negotiating school environments, and participating in age-appropriate play activities. Activities may include accommodations to or modifications of environmental and work barriers; functional training programs (eg, work hardening or conditioning programs); guidance and instruction in injury prevention or reduction; job coaching; leisure and play activity training; training in instrumental activities of daily living OADL); task simulation and adaptation; training in the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment during work (job/school/play), community, and leisure activities; and travel training. Community integration or reintegration into roles may include activities such as gaining access to transportation (eg, driving a car, boarding a bus), a neighborhood (eg, negotiating curbs, crossing streets), community businesses and services (eg, banking, shopping), and public facilities (eg, attending theaters, town hall meetings, and places of worship). Leisure integration or reintegration is the process of assuming or resuming roles and functions of avocational and enjoyable pastimes, such as recreational activities (eg, playing a sport) and age-appropriate hobbies (eg, collecting antiques, gardening, or making crafts) Physical therapists select, prescribe, and implement specific training activities when the examination findings, diagnosis, and prognosis indicate the use of functional training in work (job/school/play), community, and leisure integration or reintegration to enhance health, wellness, and fitness; improve body mechanics; improve safety and efficiency of performance of work (job/school/play), community, and leisure actions, tasks, and activities; increase independence in work and community environments; increase postural awareness; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary



Page 24 of 63

* Impairments that have an impact on function in work Gob/school/play), community, and leisure integration or reintegration actions, tasks, and activities in the following categories: - aerobic capacity/endurance (eg, shortness of breath interferes with loading delivery van) - anthropometric characteristics (eg, obesity interferes with accessing transportation) - arousal, attention, and cognition (eg, inability to recall sequencing in assembly-line processing interferes with job) - circulation (eg, chest pain interferes with walking during cold weather to catch bus) - cranial and peripheral nerve integrity (eg, tingling of the feet interferes with pushing cart up ramp) - ergonomics and body mechanics (eg, pain increases with squatting and reaching to stock shelves) - gait, locomotion, and balance (eg, unsteady gait interferes with walking in the park) - integumentary integrity (eg, finger numbness interferes with manipulative skills) - joint integrity and mobility (eg, elbow hypomobility interferes with driving a bus) - motor function (eg, ataxic movements interfere with keyboarding) - muscle performance (eg, decreased trunk strength interferes with participation in school physical education activities) - neuromotor development and sensory integration (eg, inability to go from sitting position to standing position interferes with office activities) - posture (eg, leg length discrepancy interferes with standing during food preparation) - range of motion (eg, decreased shoulder and elbow range of motion interferes with tennis swing) - reflex integrity (eg, decreased postural reflexes or reactions interfere with walking in a crowd) - sensory integrity (eg, altered proprioception interferes with stadium stair climbing) - ventilation and respiration (eg, shortness of breath interferes with postal carrier's mail delivery) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - work (job/school/play) integration or reintegration (eg, inability to perform manual labor) - community/leisure integration or reintegration (eg, inability to get on and off a train, difficulty with sports activities) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:



Page 25 of 63

- work (eg, inability to practice as a surgeon) - community/leisure (eg, inability to participate in League of Women Voters, inability to participate in local park cleanup, inability to participate as member of community soccer team) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to use correct protective equipment for a given task) - recurrence of condition (eg, need to learn correct balance of work, rest, and stretching) secondary impairments (eg, need to correctly train for each new task) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to maximize independence or safety in work [job/school/play]), community, and leisure; need to increase endurance to complete work [job/school/play], community, and leisure tasks) - health and wellness (eg, need to improve breathing efficiency for singing in choir, need to increase strength for community environmental work) Interventions Functional training in work (job/school/play), community, and leisure integration or reintegration may include: * Barrier accommodations or modifications * Device and equipment use and training - assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL - prosthetic device or equipment training during IADL * Functional training programs - back schools - job coaching - simulated environments and tasks - task adaptation - task training - travel training - work conditioning



Page 26 of 63

- work hardening * IADL training - community service training involving instruments - school and play activities training including tools and instruments - work training with tools * Injury prevention or reduction - injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention education with use of devices and equipment - safety awareness training during work (job/school/play), community, and leisure integration or reintegration * Leisure and play activities and training Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to functional training in work (job/school/play), community, and leisure integration or reintegration may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Pain is decreased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. * Impact on impairments - Balance is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Sensory awareness is increased.



Page 27 of 63

- Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in IADL with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Risk factors are reduced. - Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Costs of work-related injury or disability are reduced. - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client.



Page 28 of 63

- Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Manual Therapy Techniques (Including Mobilization/Manipulation) Manual therapy techniques are skilled hand movements intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or restriction. Procedures and modalities may include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion. Physical therapists select, prescribe, and implement manual techniques when the examination findings, diagnosis, and prognosis indicate use of manual therapy to decrease edema, pain, spasm, or swelling; enhance health, wellness, and fitness; enhance or maintain physical performance; increase the ability to move; or prevent or remediate impairments, functional limitations, or disabilities to improve physical function. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular



Page 29 of 63

- pulmonary - vascular * Impairments in the following categories: - anthropometric characteristics (eg, increased limb girth) - cranial and peripheral nerve integrity (eg, pain on forward bending) - ergonomics and body mechanics (eg, inability to flex knee) - gait, locomotion, and balance (eg, inability to flex hip) - integumentary integrity (eg, decreased skin extensibility) - joint integrity and mobility (eg, decreased joint play) - motor function (eg, decreased agility) - muscle performance (eg, decreased muscle strength) - posture (eg, forward head) - range of motion (eg, inability to flex, abduct, and externally rotate hip) - ventilation and respiration (eg, decreased rib cage mobility) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with brushing teeth, combing hair, sit-to-stand activities) - home management (eg, difficulty with carrying loads, painting, shoveling) - work (job/school/play) (eg, difficulty with typing, driving a car) - community/leisure (eg, inability to ride bicycle) * Disability--that is, the inability or the restricted ability toperform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (job/school/play) (eg, inability to assume role as family caregiver, inability to resume job as first violinist in orchestra) - community/leisure (eg, difficulty with varsity swimming, inability to volunteer at neighborhood school) * Risk reduction/prevention needs in the following areas:



Page 30 of 63

- risk factors (eg, need to perform preventive stretching) - recurrence of condition (eg, need to learn cycle of dependent position/elevation for edema control) - secondary impairments (eg, need to continue home traction and massage to maintain mobility) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to increase muscle length to optimize fitness, need to maximize flexibility for ballet) - health and wellness (eg, need to improve relaxation, need to increase flexibility for yoga) Interventions Manual therapy techniques may include: * Manual lymphatic drainage * Manual traction * Massage - connective tissue massage - therapeutic massage * Mobilization/manipulation - soft tissue - spinal and peripheral joints * Passive range of motion Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to manual therapy techniques may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is decreased. - Joint swelling, inflammation, or restriction is reduced. - Neural compression is decreased - Pain is decreased.



Page 31 of 63

- Soft tissue swelling, inflammation, or restriction is reduced. * Impact on impairments - Airway clearance is improved. - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform movement tasks is improved.. - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Preoperative and postoperative complications are reduced.



Page 32 of 63

- Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Fitness is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Prescription, application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment are processes to select, provide, and train for utilization of therapeutic implements and equipment that are intended to (1) aid patients/clients in performing tasks or movements, (2) support weak or ineffective joints or muscles and serve to enhance performance, (3) replace a missing part of the body, or (4) adapt the environment to facilitate functional performance of activities related to self-care, home management, work, community, and leisure. These devices and equipment may include adaptive, assistive, orthotic, protective, supportive, and prosthetic devices.



Page 33 of 63

Physical therapists prescribe, apply, and, as appropriate, fabricate devices and equipment when the examination findings, diagnosis, and prognosis indicate the use of devices and equipment to decrease edema and swelling; enhance health, wellness, and fitness; enhance performance and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL); enhance or maintain physical performance; increase alignment, mobility, or stability; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; protect body parts; or reduce risk factors and complications. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - aerobic capacity/endurance (eg, increased shortness of breath during ambulation with prosthesis) - anthropometric characteristics (eg, weight gain interferes with orthotic fit) - arousal, attention, and cognition (eg, decreased attention interferes with safety) - circulation (eg, decreased peripheral circulation alters venous return) - cranial and peripheral nerve integrity (eg, loss of sensation) - ergonomics and body mechanics (eg, back pain) - gait, locomotion, and balance (eg, footdrop) - integumentary integrity (eg, pressure ulcer)



Page 34 of 63

- joint integrity and mobility (eg, joint hypermobility) - motor function (eg, loss of coordination) - muscle performance (eg, decreased lower-extremity strength) - neuromotor development and sensory integration (eg, delayed development) - posture (eg, abnormal foot alignment) - range of motion (eg, increased hallux adduction) - reflex integrity (eg, decreased protective reactions) - sensory integrity (eg, altered proprioception) - ventilation and respiration/gas exchange (eg, paradoxical breathing) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with entering bathtub) - home management (eg, difficulty with keyboarding while ordering groceries) - work (job/school/play) (eg, difficulty with violin playing) - community/leisure (eg, difficulty with answering hotline telephones without headset, inability to gain access to playground) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to lift child without back support, inability to stand comfortably without orthotics while waitressing) - community/leisure (eg, difficulty with jogging without pregnancy sling, inability to attend dancing lessons without prosthesis) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to properly monitor skin) - recurrence of condition (eg, need to use protective seating system) - secondary impairments (eg, need to continue use of prosthetic device for activity) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to maximize performance with knee brace at the Special Olympics, need to enhance aerobic performance with supplemental oxygen)



Page 35 of 63

- health and wellness (eg, need to enhance endurance for dancing, need to improve use of assistive, adaptive, orthotic, protective, supportive, or prosthetic device during violin practice) Interventions Prescription, application, and, as appropriate, fabrication of devices and equipment may include: * Adaptive devices - environmental controls - hospital beds - raised toilet seats - seating systems * Assistive devices - canes - crutches - long-handled reachers - percussors and vibrators - power devices - static and dynamic splints - walkers - wheelchairs * Orthotic devices - braces - casts - shoe inserts - splints * Prosthetic devices (lower-extremity and upper-extremity) * Protective devices - braces



Page 36 of 63

- cushions - helmets - protective taping * Supportive devices - compression garments - corsets - elastic wraps - mechanical ventilators - neck collars - serial casts - slings - supplemental oxygen - supportive taping Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to prescription, application, and, as appropriate, fabrication of devices and equipment may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is reduced. - Joint swelling, inflammation, or restriction is reduced. - Pain is decreased. - Physiological response to increased oxygen demand is improved. - Soft tissue swelling, inflammation, or restriction is reduced. - Symptoms associated with increased oxygen demand are decreased. * Impact on impairments - Airway clearance is improved. - Balance is improved.



Page 37 of 63

- Endurance is increased. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint stability is in, proved. - Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - Postural control is improved. - Prosthetic fit is achieved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - Ventilation and respiration/gas exchange are improved. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in ADL and IADL with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention



Page 38 of 63

- Pressure on body tissues is reduced. - Protection of body parts is increased. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. - Stresses precipitating injury are decreased. * Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved.



Page 39 of 63

- Stressors are decreased. Airway Clearance Techniques Airway clearance techniques are a group of therapeutic activities intended to manage or prevent the consequences of impaired mucociliary transport or the inability to protect the airway (eg, impaired cough). Techniques may include breathing strategies for airway clearance, manual/mechanical techniques for airway clearance, positioning, and pulmonary postural drainage. Physical therapists select, prescribe, and implement airway clearance activities when the examination findings, diagnosis, and prognosis indicate the use of airway clearance techniques to enhance exercise performance; enhance health, wellness, or fitness; enhance or maintain physical performance; improve cough; improve ventilation; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - aerobic capacity/endurance (eg, persistent coughing) - anthropometric characteristics (eg, decreased cough because of obesity) - arousal, attention, and cognition (eg, inability to understand directions) - circulation (eg, bilateral pedal edema)



Page 40 of 63

- cranial and peripheral nerve integrity (eg, decreased gag/cough reflex) - joint integrity and mobility (eg, decreased thoracic mobility) muscle performance (eg, decreased ventilatory muscle strength) - neuromotor development and sensory integration (eg, coughing on change of position) - posture (eg, decreased thoracic mobility because of scoliosis) - ventilation and respiration (eg, increased secretions) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with dressing and bathing because of increased wheezing) - home management (eg, difficulty with vacuuming because of persistent coughing) - work (job/school/play) (eg, difficulty with repetitive overhead activities because of shortness of breath) - community/leisure (eg, inability to negotiate steps because of shortness of breath) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to assume role as caregiver of spouse, inability to return to work at a construction site) - community/leisure (eg, difficulty with walking to post office, inability to attend a theater performance) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to pursue smoking cessation) - recurrence of condition (eg, need to continue home airway clearance techniques) - secondary impairments (eg, need to strengthen muscles of breathing) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to increase diaphragmatic muscle strength, need to maximize breathing capabilities during aerobic class) - health and wellness (eg, need to increase relaxation for breathing control during speaking, need to optimize oxygen use while providing elder services) Interventions Airway clearance techniques may include:



Page 41 of 63

* Breathing strategies - active cycle of breathing or forced - expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - chest wall manipulation - suctioning - ventilatory aids * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to airway clearance techniques may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased.



Page 42 of 63

- Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Endurance is increased, - Energy expenditure per unit of work is decreased. - Exercise tolerance is improved. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Preoperative and postoperative complications are reduced. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness



Page 43 of 63

- Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Integumentary Repair and Protection Techniques Integumentary repair and protection techniques involve the application of therapeutic procedures and modalities that are intended to enhance wound perfusion, manage scar, promote an optimal wound environment, remove excess exudate from a wound complex, and eliminate nonviable tissue from a wound bed. Procedures and modalities may include debridement; dressings; orthotic, protective, and supportive devices; physical agents and mechanical and electrotherapeutic modalities; and topical agents. Physical therapists select, prescribe, and implement procedures and modalities when the examination findings, diaggnosis, and prognosis indicate the use of integumentary repair and protection techniques to enhance tissue perfusion; enhance wound and soft tissue healing; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications. Clinical Considerations



Page 44 of 63

Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - anthropometric characteristics (eg, increased limb girth) - circulation (eg, decreased peripheral perfusion) cranial and peripheral nerve integrity (eg, decreased hand sensation as a result of burn) - gait, locomotion, and balance (eg, decreased balance as a result of foot ulcer pain) - integumentary integrity (eg, open wound) joint integrity and mobility (eg, limited elbow range of motion because of scar) - muscle performance (eg, limited strength because of wound pain) - neuromotor development and sensory integration (eg, knee abrasions because of creeping) - posture (eg, pressure ulcer because of prolonged sitting) - range of motion (eg, decreased range of thorax motion as a result of surgical wound) - reflex integrity (eg, altered withdrawal response) - sensory integrity (eg, decreased proprioception) - ventilation and respiration/gas exchange (eg, delayed wound healing because of impaired tissue oxygenation) * Functional limitations in the ability to perform actions, tasks, or activities in the following



Page 45 of 63

categories: - self-care (eg, difficulty with wearing shoes as a result of edematous wound) - home management (eg, difficulty with dish washing as a result of dermatitis) - work (job/school/play) (eg, difficulty with lifting and bending because of burn scars, inability to sit in school because of sacral decubitus ulcer) - community/leisure (eg, inability to go to bank because of residual limb pressure ulcer) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to assume role as parent because of infected wound, inability to return to work as a toll taker because of sensation loss in fingers) - community/leisure (eg, inability to swim competitively because of skin breakdown, inability to attend school social events because of low serf-esteem associated with facial scarring) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to properly monitor skin) - recurrence of condition (eg, need to protect skin surfaces) - secondary impairments (eg, need to maintain scar mobility) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to limit sun exposure during gardening, need to promote foot skin protection during marathon training) - health and wellness (eg, need to improve nutrition and hydration, need to understand personal and environmental factors that promote optimal health status) Interventions Integumentary repair and protection techniques may include: * Debridement--nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement--selective



Page 46 of 63

- debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings - hydrogels - vacuum-assisted closure - wound coverings * Oxygen therapy - supplemental - topical * Topical agents - cleansers - creams - moisturizers - ointments - sealants Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to integumentary repair and protection techniques may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - Joint swelling, inflammation, or restriction is reduced. - Nutrient delivery to tissue is increased. - Pain is decreased. - Physiological response to increased oxygen demand is improved. - Soft tissue or wound healing is enhanced.



Page 47 of 63

- Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced. - Wound size is reduced. * Impact on impairments - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Range of motion is improved. - Sensory awareness is increased. - Weight-bearing status is improved. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance, is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Preoperative and postoperative complications are reduced. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced.



Page 48 of 63

- Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Electrotherapeutic Modalities Electrotherapeutic modalities are a broad group of agents that use electricity and are intended to assist functional training; assist muscle force generation and contraction; decrease unwanted muscular activity; increase the rate of healing of open wounds and soft tissue; maintain strength after injury or surgery; modulate or decrease pain; or reduce or eliminate soft tissue swelling, inflammation, or restriction. Modalities may include biofeedback, electrical stimulation (muscle and nerve), and electrotherapeutic delivery of medication. Physical therapists select, prescribe, and implement these modalities when the examination



Page 49 of 63

findings, diagnosis, and prognosis indicate the use of electrotherapeutic modalities to decrease edema and swelling; enhance activity and task performance; enhance health, wellness, or fitness; enhance or maintain physical performance; enhance wound healing; increase joint mobility, muscle performance, and neuromuscular performance; increase tissue perfusion; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications. The use of electrotherapeutic modalities in the absence of other interventions should not be considered physical therapy unless there is documentation that justifies the necessity of their exclusive use. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - aerobic capacity/endurance (eg, increased pain with activity) - anthropometric characteristics (eg, edema) - circulation (eg, increased limb girth) - cranial and peripheral nerve integrity (eg, decreased muscle - activity because of peripheral nerve compression) - ergonomics and body mechanics (eg, abnormal sequencing of muscle activation) - gait, locomotion, and balance (eg, incoordination in gait)



Page 50 of 63

- integumentary integrity (eg, open wound) - joint integrity and mobility (eg, increased joint play) - motor function (eg, muscle hypertonicity) - muscle performance (eg, increased muscle spasm) - neuromotor development and sensory integration (eg, atypical movement patterns) - posture (eg, static deviation from midline) - range of motion (eg, increased joint laxity) - ventilation and respiration/gas exchange (eg, decreased rib cage symmetry) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with rolling, sitting, reaching; inability to dress and bathe) - home management (eg, difficulty with cleaning, cooking, vacuuming) - work (job/school/play) tasks (eg, difficulty with manual handling, shoveling) - community/leisure (eg, difficulty with walking, lifting) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to return to work as court stenographer because of lack of coordination in upper extremities, inability to take care of child because of loss of strength) - community/leisure (eg, difficulty with card playing because of loss of dexterity, inability to visit friends because of wound) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to learn stress management) - recurrence of condition (eg, need to continue strengthening program) - secondary impairments (eg, need to appropriately use transcutaneous electrical nerve stimulation [TENS] for pain management) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to routinely use functional electrical stimulation [FES] to maximize muscle contraction) - health and wellness (eg, need to increase muscle force to optimize bone density, need to



Page 51 of 63

modulate pain during hospital volunteering) Interventions Electrotherapeutic modalities may include: * Biofeedback * Electrotherapeutic delivery of medications - iontophoresis * Electrical stimulation - electrical muscle stimulation (EMS) - electrical stimulation for tissue repair (ESTR) - functional electrical stimulation (FES) - high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS) Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to electrotherapeutic modalities may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is decreased. - Joint swelling, inflammation, or restriction is reduced. - Nutrient delivery to tissue is increased. - Osteogenic effects are enhanced. - Pain is decreased. - Soft tissue or wound healing is enhanced. - Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Integumentary integrity is improved.



Page 52 of 63

- Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased: * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Complications of immobility are reduced. - Preoperative and postoperative complications are reduced. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness



Page 53 of 63

- Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. * Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. Physical Agents and Mechanical Modalities Physical agents are a broad group of procedures using various forms of energy that are applied to tissues in a systematic manner and that are intended to increase connective tissue extensibility; increase the healing rate of open wounds and soft tissue; modulate pain; reduce or eliminate soft tissue swelling, inflammation, or restriction associated with musculoskeletal injury or circulatory dysfunction; remodel scar tissue; or treat skin conditions. These agents may include athermal, cryotherapy, hydrotherapy, light, sound, and thermotherapy agents. Mechanical modalities are a group of devices that use forces such as approximation, compression, and distraction and that are intended to improve circulation, increase range of motion, modulate pain, or stabilize an area that requires temporary support. These modalities may include compression therapies, gravityassisted compression devices, mechanical motion devices, and traction devices. Physical therapists select, prescribe, and implement use of these agents and modalities when the examination findings, diagnosis, and prognosis indicate the use of physical agents or mechanical modalities to decrease neural compression; decrease pain and swelling; decrease soft tissue and circulatory disorders; enhance airway clearance; enhance movement performance; enhance or maintain physical performance; improve joint mobility; improve tissue perfusion; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; reduce edema; or reduce risk factors and complications.



Page 54 of 63

The use of physical agents or mechanical modalities in the absence of other interventions should not be considered physical therapy unless there is documentation that justifies the necessity of their exclusive use. Clinical Considerations Examination findings that may direct the type and specificity of the procedural intervention may include: * Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - multiple systems - musculoskeletal - neuromuscular - pulmonary * Impairments in the following categories: - aerobic capacity/endurance (eg, decreased muscle endurance) - anthropometric characteristics (eg, increased edema) - circulation (eg, decreased peripheral circulation) - cranial and peripheral nerve integrity (eg, neural compression) - ergonomics and body mechanics (eg, segment instability) - gait, locomotion, and balance (eg, antalgic gait) - integumentary integrity (eg, skin condition irritated by device) - joint integrity and mobility (eg, increased joint compression) - muscle performance (eg, incontinence because of decreased muscle strength) - neuromotor development and sensory integration (eg, limited tolerance to upright position)



Page 55 of 63

- posture (eg, abnormal postural alignment) - range of motion (eg, postoperative limitation of motion) - reflex integrity (eg, decreased deep reflex response) - sensory integrity (eg, altered proprioception) - ventilation and respiration (eg, small airway congestion) * Functional limitations in the ability to perform actions, tasks, or activities in the following categories: - self-care (eg, difficulty with hair care and ironing, inability to maintain positions) - work (job/school/play) (eg, difficulty with operating heavy machinery, difficulty with washing windows) - community/leisure (eg, difficulty with serving in soup kitchen) * Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories: - work (eg, inability to return to work as a taxi driver because of neck pain, inability to put child in car seat because of back pain) - community/leisure (eg, difficulty with jogging with baby stroller because of Achilles tendinitis, inability to go to the movies as a result of incontinence) * Risk reduction/prevention needs in the following areas: - risk factors (eg, need to learn how to use proper lower-limb compressive garments) - recurrence of condition (eg, need to continue daily standing program) - secondary impairments (eg, need to participate in continuous exercise program) * Health, wellness, and fitness needs: - fitness, including physical performance (eg, need to increase muscle length for aquatics, need to maximize pelvic-floor muscle function) - health and wellness (eg, need to increase circulation during skating, need to modulate pain during shopping) Interventions Physical agents may include: * Athermal agents



Page 56 of 63

- pulsed electromagnetic fields * Cryotherapy - cold packs - ice massage - vapocoolant spray * Hydrotherapy - contrast bath - pools - pulsatile lavage - whirlpool tanks * Light agents - infrared - laser - ultraviolet * Sound agents - phonophoresis - ultrasound * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments



Page 57 of 63

- taping - total contact casting - vasopneumatic compression devices * Gravity-assisted compression devices - standing frame - tilt table * Mechanical motion devices - continuous passive motion (CPM) * Traction devices - intermittent - positional - sustained Anticipated Goals and Expected Outcomes Anticipated goals and expected outcomes related to physical agents and mechanical modalities may include: * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Debridement of nonviable tissue is achieved. - Edema, lymphedema, or effusion is reduced. - Joint swelling, inflammation, or restriction is reduced. - Neural compression is decreased. - Nutrient delivery to tissue is increased. - Osteogenic effects are enhanced. - Pain is decreased. - Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced.



Page 58 of 63

* Impact on impairments - Airway clearance is improved. - Integumentary integrity is improved. - Muscle performance (strength, power, and endurance) is increased. - Range of motion is improved. - Relaxation is increased. - Weight-bearing status is improved. * Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living OADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. * Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Complications of soft tissue and circulatory disorders are decreased. - Risk of secondary impairment is reduced. - Self-management of symptoms is improved. - Stresses precipitating injury are decreased. * Impact on health, wellness, and fitness - Fitness is improved. - Physical capacity is increased. - Physical function is improved. * Impact on societal resources - Utilization of physical therapy services is optimized.



Page 59 of 63

* Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. - Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense of well-being is improved. - Stressors are decreased. PART TWO: Preferred Practice Patterns Musculoskeletal Neuromuscular Cardiovascular/Pulmonary Integumentary How to Use the Preferred Practice Patterns Part Two contains the preferred practice patterns, which are grouped under flour categories of conditions: Musculoskeletal (Chapter 4), Neuromuscular (Chapter 5), Cardiovascular/Pulmonary (Chapter 6), and Integumentary (Chapter 7). A table of contents preceding each set of patterns lists the pattern titles for that set. Below is an at-a-glance depiction of the contents of each pattern; on the following pages, take a walk through one example of how physical therapists may use Part Two in the management of patients/clients. Contents of Each Pattern at a Glance (1) Patient/Client Diagnostic Classification * Criteria for inclusion (based on examination findings regarding risk factors or consequences of pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities) * Criteria for exlusion from pattern or for multiple-pattern classification (based on examination findings) (2) ICD-9-CM Codes Codes that may relate to the practice pattern--intended only for information purposes, not for coding purposes



Page 60 of 63

The Five Elements of Patient/Client Management (3) Examination Description of the history, systems review, and tests and measures that generate data that help the physical therapist confirm classification of the patients/clients in the pattern (4) Evaluation, Diagnosis, and Prognosis (Including Plan of Care) Description of the evaluation, diagnostic, and prognostic processes, including the expected range of number of visits and factors that may require a new episode of care or that may modify frequency of visits and duration of the episode (5) Intervention A listing of the interventions that may be used for patients/clients who are classified in the pattern (6) Reexamination, Global Outcomes, and Criteria for Termination of Physical Therapy Services Description of when reexamination is indicated; measurement of global outcomes of physical therapy services in 8 domains; the 2 ways in which physical therapy services are terminated Examination First, the patient/client provides a history. Through the history, the physical therapist gathers data-from both the past and the present--related to why the patient/client is seeking physical therapy services. Through the history, the physical therapist learns the chief complaints of the patient/client--in this example, the inability to walk without pain and a sensation of "buckling" in both knees and the inability to participate in recreational sports. Next, the physical therapist performs a systems review, which is a brief examination of the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. The systems review not only helps focus the examination, it indicates whether the patient/client should be referred for other health care services in addition to physical therapy. In this example, the systems review findings indicate that the patient/client has impairments in the cardiovascular/pulmonary system (high blood pressure at rest), musculoskeletal system (impaired gross range of motion, impaired gross strength, disproportionate weight for height), and neuromuscular system (impaired gait, impaired balance). The systems review suggests there are no current impairments in the integumentary system; however, the history shows the presence of diabetes, which is a risk factor for cardiovascular/pulmonary, neuromuscular, and integumentary conditions. There are no limitations in communication, affect, cognition, language, and learning style. Based on the history and systems review findings, the physical therapist notes key clinical indications for the use of particular tests and measures during the in-depth portion of the examination. (For examples of clinical indications for the use of tests and measures, refer to Chapter 2.) The key clinical indications in this case example: impaired gait; impaired joint integrity and mobility; impaired muscle performance; and a history of diabetes, hypertension, and morbid obesity. Based on these key clinical indications, the physical therapist decides to examine the following test-and-measure categories in detail: aerobic capacity/endurance, circulation (arterial,



Page 61 of 63

venous, and lymphatic), community and work (job/school/play) integration or reintegration (including instrumental activities of daily living [IADL]); environmental, home, and work (job/school/play) barriers; gait, locomotion, and balance; joint integrity and mobility; muscle performance (strength, power, and endurance); pain; range of motion (including muscle length); self-care and home management (including activities of daily living [ADL] and IADL), and ventilation and respiration/gas exchange. Due to the presence of cardiovascular/pulmonary risk factors such as hypertension, the monitoring of vital signs during ambulation will be an important part of the in-depth examination. Evaluation, Diagnosis, and Prognosis (Including Plan of Care) During the evaluation process, all data from the history, systems review, and tests and measures are synthesized to establish the diagnosis and the prognosis, including the plan of care. In this example, based on the evaluation of the history, systems review, and tests-and-measures data, the physical therapist determines that the patient/client has the following primary impairments: impaired joint integrity and mobility in the knees; decreased muscle performance; decreased range of motion; and decreased aerobic capacity/endurance with ambulation. The physical therapist hypothesizes that the morbid obesity may be contributing to the knee pain as well as to the decrease in aerobic capacity/endurance. The physical therapist notes the following functional limitations: difficulty in performing ADL and IADL, inability to run bases during softball league games, and inability to perform heavy household chores. Disability is noted in the following roles: community/leisure (inability to participate on the league softball team), work (job/school/play) (inability to walk to different work sites within the same plant), and home management (inability to perform as homemaker). Even though patients/clients may be referred to physical therapy services with a medical diagnosis, that does not tell the physical therapist how to manage the patient/client. The medical diagnosis is a diagnostic label that identifies disease at the level of the cell, tissue, organ, or system. In this case, for instance, the medical diagnosis may be osteoarthritis of the knees. The physical therapist's diagnosis, however, is a diagnostic label that identifies the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person. The physical therapist's goal is to restore function, and therefore the physical therapist's examination, evaluation, and interventions focus on impairments, functional limitations, disabilities, risk factor reduction, and prevention. In this example, the physical therapist determines that decreased muscle performance, decreased range of motion, and pain are the primary contributors to the identified functional limitations. The physical therapist also has noted that the patient/client has decreased aerobic/capacity endurance. The physical therapist therefore focuses on four preferred practice patterns: "Impaired Muscle Performance" (Pattern 4C) "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction" (Pattern 4D) "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4E) and "Impaired Aerobic Capacity/Endurance Associated With Deconditioning" (Pattern 6B). The physical therapist considers the primary impairments to determine which of the four possible patterns may be the most appropriate classification for the patient/client. The physical therapist scans the inclusions and exclusions for each pattern and the ICD-9-CM codes that are listed in each pattern. If the physical therapist remains uncertain about patient/client classification, the tests-and-measures sections of the individual patterns may suggest additional tests and measures



Page 62 of 63

that the physical therapist can perform to confirm placement of the patient/client into a pattern. In this example, the history and systems review show signs and symptoms of joint effusion but indicate that joint integrity and mobility are not contributing factors. The physical therapist therefore classifies the patient/client in "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4F). The patient/client also has a history of diabetes. If the physical therapist determines that patient/client monitoring for primary prevention of lower-extremity vascular problems and the need to increase aerobic capacity are high priorities, the physical therapist may place the patient/client in an additional pattern: "Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders" (Pattern 6B). Based on the evaluation, the physical therapist makes the prognosis--that is, determines the predicted optimal level of improvement in function and the amount of time needed to reach that level. The physical therapist refers to the evaluation section of the selected pattern to ascertain whether the therapist's prediction of improvement, frequency of visits, and duration of episode of care are consistent with the expected prognosis and range of number of visits for patients/clients who are classified in that pattern. The physical therapist also notes any factors (eg, age, chronicity or severity of the current condition, adherence to the intervention program) that may modify the frequency of visits or duration of the episode. In this example, on the basis of such modifying factors as extremely high patient/client motivation, the physical therapist may determine that the patient/client will require fewer visits than are expected to achieve the anticipated goals and expected outcomes for 80% of patients/clients who are classified in the pattern. On the other hand, the presence of morbid obesity may indicate that the patient/client may not be able to improve aerobic capacity/endurance at an expected rate. In addition, if the hypertension and diabetes become uncontrolled, the ability of the patient/client to participate in physical therapy may be affected. Intervention As part of the prognostic process, the physical therapist develops a plan of care. This plan delineates the types of interventions (physical therapy procedures and techniques) to be used to produce changes in the condition and in patient/client status, the frequency and duration of those interventions, anticipated goals, expected outcomes, and discharge plans. Anticipated goals and expected outcomes should be measurable and time limited. Each pattern contains a listing of interventions that are likely to be used for patients/clients who are classified in the pattern. Coordination, communication, and documentation and patient/clientrelated instruction are interventions that are provided to all patients/clients across all settings. The use of procedural interventions varies for the particular patient/client in the specific pattern. (For examples of clinical considerations for the use of procedural interventions, refer to Chapter 3.) In this example, the physical therapist might select interventions that emphasize therapeutic exercise, functional training in self-care and home management (including ADL and IADL), and functional training in community and work (job/school/play) integration or reintegration (including IADL, work hardening, and work conditioning) in addition to interventions to modulate pain and diminish the effects of joint effusion. Reexamination, Global Outcomes, and Criteria for Termination of Physical Therapy Services Reexamination--the process of performing selected tests and measures after the initial examination to determine progress and modify or redirect interventions--may be indicated more



Page 63 of 63

than once during a single episode of care. In this example, the physical therapist may decide to perform a reexamination if the patient/client develops a new condition or shows no progress. Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These goals and outcomes are delineated in the shaded boxes that accompany each list of interventions in each pattern. As the patient/ client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes (that is, the impact) of the physical therapy services in the following domains: pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/prevention; impact on health, wellness, and fitness; societal resources; and patient/client satisfaction. The physical therapist uses two processes for terminating physical therapy services: discharge and discontinuation. If the physical therapist determines that the anticipated goals and expected outcomes have been achieved, the patient/client is discharged from physical therapy services. Physical therapy services are discontinued (1) when the patient/client declines to continue intervention, (2) when the patient/client is unable to continue to progress toward the anticipated goals and expected outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended, or (3) when the physical therapist determines that the patient/client will no longer benefit from physical therapy. A template for documenting all aspects of patient/client management, including termination of physical therapy services, is provided in Appendix 6. Patient/client satisfaction outcomes may be collected using the Patient/Client Satisfaction Questionnaire in Appendix 7.

Named Works: A Guide to Physical Therapist Practice (Book) Source Citation:"What Types of Interventions Do Physical Therapists Provide?." Physical Therapy 81.1 (Jan 2001): 105. Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 15

Who are physical therapists, and what do they do?(A Description of Patient/Client Management)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1177(11). (5814 words)


Physical therapists are professionally educated at the college or university level and are required to be licensed in the state or states in which they practice. Graduates from 1960 to the present have successfully completed professional physical therapist education programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). Graduates from 1926 to 1959 completed physical therapy curricula approved by appropriate accreditation bodies. The CAPTE with limit its scope in 2002 to accredit only those professional programs that award the postbaccalaureate degree. Physical therapists also may obtain clinical specialist certification through the American Board of Physical Therapy Specialties (ABPTS). Practice Settings Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings, including the following, in order of most common setting: * Hospitals (eg, critical care, intensive care, acute care, and subacute care settings) * Outpatient clinics or offices * Rehabilitation facilities * Skilled nursing, extended care, or subacute facilities * Homes * Education or research centers * Schools and playgrounds (preschool, primary, and secondary) * Hospices * Corporate or industrial health centers * Industrial, workplace, or other occupational environments * Athletic facilities (collegiate, amateur, and professional) * Fitness centers and sports training facilities



Page 2 of 15

Patients and Clients Physical therapists are committed to providing necessary, appropriate, and high-quality health care services to both patients and clients. Patients are individuals who are the recipients of physical therapy care and direct intervention. Clients are individuals who are not necessarily sick or injured but who can benefit from a physical therapist's consultation, professional advice, or prevention services. Clients also are businesses, school systems, and others to whom physical therapists provide services. The generally accepted elements of patient/client management typically apply to both patients and clients. Scope of Practice Physical therapy is the care and services provided by or under the direction and supervision of a physical therapist (Fig. 1). APTA emphasizes that an examination, evaluation, or intervention -unless provided by a physical therapist or under the direction and supervision of a physical therapist -- is not physical therapy, nor should it be represented or reimbursed as such. Figure 1. Model Definition of Physical Therapy for State Practice Acts(a) [BOD 02-97-03-06; Amended BOD 03-95-24-64, BOD 06-94-03-04, BOD 03-93-18-46] Physical therapy, which is the care and services provided by or under the direction and supervision of a physical therapist includes: 1) Examining (history, systems review, and tests and measures) individuals with impairment, functional limitation, and disability or other health-related conditions in order to determine a diagnosis, prognosis, and intervention; tests and measures may include the following: * Aerobic capacity and endurance * Anthropometric characteristics * Arousal, mentation, and cognition(b) * Assistive and adaptive devices * Community and work (job/school/play) integration or reintegration * Cranial nerve integrity * Environmental, home, and work (job/school/play) barriers * Ergonomics and body mechanics * Gait locomotion, and balance * Integumentary integrity * Joint integrity and mobility * Motor function



Page 3 of 15

* Muscle performance * Neuromotor development and sensory integration * Orthotic, protective, and supportive devices * Pain * Posture * Prosthetic requirements * Range of motion * Reflex integrity * Self-care and home management * Sensory integrity * Ventilation, respiration, and circulation 2) Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions that may include, but are not limited to: * Coordination, communication, and documentation * Patient/client-related instruction * Therapeutic exercise (including aerobic conditioning) * Functional training in self-care and home management (including activities of daily living and instrumental activities of daily living) * Functional training in community and work (job/school/play) integration or reintegration activities (including instrumental activities of daily living, work hardening, and work conditioning) * Manual therapy techniques (including mobilization and manipulation) * Prescription application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment * Airway clearance techniques * Wound management * Electrotherapeutic modalities * Physical agents and mechanical modalities



Page 4 of 15

3) Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in all age populations 4) Engaging in consultation, education, and research (a) Direct interventions, which begin with "Therapeutic exercise," are listed in order of preferred usage. (b) This category of tests and measures is referred to as "arousal, attention, and cognition" in the Guide. Physical therapists: * Provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. In the context of the model of disablement(1,2) on which this Guide is based, impairment is defined as loss or abnormality of physiological, psychological, or anatomical structure or function; functional limitation, as restriction of the ability to perform -- at the level of the whole person -- a physical action, activity, or task in an efficient, typically expected, or competent manner; and disability, as the inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment. * Interact and practice in collaboration with a variety of professionals, including physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, and audiologists. Physical therapists acknowledge the need to educate and inform other professionals, government agencies, third-party payers, and other health care consumers about the cost-efficient and clinically effective services that physical therapists render. * Provide prevention and wellness services, including screening and health promotion. Physical therapists are involved in wellness initiatives, including health promotion and education, that stimulate the public to engage in healthy behaviors. They provide preventive care that forestalls or prevents functional decline and the need for more intense care. Through timely and appropriate screening, examination, evaluation, and intervention, they frequently reduce or eliminate the need for costlier forms of care, such as surgery, and also may shorten or even eliminate institutional stays. * Consult, educate, engage in critical inquiry, and administrate. * Direct and supervise physical therapy services, including support personnel. Roles in Primary Care Physical therapists have a major role to play in the provision of primary care, which has been defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community.(3) APTA has endorsed the concepts of primary care set forth by the Institute of Medicine's Committee on the Future of Primary Care,(3) including the following: * Primary care can encompass a myriad of needs that go well beyond the capabilities and competencies of individual caregivers and that require the involvement and interaction of varied



Page 5 of 15

practitioners. * The "gatekeeper" concept is rejected because of the pejorative connotation that the primary care practitioner's role is to manage costs and, for the most part, keep the "gate" closed. * Primary care is not limited to the "first contact" or point of entry into the health care system. * The primary care program is a comprehensive one. * The role of family and community in the provision of primary care is an important one, and caregivers and care-receivers function in the context of, and are dependent on, a wide range of societal and environmental factors. As clinicians involved in examination and in the evaluation, diagnosis, prognosis, intervention, and prevention of musculoskeletal and neuromuscular disorders, physical therapists are well positioned to provide those services as members of primary care teams. On a daily basis, physical therapists practicing at acute, chronic, rehabilitative, and preventive stages of care assist patients/clients in the following: restoring health; alleviating pain; and preventing the onset of impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Prevention and wellness activities, including health promotion, are a vital part of physical therapy. For acute musculoskeletal and neuromuscular conditions, triage and initial examination are appropriate physical therapist responsibilities. The primary care team may function more efficiently when it includes physical therapists, who can recognize musculoskeletal and neuromuscular disorders, perform examinations and evaluations, and intervene without delay. For patients/clients with low back pain, for example, physical therapists can provide immediate pain reduction and programs for strengthening, flexibility, endurance, postural alignment, instruction in activities of daily living, and work modification. Physical therapist intervention may result not only in more efficient and effective patient care but in more Appropriate utilization of other members of the primary care team. With physical therapists functioning in a primary care role and delivering early intervention for work-related musculoskeletal injuries, time and productivity lost due to injuries may be dramatically reduced. For certain chronic conditions, physical therapists should be recognized as the principal providers of care within the collaborative primary care team. Physical therapists are well prepared to coordinate care related to loss of physical function as a result of musculoskeletal, neuromuscular, cardiopulmonary, or integumentary disorders. Through community-based agencies, physical therapists coordinate and integrate provision of services to patients/clients with chronic neuromuscular and musculoskeletal disorders. Physical therapists also provide primary care in industrial or workplace settings, in which they manage the occupational health services provided to employees and prevent injury by designing or redesigning the work environment. These services focus both on the individual and on the environment to ensure comprehensive and appropriate intervention. Roles in Secondary and Tertiary Care Physical therapists play major roles in secondary and tertiary care. Patients with musculoskeletal, neuromuscular, cardiopulmonary, or integumentary conditions frequently are treated initially by another health care practitioner and then are referred to physical therapists for secondary care. Physical therapists provide secondary care in a wide range of settings, from hospitals to



Page 6 of 15

preschools. Tertiary care is provided by physical therapists in highly specialized, complex, and technologybased settings (eg, heart and lung transplant services, burn units) or when supplying specialized services (eg, to patients with spinal cord lesions or closed--head trauma) in response to requests for consultation that are made by other health care practitioners. Roles in Prevention and Wellness (Including Screening Programs and Health Promotion) Physical therapists are involved in prevention and wellness activities, screening, and the promotion of positive health behavior. These initiatives decrease costs by helping patients/clients (1) achieve and restore optimal functional capacity, (2) minimize impairments, functional limitations, and disabilities related to congenital and acquired conditions, (3) maintain health (thereby preventing further deterioration or future illness), and (4) create appropriate environmental adaptations to enhance independent function. There are three types of prevention: * Primary prevention -- Preventing disease in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts * Secondary prevention -- Decreasing duration of illness, severity of disease, and sequelae through early diagnosis and prompt intervention * Tertiary prevention -- Limiting the degree of disability and promoting rehabilitation and restoration of function in patients with chronic and irreversible diseases Physical therapists conduct screenings to determine the need for primary, secondary, or tertiary prevention services; for further examination, intervention, or consultation by a physical therapist; or for referral to another health care practitioner. Candidates for screening generally not patients/clients currently receiving physical therapy services. Screening is based on a problemfocused, systematic collection and analysis of data. Examples of screening activities in which physical therapists engage include: * Identifying lifestyle factors (eg, amount of exercise, stress, weight) that may lead to increased risk for serious health problems * Identifying children who may need an examination for idiopathic scoliosis * Identifying elderly individuals in a community center or nursing home who are at high risk for slipping, tripping, or falling * Identifying risk factors in the workplace * Pre-performance testing of individuals who are active in sports * Conducting prework screening programs Examples of prevention and wellness activities in which physical therapists engage include: * Back schools, workplace redesign, strengthening, stretching, endurance exercise programs, and



Page 7 of 15

postural training to prevent and treat low back pain, a condition afflicting millions of Americans * Workplace redesign, strengthening, stretching, endurance exercise, and postural training to prevent job-related disabilities, including trauma and repetitive stress injuries * Exercise programs, including weight bearing and weight training, to increase bone mass and bone density (especially important in older adults with osteoporosis) * Exercise programs, gait training, and balance and coordination activities to reduce the risk of falls and fractures from falls in older adults * Exercise programs and instruction in activities of daily living (ADL) (self-care, communication, and mobility skills required for independence in daily living) and instrumental activities of daily living (IADL) (activities that are important components of maintaining independent living, such as shopping and cooking) to decrease utilization of health care services and enhance function in patients with cardiopulmonary disorders * Exercise programs, cardiovascular conditioning, postural training, and instruction in ADL and IADL to prevent disability and dysfunction in women who are pregnant * Broad-based consumer education and advocacy programs to prevent problems (eg, prevent head injury by promoting the use of helmets, prevent pulmonary disease by encouraging smoking cessation) The Five Elements of Patient/Client Management The physical therapist integrates five elements of patient/client management -- examination, evaluation, diagnosis, prognosis, and intervention -- in a manner designed to maximize outcomes (Fig. 2). Examination, evaluation, and establishment of a diagnosis and a prognosis are all part of the process that guides the therapist in determining the most appropriate intervention. [ILLUSTRATION OMITTED] Examination Examination is required prior to any intervention and is performed for all patients/clients. The initial examination, which is an investigation, has three components: the patient/client history, relevant Systems reviews, and tests and measures. History -- The history is an account of past and current health status. It includes identification of complaints, provides the initial source of information about the patient/client, and also suggests the individual's ability to benefit from physical therapy. While taking the history, the physical therapist identifies health-risk factors, health restoration and prevention needs, and coexisting health problems that have implications for intervention. This history commonly is obtained through the gathering of data from the patient/client, family, significant others, caregivers, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer); through consultation with other members of the health care team; and through review of the medical record. Figure 3 lists the types of data that may be generated from the history. [ILLUSTRATION OMITTED] Systems Review -- The systems review is a brief or limited examination that provides additional



Page 8 of 15

information about the general health of the patient/client to help the physical therapist formulate a diagnosis, a prognosis, and a plan of care and select direct interventions. The systems review also assists the physical therapist in identifying possible health problems that require consultation with or referral to another health care provide. Data generated from a systems review that may affect subsequent examination and intervention include: (1) physiologic and anatomic status (cardiopulmonary, integumentary, musculoskeletal, and neuromuscular) and (2) communication ability, affect, cognition, language, and learning style. Tests and Measures -- After analyzing all relevant information gathered from the history and systems review, the physical therapist examines the patient/client more closely, selecting tests and measures to elicit additional information. Before, during, and after administering the tests and measures, physical therapists frequently apply their hands to the patient/client to gauge responses, assess physical status, and obtain a more specific understanding of the condition and the diagnostic and therapeutic requirements. Tests and measures commonly performed by physical therapists and the types of data generated are listed in Figure I and are discussed in detail in Chapter 2. The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination, based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision-making process. As the examination progresses, the physical therapist may identify additional problems that were not uncovered by the history and systems review and may conclude that other specific tests and measures or portions of other specific tests and measures are required to obtain sufficient data to make an evaluation, establish a diagnosis and a prognosis, and select direct interventions. The examination therefore may be as brief or as lengthy as necessary. For instance, the physical therapist may conclude from the history and systems review that further examination and management are not required, that the patient/client should be referred to another health care practitioner, or both. Conversely, the physical therapist may decide that a full examination is necessary and then select appropriate tests and measures. Physical therapists frequently perform one or more reexaminations, which are examinations that take place after the initial examination is completed. Because physical therapy is most often an ongoing process delivered over a period of weeks for a single episode of care -- rather than one service delivered during a single visit -physical therapists rely on reexaminations to modify or redirect intervention and to evaluate progress toward the anticipated goals and desired outcomes. If a reexamination is indicated (eg, because of new clinical indications or failure to respond to intervention), the physical therapist selects and administers additional specific tests and measures. The reexamination has an important quality assurance component, as it allows the physical therapist to focus on the relationship between the elements of patient/client management and the outcomes. Note: In the course of examining and establishing the diagnosis and the prognosis, the physical therapist may find evidence of physical abuse or domestic violence. In such cases, the physical therapist is bound by ethical principles -- and may be bound by state law or regulation -- to report such findings to the appropriate agencies. Evaluation Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the examination. Factors that influence the complexity of the examination and the evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's/client's overall physical function and health status. Thus, the evaluation reflects the



Page 9 of 15

chronicity or severity of the current problem, the possibility of multisite or multisystem involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; potential discharge destinations; and the social supports. Diagnosis A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the decision reached as a result of the diagnostic process, which includes evaluating the information obtained during the examination; organizing it into clusters, syndromes, or categories; and interpreting it. The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client. In the event that the diagnostic process does not yield an identifiable cluster, syndrome, or category, intervention may be guided by the alleviation of symptoms and remediation of deficits. Alternatively, the physical therapist may determine that a reexamination is in order and proceed accordingly. In carrying out the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other professionals. In addition, as the diagnostic process continues, physical therapists may identify findings that should be shared with other professionals, including referral sources, to ensure optimal care. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist refers the patient/client to an appropriate practitioner. Prognosis The prognosis includes the predicted optimal level of improvement in function and amount of time needed to reach that level; it also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. At this point in patient/client management, the physical therapist establishes plan of care. In designing the plan of care, the physical therapist integrates all of the previous data, incorporates all of the prognostic predictions, and determines the degree to which interventions are likely to achieve anticipated goals and desired outcomes. Goals generally relate to the remediation (to the extent possible) of impairments, whereas outcomes relate to minimization of functional limitation, optimization of health status, prevention of disability, and optimization of patient/client satisfaction. Thus, the plan of care specifies long-term and short-term goals and outcomes, the specific interventions to be used, the duration and frequency of intervention required to reach the goals and outcomes, and criteria for discharge. Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about intervention are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and the desired outcomes. Physical therapist intervention has three components: coordination, communication, and documentation; patient/client-related instruction; and direct interventions Fig. 1).



Page 10 of 15

Coordination, Communication, and Documentation - These services, which are provided for an patients/clients, may include case management; communication (direct or indirect); coordination of care with the patient/client, family, significant others, caregivers, other professionals, and other interested persons; discharge planning; documentation of all elements of patient/client management; education plans; patient care conferences; record reviews; and referrals to other professionals or resources. Through these services, the physical therapist ensures appropriate, coordinated, comprehensive, and cost-effective services between admission and discharge and cost-effective and efficient integration or reintegration to home, community, and work (job/school/play), and leisure environments. Documentation should follow APTA's Guidelines for Physical Therapy Documentation (Appendix 7). Patient/Client-Related instruction -- These services, which are provided to all patients/clients, may include computer-assisted instruction, demonstration by patient/client or caregivers in the appropriate environment, periodic reexamination and reassessment of the home program, use of audiovisual aids for both teaching and home reference, use of demonstration and modeling for teaching, verbal instruction, and written or pictorial instruction. The physical therapist uses these services to educate the patient/client -- and also the family, significant others, caregivers, or other professionals -- about the current condition, plan of care, and future transition to home, work, or community roles. The physical therapist may include information and training in activities for maintenance of function and primary and secondary prevention. The educational backgrounds, needs, and learning styles of individuals must be taken into account during this process. Direct interventions -- The physical therapist selects, applies, or modifies direct interventions based on examination and evaluation data, the diagnosis and the prognosis, and the anticipated goals and desired outcomes for a particular patient in a specific patient/client diagnostic group. Based on the results of the interventions, the physical therapist may decide that reexamination is necessary, a decision that may lead to the use of different interventions or, alternatively, the discontinuation of care. Chapter 3 details, in order of preferred usage, the types of direct interventions commonly selected by the physical therapist. Forming the core of most physical therapy plans of care: therapeutic exercise, including aerobic conditioning; functional training in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL); and functional training in community and work (job/school/play) integration or reintegration, including IADL, work hardening, and work conditioning. Factors that influence the complexity, frequency, and duration of the intervention and the decisionmaking process may include the following: anatomic and physiologic changes related to growth and development; chronicity or severity of the current condition; cognitive status; level of impairment; living environment; multisite or multisystem involvement; overall physical function and health status; potential discharge destinations; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; social supports; and stability of the condition. Outcomes At each step of patient/client management, the physical therapist considers the possible outcomes (remediation of functional limitation and disability, optimization of patient/client satisfaction, and primary or secondary prevention). Beginning with the history, the physical therapist identifies patient/client expectations for therapeutic interventions, perceptions about the clinical situation, and desired outcomes. The



Page 11 of 15

physical therapist then considers whether these expectations and outcomes are realistic in the context of the examination and evaluation data. In establishing a diagnosis and a prognosis and selecting direct interventions, the physical therapist asks the question, "What outcome is likely, given the diagnosis?" The physical therapist may use reexamination to determine whether predicted outcomes are reasonable and then modify them as necessary. The physical therapist engages in outcomes data collection and analysis -- that is, the systematic review of outcomes of care in relation to selected variables (eg, age, sex, diagnosis, interventions performed) -- and develops statistical reports for internal or external use. Discharge Planning Discharge -- the process of discontinuing interventions in a single episode of care--occurs based on the physical therapist's analysis of the dynamic interplay between the achievement of anticipated goals and the achievement of desired outcomes. Other indications for discharge include the following: * The patient/client declines to continue treatment. * The patient/client is unable to continue to progress toward goals because of medical or psychosocial complications. * The physical therapist determines that the patient/client will no longer benefit from physical therapy services. In consultation with appropriate individuals, and in consideration of the goals and outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral. if the physical therapist determines, through examination and evaluation, that intervention is unlikely to be beneficial, the physical therapist discusses those findings and conclusions with the individuals concerned, and there is no further physical therapist intervention. When a patient/client is discharged prior to achievement of desired outcomes, patient/client status and the rationale for discontinuation are documented. A physical therapy episode of care consists of all patient/client management activities conducted by a physical therapist from initial contact through discharge. A single episode of care should not be confused with multiple episodes of care that may be required by certain individuals in particular patient/client diagnostic groups. For these patients/clients, periodic follow-up is needed over a lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, the environment, or task demands. Other Professional Roles Consultation Physical therapist consultants render professional or expert opinion or advice, applying highly specialized knowledge and skills to identify problems, recommend solutions, or produce a specified outcome or product in a given amount of time on behalf of a patient/client. Patient-related consultation is a service provided by a physical therapist at the request of a patient, health care practitioner, or health care organization either to recommend physical therapy services that are needed or to evaluate the quality of physical therapy services being provided. Such consultation usually does not involve actual treatment. Client-related consultation is a service provided by a physical therapist at the request of an individual, business, school, government agency, or other organization.



Page 12 of 15

Examples of consultation activities in which physical therapists engage include: * Advising a referring practitioner about the indications for intervention * Advising employers about the requirements of the Americans With Disabilities Act (ADA) * Conducting a program to determine the suitability of employees for specific job assignments * Developing programs that evaluate the effectiveness of an intervention plan in reducing workrelated injuries * Educating other health care practitioners (eg, in injury prevention) * Examining school environments and recommending changes to improve accessibility for students with disabilities * Instructing employers about job preplacement in accordance with provisions of the ADA * Participating at the local, state, and federal levels in policymaking for physical therapy services * Performing environmental assessments to minimize the risk of falls * Providing peer review and utilization review services * Responding to a request for a second opinion * Serving as an expert witness in legal proceedings * Working with employees, labor unions, and government agencies to develop injury reduction and safety programs Education Education is the process of imparting information or skills and instructing by precept, example, and experience so that individuals acquire knowledge, master skills, or develop competence. In addition to instructing patients/ clients as an element of intervention, physical therapists may engage in education activities such as the following: * Planning and conducting academic education, clinical education, and continuing education programs for physical therapists, other health care providers, and students * Planning and conducting education programs for local, state, and federal health agencies * Planning and conducting programs for the public to increase awareness of issues in which physical therapists have expertise Critical inquiry Critical inquiry is the process of applying the principles of scientific methods to read and interpret professional literature; participate in, plan, and conduct research; evaluate outcomes; and assess new concepts and technologies. Examples of critical inquiry activities in which physical therapists engage include: * Analyzing and applying research findings to physical therapy practice and education



Page 13 of 15

* Disseminating the results of research * Evaluating the efficacy and effectiveness of both new and established interventions and technologies * Participating in, planning, and conducting clinical, basic, or applied research Administration Administration is the skilled process of planning, directing, organizing, and managing human, technical, environmental, and financial resources effectively and efficiently. Administration includes the management, by individual physical therapists, of resources for patient/client management and for organizational operations. Examples of administration activities in which physical therapists engage include: * Ensuring fiscally sound reimbursement for services rendered * Budgeting for physical therapy services * Managing staff resources, including the acquisition and development of clinical expertise and leadership abilities * Monitoring quality of care and clinical productivity * Negotiating and managing contracts * Supervising physical therapist assistants, physical therapy aides, and other support personnel The Physical Therapy Service: Direction and Supervision of Personnel Direction and supervision are essential to the provision of high-quality physical therapy The degree of direction and supervision necessary for ensuring high-quality physical therapy depends on many factors, including the education, experience, and responsibilities of the parties involved (Fig. 4); the organizational structure in which the physical therapy is provided; and applicable state law. In any case, supervision should be readily available to the individual being supervised. The director of a physical therapy service is a physical therapist who has demonstrated qualifications based on education and experience in the field of physical therapy and who has accepted the inherent responsibilities of the role. The director of a physical therapy service must: * Establish guidelines and procedures that will delineate the functions and responsibilities of all levels of physical therapy personnel in the service and the supervisory relationships inherent to the functions of the service and the organization * Ensure that the objectives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization and in accordance with safe physical therapist practice * Interpret administrative policies * Act as a liaison between line staff and administration * Foster the professional growth of the staff



Page 14 of 15

Written practice and performance criteria should be available for all levels of physical therapy personnel in a physical therapy service. Regularly scheduled performance appraisals should be conducted by the supervisor based on applicable standards of practice and performance criteria. Delegated responsibilities should be commensurate with the qualifications -- including experience, education, and training -- of the individuals to whom the responsibilities are being assigned. When the physical therapist of record delegates patient care responsibilities to physical therapist assistants or other support personnel, that physical therapist holds responsibility for supervision of the plan of care. Regardless of the setting in which the services are given, the following responsibilities must be held solely by the physical therapist: * Interpretation of referrals when available * Initial examination, evaluation, problem identification, diagnosis, and prognosis * Development or modification of a plan of care that is based on the initial examination and that includes anticipated goals and desired outcomes * Administration of intervention and, as appropriate, determination of (1) tasks that require the expertise and decision-making capacity of the physical therapist and that must be personally rendered by the physical therapist and (2) tasks that may be delegated. Prior to delegating any procedure, the physical therapist should determine that the consequences of the procedure are predictable, the situation is stable, and the basic indicators are not ambiguous and do not require ongoing observation by the physical therapist. * Delegation of the tasks to be rendered by the physical therapist assistant or other support personnel, including, but not limited to, specific treatments, precautions, special problems, and contraindicated procedures * Timely review of treatment documentation, reexamination of the patient/client and the anticipated goals and desired outcomes, and revision of the plan of care when indicated * Establishment of the discharge plan and documentation of discharge summary or status References [1] Physical Disability. Special issue. Phys Ther. 1994;74:375-506. [2] Verbrugge L, Jette A. The disablement process. Soc Sci Med. 1994;38:1-14, [3] Defining Primary Care: An Interim Report. Washington, DC: Institute of Medicine, National Academy Press; 1995. Physical Therapist Assistants The physical therapist assistant is an educated health care provider who assists the physical therapist in the provision of physical therapy. The physical therapist assistant is a graduate of a physical therapist assistant associate degree program accredited by an agency recognized by the commission on Accreditation in Physical Therapy Education (CAPTE). The physical therapist of record is the person who is directly responsible for the actions of the



Page 15 of 15

physical therapist assistant. The physical therapist assistant may perform physical therapy procedures and related tasks that have been selected and delegated by the supervising physical therapist. Where permitted by law, the physical therapist also may carry out routine operational functions, including supervision of the physical aide and documentation of progress. The ability of the physical therapist assistant to perform the selected and delegated tasks should be assessed on an ongoing basis by the supervising physical therapist. The physical therapist assistant may modify a specific intervention procedure in accordance with changes in patient/client status and within the scope of the establish plan of care. Physical Therapist Aides The physical therapy aide is a non-licensed worker who is specifically trained under the direction of a physical therapist. The physical therapy aide performs designated routine tasks related to the operation of a physical therapy service delegated by the physical therapist or in accordance with the law, by a physical therapist assistant. The physical therapist of record is the person who is directly responsible for the actions of the physical therapy aide. The physical therapy aide providers support that may include patientrelated and non-patient-related duties. The physical therapy aide functions only with the continuous on-site supervision of the physical therapist or, where allowable by law or regulation, the physical therapist assistant. Continuous on-site supervision requires the presence of the physical therapist or physical therapist assistant in the immediate area. Other Support Personnel When other personnel (eg, exercise physiologists, athletic trainers, massage therapist) work within the supervision of a physical therapy service, they should be employed under their appropriate title. Any involvement in patient/client care activities should be within the limits of their education, in accordance with applicable laws and regulations, and at the discretion of the physical therapist. If such personnel function as an extension of the physical therapist's license, however, their title and all services that they provide must be in accordance with state and federal laws and regulations.

Source Citation:"Who are physical therapists, and what do they do?." Physical Therapy 77.n11 (Nov 1997): 1177(11). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 47

What types of tests and measures do physical therapists use?(A Description of Patient/Client Management)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1189(24). (9688 words)


Depending on the data generated during the history and systems review, the physical therapist may use one or more tests and measures, in whole or in part, to help identify impairments, functional limitations, and disabilities and establish the diagnosis and the prognosis. Physical therapists may perform more than one test or measure at a time. The physical therapist individualizes the selection of tests and measures, rather than basing selection solely on diagnosis. When examining a patient/client with impairment, functional limitation, or disability resulting from brain injury, for example, the physical therapist may decide to perform part or all of several tests and measures, based on the pattern of involvement. This chapter contains 24 groupings of specific tests and measures (Fig. 5) that the physical therapist may decide to use during the examination. Tests and measures are listed in alphabetical order. Each pattern in Part Two contains a list of specific related tests and measures. Note: Physical therapists also may decide to use other tests and measures that are not described in the Guide. Each grouping of tests and measures includes the following: * General purposes of the tests and measures. All tests and measures produce information used to identify the possible or actual causes of difficulties during performance of essential everyday activities, work tasks, and leisure pursuits. Selection of specific tests and measures depends on the findings of the history and systems review. The examination findings may indicate, for instance, that tests should be performed while the patient/client performs specific activities. In all cases, the purpose of tests and measures is to ensure the gathering of information that leads to an evaluation, a diagnosis, a prognosis, and the selection of appropriate interventions. * Clinical indications, such as impairments, functional limitations, disabilities, or special requirements that may prompt the physical therapist to conduct the tests and measures. All tests and measures are appropriate in the presence of: - Impairment, functional limitation, disability, developmental delay, injury, or suspected or identified pathology that prevents or alters performance of daily activities, including self-care, home management, community and work (job/school/play)



Page 2 of 47

integration or reintegration, and leisure tasks, movements, or activities - Requirements of employment that specify minimum capacity for performance - Identified need to initiate or change a prevention or wellness program * Specific tests and measures methods and techniques) * Types of data that ma be generated from the tests and measures Other information that may be required for the examination includes: findings of other professionals; results of diagnostic imaging, clinical laboratory, and electrophysiologic studies; federal, state, and local work surveillance and safety reports and announcements; and observations of family, significant others, caregivers, and other interested persons. An examination, evaluation, or intervention -- unless performed by a physical therapist -- is not physical therapy, nor should it be represented or reimbursed as such. Aerobic Capacity and Endurance Aerobic capacity and endurance are measures of the ability to perform work or participate in activity over time using the body's oxygen uptake and delivery and energy release mechanisms. During activity, the physical therapist uses tests ranging from simple determinations blood pressure, heart rate, and respiratory rate to complex calculations of oxygen consumption and carbon dioxide production to determine the appropriateness of the response to increased oxygen demand. Monitoring responses at rest and during and after activity may indicate the degree and severity of impairment, identify cardiopulmonary deficits that result in functional limitation, and indicate the need to use or recommend other tests and measures and specific interventions. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - dizziness - dyspnea at rest or on exertion - edema or lymphedema - impaired gait, locomotion, and



Page 3 of 47

balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (including strength, power, and especially endurance) - impaired range of motion (ROM) (including muscle length) - impaired ventilation, respiration (gas exchange), and circulation Specific Tests and Measures Tests and measures may include: * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, treadmill, ergometer, 6minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity



Page 4 of 47

* Palpation of pulses * Claudication time tests * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics * Performance or analysis of an electrocardiogram Data Generated Data generated may include: * Activities that aggravate or relieve symptoms * Anaerobic threshold * Arrhythmias at rest and during activity * Autonomic responses to positional changes * Thoracoabdominal movement and breathing patterns with activity * Inspiratory and expiratory muscle force before and after activity (including comparison of actual to predicted) * Maximum oxygen consumption ([VO.sub.2]) (including comparison of actual to predicted) * Oxygen consumption ([VO.sub.2]) for particular activity (including comparison of actual to predicted) * Oxygen saturation ([SaO.sub.2]) at rest and during and after activity * Peripheral vascular integrity * Physical exertion scale grading and degree of dyspnea or angina with activity * Standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Symptoms that limit activity * Ventilatory volumes and flow at rest and during and after activity (including comparison of actual to predicted) Anthropometric Characteristics Anthropometric characteristics describe human body measurements such as height, weight, girth, and body fat composition. The physical therapist uses these tests and measures to test for muscle atrophy, gauge the extent of edema, and establish a baseline to allow patients/clients to be



Page 5 of 47

compared to national norms on such variables as weight and body fat composition. Results of these tests and measures may indicate the need to use or recommend other tests and measures. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - edema, lymphedema, or effusion - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired muscle performance (strength, power, endurance) - impaired sensory integrity - impaired ventilation, respiration (gas exchange) and circulation - pain Specific Tests and Measures Tests and measures may include: * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth * Observation and palpation of trunk and extremities at rest and during and after activity Data Generated



Page 6 of 47

Data generated may include: * Activities and postures that aggravate or relieve edema, lymphedema, or effusion * Body fat composition * Girths of extremities and chest and lengths of extremities in inches or centimeters * Height in feet and inches or centimeters * Integrity of lymphatic system * Volume displacement in liters * Weight in pounds or kilograms Arousal, Attention, and Cognition Arousal is the stimulation to action or to physiologic readiness for activity. Attention is selective awareness of a part or aspect of the environment or selective responsiveness to one class of stimuli. Cognition is the act or process of knowing, including both awareness and judgment. The physical therapist uses specific tests and measures to assess responsiveness; orientation to time, person, place, and situation; and ability to follow directions. These tests and measures guide the physical therapist in the selection of interventions by indicating whether the patient/client has the cognitive ability to participate in the plan of care. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired reflex integrity - impaired neuromotor development and sensory integration - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired joint integrity and mobility



Page 7 of 47

- impaired motor function (motor control and motor learning) - impaired muscle performance strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration gas exchange), and circulation - pain Specific Tests and Measures Tests and measures may include: * Assessment of arousal, attention, and cognition, using standardized instruments * Assessment of factors that influence motivation level * Assessment of level of consciousness * Assessment of level of recall (eg, short-term and long-term memory) * Assessment of orientation to time, person, place, and situation * Screening for cognition (eg, to determine ability to process commands, to measure safety awareness) * Screening for gross expressive (eg, verbalization) deficits Data Generated Data generated may include: * Level of arousal, attention, or cognition deficits * Scores on standardized instruments for measuring level of arousal, attention, or cognition * Variation over time of arousal, attention, or cognition deficits Assistive and Adaptive Devices Assistive and adaptive devices include a variety of implements or equipment used to aid



Page 8 of 47

patients/clients in performing tasks or movements. Assistive devices include crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, and static and dynamic splints. Adaptive devices include raised toilet seats, seating systems, and environmental controls. The physical therapist uses specific tests and measures to determine whether a patient/client might benefit from such a device or, when such a device already is in use, to determine how well the patient/client performs with it. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - edema or lymphedema impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation pain Specific Tests and Measures Tests and measures may include: * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to use and care for device



Page 9 of 47

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of a device * Assessment of alignment and fit of the device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device Review of reports provided by the patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of the patient/ client using device Data Generated Data generated may include: * Ability to use the device and to understand its appropriate use and care * Alignment of anatomical parts with the device * Deviations and malfunctions that can be corrected or alleviated using a device * Level of adherence to use of the device * Patient/client expressions of comfort, cosmesis, and effectiveness using the device * Practicality and ease of use of device * Safety and effectiveness of the device in providing protection, promoting stability, or improving performance of tasks and activities Community and Work (Job/School/Play) integration or Reintegration (including instrumental Activities of Daily Living) Community and work (job/school/play) integration or reintegration is the process of assuming roles in the community or at work. The physical therapist uses the following tests and measures to (1) make an informed judgment as to whether a patient/client is currently prepared to assume community or work roles, including all instrumental activities of daily living (IADL), or (2) determine when and how such integration or reintegration might occur. The physical therapist also uses these tests and measures to determine whether an individual is a candidate for a work hardening or work conditioning program. The physical therapist considers patient/client safety, perceptions, and expectations while performing the test and measures. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities: - impaired aerobic capacity and



Page 10 of 47

endurance - impaired arousal, attention, and cognition - impaired gait, locomotion, and balance - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation pain Specific Tests and Measures Tests and measures may include: * Analysis of adaptive skills * Analysis of community, work (job/ school/play), and leisure activities * Analysis of community, work (job/ school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of environment and work (job/school/play) tasks * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work job/ school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes



Page 11 of 47

* Observation of response to nonroutine occurrences * Questionnaires completed by and interviews conducted with the patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by the patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Data Generated Data generated may include: * Adaptive skills * Aerobic capacity or endurance * Appropriateness of assistive and adaptive devices * Appropriateness of orthotic, protective, supportive, or prosthetic devices or equipment * Daily activity level * Effort in specific movement tasks * Functional capacity for community and work (job/school/play) tasks * Gross and fine motor function * Attention and cognition deficits * Physical, functional, behavioral, and vocational status * Muscle strength, power, and endurance * Numerical scores on standardized rating scales * Performance of community and work (job/school/play) activities and level of dependence on human and mechanical assistance * Prosthetic requirements * Spatial and temporal requirements for performing specific tasks related to community and work (job/school/ play) activities * Standard vital signs (blood pressure, heart rate, respiratory rate) at rest and during and after activity * Strength, flexibility, and endurance Cranial Nerve Integrity



Page 12 of 47

Cranial nerve integrity involves somatic, visceral, and afferent and efferent components. The physical therapist uses cranial nerve integrity tests and measures to localize a dysfunction in the brain stem and to identify cranial nerves that merit an in-depth examination. The physical therapist uses a number of these tests to assess sensory and motor functions, such as taste, smell, and facial expression. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired neuromotor development and sensory integration - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired reflex integrity - impaired sensory integrity pain Specific Tests and Measures Tests and measures may include: * Assessment of dermatomes innervated by the cranial nerve * Assessment of gag reflex * Assessment of muscles innervated by the cranial nerves * Assessment of response to the following stimuli: auditory gustatory



Page 13 of 47

olfactory visual vestibular * Assessment of swallowing Data Generated Data generated may include: * Constriction and dilation of pupils * Equilibrium responses * Eye movements * Functional loss in muscles innervated by the cranial nerves * Gag reflex integrity * Gross auditory activity * Pain, touch, temperature localization * Swallowing characteristics * Taste loss * Visual deficits Environmental, Home, and Work (Job/school/play) Barriers Environmental, home, and work (job/school/play) barriers are the physical impediments that keep patients/clients from functioning optimally in their surroundings. The physical therapist uses the barriers tests and measures to identify any of a variety of possible impediments, including safety hazards (eg, throw rugs, slippery surfaces), access problems (eg, narrow doors, thresholds, high steps, absence of power doors or elevators), and home or office design barriers (eg, excessive distances to negotiate, multistory environment, sinks, bathrooms, counters, placement of controls or switches). The physical therapist uses these tests and measures, often in conjunction with portions of other tests and measures, to suggest modifications to the environment (eg, grab bars in the shower, ramps, raised toilet seats, increased lighting) that will allow the patient/client to improve functioning in the home, workplace, and other settings. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and



Page 14 of 47

endurance - impaired bowel and bladder function - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity pain Specific Tests and Measures Tests and measures may include: * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/ client and others as appropriate Data Generated Data generated may include: * Adaptations, additions, or modifications that would enhance safety * Level of compliance with standards set forth in federal and state laws and regulations * Recommendations for eliminating environmental barrier * Space limitations and other barriers, including their dimensions, that limit ability to perform



Page 15 of 47

specific movement tasks during home, work (job/school/ play), and leisure activities Ergonomics and Body Mechanics Ergonomics refers to the relationships among the worker, the work that is done, the tasks and activities inherent in that work, and the environment in which the work is performed. Ergonomics uses scientific and engineering principles to improve the safety, efficiency, and quality of movement involved in work. Body mechanics refers to the interrelationships of the muscles and joints as they maintain or adjust posture in response to environmental forces. The physical therapist uses the ergonomics and body mechanics tests and measures to examine the work environment on behalf of patients/clients and to determine the potential for trauma or repetitive stress injuries from inappropriate workplace design. These tests and measures may be conducted after a work injury or as a preventive measure, particularly when a patient/client is returning to the work environment after an extended absence. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations experienced during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - abnormal body alignment and movement patterns - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle



Page 16 of 47

performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation pain Specific Tests and Measures Ergonomics tests and measures may include: * Analysis of the performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomics analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration



Page 17 of 47

- assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform the task or activity * Videotape analysis of the patient/client at work Body mechanics tests and measures may include: * Computer-assisted motion analysis of performance of selected movements or activities * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Measurement of height, weight, length, and girth * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Data Generated Data generated may include: * Aerobic capacity or endurance * Body alignment, timing, and sequencing of component movements during specific job tasks or activities * Chest and extremity girth



Page 18 of 47

* Difficulty or pain expressed during the performance of specific job tasks or activities * Effort in specific movement tasks * Gross and fine motor function * Height in feet and inches or meters and centimeters * Physical, functional, behavioral, and vocational status * Potential and actual ergonomic stressors * Safety records and accident reports * Strength, flexibility, and endurance * Temporal and spatial characteristics of movements during job tasks or activities * Weight in pounds or kilograms * Work (job/school/play) performance Gait, Locomotion, and Balance Gait is the manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed. Locomotion is the ability to move from one place to another. Balance is the ability to maintain the body in equilibrium with gravity both statically (eg, while stationary) and dynamically (eg, while walking). The physical therapist uses gait, locomotion, and balance tests and measures to investigate disturbances in gait, locomotion, and balance because they frequently lead to decreased mobility, a decline in functional independence, and an increased risk of falls. Gait, locomotion, and balance problems often involve difficulty in integrating sensory, motor, and neural processes. The physical therapist also uses these tests and measures to determine whether the patient/client is a candidate for assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment. Clinical indications Tests and measures are appropriate in the presence of * Expectation or indication of one or more of the following impairments or functional limitations experienced during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - dizziness - impaired aerobic capacity and endurance - impaired joint integrity and



Page 19 of 47

mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation - pain Specific Tests and Measures Tests and measures may include: * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of autonomic responses to positional changes * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles. * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Data Generated



Page 20 of 47

Data generated may include: * Charts and videotapes that reflect gait, locomotion, and balance changes over time * Energy expenditure requirements * Gait cycle, gait deviations, and the safety and quality of gait and balance over time in different environments and on a variety of surfaces * Number ratings from standardized gait-testing instruments * Activities that aggravate or diminish difficulties with gait, locomotion, or balance * Ability to negotiate varied surfaces and elevations * Patient/client perception of gait, locomotion, and balance problems * Physiologic responses during gait, locomotion, and balance activities * Qualitative and quantitative descriptions of gait, locomotion, and balance * Safety and quality of gait and the gait cycle over time using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Safety and quality of locomotion in different environments and over different terrains * Safety awareness * Weight-bearing status Integumentary Integrity Integumentary integrity is the health of the skin, including its ability to serve as a barrier to environmental threats (eg, bacteria, parasites). The physical therapist uses integumentary integrity tests and measures to assess the effects of a wide variety of problems that result in skin and subcutaneous changes, including pressure and vascular, venous, arterial, diabetic, and necropathic ulcers; burns and other traumas; and a number of diseases (eg, soft tissue disorders). These tests and measures also are used to obtain more information about circulation through inspection of the skin or the nail beds. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired bowel and bladder function



Page 21 of 47

- impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired sensory integrity - impaired ventilation, respiration (gas exchange) and circulation - pain Specific Tests and Measures Tests and measures for skin associated with integumentary disruption may include: * Assessment for presence of blistering * Assessment for presence of hair growth * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile)



Page 22 of 47

* Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture Tests and measures for the wound may include: * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair or nail growth * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the wound or scar or thai may produce additional trauma * Assessment of bleeding * Assessment of burn * Assessment of ecchymosis * Assessment of exposed anatomical structures * Assessment of pigment (color) * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture * Assessment of wound contraction, drainage, location, odor, shape, size, and depth (eg, linear, tracing, photography), tunneling, and undermining * Assessment of wound tissue, including epithelium, granulation, mobility, necrosis, slough, texture, and turgor Data Generated Data generated may include: * Activities and postures that aggravate the wound or that may produce pain or additional trauma * Extremity characteristics in terms of color and temperature (in degrees or words) * Grid photograph of wound * Girths in inches or centimeters or volume displacement in milliliters * Minimal erythematous dose reactions in seconds



Page 23 of 47

* Skin condition * Skin temperature in degrees * Soft tissue and scar tissue (mobility and cicatrix) condition * Wound characteristics (eg, inflamed, macerated, necrotic) * Wound dimensions in square or cubic inches or centimeters * Wound drainage characteristics (eg, serous, serosanguineous, pus, slough) Joint integrity and Mobility Joint integrity is the conformance of a joint to expected anatomic and biomechanical norms. joint mobility involves the capacity of a joint to be moved passively in certain ways that take into account the structure and shape of the joint surface in addition to characteristics of the tissue surrounding the joint. The assessment of joint mobility involves the performance of accessory joint movements by the physical therapist because these movements are not under the voluntary control of the patient. The physical therapist uses the joint integrity and mobility tests and measures to determine whether there is excessive or limited motion of the joint. Excessive joint motion necessitates a program of protection, whereas limited joint motion calls for interventions to increase mobility and enhance functional capability. Clinical indications Tests and measures are appropriate in the presence of * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - edema. lymphedema. or effusion - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture



Page 24 of 47

- pain - soft tissue swelling, inflammation, or restriction Specific Tests and Measures Tests and measures may include: * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of sprain Data Generated Data generated may include: * Clinical signs or pain in response to a specific movement or provocation * Joint mobility classification and grade * Joint movement quality and quantity) * Sprain classification and grade Motor Function (Motor Control and Motor Learning) Motor function is the ability to learn or demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns. The physical therapist uses motor function tests and measures in the diagnosis of underlying impairments and their contributions to functional limitation and disability. Deficits in motor function reflect the type, location, and extent of the impairment, which may be the result of pathology or other disorders. Weakness, paralysis, dysfunctional movement patterns, abnormal timing, poor coordination, clumsiness, involuntary movements, or dysfunctional postures may be manifestations of impaired motor function. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations



Page 25 of 47

during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired arousal, attention, and cognition - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired muscle performance (strength, power, endurance) - impaired neuromotor development and sensory integration - impaired posture - impaired reflex integrity - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation - pain - soft tissue swelling, inflammation, or restriction Specific Tests and Measures Tests and measures may include: * Analysis of gait, locomotion, and balance * Analysis of head, trunk, and limb movement



Page 26 of 47

* Analysis of myoelectric activities and neurophysiological integrity using electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG], motor nerve conduction) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of autonomic responses to positional changes * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Assessment of sensorimotor integration * Motor assessment scales * Physical performance scales Data Generated Data generated may include: * Abnormal movement patterns (eg, synergies, athetotic movements) * Amplitude, duration, waveform, and frequency of normal or abnormal electrical potentials in muscles * Conduction velocity along peripheral motor nerves * Coordination of maturation with stages of development * Deviations from standardized age and sex norms for motor function (motor control and motor learning) * Muscle activity characteristics during movement * Physiologic responses during activities * Skin and efficiency of motor function, including the ability to initiate, control, and terminate movement * Timing, accuracy, sequencing, and number of repetitions of specific movement patterns and postures Muscle Performance (Including Strength, Power, and Endurance) Muscle performance is the capacity of a muscle to do work (force x distance). Muscle strength is the (measurable) force exerted by a muscle or a group of muscles to overcome a resistance in one maximal effort. Muscle power is work produced per unit of time or the product of strength and



Page 27 of 47

speed. Muscle endurance is the ability to contract the muscle repeatedly over a period of time. The performance of an individual muscle depends on its characteristics of length, tension, and velocity. Integrated muscle performance over time is mediated by neurologic stimulation, fuel storage, and fuel delivery in addition to balance, timing, and sequencing of contraction. The physical therapist uses muscle performance tests and measures to determine the ability to produce movements that a pre-requisite to functional activity. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired bowel and bladder function - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation - pain Specific Tests and Measures



Page 28 of 47

Tests and measures may include: * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance, using manual muscle tests or dynamometry * Assessment of muscle tone * Assessment of pain and soreness * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity) Data Generated Data generated may include: * Amplitude, duration, waveform, and frequency of EMG signals * Changes in muscle performance over time * Consistency of effort and performance * Force, velocity, torque, work, and power of muscle performance * Muscle contraction characteristics (eg, maximal, painful, smooth, coordinated, cogwheel) * Numbers, percentages, or letter grades from standardized grading systems for manual and functional muscle testing * Pain, soreness, or other symptoms produced by provocation of muscle contractions * Strength of the pelvic-floor musculature Neuromotor Development and Sensory Integration Neuromotor development is the acquisition and evolution of movement skills throughout the life span. Sensory integration is the ability to integrate information from the environment to produce movement. The physical therapist uses neuromotor development and sensory integration tests and measures to assess motor capabilities in infants, children, and adults. The tests and measures may be used to assess mobility, achievement of motor milestones and healthy responses, postural control, and voluntary and involuntary movement. The physical therapist also uses these tests and measures to test balance, righting and equilibrium reactions, eye-hand coordination, and other motor capabilities. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations



Page 29 of 47

during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired reflex integrity - impaired sensory integrity - pain Specific Tests and Measures Tests and measures may include: * Analysis of age-appropriate and sex-appropriate development * Assessment of arousal, attention, and cognition * Analysis of gait and posture * Analysis of involuntary movement * Analysis of reflex movement patterns * Analysis of sensory integration tests * Analysis of voluntary movement * Assessment of behavioral response * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions



Page 30 of 47

* Assessment of gross and fine motor skills * Assessment of motor function (motor control and motor learning) * Assessment of oromotor function, phonation, and speech production Data Generated Data generated may include: * Movement patterns, postures, and sequences * Movement asymmetries * Postural alignment * Primitive reflexes * Gross and fine motor developmental level * Information organization and processing quality Orthotic, Protective, and Supportive Devices Orthotic, protective, and supportive devices are used to support weak or ineffective joints or muscles and may serve to enhance performance. Orthotic devices include splints, braces, shoe inserts, and casts. Protective devices include braces, protective taping, cushions, and helmets. Supportive devices include supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, and oxygen. The physical therapist uses specific tests and measures to determine the need for orthotic, protective, and supportive devices in patients/clients not currently using them and to evaluate the appropriateness and fit of those devices already in use. The physical therapist correlates patient/client problems with available devices to make a choice that best serves the individual. For example, the physical therapist may have to choose between an orthosis that provides maximum control of motion and one that allows considerable movement. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance



Page 31 of 47

- impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation - pain Specific Tests and Measures Tests and measures may include: * Analysis of ability to care for device independently * Analysis of appropriate components of the device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears the device * Analysis of movement while patient/client wears the device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of the device * Analysis of practicality and ease of use of the device * Assessment of alignment and fit of the device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove the device and to understand its use and care * Assessment of patient/client use of the device * Assessment of safety during use of the device



Page 32 of 47

* Review of reports provided by the patient/client, family, significant others, caregivers, or other professionals concerning use of or need for the device Data Generated Data generated may include: * Ability to put on, use, and remove the device and to understand its use and care * Alignment of anatomical parts with the device * Adherence to use of the device * Deviations and dysfunctions that can be corrected or alleviated by the device * Effectiveness of the device in providing protection, promoting stability, or improving performance of tasks and activities * Energy expenditure requirements during use of die device * Patient/client expressions of comfort, cosmesis, and effectiveness using the device * Practicality and ease of use of the device Pain Pain is a disturbed sensation that causes suffering or distress. The physical therapist uses pain tests and measures to determine the intensity, quality, and temporal and physical characteristics of any pain that is important to the patient. The physical therapist may determine a cause or a mechanism for the pain through these tests and measures. The tests and measures also may be used to determine whether referral to another health care professional is appropriate. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired joint integrity and mobility



Page 33 of 47

- impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation Specific Tests and Measures Tests and measures may include: * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Data Generated Data generated may include: * Activities that aggravate or relieve pain * Behavior or pain reactions observed during particular movement tasks * Muscle soreness classification and grade * Numerical ratings from standardized rating instruments * Pain patterns over time * Pain reactions to cumulative stress or trauma * Response to pain * Response to noxious stimuli



Page 34 of 47

* Response during specific movement tasks and to provocation tests * Sensory and temporal qualities of pain * Somatic distribution of pain Posture Posture is the alignment and positioning of the body in relation to gravity, center of mass, and base of support. The physical therapist uses posture tests and measures to assess structural abnormalities in addition to the ability to right the body against gravity. "Good posture" is a state of musculoskeletal balance that protects the supporting structures of the body against injury or progressive deformity. Findings from these tests and measures may lead the physical therapist to perform additional tests and measures (eg, joint integrity and mobility, respiration, ventilation [gas exchange], and circulation). Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - abnormal bony alignment - impaired aerobic capacity and endurance - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired sensory integrity - pain * Pregnancy



Page 35 of 47

Specific Tests and Measures Tests and measures may include: * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Data Generated Data generated may include: * Alignment and symmetry of body landmarks within segmental planes, while at rest or in motion * Postural alignment during standing, sitting, lying, or movement * Postural deviations within lines or grid marks Prosthetic Requirements A prosthesis is an artificial device used to replace a missing part of the body. Physical therapists use specific tests and measures for patients/clients who might benefit from a prosthesis or for patients wearing a prosthesis. The physical therapist selects a prosthesis that will allow optimal freedom of movement and functional capability with minimal discomfort and inconvenience. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired gait, locomotion, and balance - impaired motor function (motor control and motor learning) - impaired muscle performance strength, power, endurance) - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation



Page 36 of 47

- pain * Loss of limb or body part Specific Tests and Measures Tests and measures may include: * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while the patient/client wears device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of the practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of residual limb or adjacent segment for range of motion, strength, skin integrity, and edema * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Data Generated Data generated may include: * Ability to put on, use, and remove the device and to understand its use and care * Alignment of anatomical parts with the device * Adherence to use of the device * Deviations and dysfunctions that can be corrected or alleviated using the device * Effectiveness of the device in providing protection, promoting stability, or improving performance of tasks and activities and enhancing function at home, at work job/school/play), and in community



Page 37 of 47

* Energy expenditure requirements during use of the device * Patient/client expressions of comfort, cosmesis, and effectiveness using the device * Practicality and ease of use of the device * Range of motion (ROM), strength, skin integrity, and edema in residual limb or adjacent segment Range of Motion (Including Muscle Length) Range of motion (ROM) is the space, distance, or angle through which movement occurs at a joint or a series of joints. Muscle length is measured at various joint angles through the range. Muscle length, in conjunction with joint integrity and soft tissue extensibility, determines flexibility. The physical therapist uses ROM tests and measures to determine the arthrokinematics and biomechanics of a joint, including flexibility and movement characteristics. Adequate ROM is valuable for injury prevention because it allows the tissues to adjust to imposed stresses. Loss of ROM is associated in most cases with loss of function. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/ school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation - pain



Page 38 of 47

Specific Tests and Measures Tests and measures may include: * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Data Generated Data generated may include: * Deviations from planes in degrees or inches or centimeters * Excursion distances in inches or centimeters * Pain or tenderness in muscles, joints, and soft tissue during movements or activities that require elongation of muscle * Passive tension during multisegmental movement that requires elongation of muscle * Joint ROM in degrees Reflex Integrity A reflex is a stereotypic, involuntary reaction to any of a variety of sensory stimuli. The physical therapist uses reflex integrity tests and measures to determine the excitability of the nervous system and the integrity of the neuromuscular system. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired arousal - impaired gait, locomotion, and balance - impaired motor function (motor control and motor learning)



Page 39 of 47

- impaired muscle performance (strength, power, endurance) - impaired neuromotor development and sensory integration - impaired posture - impaired sensory integrity - pain Specific Tests and Measures Tests and measures may include: * Assessment of developmentally appropriate reflexes over time * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathologic reflexes (eg, Babinski's reflex) * Electrophysiological tests (eg, H-reflex) Data Generated Data generated may include: * Normal or pathologic reflexes * Variation in reflex activity over time or with positioning Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living) Self-care includes activities of daily living (ADL), such as bed mobility, transfers, gait, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting. Home management includes more complex instrumental activities of daily living (IADL), such as maintaining a home, shopping, cooking, performing heavy household chores, managing money, driving a car or using public transportation, structured play (for infants and children), and negotiating school environments. The physical therapist uses the following tests and measures to determine the level of performance of the tasks necessary for independent living. The results of these tests and measures may lead the physical therapist to determine that the patient/client needs assistive and adaptive, orthotic, protective, supportive, or prosthetic devices or equipment; body mechanics training; organized functional training programs; or therapeutic exercise programs. The physical therapist considers patient/client safety, perceptions, and expectations while performing the tests and measures.



Page 40 of 47

Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care or home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - impaired aerobic capacity and endurance - impaired arousal, attention, and cognition - impaired body mechanics - impaired bowel and bladder function - impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired neuromotor development and sensory integration - impaired posture - impaired sensory integrity - impaired ventilation, respiration (gas exchange), and circulation



Page 41 of 47

- pain Specific Tests and Measures Tests and measures may include: * ADL or IADL scales or indexes * Analysis of adaptive skills * Analysis of environment and tasks * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of self-care performed in unfamiliar environments * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Assessment of safety in self-care and home management activities * Observation of response to non-routine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by the patient/client, family, significant others, caregivers, or other professionals Data Generated Data generated may include: * Ability to transfer * Adaptive skills * Aerobic capacity or endurance * Appropriateness of assistive and adaptive devices



Page 42 of 47

* Appropriateness of orthotic, protective, supportive, or prosthetic devices and equipment * Daily activity level * Effort in specific movement tasks * Functional capacity for self-care and home management tasks * Gross and fine motor function * Attention and cognition deficits * Movement patterns during performance of self-care and home management activities * Muscle strength, power, and endurance * Numerical scores on standardized rating scales * Performance of self-care and home management activities and level of dependence on human and mechanical assistance * Spatial and temporal requirements for performing specific tasks related to self-care and home management activities * Standard vital signs (blood pressure, heart rate, respiratory rate) at rest and during and after activity * Strength, flexibility, and endurance Sensory integrity (Including Proprioception and Kinesthesia) Sensory integrity includes peripheral sensory processing (eg, sensitivity to touch) and cortical sensory processing (eg, two-point and sharp/dull discrimination). Proprioception includes position sense and the awareness of the joints at rest. Kinesthesia is the awareness of movement. The physical therapist uses sensory integrity tests and measures to determine the integrity of the sensory, perceptual, or somatosensory processes. Sensory, perceptual, or somatosensory abnormalities are frequent indicators of pathology. Clinical indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - edema, lymphedema, or effusion - impaired arousal, attention, and cognition



Page 43 of 47

- impaired gait, locomotion, and balance - impaired joint integrity and mobility - impaired motor function (motor control and motor learning) - impaired muscle performance (strength, power, endurance) - impaired neuromotor development and sensory integration - impaired reflex integrity - impaired posture - impaired sensory integrity impaired ventilation, respiration (gas exchange), and circulation - pain Specific Tests and Measures Tests and measures may include: * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp/dub discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Data Generated



Page 44 of 47

Data generated may include: * Accuracy of cortical perceptions (eg, tactile recognition of objects, recognition of symbols drawn on the skin, ability to localize touch sensations) * Conduction times and velocities along peripheral or central musculoskeletal sensory pathways * Joint position sense * Perception of movement in the extremities * Skin breakdown or injury that may cause decreased sensation * Superficial sensory capacities Ventilation, Respiration (Gas Exchange), and Circulation Ventilation is the movement of a volume of gas into and out of the lungs. Respiration refers primarily to the exchange of oxygen and carbon dioxide across a membrane into and out of the lungs and at the cellular level. Circulation is the passage of blood through the heart, blood vessels, organs, and tissues; it also describes the oxygen delivery system. The physical therapist uses ventilation, respiration, and circulation tests and measures to determine whether the patient has an adequate ventilatory pump and oxygen uptake and delivery system to perform activities of daily living (ADL), ambulation, and aerobic exercise. Clinical Indications Tests and measures are appropriate in the presence of: * Expectation or indication of one or more of the following impairments or functional limitations during attempts to perform self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, or activities: - abnormal breathing patterns or abnormal blood gases - abnormalities of heart rate, blood pressure, respiratory rate or pattern of breathing, or heart muscle function - dizziness - dyspnea at rest or on exertion - edema or lymphedema



Page 45 of 47

- impaired aerobic capacity and endurance - airway clearance dysfunction - impaired joint integrity and mobility - impaired muscle performance (strength, power, endurance) - impaired posture - impaired ventilation, respiration (gas exchange), and circulation - pain Specific Tests and Measures Tests and measures may include: * Analysis of thoracoabdominal movements and breathing patterns at rest and during activity and exercise * Assessment and classification of edema through volume and girth measurements * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of autonomic responses to positional changes * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity



Page 46 of 47

* Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation and mediate percussion of the lungs * Auscultation of major vessels for bruits * Auscultation of the heart * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Data Generated Data generated may include: * Activities that aggravate or relieve symptoms * Adequacy of airway protection mechanisms * Chest wall mobility and expansion * Cough, sputum, and phonation characteristics * Edema (girth, volume displacement) * Inspiratory and expiratory muscle force before and after activity (including comparison of actual to predicted) * Normal and abnormal heart and lung sounds * Oxygen saturation ([SaO.sub.2]) at rest and during and after activity * Peripheral vascular integrity * Pulse characteristics * Rate of perceived exertion and dyspnea at rest and during activity * Symptoms that limit activity * Thoracoabdominal movements and breathing patterns at rest and during activity



Page 47 of 47

* Ventilatory muscle performance (strength, power, and endurance) and ventilatory pump mechanics * Ventilatory volumes and flow at rest and during and after activity (including comparison of actual with predicted) * Vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Work of breathing and ventilatory reserve capacity

Source Citation:"What types of tests and measures do physical therapists use?." Physical Therapy 77.n11 (Nov 1997): 1189(24). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 26

What types of interventions do physical therapists provide?(A Description of Patient/Client Management)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1213(14). (6529 words)


Introduction Policy decisions about the use of physical therapy personnel and resources to manage patients/clients with impairments, functional limitations, and disabilities should be based on knowledge of the elements of the patient/client management that is provided by physical therapists. Fading to intervene appropriately to prevent illness -- and failing to habilitate or rehabilitate patients/clients with impairments, functional limitations, and disabilities -- lead to greater costs at both the personal level and the societal level. The Guide provides administrators and policymakers with the information they need to make decisions about the cost-effectiveness of physical therapist intervention. Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client -- and, when appropriate, with other individuals involved in care -- using various methods and techniques to produce changes in the condition that are consistent with the evaluation, diagnosis, and prognosis. Decisions are contingent on the timely monitoring of response to intervention and the progress made toward anticipated goals and desired outcomes. Patient/client management provided by physical therapists includes ongoing examination, evaluation, and modification of the plan of care when necessary. The physical therapist selects interventions based on the complexity of the clinical problems. The plan of care includes discharge planning that begins early and that is based on anticipated goals and desired outcomes as determined by periodic reexamination. As soon as clinically appropriate, the patient/client is informed of the prognosis and begins, with the assistance of the physical therapist, long-range planning for managing any residual impairment, functional limitation, or disability. Through appropriate education and instruction, the patient/client is encouraged to develop health habits that will maintain or improve function, prevent recurrence of problems, and promote wellness. Physical therapist intervention encourages functional independence, emphasizes patient/clientrelated instruction, and promotes proactive, wellness-oriented lifestyles. Physical therapists actively facilitate the participation of the patient/client, family, significant others, and caregivers in the plan of care. Physical therapist intervention has three components: (1) coordination, communication, and documentation, (2) patient/client-related instruction, and (3) direct interventions (Fig. 1). Coordination, communication, and documentation and patient/client-related instruction are a part of all patient/client management. Direct interventions vary because they are selected, applied, or modified according to data and anticipated goals for a particular patient/client in a specific diagnostic group. An examination, evaluation, or intervention -- unless performed by a physical therapist -- is not physical therapy, nor should it be represented or reimbursed as such.



Page 2 of 26

Coordination, Communication, and Documentation Coordination, communication, and documentation are processes that ensure (1) appropriate, coordinated, comprehensive, and cost-effective services between admission and discharge and (2) cost-effective and efficient integration or reintegration into home, community, or work (job/school/play) environments. These processes involve collaborating and coordinating with agencies; coordinating and monitoring the delivery of available resources; coordinating data on transition; coordinating the patient/client management provided by the physical therapist; ensuring and facilitating access to health care services and resources and to appropriate community resources; facilitating the development of the discharge plan; facilitating timely delivery of available services; identifying current resources; providing information regarding the availability of advocacy services; obtaining informed consent; protecting patient/client rights through procedural safeguards and services,; providing information, consultation, and technical assistance; and providing oversight for outcomes data collection and analysis. Clinical indications Coordination, communication, and documentation are essential to all patient/client management. They are used to identify or quantify: * Comorbidities that may affect the plan of care, prognosis, or outcome * Discharge destinations * Impairment, functional limitation, or disability that will be the focus of the plan of care * Interventions used, including frequency and duration * Other interventions (eg, medications) that may affect outcomes * Progress toward anticipated goals, using appropriate tests and measures * Rehabilitation potential Documentation is required at the onset of and throughout each episode of care. Clinical documentation indicates, in order of sequence: * Modes of interventions selected and the parameters of application * Direct effects of each intervention in terms of impairment status (eg, change in level of pain, sensation, reflexes, strength, endurance, range and quality of joint movement) * Changes in functional limitation and disability, especially as they relate to meaningful, practical, and sustained change in the life of the patient/client. If pain reduction is a goal, for example, the outcome should be documented in terms of how the level of pain reduction relates to a change in functional performance. * Changes since previous intervention and any alteration in technique or intervention Documentation should follow APTA's Guidelines for Physical Therapy Documentation (Appendix 7).



Page 3 of 26

Anticipated Goals All benefits of coordination, communication, and documentation are measured in terms of remediation or prevention of impairment, functional limitation, or disability. Specific goals may include: * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions Coordination, communication, and documentation services may include: * Case management * Communication (direct or indirect) * Coordination of care with the patient/client, family, significant others, caregivers, other professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Patient/client-related instruction is the process of imparting information and developing skills to



Page 4 of 26

promote independence and to allow care to continue after discharge. Instruction should focus not only on the patient but on the family, significant others, and caregivers regarding the current condition, plan of care, and transition to roles at home, at work, or in the community, with the goal of ensuring (1) short-term and long-term adherence to the interventions and (2) primary and secondary prevention of future disability. The development of an instruction program should be consistent with the goals of the plan of care and may include information about the cause of the impairment, functional limitation, or disability; the prognosis; and the purposes and benefits and risks of the intervention. All instruction should take into consideration the influences of patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Clinical indications A patient/client-related instruction program should be developed for all patients for whom physical therapy is indicated. A thorough examination must be performed to determine whether the cognitive status, physical status, and resource status of the patient/client would allow independent performance of a home program or whether family, significant other, or caregiver assistance is required. When family, significant others, or caregivers -- including home health aides -- are required to assist the patient/client with intervention procedures, they must be given instruction. Anticipated Goals All benefits of patient/client-related instruction programs are measured in terms of remediation or prevention of impairment, functional limitation, or disability. Specific goals may include: * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved.



Page 5 of 26

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is increased. * Utilization and cost of health care services are decreased. Interventions Activities to be included in the development of a patient/client-related instruction program may include: * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions The physical therapist selects, applies, or modifies one or more direct interventions (Fig. 1) based on anticipated goals that are discussed with the patient/client and that relate to specific impairments, functional limitations, and disabilities. Three of the direct interventions -- therapeutic exercise, functional training in self-care and home management, and functional training in community and work (job/school/play) integration or reintegration -- form the core elements of most physical therapy plans of care. Plans of care frequently may include the use of other interventions to augment therapeutic exercise and functional training. The use of any intervention, unless performed by, a physical therapist or under the direction and supervision of a physical therapist, is not physical therapy, nor should it be represented or reimbursed as such. The physical therapist's selection of any direct intervention should be supported by the following: * Examination findings (including those of the history, systems review, and tests and measures), evaluation, and a diagnosis that supports physical therapist intervention * Prognosis that is associated with improved or maintained health status through the remediation of impairment, functional limitation, or disability



Page 6 of 26

* A plan of care designed to improve function through the use of interventions of appropriate intensity, frequency and duration to achieve specific anticipated goals efficiently with available resources Physical therapists select interventions based on the data gathered during the examination process and based on anticipated goals and desired outcomes. Factors that influence the complexity of both the evaluation process and the intervention may include the following: chronicity or severity of current condition; level of current impairment and probability of prolonged impairment, functional limitation, or disability; living environment; multisite or multisystem involvement; overall physical function and health status; potential discharge destinations; preexisting systemic conditions or diseases; social supports; and stability of the condition. Through routine monitoring and reexamination, the physical therapist determines the need for any alteration in an intervention or in the plan of care. The interventions used, including their frequency and duration, are consistent with patient/client needs and physiologic and cognitive status, anticipated goals, and resource constraints. The independent performance of the procedure or technique by the patient/client (or significant other, family, or caregiver) is encouraged following instruction in safe and effective application. Discontinuation of an intervention may be indicated because of lack of progress, lack of tolerance, lack of motivation, attainment of optimal improvement or achievement of other desired outcomes, or determination of a more effective alternative. In the following pages, each type of direct intervention is described. Included are general criteria for appropriate use of the intervention; possible methods, procedures, or techniques; and anticipated goals. Direct INterventions Therapeutic Exercise including Aerobic Conditioning) Therapeutic exercise includes a broad group of activities intended to improve strength, range of motion (ROM) (including muscle length), endurance, breathing, balance, coordination, posture, motor function (motor control and motor learning), motor development, or confidence when any of a variety of problems constrains the ability to perform a functional activity. The physical therapist targets problems with performance of a movement or task and specifically directs therapeutic exercise to alleviate impairment, functional limitation, or disability. Therapeutic exercise includes activities to improve physical function and health status (or reduce or prevent disability) resulting from impairments by identifying specific performance goals that will allow patients/clients to achieve a higher functional level in the home, school, workplace, or community. Also included: activities that allow well clients to improve or maintain their health or performance status (for work, recreational, or sports purposes) and prevent or minimize future potential health problems. Therapeutic exercise also is a part of fitness and wellness programs designed to promote overall well-being or, in general, to prevent complications related to inactivity or overuse. The intervention may be used during pregnancy and the postpartum period to improve function and reduce stress. it also may be used (with proper guidance) in patients with hematologic and oncologic disorders to combat fatigue and systemic breakdowns. Therapeutic exercise may prevent further complications and decrease utilization of health care resources before, during, and after surgery or hospitalization. Therapeutic exercise is performed actively, passively, or against resistance. When the



Page 7 of 26

patient/client cannot participate actively due to weakness or other problems, passive exercise may be necessary. Resistance may be provided manually, by gravity, or through use of a weighted apparatus or of mechanical or electromechanical devices. Aquatic physical therapy uses the physical and hydrodynamic properties of water to facilitate performance. Clinical indications Before applying therapeutic exercise, a thorough examination is performed to identify those patients/clients for whom therapeutic exercise would be contraindicated or for whom therapeutic exercise must be applied with caution. Candidates for therapeutic exercise include patients/clients who: * Are at risk of postsurgical complications * Are at risk of developing or have developed impairment, functional limitation, or disability as a result of defects in the following body systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - lymphatic - musculoskeletal - neuromuscular - pulmonary * Engage in recreational, organized amateur, or professional athletics * Are prepartum or postpartum * Are restricted from performing necessary self-care, home management, community and work (job/school /play) integration or reintegration, and leisure tasks, movements, or activities Anticipated Goals All benefits of therapeutic exercise are measured in terms of remediation or prevention of impairment, functional limitation, or disability. Specific goals related to therapeutic exercise may include: * Ability to performing physical tasks related to self-care, home management, community and work (job/ school/ play) integration or reintegration, or leisure activities is increased. * Aerobic capacity is increased. * Airway clearance is improved.



Page 8 of 26

* Atelectasis is decreased. * Balance is improved. * Endurance is increased. * Energy expenditure is decreased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Need for assistive, adaptive, orthotic, protective, or supportive equipment and devices is decreased. * Nutrient delivery to tissue is increased. * Osteogenic effects of exercise are maximized. * Pain is decreased. * Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IKDL) are increased. * Physical function and health status are improved. * Physiologic response to increased oxygen demand is improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairment is reduced.



Page 9 of 26

* Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Sensory awareness is increased. * Strength, power, and endurance are increased. * Stress is decreased. * Symptoms associated with increased oxygen demand are decreased. * Tissue perfusion and oxygenation are enhanced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. * Work of breathing is decreased. Specific Direct interventions Therapeutic exercise may include: * Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Conditioning and reconditioning (including ambulation activities with manual resuscitator bag or portable ventilator * Developmental activities training * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining



Page 10 of 26

* Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Perceptual training * Posture awareness training * Sensory training or retraining * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching * Structured play or leisure activities Functional Training in Self-care and Home Management (Including Activities of Daily Living and instrumental Activities of Daily Living) Functional training in self-care and home management includes a broad group of performance activities designed to (1) enhance neuromusculoskeletal, cardiovascular, and pulmonary capacities and (2) integrate or return the patient/client to self-care or home management as quickly and efficiently as possible. Functional training is used to improve the physical function and health status of patients/clients with physical disability, impaired sensorimotor function, pain, injury, or disease. Functional training also is used for well clients. It frequently is based on activities associated with growth and development. The physical therapist targets problems with performing a movement or task and specifically directs the functional training to alleviate impairment, functional limitation, and disability. The physical therapist may select from a number of options, including training in the following: activities of daily living (ADL); instrumental activities of daily living (IADL); body mechanics; therapeutic exercise; and use of therapeutic assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment. Organized functional training programs such as back schools also may be selected. Clinical indications



Page 11 of 26

Before applying functional training, a thorough examination is performed to identify those patients/clients for whom functional training in self-care and home management would be contraindicated or for whom functional training in self-care and home management must be applied with caution. Candidates for functional training in self-care and home management include patients/clients who: * Are at risk of developing or have developed impairment, functional limitation, or disability as a result of defects in the following body systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - lymphatic - musculoskeletal - neuromuscular - pulmonary * Are at risk of developing or have developed impairment, functional limitation, or disability as a result of surgical complications * Are restricted from performing necessary self-care, home management, community, or work job/school/play) integration or reintegration, or leisure tasks, movements, or activities Anticipated Goals All benefits of functional training in self-care and home management ate measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specific goals related to functional training in self-care and home management may include: * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in * ADL and IADL are increased. * Level of supervision required for task performance is decreased.



Page 12 of 26

* Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Sense of well-being is improved. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct interventions Functional training activities may include: * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, toileting) * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training * Self-care or home management task adaptation Functional Training in Community and Work (Job/school/play) integration or Reintegration (Including instrumental Activities of Daily Living, Work Hardening, and Work Conditioning) Functional training in community and work job/school/play) integration or reintegration includes a broad group of activities designed to integrate or to return the patient/client to community, work job/school/play), or leisure activities as quickly and efficiently as possible. It involves improving physiologic capacities to facilitate the fulfillment of community- and work-related roles. Functional training is used to improve the physical function and health status of patients/clients with physical disability, impaired sensorimotor function, pain, injury, or disease; it also is used for well individuals. It frequently is based on activities associated with growth and development. The physical therapist targets the problems in performance of movements, community activities, work tasks, or leisure activities and specifically directs the functional training to enable return to the community, work, or leisure environment. A variety of approaches may be taken, depending on patient/client needs; for example, the physical therapist may provide training in instrumental activities of daily living (IADL) to a patient/client who needs to live more independently, and body mechanics and posture awareness training to a patient/client who is deficient in those areas.



Page 13 of 26

Work hardening and work conditioning are specialized functional training programs designed to reduce the impairment, functional limitation, or disability associated with work-related injuries. Clinical indications Before applying functional training in community and work (job/school/play) integration or reintegration, a thorough examination is performed to identify those patients/clients for whom functional training would be contraindicated or for whom functional training must be applied with caution. Candidates for functional training in community and work (job/school/play) integration or reintegration include patients/clients who: * Are at risk of developing or have developed impairment, functional limitation, or disability as a result of defects in the following body systems: - cardiovascular - endocrine/metabolic - genitourinary - integumentary - lymphatic - musculoskeletal - neuromuscular - pulmonary * Are at risk of developing or have developed impairment, functional limitation, or disability as a result of surgical complications * Are engaged in recreational, organized amateur, or professional athletics * Are restricted from performing necessary self-care, home management, community or work (job/school/play) integration or reintegration, or leisure tasks, movements, or activities * Have a known work-related injury, impairment, functional limitation, or disability Anticipated Goals All benefits of functional training in community and work (job/school/play) reintegration and leisure activities are measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specific goals related to functional training in community and work (job/ school/play) integration or reintegration and leisure activities may include: * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.



Page 14 of 26

* Costs of work-related injury or disability are reduced. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/ school/play), and leisure tasks and activities. * Tolerance to positions and activities is increased. * Sense of well-being is improved. * Utilization and cost of health care services are decreased. Specific Direct interventions Functional training activities in community and work integration or reintegration may include: * Assistive and adaptive device or equipment training * Environmental, community, work job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, structured play for infants and children, negotiating school environments) job coaching job simulation * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Manual therapy techniques consist of a broad group of passive interventions in which physical therapists use their hands to administer skilled movements designed to modulate pain; increase joint range of motion (ROM); reduce or eliminate soft tissue swelling, inflammation, or restriction; induce relaxation; improve contractile and noncontractile tissue extensibility; and improve pulmonary function. These interventions involve a variety of techniques, such as the application of graded forces.



Page 15 of 26

Physical therapists use manual therapy techniques to improve physical function and health status (or reduce or prevent disability) resulting from impairments by identifying specific performance goals that allow patients/clients to achieve a higher functional level in self-care, home management, community and work (job/school/play) integration or reintegration, or leisure tasks and activities. Clinical Indications Before applying manual therapy techniques, a thorough examination is performed to identify those patients/clients for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution. Candidates for manual therapy include patients/ clients with: * Limited ROM * Muscle spasm * Pain * Scar tissue or contracted tissue * Soft tissue swelling, inflammation, or restriction Anticipated Goals All benefits of manual therapy techniques are measured in terms of a remediation or prevention of impairment, functional limitation, and disability. Specific goals related to manual therapy techniques may include: * Ability to perform movement tasks is increased. * Edema, lymphedema, or effusion is decreased. * Integumentary integrity is improved. * joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairment is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased.



Page 16 of 26

* Ventilation, respiration (gas exchange), and circulation are increased. Specific Direct Interventions Manual therapy techniques may include: * Connective tissue massage * Joint mobilization and manipulation * Manual lymphatic drainage * Manual traction * Passive ROM * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Prescription, application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment include the use of a broad group of therapeutic appliances, implements, devices, and equipment to enhance performance of tasks or movements, support weak or ineffective joints or muscles, protect body parts from injury, and adapt the environment to facilitate activities of daily living (IADL) and instrumental activities of daily living (IADL). These devices and equipment often are used in conjunction with therapeutic exercise, functional training, work conditioning and work hardening, and other interventions and should be selected in the context of patient/client needs and social and cultural environments. The physical therapist targets the problems in performance of movements or tasks and selects (or fabricates) the most appropriate device or equipment, then fits it and trains the patient/client in its use and application. The goal is for the patient/client to function at a higher level and to decrease functional limitation. Clinical indications Before prescribing, applying, or, as appropriate, fabricating any device or equipment, a thorough examination is performed to identify those patients/clients for whom these devices and equipment would be contraindicated or for whom these therapeutic devices and equipment must be applied with caution. Candidates for these therapeutic devices and equipment include patients/clients who: * Are at risk of developing impairment, functional limitation, or disability as a result of defects in the following body systems: - cardiovascular



Page 17 of 26

- endocrine/metabolic - genitourinary - integumentary - lymphatic - musculoskeletal - neuromuscular - pulmonary * Are engaged in recreational, organized amateur, or professional athletics * Are restricted from performing necessary self-care, home management, community and work (job/school/play) integration or reintegration, and leisure tasks, movements, and activities Anticipated Goals All benefits of these therapeutic devices and equipment are measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specific goals related to the prescription, application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment may include: * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Independence in bed mobility, transfers, and gait is maximized. * Edema or effusion is reduced. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is increased. * Optimal joint alignment is achieved. * Functional status is maintained while awaiting recovery. * Pain is decreased.



Page 18 of 26

* Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Pressure areas (eg, pressure over bony prominence) are prevented. * Prosthetic fit is achieved. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions The selection of these therapeutic devices and equipment may include the prescription, application, and, as appropriate, fabrication of: * Adaptive devices (eg, raised toilet seats, seating systems, hospital beds, environmental controls) * Assistive devices (eg, crutches, canes, walkers, wheel-chairs, power devices, long-handled reachers, static and dynamic splints) * Orthotic devices (eg, splints, braces, shoe inserts, casts) * Prosthetic devices (eg, artificial limbs) * Protective devices (eg, braces, protective taping, cushions, helmets) * Supportive devices (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Airway clearance techniques include a broad group of activities used to manage or prevent consequences of acute and chronic lung diseases and impairment, including those associated with surgery. Airway clearance techniques may be used with therapeutic exercise, manual therapy techniques, or mechanical modalities to improve pulmonary function.



Page 19 of 26

The physical therapist performs airway clearance techniques to improve physical function and health status (or reduce or prevent disability) resulting from impairments, functional limitations, and disabilities by identifying specific performance goals that allow the patient/client to achieve a higher functional level in home management, community and work (job/school/play) integration or reintegration, and leisure movements, tasks, and activities. Clinical Indications Before applying airway clearance techniques, a thorough examination is performed to identify those patients/clients for whom these techniques would be contraindicated or for whom these techniques must be applied with caution. Candidates for airway clearance techniques include patients/clients who: * Are at risk for postsurgical complications * Are restricted from performing necessary self-care, home management; community and work (job/school/ play) integration and reintegration and leisure tasks, movements, and activities * Have altered breathing patterns * Have impaired airway clearance * Have impaired gas exchange * Have impaired ventilatory pump * Are at risk of developing impairment, functional limitation, or disability as a result of defects in the following body systems: - cardiovascular - endocrine/metabolic - musculoskeletal - neuromuscular - pulmonary Anticipated Goals All benefits of airway clearance techniques are measured in terms of a remediation or prevention of impairment, functional limitation, and disability. Specific goals related to airway clearance techniques may include: * Airway clearance is improved. * Cough is improved. * Exercise tolerance is improved.



Page 20 of 26

* Independence in self-care for airway clearance techniques is increased. * Need for an assistive device (mechanical ventilation) is decreased. * Physical function and health status are improved. * Risk of secondary complications is reduced. * Risk of recurrence of condition is reduced. * Utilization and cost of health care services are decreased. * Ventilation, respiration (gas exchange), and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions Airway clearance techniques may include: * Active cycle of breathing or forced expiratory techniques * Assistive cough techniques * Assistive devices for airway clearance (eg, flutter valve) * Autogenic drainage * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyper-inflation) Wound Management Wound management includes procedures used to achieve a clean wound bed, promote a moist wound environment, facilitate autolytic debridement, absorb excessive exudate from a wound complex, and enhance perfusion and oxygen and nutrient delivery to tissues in addition to management of the resulting scar. As a component of wound management, debridement is a therapeutic procedure involving removal of nonviable tissue from a wound bed, most often by the use of instruments, autolysis, therapeutic modalities, or enzymes. The desired effects of wound management may be achieved in a variety of ways. The physical therapist may use physical agents, electrotherapeutic and mechanical modalities, dressings, topical agents, debridement, and oxygen therapy as part of a plan of care to alter the function of



Page 21 of 26

tissues and organ systems required for repair. Wound management interventions are used directly by the physical therapist, based on patient/client needs and the direct physiological effects that are required. Clinical Indications Before applying wound management techniques, a thorough examination is performed to identify those patients/ clients for whom these interventions would be contraindicated or for whom the interventions must be applied with caution. Candidates for wound management include patients/clients with: * Exuding wounds or reepithelialization or connective tissue repair or both * Full- or partial-thickness skin involvement * Nonviable tissue * Signs of inflammation Anticipated Goals All benefits of wound management are measured in terms of remediation or prevention of impairments, functional limitations, and disability. Specific goals related to wound management may include: * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are improved. * Risk factors for infection are reduced. * Risk of secondary impairments is reduced. * Tissue perfusion and oxygenation are enhanced. * Utilization and cost of health care services are decreased. * Wound and soft tissue healing is enhanced. * Wound size is reduced. Specific Direct Interventions Methods of wound management may include: * Assistive and adaptive devices * Debridement -- nonselective



Page 22 of 26

- enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement -- selective - enzymatic debridement - sharp debridement - debridement with other agents (eg, autolysis) * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic Modalities, (see Electrotherapeutic Modalities, page 3-13) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical Agents and Mechanical Modalities, page 3-14) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Electrotherapeutic modalities, which include a broad group of agents involving electricity, are used by physical therapists to augment other active or functionally oriented procedures in the plan of care. Specifically, these modalities are used to help patients/clients modulate or decrease pain; reduce or eliminate soft tissue swelling, inflammation, or restriction; maintain strength after injury or surgery; decrease unwanted muscular activity; assist muscle contraction in gait or other functional training; or increase the rate of healing of open wounds and soft tissue. Clinical Indications Before applying electrotherapeutic modalities, a thorough examination is performed to identify those patients/ clients for whom these interventions would be contraindicated or for whom these interventions must be applied with caution. Candidates for application of electrotherapeutic modalities include patients/ clients with: * Impaired integumentary integrity * Impaired motor function (motor control and motor learning) * Impaired muscle performance



Page 23 of 26

* Muscle spasm * Pain * Soft tissue swelling, inflammation, or restriction Anticipated Goals All benefits of electrotherapeutic procedures are measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specific goals related to electrotherapeutic modalities may include: * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is decreased. * joint integrity and mobility are improved. * Muscle performance is increased. * Neuromuscular function is increased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tissue perfusion and oxygenation are improved. * Utilization and cost of health care services are decreased. * Wound and soft tissue healing is enhanced. Specific Direct Interventions Electrotherapeutic modalities may include: * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Iontophoresis * Neuromuscular electrical stimulation (NMES)



Page 24 of 26

* Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Physical agents and mechanical modalities are used by physical therapists in conjunction with or in preparation for other interventions, such as therapeutic exercise and functional training. Physical agents -- which involve thermal, acoustic, or radiant energy -- are used by physical therapists in increasing connective tissue extensibility; modulating pain; reducing or eliminating soft tissue swelling, inflammation, or restriction caused by musculoskeletal injury or circulatory dysfunction; increasing the healing rate of open wounds and soft tissue; remodeling scar tissue; or treating skin conditions. Mechanical modalities include a broad group of procedures used by physical therapists in modulating pain; stabilizing an area that requires temporary support; increasing range of motion (ROM); or applying distraction, approximation, or compression. Clinical Indications Before using either physical agents or mechanical modalities, a thorough examination is performed to identify those patients/clients for whom these interventions would be contraindicated or for whom the interventions must be applied with caution. Candidates for physical agents or mechanical modalities include patients/clients with: * Edema, lymphedema, or effusion * Impaired integumentary integrity * Impaired joint integrity and mobility * Need for assisted weight bearing or upright activity support * Impaired sensory integrity * Pain * Pulmonary secretion retention * Soft tissue swelling, inflammation, or restriction Anticipated Goals All benefits of physical agents and mechanical modalities are measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specific goals related to the use of physical agents and mechanical modalities may include: * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Independence in airway clearance is achieved.



Page 25 of 26

* Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Neural compression is decreased. * Pain is decreased. * Risk of secondary impairment is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tissue perfusion and oxygenation are improved. * Utilization and cost of health care services are decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents may include: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage, vapocoolant spray) * Deep thermal modalities (eg, pulsed short-wave diathermy, ultrasound, phonophoresis) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities may include: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, and total contact casting) * Continuous passive motion (CPM) * Mechanical percussors * Tilt table or standing table * Traction (sustained, intermittent, or positional)



Page 26 of 26

Source Citation:"What types of interventions do physical therapists provide?." Physical Therapy 77.n11 (Nov 1997): 1213(14). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 234

Musculoskeletal. (includes related information)(Preferred Practice Patterns)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1229 (138). (56576 words)


The following patterns describe the elements of patient/client management provided by physical therapists -- examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Each pattern also describes primary prevention/risk factor reduction strategies for the specific patient/client diagnostic group. This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients at risk of bone demineralization, with or without clinical signs of osteological involvement. INCLUDES patients/clients with: * Activity-induced hormonal changes * Certain medications (eg, steroids) * Joint immobilization * Known high risk (eg, based on sex, ethnicity, age, lifestyle, menstrual or hormonal changes related to hysterectomy or menopause) * Nutritional deficiency * Prolonged non-weight-bearing state EXCLUDES patients/clients with: * Acute fractures * Neoplasms of the bone * Osteogenesis imperfecta * Paget's disease ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International



Page 2 of 234

Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 344 other paralytic syndromes 334.0 Quadriplegia and quadriparesis 344.1 Paraplegia 714 Rheumatoid arthritis and other inflammatory polyarthropathies 719 Other and unspecified disorders of joint 719.5 Stiffness of joint, not elsewhere classified 719.7 Difficulty in walking 719.8 Other specified disorders of joint (calcification of joint), 722 Intervertebral disk disorders 722.4 Degeneration of cervical intervertebral disk 722.5 Degeneration of thoracic or lumbar intervertebral disk 722.6 Degeneration of intervertebral disk, site unspecified 728 Disorders of muscle, ligament, and fascia 728.2 muscular wasting and disuse atrophy, not elsewhere classified 729 Other disorders of soft tissues 729.9 Other unspecified disorders of soft tissue 733 Other disorders of bone and cartilage 733.0 Osteoporosis 737 Curvature of spine 737.3 Kyphoscoliosis and scoliosis 737.4 Curvature of spine associated with other conditions Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment



Page 3 of 234

* Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function



Page 4 of 234

(eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity Anthropometric Characteristics * Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment and work (job/school/play) tasks * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Ergonomics and Body Mechanics * Functional capacity, evaluation, including: - postures required to perform task or activity - strength required in the work postures necessary to perform the work (job/school/play) task or activity



Page 5 of 234

Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness Motor Function (Motor Control and Motor Learning) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of dexterity, coordination, and agility Muscle Performance including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance Orthotic, Protective, and Supportive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, stiff photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM Self-Care and Home Management (Including ADL and IADL) * Analysis of self-care and home management activities * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing he diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and



Page 6 of 234

symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Through lifestyle modification, patient/client at risk of low bone density will maintain bone mineral density above fracture threshold. Through lifestyle modification, patient/client with identified low bone density will reverse the demineralization process and achieve bone mineral density above fracture threshold. Expected Range of Number of Visits Per Episode of Care 3 to 18 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Modify Frequency of Visits * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities



Page 7 of 234

* Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of client and use of health care resources by client, family, significant others, and caregivers. Specific Interventions * Communication (direct or indirect) * Coordination of care with client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of client management * Education plans



Page 8 of 234

* Referrals to other professionals or resources Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of client and use of health care resources by client. * Client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by client in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Endurance is increased.



Page 9 of 234

* Osteogenic effects of exercise are maximized. * Postural control is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises * Conditioning * Motor function (motor control and motor learning) training * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Doily Living [IADL]) Anticipated Goals * Performance of and independence in ADL and IADL are increased.



Page 10 of 234

Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, toileting) * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Functional Training in Community and Work (Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Performance of and independence in IADL are increased. Specific Direct Interventions * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Optimal joint alignment is achieved. * Tolerance to positions and activities is increased. Specific Direct Interventions * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, compression, garment, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, elastic wraps, oxygen) Outcomes At each step of patient/client management, the physical therapist considers the desired outcomes. Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent



Page 11 of 234

manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Consequences of falls are reduced. * Health-related quality of life is enhanced. * Optimal role function (eg, worker, student, spouse, grandparent) is maintained. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of prevention strategies is demonstrated. Client Satisfaction * Access, availability, and services provided are acceptable to client. * Administrative management of practice is acceptable to client. * Clinical proficiency of physical therapist is acceptable to client. * Coordination and conformity of care are acceptable to client. * Interpersonal skills of physical therapist are acceptable to client, family, and significant others. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is



Page 12 of 234

needed over the fife span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments * Endocrine or hormonal status * Habitual suboptimal body mechanics * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - nutritional status (eg, calcium and vitamin D intake) - physical activity level - physical work job/school/play) demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Medication history * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Previous history of injury or surgery affecting spine, posture, or body mechanics



Page 13 of 234

* Systematic condition predisposing patient/client to spinal pain with radiculopathy * Underlying spinal dysfunction (eg, postural dysfunction) in home, community, and work (job/school/play) tasks and activities Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and demineralization and (2) strategies to prevent demineralization * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Posture This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitation secondary to impaired posture with one or more of the following: * Associated muscle weakness or imbalance * Associated pain * Structural or functional deviation from normal posture * Suboptimal joint mobility INCLUDES patients/clients with: * Appendicular postural deficits * Cumulative effects of poor habitual posture in addition to poor work-related posture



Page 14 of 234

* Pregnancy-related postural changes * Scoliosis or other excessive spinal curvature EXCLUDES patients/clients with: * Neuromuscular disorders or disease (eg, spina bifida) * Radicular signs * Spinal stabilization (fusion or rodding), less than 1 year postsurgery ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because die patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 718 Other derangement of joint 718.8 Other joint derangement, not elsewhere classified 719 Other and unspecified disorders of joint 719.5 Stiffness of joint, not elsewhere classified 719.7 Difficulty in walking 722 Intervertebral disk disorders 722.4 Degeneration of cervical intervertebral disk 722.5 Degeneration of thoracic or lumbar intervertebral disk 722.6 Degeneration of intervertebral disk, site unspecified 723 Other disorders of cervical region 723.1 Cervicalgia 724 Other and unspecified disorders of back 724.2 Lumbago Low back pain, low back syndrome, lumbalgia 724.9 Back disorders, other unspecified Ankylosis of spine, not otherwise specified;



Page 15 of 234

compression of spinal nerve root, not elsewhere classified; spinal disorders, not otherwise specified 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.9 Other and unspecified disorders of soft tissue 733 Other disorders of bone and cartilage 733.0 Osteoporosis 737 Curvature of spine 737.1 Kyphosis (acquired) 737.2 Lordosis (acquired) 737.3 Kyphoscoliosis and scoliosis 738 Other acquired deformity 738.4 Acquired spondylolisthesis 756 Other congenital musculoskeletal anomalies 756.1 Anomalies of spine 781 Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait Gait: ataxic, paralytic, spastic, staggering 781.9 Other symptoms including nervous and musculoskelatal systems Abnormal posture Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language



Page 16 of 234

* Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)



Page 17 of 234

Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue)



Page 18 of 234

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Measurement of height, weight, length, and girth Assistive and Adaptive Devices * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities



Page 19 of 234

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment and work (job/school/play) tasks * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or



Page 20 of 234

activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis during performance of - selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Computer-assisted motion analysis of the performance of selected movements or activities * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, or supportive devices * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water



Page 21 of 234

* Assessment of safety * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device



Page 22 of 234

Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) Self-Care and Home Management (Including ADL and IADL) * Analysis of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach



Page 23 of 234

that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 12 months, patient/client will demonstrate the ability to maintain preferred posture during various activities (activities of daily living [ADL]; instrumental activities of daily living [IADL]; and community, work, and leisure activities). Expected Range of Number of Visits Per Episode of Care 6 to 20 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities



Page 24 of 234

* Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific interventions * Case management * Communication (direct or indirect)



Page 25 of 234

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.



Page 26 of 234

* Risk of recurrence of condition is reduced. * Risk of secondary, impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased.



Page 27 of 234

* Motor function (motor control and motor learning) is improved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation



Page 28 of 234

* Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices) * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved when performing self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Functional Training in Community and Work (Job/school/play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.



Page 29 of 234

* Costs of work-related injury or disability are reduced. * Safety is improved during performance of community and work (job/school/play) tasks and activities. * Tolerance to positions and activities is increased. Specific Direct interventions * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * job coaching * job simulation * Organized functional training programs (eg, back schools, simulated environments and tasks) Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Joint mobilization and manipulation * Manual traction * Passive range of motion



Page 30 of 234

* Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Edema, lymphedema, or effusion is reduced. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Physical function and health status are improved. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garment, corsets, slings,



Page 31 of 234

neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Muscle performance is increased. * Pain is decreased. joint integrity and mobility are improved. * Risk of secondary impairments is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Joint integrity and mobility are * Risk of secondary impairments is * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Cryotherapy (eg, cold pack, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)



Page 32 of 234

Mechanical modalities: * Traction (sustained, intermittent, or positional) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment),primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with postural dysfunction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)--and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.



Page 33 of 234

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not



Page 34 of 234

inevitable. Physical therapist intervention can prevent impairment, functional [imitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Age-related somatosensory changes * Attitude * Habitual suboptimal body mechanics * Habitual suboptimal posture * Inflexibility * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level and demand - substance abuse (eg, smoking, alcohol, drugs) * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Physical demands of work (job/school/play) * Suboptimal particular extensibilty Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, retirement centers, senior centers, assisted-living centers) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and posture and (2) strategies to prevent impaired posture * Risk factor reduction through individual and group therapeutic exercise and symptom management



Page 35 of 234

* Screening programs (eg, school scoliosis screening program, programs identifying those with postural dyscontrol tendencies) * Workplace, home, and community ergonomic analysis and modification Impaired Muscle Performance This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations secondary to impaired muscle performance. INCLUDES patients/clients with: * Cardiovascular insufficiency * Disuse atrophy secondary to prolonged bed rest, congestive heart failure, chronic obstructive pulmonary disease (COPD), pneumonia * Dysfunction of the pelvic-floor musculature * Muscle weakness due to immobilization or lack of activity * Renal disease * Vascular insufficiency, EXCLUDES patients/clients with: * Amputation * Primary capsular restriction * Primary joint arthroplasty * Primary localized inflammation * Recent bony and surgical soft tissue procedures * Recent fracture * Upper and lower motor neuron disease ICD-9-CM-Codes



Page 36 of 234

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 359 Muscular dystrophies and other myopathies 359.9 Myopathy, unspecified 410 Acute myocardial infarction 428 Heart failure 428.0 Congestive heart failure 443 Other peripheral vascular disease 482 Other bacterial pneumonia 492 Emphysema 492.8 Other emphysema 496 Chronic airway obstruction, not elsewhere classifed Chronic: obstructive pulmonary disease (COPD), not otherwise specfied 618 Genital prolapse 618.8 Other specified genital prolapse Incompetence or weakening of pelvic fundus; relaxation of vaginal outlet or pelvis 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 719 Other and unspecified disorders of joint 719.7 Difficulty in walking 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 733 Other disorders of bone and cartilage 733.0 osteoporosis 733.1 Pathologic fracture 739 Nonallopathic lesions. not elsewhere classified 780 General symptoms 780.7 Malaise and fatigue 781 Symptoms involving nervous and musculoskeletal systems 781.0 Abnormal involuntary movements 781.2 Abnormality of gait Gait ataxic, paralytic, spastic, staggering 781.3 Lack of coordination Ataxia, not otherwise specified; muscular incoordination 781.4 Transient paralysis of limb 781.9 Other symptoms involving nervous and musculoskeletal systems Abnormal posture 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 799 Other illdefined and unknown causes of morbidity and mortality 799.3 Debility, unspecified Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language



Page 37 of 234

* Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)



Page 38 of 234

Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and * preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception



Page 39 of 234

* Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales Assessment of performance during established exercise protocols eg, using treadmill, ergometer, 6- minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Assistive and Adaptive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability), through use of device Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers,



Page 40 of 234

and other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work (job/school/play) through batteries of tests * Assessment of workstation * Determination of dynamic capabilities and limitations during specific work job/school/play) activities Body mechanics: * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of autonomic responses to positional changes * Assessment of safety Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during the performance of specific movement tasks * Assessment of joint hypermobdity and hypomobility * Assessment of pain and soreness Muscle Performance including Strength, Power and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV) Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device



Page 41 of 234

Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position Range of Motion (ROM) including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Self-Care and Home Management (Including ADL and IADL) * Analysis of adaptive skills * Analysis of environment and work (job/school/play) tasks * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, and supportive devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory integrity including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, fight touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest and during activity or exercise * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of chest wall mobility, expansion, and excursion * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of ventilatory muscle strength, power, and endurance * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity



Page 42 of 234

of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 2 to 10 months, patient/client will demonstrate a return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care 6 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally, utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding tile health of patient/client and use of health care resources by patient/client, family significant others, and caregivers. * Other health



Page 43 of 234

care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits. wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others. and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family. significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved.



Page 44 of 234

* Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Pain decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are unproved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning



Page 45 of 234

* Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home-Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Performance of and independence m ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training



Page 46 of 234

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased, * Costs to work-related injury or disability are reduced. * Safety is improved during performance of community and work tasks and activities. * Tolerance to position * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Injury prevention or reduction training * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training



Page 47 of 234

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Overall independence is increased. * Physical function and health status are improved. * Protection of body parts is increased. * Safety is improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)



Page 48 of 234

* Assistive devices or equipment (eg, canes, crutches, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splits, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, helmets, cushions, protective taping) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or lymphedema, is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, and restriction are reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals



Page 49 of 234

* Ability to perform movement tasks is increased. * Complications from soft tissue and circulatory disorders are decreased. * Edema, effusion, or lymphedema is reduced. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, and restriction are reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, total contact casting) * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent



Page 50 of 234

manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of fife is improved. * Optimal return to role function (eg, * worker, student, spouse, grandparent) is achieved. * Risk of disability associated with muscle performance dysfunction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention



Page 51 of 234

outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Primary Prevention/risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture in home,



Page 52 of 234

community, or work (job/school/play) environments * Habitual suboptimal posture or body mechanics (eg, scapular retraction, forward-head position, hyperextension of the knees) * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Musculotendinous tightness or inflexibitity (eg, Achilles tendon, hamstring muscles, pectoral muscles) * Musculotendinous weakness or imbalance (eg, quadriceps femoris. hamstring, rhomboid, lower trapezius, pectoral muscles) * Previous history. of injury or surgery affecting posture or body mechanics (eg, shoulder injury resulting in forearm compensation, foot pain resulting in knee or hip compensation) Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise program, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and inflammatory conditions and (2) strategies to prevent these conditions * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated Wit Capsular Restriction



Page 53 of 234

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations as a primary result of capsular restriction following prolonged joint immobilization. Patients/clients may have one or both of the following: * Decreased range of motion * Pain INCLUDES patients/clients with: * External supports or protective devices * Protective muscle guarding EXCLUDES patients/clients with: * Impaired reflex integrity or lack of voluntary movement * Immobility as a primary result of prolonged bed rest * Joint hemarthrosis, active sepsis, or deep vein thrombosis * Traumatic wounds or burns not associated with prolonged immobilization ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 337 Disorders of the autonomic nervous system 337.2 Reflex sympathetic dystrophy 354 Mononeuritis of upper limb and mononeuritis multiplex 354.4 Causalgia of upper limb 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.5 Unspecified



Page 54 of 234

polyarthropathy or polyarthritis 716.9 Arthropathy, unspecified Inflammation of joint, not otherwise specified 718 Other derangement of joint 718.8 Other joint derangement, not elsewhere classified 719 Other and unspecified disorders of joint 719.7 Difficulty in walking 719.8 Other specified disorders of joint Calcification of joint 726 Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.10 Disorders of bursae and tendons in shoulder region, unspecified 726.2 Other affections of shoulder region, not elsewhere classified 726.9 Unspecified enthesopathy 726.90 Enthesopathy of unspecified site Tendinitis 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 727.6 Rupture of tendon, nontraumatic 727.61 complete rupture of rotator cuff 727.8 Other disorders of synovium, tendon, and bursa 727.91 Contracture of tendon (sheath) Short Achilles tendon (acquired) 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.6 Contracture of palmar fascia Dupuytren's contracture 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 729 Other disorders of soft tissue 729.8 Other musculoskeletal symptoms referable to limbs 729.81 swelling of limb 730 Osteomyelitis, periostitis and other infections involving bone 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 733.8 Malunion and nonunion of fractures 733.82 Nonunion of fracture 802 Fracture of face bones 805 Fracture of vertebral column without mention of spinal cord injury 808 Fracture of pelvis 811 Fracture of scapula 812 Fracture of humerus 812.4 Lower end, closed Distal end of bumerus, elbow 813 Fracture of radius and ulna 813.4 Lower end, closed 813.41 Colles'fracture 813.5 Lower end, open 813.51 Colles'fracture 814 Fracture of carpal bone(s) 814.0 Closed 815 Fracture of metacarpal bone(s) 816 Fracture of one or more phalanges of hand 820 Fracture of neck of femur 821 Fracture of other and unspecified parts of femur 822 Fracture of patella 823 Fracture of tibia and fibula 824 Fracture of woe 825 Fracture of one or more tarsal and metatarsal bones 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff capsule) 879 Open wound of other and unspecified sites, except limbs 998 Other complications of procedures, not elsewhere classifed 998.5 Postoperative infection Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History



Page 55 of 234

Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goats for the therapeutic intervention



Page 56 of 234

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (ADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History



Page 57 of 234

* Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, lanquage, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device



Page 58 of 234

* Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of environment and work (job/school/play) tasks * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety



Page 59 of 234

* Identification and quantification of gait characteristics Joint Integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of joint hypermobility and hypomobility Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Electrophysiologic tests (eg, electromyography [EMG]) Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales



Page 60 of 234

Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) Self-Care and Home Management (Including ADL and IADL) * Analysis of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also man, include a prediction of the improvement levels that may be



Page 61 of 234

reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 4 months, patient/client will demonstrate a return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care 6 to 36 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 36 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Delayed healing * Level of patient/client adherence to the intervention program



Page 62 of 234

* Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care



Page 63 of 234

professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced.



Page 64 of 234

* Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved.



Page 65 of 234

* Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation



Page 66 of 234

* Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Functional Training in Community and Work Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.



Page 67 of 234

* Costs of work-related injury or disability are reduced. * Safety is improved during performance of community, work (job/school/play), or leisure tasks and activities. * Tolerance to positions and activities is increased. Specific Direct Interventions * Environmental, community, work (job/school/play). or leisure task adaptation * Ergonomic stressor reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving car or using public transportation, structured play for infants and children, negotiating school environments) * Injury prevention or reduction training * Job coaching * Job simulation * Organized functional training programs (eg. back schools, simulated environments and tasks) Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Muscle spasm is reduced. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Quality and quantity of movement between and across body segments is improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage



Page 68 of 234

* Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Joint stability is increased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Physical function and health status are improved. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased.



Page 69 of 234

* Utilization and cost of health care services are decreased. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, plastic wraps) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Iontophoresis * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS)



Page 70 of 234

Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased: * Complications resulting from soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning is improved. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold pack, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting) * Continuous passive motion (CPM) * Traction (sustained, intermittent, or positional) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be



Page 71 of 234

performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with capsular restriction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safety, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.



Page 72 of 234

Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Primary Prevention/Risk Factor Reduction Strategies Prima prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age



Page 73 of 234

* Attitude * Cognitive status (eg, sufficient to understand risk reduction processes) * Heredity * Lifestyle: - general physical condition - physical activity level - substance abuse (eg, smoking, alcohol, drugs) * Overly conservative medical management * Pain tolerance * Vascular integrity, including faster or slower metabolic or healing rates Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise program, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and capsular restriction and (2) strategies to prevent related impairments. * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With Ligament or Other Connective Tissue Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.



Page 74 of 234

Patient/Client Diagnostic Group Patients/clients with functional limitation due to ligamentous sprain or musculotendinous strain. Patients/clients may have any one or a combination of the following: * Joint subluxation or dislocation * Muscle guarding or weakness * Swelling (edema) or effusion INCLUDES patients/clients with: * Ligamentous, cartilaginous, capsular, or fascial sprain * Muscle and tendon strain EXCLUDES patients with: * Fractures * Neurological dysfunction (upper motor neuron or lower motor neuron lesions) * Open wounds and recent associated surgical procedures * Radiculopathy, with or without spinal pain ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 717 Internal derangement of knee 717.7 Chondromalacia of patella 717.8 Other internal derangement of knee 717.9 Unspecified internal derangement of knee 718.8 Other joint derangement, not elsewhere classified Instability of joint 718 Other derangement of joint 719 Other and unspecified disorders of joint 719.0 Effusion of joint 719.5 Stiffness of joint, not elsewhere classified



Page 75 of 234

724 Other and unspecified disorders of back 724.2 Lumbago Low, back pain, Low, back syndrome, lumbalgia 724.3 Sciatica 724.9 Other unspecified back disorders Ankylosis of spine, not otherwise specified; compression of spinal nerve root, not elsewhere classified; spinal disorder not otherwise specified 726 Peripheral enthesopathies and allied syndromes 726.1 Rotator cuff syndrome of shoulder and allied disorders 728 Disorders of muscle, ligament, and fascia 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 729 Other an unspecified disorders of soft tissue 729.9 Other disorders of soft tissue Imbalance of posture 830 Dislocation of jaw 831 Dislocation of shoulder 832 Dislocation of elbow 833 Dislocation of wrist 836 Dislocation of knee 837 Dislocation of ankle 838 Dislocation of foot 839 Other, multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.8 Multiple and ill-defined, closed Arm;back; hand; multiple locations; except fingers or toes; other ill-defined locations; unspecified location 840 Sprains and strains of shoulder and upper arm 841 Sprains and strains of elbow and forearm 842 Sprains and strains of wrist and hand 843 Sprains and strains of hip and thigh 844 Sprains and strains of knee and leg 845 Sprains and strains of ankle and foot 846 Sprains and strains of sacroiliac region 847 Sprains and strains of other and unspecified parts of back 848 Other and ill-defined sprains and strains 848.1 Jaw 848.3 Ribs 848.4 Sternum 848.5 Pelvis Symphysis pubis



Page 76 of 234

Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations



Page 77 of 234

History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals, for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic



Page 78 of 234

* Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work (job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary. * Musculoskeletal * Neuromuscular



Page 79 of 234

Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion Assistive and Adaptive Devices * Analysis of alignment and fit of device and inspection of related changes in skin condition * Analysis of appropriate components of device * Analysis of patient/client and caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability, through use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of environment and work (job/school/play) tasks * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Observation of response to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)



Page 80 of 234

Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Observation of performance of selected movements or activities * Videotape analysis of patient/client at work Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective,



Page 81 of 234

supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during the performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Electrophysiologic tests (eg, electromyography [EMG]) Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation. or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device



Page 82 of 234

* Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of activities and postures that aggravate or relieve pain or other disturbed sensations * Assessment of muscle soreness * Assessment of pain using questionnaires, graphs, behavioral scales. symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Self-Care and Home Management (Including ADL and IADL) * Analysis of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms,



Page 83 of 234

syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 2 weeks to 4 months, patient/client will demonstrate a return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care 3 to 21 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 21 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program



Page 84 of 234

* Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care



Page 85 of 234

professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced.



Page 86 of 234

* Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, imflammation, or restriction is reduced. * Level of supervision required for task performance is * decreased.



Page 87 of 234

* Motor function (motor control and motor learning) is, improved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Joint integrity and mobility are improved. * Quality and quantity of movement between and across body segments are improved. * Risk of recurrence of condition is reduced, * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining



Page 88 of 234

* Neuromuscular education or reeducation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management task and activities. * Utilization and cost of health care services are decreased. * Tolerance to positions and activities is increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, and supportive device training Direct interventions continued



Page 89 of 234

Functional Training in Community and Work (Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Cost of work-related injury or disability is reduced, * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement task is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased.



Page 90 of 234

* Joint integrity and mobility are improved. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Connective tissue massage * Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Edema, lymphedema, or effusion is reduced. * Joint stability is increased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Physical function and health status are improved.



Page 91 of 234

* Protection of body parts is increased. * Joint integrity and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, cushions, casts) * Protective devices or equipment (eg, braces, helmets, protective taping) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars,. serial casts, elastic wraps) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Ventilation, respiration (gas exchange), and circulation are improved. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved.



Page 92 of 234

* Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct interventions * Biofeedback * Electrical muscle stimulation * Iontophoresis * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications resulting from soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * (Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage)



Page 93 of 234

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting) * Continuous passive motion (CPM) * Traction (sustained, intermittent, or positional) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the fife span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with ligament or other connective tissue disorders is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated.



Page 94 of 234

Patient/Client Satisfaction * Access, availability, and services provide are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are



Page 95 of 234

documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in home, community, or work (job/school/play) environments. * Habitual suboptimal body mechanics * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Previous history of injury or surgery affecting spine, posture, or body mechanics * Systemic condition predisposing patient/client to spinal pain with radiculopathy Primary Prevention/Risk Factor Reduction Strategies



Page 96 of 234

* Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors, diet) and sprain and strain and (2) strategies to prevent or reduce these conditions * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated Wit Localized inflammation This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/client Diagnostic Group Patients/clients with functional limitation and impairment secondary to protective tissue response of the synovial joint and the periarticular connective tissue. Patients/clients may or may not have additional contributing factors (eg, workstation and tool design, work rates, physical fitness level, pregnancy, habitual posture) with one or more of the following: * Edema * Inflammation of periarticular connective tissue * Muscle weakness or strain * Neurovascular changes * Pain * Sensory changes INCLUDES patients/clients with:



Page 97 of 234

* Bursitis * Capsulitis * Epicondylitis * Fasciitis * Osteoarthritis * Synovitis * Tendinitis EXCLUDES patients with: * Associated postsurgical procedures * Deep vein thrombosis (DVT) * Dislocations * Fractures * Hemarthrosis * Open wounds * Sepsis * Systemic disease processes ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 274 Gout 274.0 Gouty arthropathy 350 Trigeminal nerve disorders 350.1 Trigeminal neuralgia 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions Thoracic outlet syndrome 354 Mononeuritis of upper limb and mononeuritis multiplex 354.0 Carpal tunnel syndrome 354.2 Lesion of ulnar nerve



Page 98 of 234

Cubital tunnel syndrome 355 Mononeuritis of lower limb, unspecified site 355.6 Lesion of plantar nerve Morton's neuroma 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 682 Other cellulitis and abscess 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.6 unspecified monoarthritis knee) 716.66 Lower leg 716.9 Arthropathy, unspecified Inflammation of joint 718 Other derangement of joint 718.8 Other joint derangement, not elsewhere classified Instability of joint 719 Other and unspecified disorders of joint 719.0 Effusion of joint 719.2 Villonodular synovitis 720 Ankylosing spondylitis and other inflammatory spondylopathies 720.2 Sacroiliitis, not elsewhere classified 722 intervertebral disk disorders 724 Other and unspecified disorders of back 724.0 spinal stenosis, other than cervical 724.2 Lumbago Low back pain, low back syndrome, lumbalgia 726 Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.10 Disorders of bursae and tendons in shoulder region, unspecified 726.2 Other affections of shoulder region, not elsewhere classified 726.3 Enthesopathy of elbow region 726.31 Medial epicondylitis 726.32 Lateral epicondylitis 726.5 Enthesopathy of hip region Bursitis of hip 726.6 Enthesopathy of knee, unspecified Bursitis of knee, not otherwise specified 726.9 Unspecified enthesopathy 726.90 Enthesopathy of unspecified site Tendinitis, not otherwise specified 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 727.04 Radial styloid tenosynovitis de Quervain's disease 727.6 Rupture of tendon, nontraumatic 727.61 complete rupture of rotator cuff 727.9 Unspecified disorder of synovium, tendon, and bursa 728 Disorders of muscle, ligament, and fascia 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 729.2 Neuralgia, neuritis and radiculitis, unspecified 729.4 Fasciitis, unspecified 732 Osteochondropathies 732.9 Unspecified osteochondropathy 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff capsule) 923 Contusion of upper limb 924 Contusion of lower limb and other unspecified sites Examination



Page 99 of 234

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental History Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition



Page 100 of 234

* Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current rent clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal



Page 101 of 234

* Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep * patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular



Page 102 of 234

Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6- minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) Assistive and Adaptive Devices * Assessment of alignment and fit of device and inspection of related changes in skin condition * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment and work (job/school/play) tasks



Page 103 of 234

* Assessment of functional capacity * Review of daffy activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work (job/school/play) * Determination of dynamic capabilities and limitations during specific work job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of patient/client during performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual or potential trauma, cumulative trauma, and repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities



Page 104 of 234

- joint range of motion (ROM) used to performing task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work activities * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Integumentary Integrity For skin associated with integumentary disruption: * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation or restriction. Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance



Page 105 of 234

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, video-tape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM



Page 106 of 234

* Analysis of multisegmental movement * Analysis of ROM using a goniometer, tape measure, flexible ruler, inclinometer, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, and soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) Self-care and Home Management including ADL and IADL) * ADL or IADL scales or indexes Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis 1. Over the course of 8 to 16 weeks, patient/client with demonstrate a return to premorbid or highest level of function.



Page 107 of 234

Expected Range of Number of Visits Per Epis-ode of Care 6 to 24 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group of achieve the goals and outcomes within 6 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Associated medical interventions (eg, injections, medications, tests) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Ongoing aggravating risk factors (eg, * repetititve motion) * Preexisting systemic conditions or diseases * Premorbid condition * Psychosocial and socioeconomic stressors * Support provided by family unit



Page 108 of 234

Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of Patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management



Page 109 of 234

* Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers * Disability associated with acute or chronic illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is de * Patient/client, family, required,and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved * Physical function and health status are improved. * Progress is enhanced through die participation of patient/client, others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved.



Page 110 of 234

* Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Need for assistive, adaptive, orthotic, protective, or supportive devices is decreased. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Joint integrity and mobility are improved.



Page 111 of 234

* Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary, impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Conditioning and reconditioning * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and



Page 112 of 234

IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Intensity of care is decreased. * Performance of and independence in IADL is increased. * Level of supervision required for task performance is decreased. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities. * Tolerance to positions and activities is increased.



Page 113 of 234

* Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage



Page 114 of 234

* Joint mobilization or manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is increased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved.



Page 115 of 234

* Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions



Page 116 of 234

* Electrical muscle stimulation * Functional electrical stimulation (FES) * Iontophoresis * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Neural compression is decreased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths) * Superficial thermotherapy (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities:



Page 117 of 234

* Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting) * Continuous passive motion (CPM) * Traction (sustained, intermittent, or positional) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with localized inflammation is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.



Page 118 of 234

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.



Page 119 of 234

Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments * Habitual suboptimal posture or body mechanics (eg, scapular retraction, forward-head position, hyperextension of the knees) * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Musculotendinous tightness or inflexibility (eg, Achilles tendon, hamstring muscles, pectoral muscles) * Musculotendinous weakness or imbalance (eg, quadriceps femoris, hamstring, rhomboid, lower trapezius, pectoral muscles) * Previous history of injury or surgery affecting posture or body mechanics (eg, shoulder injury resulting in forearm compensation, foot pain resulting in knee or hip compensation) Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg. senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic



Page 120 of 234

assessment) * Lifestyle education and modification through individual or group activities that (1) highlight the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and inflammatory conditions and (2) strategies to prevent or reduce these conditions. * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, pre-employment) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, or Reflex Integrity Secondary to Spinal Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations secondary to spinal impairment with or without radiculopathy. Patients/clients may have any one or a combination of the following: * Altered sensation * Deep tendon reflex changes * Muscle weakness * Positive neural tension tests * Associated surgical procedures INCLUDES patients/clients with: * Cervical, thoracic, or lumbar disk herniation * Disk disease * Nerve root compression * Spinal stenosis



Page 121 of 234

* Stable spondylolisthesis EXCLUDES patients/clients with: * Failed surgical procedures * Fractures or unstable spondylolisthesis * Neuromuscular disease * Referred pain with systemic condition * Sepsis * Systemic condition (eg, ankylosing spondylitis, Scheurmann's disease, juvenile rheumatoid arthritis, Reiter's disease) * Traumatic spinal cord injury * Tumor ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes man not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 353 Nerve root and plexus disorders 715 Osteoarthrosis and allied disorders 716 Other an unspecified arthropathies 716.9 Arthropathy, unspecified Inflammation of joint, not otherwise specified 718 Other derangement of joint 718.3 Recurrent dislocation of joints 718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint 719.2 Villonodular synovitis 719.8 Other specified disorders of joint Calcification of joint 720 Ankylosing spondylitis and other inflammatory spondylopathies 721 Spondylosis and allied disorders 721.1 Cervical spondylosis with myelopathy 721.4 Thoracic or lumbar spondylosis with myelopathy 722 Intervertebral disk disorders



Page 122 of 234

722.7 Intervertebral disk disorder with myelopathy 722.71 Cervical region 722.8 Postlaminectomy syndrome 723 Other disorders of cervical region 723.0 Spinal stenosis other than cervical 724 Other and unspecified disorders of back 724.0 Spinal stenosis, unspecified region 724.00 Spinal stenosis, unspecified region 724.2 Lumbago Low back pain, low back syndrome, lumbalgia 724.9 Other unspecified back disorders 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 728.9 Unspecified disorder of muscle, ligament, and fascia 733 Other disorders of bone and cartilage 733.0 Osteoporosis 738 Other acquired deformity 738.4 Acquired spondylolisthesis 756 Other congenital musculoskeletal anomalies 756.1 Anomalies of spine 756.12 Spondylolisthesis 846 Sprains and strains of sacroiliac region 846.0 Lumbosacral (joint) (ligament) 847 Sprains and strains of other and unspecified parts of back 847.0 Neck 922 Contusion of trunk 922.3 Back 922.31 Back 922.32 Buttock 922.33 Interscapular region



Page 123 of 234




Page 124 of 234

History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic



Page 125 of 234

* Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep * patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal



Page 126 of 234

* Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity Assistive and Adaptive Devices * Assessment of alignment and fit of device and inspection of related changes in skin condition * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (Job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as



Page 127 of 234

appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work (job/school/play) * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Endurance required to perform aerobic endurance activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of joint range of motion (ROM) used to perform task or activity - assessment of postures required to perform task or activity - assessment of strength required in the work postures necessary to perform task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis during performance of selected movements or activities - identification of essential functions of task or activity



Page 128 of 234

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including assessment of: - endurance required to perform aerobic endurance activities - joint ROM used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of sprain Muscle Performance (Including Strength, Power, and Endurance)



Page 129 of 234

* Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV]) Neuromotor Development and Sensory integration * Assessment of dexterity, agility, and coordination Orthotic, Protective, and Supportive Devices * Analysis of ability to care for device independently * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement



Page 130 of 234

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management including ADL and IADL) * ADL or IADL scales or indexes * Analysis of environment * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory integrity (Including Proprioception and Kinesthesia)



Page 131 of 234

* Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 1 to 6 months, patient/client will demonstrate a return to premorbid or highest level of function and integration or reintegration into home, community, work, or leisure activities safely and efficiently. Expected Range of Number of Visits Per Episode of Care 8 to 24 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 8 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency



Page 132 of 234

of Visits/Duration of Episode * Ability to obtain job reclassification or redesign, including job or home * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Previous history of spine injury or surgery * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized.



Page 133 of 234

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced.



Page 134 of 234

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage:



Page 135 of 234

Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Energy expenditure is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Postoperative complications are reduced. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Conditioning and reconditioning * Gait, locomotion, and balance training * Neuromuscular education or reeducation * Posture awareness training * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL)



Page 136 of 234

Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions



Page 137 of 234

* Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced, * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage



Page 138 of 234

* Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization or manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Gait, locomotion and balance are improved. joint stability is increased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Performance of and independence ADL and IADL are increased. * Pain is decreased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity and mobility are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions



Page 139 of 234

* Adaptive devices or equipment (eg, raised toilet seats, seating systems. environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts. casts) * Protective devices or equipment (eg, braces. protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased, * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Iontophoresis * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS)



Page 140 of 234

Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased * Edema, lymphedema, or effusion is reduced * Joint integrity and mobility is improved. * Neural compression is decreased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Traction (sustained, intermittent, or positional) Reexamination The physical therapist relies on reexamination, the process of performing of selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also man be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform. at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent



Page 141 of 234

manner), disability, (inability to engage in age-specific. gender-specific, or sex-specific roles in a particular social context and physical environment), primary, or secondary, prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with spinal disorders is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers, * Coordination and conformity of care are acceptable to patient/client, family significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:



Page 142 of 234

* Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle, factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight. leg-length discrepancy, body, type) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in community, home, or work (job/school/play) environments



Page 143 of 234

* Habitual suboptimal body mechanics * Systemic condition predisposing patient/client to spinal pain with radiculopathy * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Previous history of injury or surgery affecting spine, posture, or body mechanics Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy, exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and spinal pain and (2) strategies to prevent or reduce pain * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With Fracture This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs: the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation,



Page 144 of 234

and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations and impairments secondary to fracture. INCLUDES patients with: * Activity-induced hormonal changes * Certain medications (eg, steroids) * Known high risk (eg, based on sex, ethnicity, age, lifestyle, menstrual or hormonal changes related to hysterectomy or menopause) * Nutritional deficiency * Traumatic injuries EXCLUDES patients with: * Bone neoplasms * Osteogenesis imperfecta * Paget's disease ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 715 Osteoarthrosis and related disorders 719 Other an unspecified disorders of joint 719.5 Stiffness of joint, not elsewhere classified 719.8 Other specified disorders of joint Calcification ofjoint 722 Intervetebral disk disorders 726 Peripheral enthesopathies and allied syndromes 726.2 Other affections of shoulder region, not elsewhere classified Periarthritis of shoulder scapulohumeral fibrositis 728 Disorders of muscle, ligament. and fascia 728.2 Muscle wasting and disuse atrophy, not elsewhere classified 729 Other disorders of soft tissues



Page 145 of 234

729.9 Other and unspecified disorders of soft tissue Imbalance of posture 732 Osteochondropathies 732.4 Juvenile osteochondrosis of lower extremity, excluding foot tibial tubercle (of Osgoodschlatter) 733 Other disorders of bone and cartilage 733.0 Osteoporosis 733.1 Pathologic fracture 733.8 Malunion and nonunion of fracture 733.82 Nonunion of fracture 736 Other acquired deformities of limbs 736.8 Acquired deformities of other parts of limbs 736.81 Unequal leg length (acquired) 781 Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait Gait: ataxia, paralitic, spastic, staggering 802 Fracture of face bones 805 Fracture of vertebral column without mention of spinal cord injury 808 Fracture of pelvis 810 Fracture of clavicle 811 Fracture of scapula 812 Fracture of humerus 813 Fracture of radius and ulna 813.4 Lower end, closed 813.41 Colles'fracture 813.5 Lower end, open 813.51 Colles'fracture 814 Fracture of carpal bone(s) 815 Fracture of metacarpal bone(s) 816 Fracture of one or more phalanges of hand 820 Fracture of neck of femur 821 Fracture of other unspecified parts of femur 822 Fracture of patella 823 Fracture of tibia and fibula 824 Fracture of ankle 825 Fracture of one or more tarsal or metatarsal bones 826 Fracture of one or more phalanges of foot Examination Through the examination (history systems review, and tests and measures), the physical terapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem: stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include:



Page 146 of 234

General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease. including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family significant other, and caregiver perceptions of patient's/ clients emotional



Page 147 of 234

response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Family History



Page 148 of 234

* Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management.. community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communications, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may, include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of standard vital signs (eg. blood pressure, heart rate, respiratory. rate) at rest and during and after activity Anthropometric Characteristics * Measurement of height, weight, length, and girth Assistive and Adaptive Devices * Analysis of alignment and fit of device and inspection of related changes in skin condition



Page 149 of 234

* Analysis of appropriate components of device * Analysis of effects and benefits (including energy, conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of environment, work (job/school,play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination



Page 150 of 234

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities joint range of motion (ROM) used to perform task or activity postures required to perform task or activity strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematc, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of gait characteristics



Page 151 of 234

* Identification and quantification of static and dynamic balance characteristics Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermoblility and hypomobility * Assessment of pain and soreness * Assessment of soft tissue swelling, inflammation, or restriction Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of autonomic responses to positional changes * Assessment of dexterity, coordination, and agility * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy, conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care



Page 152 of 234

* Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of environment * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of physiologic responses during self-care and home management activities



Page 153 of 234

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family significant others, caregivers, or other professionals Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity, of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity, of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition: preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement: social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and



Page 154 of 234

prognosis for a specific patient/client. Prognosis Postfracture, patient/client will minimize rate of bone loss or will increase bone mineral density and will achieve highest level of function. Expected Range of Number of Visits Per Episode of Care 6 to 18 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility, of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized.



Page 155 of 234

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced.



Page 156 of 234

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals



Page 157 of 234

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Need for assistive, adaptive, orthotic, protective, or supportive devices or equipment is decreased. * Osteogenic effects of exercise are maximized, * Pain is decreased. * Performance of and independence ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased.



Page 158 of 234

* Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body, mechanics and ergonomics training * Conditioning and reconditioning * Gait, locomotion, and balance training * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased.



Page 159 of 234

* Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing. eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car of using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Performance of and independence in IADL are increased. * Prosthetic devices are used appropriately. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased, * Utilization and cost of health care services are decreased. Specific Direct Interventions



Page 160 of 234

* Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct interventions * Connective tissue massage * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint stability is increased. * Edema, lymphedema, or effusion is reduced. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased, * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is increased. * Pain is decreased. * Performance of and independence in ADL and IADL are increased.. * Physical function and health status are improved. * Protection of body parts is increased. joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weightbearing status is improved.



Page 161 of 234

Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats,. seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Protective devices or equipment (eg, braces, protective taping, cushions. helmets) * Supportive devices or equipment (eg, supportive taping, compression garments,. corsets, slings, neck collars, serial casts. elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct interventions * Electrical muscle stimulation * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle spasm is decreased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination maybe indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which-for some patient/client diagnostic groups-may be the life span, Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected. or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then, are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:



Page 162 of 234

Functional Limitation/Disability * Health-related quality of life is improved. Optimal return to role function (eg, worker, student, spouse. grandparent) is achieved. * Risk of disability associated with fracture is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability and services provided are acceptable to patient/client, family 11/2-. significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family significant others, and caregivers. * Interpersonal skills of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others. and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that ma,%. indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). in consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety, and effective adaptation following changes in physical status. caregivers. environment. or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology-or from pathology or impairment to disability-is not inevitable.



Page 163 of 234

Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design. equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in home, community, or work job/school/play) environments * Endocrine or hormonal status * Habitual suboptimal body mechanics * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - nutritional status (calcium and vitamin D intake) - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Medication history * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Systematic condition predisposing patient/client to spinal pain with radiculopathy Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and fracture and (2) strategies to prevent or reduce fracture * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, pre-employment) * Workplace. home, and community ergonomic analysis and modification Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations secondary to joint arthroplasty with total or partial resurfacing of the joint. INCLUDES patients/clients with: * Ankylosing spondylitis * Bone tumor * Juvenile rheumatoid arthritis * Osteoarthritis



Page 164 of 234

* Paget's disease * Rheumatoid arthritis * Small joint (eg, interphalangeal) and large joint arthroplasties (eg, hip) * Steroid-induced avascular necrosis * Temporomandibular joint (TMJ) syndrome * Trauma EXCLUDES patients/clients with: * Failed surgical procedures * Unrelated postoperative complications during recovery or rehabilitation (eg, fall with fracture, proximal or distal to prosthesis) ICD-9-CM Codes As of press time, the listing below, contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 524.60 Temporomandibular joint disorders, unspecified 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.8 Other specified arthropathy 717 Internal derangement of knee 717.9 Unspecified internal derangement of knee 718 Other derangement of joint 718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint 719.5 Stiffness of joint. not elsewhere classified 719.7 Difficulty in walking 719.8 Other specified disorders of joint Calcification of joint 729 Other disorders of soft tissue 729.8 Other musculoskeletal symptoms referable to limbs 730 Osteomyelitis, periostitis, and other infections involving bone 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 Osteitis deformans without mention of bone tumor Paget's disease of bone 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 733.8 Malunion and nonunion of fracture 808 Fracture of pelvis 808.0 Acetabulum, closed 812 Fracture of humerus 812.0 Upper end, closed 812.00 Upper end, unspecified part 820 Fracture of neck of femur 820.8 Unspecified part of neck of femur, closed 820.9 Unspecified part of neck of femur, open 835 Dislocation of hip 836 Dislocation of knee 836.5 Other dislocation of knee, closed 837 Dislocation of ankle 958 Certain early complications of trauma 958.3 Posttraumatic wound infection, not elsewhere classified Examination



Page 165 of 234

Through the examination (history, systems review,. and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late. return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History and System Review Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destination(s) History of Current Condition



Page 166 of 234

* Concerns that led the individual to seek the services of a physical therapist * Concerns or needs of the individual requiring the services of a physical therapist * Current therapeutic interventions * Onset and pattern of symptoms * Mechanism(s) of injury or disease, including date of onset and course of events * Patient/client, family, significant other, and caregiver perceptions of the patient's/client's emotional response to the current clinical situation * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Functional Status and Activity Level * Current and prior functional status in self-care and home management, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary



Page 167 of 234

* Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management. community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and Measures



Page 168 of 234

Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy in determining the effects of other medical or health-related conditions during surgical procedures, after drug therapy) Assistive and Adaptive Devices * Analysis of patient/client or caregiver ability to care for device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * IADL scales or indexes * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of autonomic responses to positional changes * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers



Page 169 of 234

* Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics : * Analysis of preferred postures during performance of tasks and activities Body mechanics: * Determination of dynamic capabilities and limitations during specific work, (job/school/play) activities * Measurement of height, weight, length, and girth * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance characteristics Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of pain and soreness * Assessment of soft tissue swelling, inflammation, or restriction Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength. power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices



Page 170 of 234

* Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation. or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs. behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids. plumb lines. still photograph), videotape, or visual analysis Range of Motion (ROM) Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle. joint, or soft tissue characteristics



Page 171 of 234

Self-care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, using assistive. adaptive, orthotic. protective, or supportive devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation (Gas Exchange), Respiration, and Circulation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity, Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing. and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity, of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.



Page 172 of 234

Prognosis Within 6 months, patient/client who has no surgical or postsurgical complications will demonstrate improvement in impairment, functional limitation, and disability as compared with premorbid status. Expected Range of Number of Visits Per Episode of Care 12 to 60 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 12 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aides) expertise and consistency * Chronic dislocation * Chronicity or severity of condition * Comorbidities (eg, sepsis, hemarthroses, or surgical or postoperative complications) * Degree of system involvement (eg, rheumatoid arthritis, Parkinson's disease) * Level of patient/client adherence to the intervention program * Multiple arthroplasties within the same period * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Revision arthroplasty * Support provided by family unit * Type of surgical technique used cement or cementless) * Wearing-bearing status



Page 173 of 234

Intervention Invention, is the purpose and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may, be selected, applied, or modifed by, the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family. significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goats and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' * Compensation claims manager, employer) * Discharge planning



Page 174 of 234

* Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referral to other professionals or resources Patient/client-related instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of that living (ADL) and instrumental activities of daily living (IKDL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved.



Page 175 of 234

* Self-management of symptoms is improved * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Intervention Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform tasks related to self-care, home arguments (job/school/play) integration or reintegration and leisure activities is increased. * Aerobic capacity is * Endurance is * Intensity of care is decreased. * Gait, locomotion, and balance are improved * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Osteogenic effects of exercise are maximized.



Page 176 of 234

* Pain is decreased. * Performance of and independence in ADL and IKDL are increased. * Physical function and health status are improved, * Postural control is improved * Preoperative and postoperative complications are reduced. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved * Self-management of symptoms is improved * Sense of is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular relaxation, inhibition, and facilitation



Page 177 of 234

* Posture awareness training * Strengthening: active - active assistive - resistive, using manual resistance, pulleys, weights, - hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Intensity of care is decreased. * Perfomance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities, * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * Self-care or home management task adaptation * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Leisure and play activity training * Organized functional training programs (eg, back schools, simulated environments and tasks)



Page 178 of 234

* Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community, work (job/school/play), and leisure activities is increased. * Costs of work-related injury or disability are reduced. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured plan, for infants and children) * Job coaching * Job simulation * Leisure and play activity training



Page 179 of 234

* Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Risk of secondary impairments is reduced. * Scar mobility is increased. * Soft tissue swelling, inflammation, or restriction is reduced. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage * Passive range of motion * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased.



Page 180 of 234

* Edema, lymphedema, or effusion is reduced. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity and mobility are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings,



Page 181 of 234

neck collars, serial casts, elastic wraps) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation. or restriction is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications resulting from soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved.



Page 182 of 234

* Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) * Hydrotherapy (eg, aquatic therapy), whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities may include: * Continuous passive motion (CPM) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically, expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg. worker, student, spouse, grandparent) is achieved.



Page 183 of 234

* Risk of disability associated with joint arthroplasty is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability,, and services provided are acceptable to patient/client, family significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment * progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community, adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community work job/school/play), or



Page 184 of 234

leisure environments. * Utilzation and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological. psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals. the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved, Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/client who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Primary prevention is the prevention of disease in a susceptible or a potentially, susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factor5 for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, genu valgum, femoral or tibial torsion, foot deformities) * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community work (job/school/play), or leisure activity environments * Habitual suboptimum body mechanics in in work and leisure activities and activities of daily living (ADL) * Heredity * Systemic diseases (eg, rheumatoid arthritis) * Lifestyle:



Page 185 of 234

- overuse or improper movement patterns that stress joints - physical activity level (lack of regular exercise) - physical work demands - substance abuse (eg, smoking, alcohol, drugs) * Muscle tightness or inflexibility * Muscle weakness or imbalance * Previous history of joint trauma or surgery Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and joint arthroplasty, or arthritis * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, youth sports, elderly foot clinics, senior centers) * Workplace, home, and community ergonomic analysis and modification Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgical Procedures This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety, of factors, such as individual patient/client needs- the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations following bony or soft tissue surgical procedures INCLUDES patients/clients with:



Page 186 of 234

* Abrasion arthroplasty, open reduction internal fixation (ORIF), fusions, osteotomies, laminectomies, and tibial tuberosity procedures * External fixators, rod procedures bony debridement, and multiple fractures * Fascial release procedures, debridement, decompression, meniscal repair or removal, labral repair, removal of synovium, or soft tissue realignment * Hardware removal, bone graft, and bone-lengthening procedures * Hip fracture with ORIF stabilization * Muscle or tendon or ligament repair or reconstruction. capsular reconstruction, stabilization, or reefing EXCLUDES patients/clients with: * Amputation * Amputation, associated peripheral nerve lesions, and closed head trauma * Breast reconstructive procedures * Failed surgical procedures * Joint resurfacing and abrasion: muscle tendon transfers * Nonunion of fractures * Obstetric and gynecological surgical procedures * Vascular or neurologic sequelae, nerve compression, muscle-lengthening procedures, hemarthrosis, deep vein thrombosis, or sepsis * Total joint arthroplasties, closed reduction, neoplasms, and primary soft tissue procedures ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9- CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairment and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 715 Osteoarthrosis and allied disorders 717 Internal derangement of knee 717.8 Other internal derangement of knee 718 Other derangement of joint 718.0 Articular cartilage disorder 718.2 Pathological dislocation 718.3 Recurrent dislocation of joint 718.4 Contracture of joint 718.40 Site



Page 187 of 234

unspecified 718.5 Ankylosis of joint 718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint 721 Spondylosis and allied disorders 722 Intervertebral disk disorders 722.7 Intervertebral disk disorder with myelopathy 723 Other disorders of cervical region 724 Other and unspecified disorders of back 724.0 Spinal stenosis, other than cervical 724.00 Spinal stenosis, unspecified region 724.3 Sciatica 726 Peripheral enthesopathies and allied disorders 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome and allied disorders 726.12 Bicipital tenosynovitis 726.2 Other affections of shoulder, not elsewhere classified Periarthritis of shoulder scapulohumeral fibrositis 726.9 Unspecified enthesopathy 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 727.1 Bunion 727.4 Ganglion and cyst of synonum, tendon, and bursa 727.6 Rupture of tendon, nontraumatic 727.61 Complete rupture of rotator cuff 728 Disorders of muscle, ligament, and fascia 728.6 Contracture of palmar fascia Dupuytren's contracture 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 Osteitis deformans without mention of bone trauma Paget's disease of bone 732 Osteochondropathies 732.4 Juvenile osteochondrosis of lower extremity, excluding foot tibial tubercle (of Osgood-Schlatter) 732.9 Unspecified osteochondropathy 733 Other disorders of bone and cartilage 733.1 Pathologic fracture Spontaneous fracture 733.13 Pathologic fracture of vertebrae 733.8 Malunion and nonunion of fracture 733.82 Nonunion of fracture 736 Other acquired deformities of limbs 736.8 Acquired deformities of other parts of limbs 736.81 Unequal leg length (acquired) 737 Curvature of spine 738 Other acquired deformity 738.4 Acquired spondylolistheses 756 other congenital musculoskeletal anomalies 756.1 Anomalies of spine 756.12 Spondylolisthesis 802 Fracture of face bones 805 Fracture of vertebral column without mention of spinal cord injury 808 Fracture of pelvis 810 Fracture of clavicle 811 Fracture of scapula 812 Fracture of humerus 813 Fracture of radius and ulna 814 Fracture of metacarpal bones(s) 815 Fracture of metacarpal bone(s) 816 Fracture of one or more phalanges of hand 820 Fracture of neck of femur 821 Fracture of other and unspecified parts of femur 822 Fracture of patella 823 Fracture of tibia and fibula 824 Fracture of ankle 825 Fracture of one or more tarsal and metatarsal bones 826 Fracture of one or more phalanges of foot 830 Dislocation of jaw 831 Dislocation of shoulder 832 Dislocation of elbow 833 Dislocation of wrist 834 Dislocation of finger 835 Dislocation of hip 836 Dislocation of knee 836.0 Tear of medial cartilage or meniscus of knee, current 836.1 Tear of lateral cartilage or meniscus of knee, current 836.2 Other tear of cartilage or meniscus of knee, current 836.5 Other dislocation of knee, closed 837 Dislocation of ankle 838 Dislocation of foot 839 Other, multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.3 Thoracic and lumbar vertebra, open 839.8 Multiple and ill-defined, closed Arm; back; hand; multiple locations, except for fingers or toes alone 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff (capsule) 841 Sprains and strains of elbow and forearm 842 Sprains and strains of wrist and hand 843 Sprains and strains of hip and thigh 844 Sprains and strains of knee and leg 845 Sprains and strains of ankle and foot 846 Sprains and strains of sacroiliac region 847 Sprains and strains of other and unspecified parts of back 848 Other and ill-defined sprains and strains Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.



Page 188 of 234

History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms



Page 189 of 234

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Post Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum



Page 190 of 234

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction. social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during



Page 191 of 234

pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of environment, work (job/school/play), and leisure activities * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environment * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers



Page 192 of 234

* Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work, hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma. or repetitive stress * Functional capacity evaluation, including:



Page 193 of 234

- endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Measurement of height, weight, length, and girth * Observation of performance of selected movements or activities * Videotape analysis of patient/client performing selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Gait, locomotion, and balance profiles * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness



Page 194 of 234

* Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction Motor Function (Motor Control and Motor Learning) * Assessment of motor control and motor learning Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV]) Orthotic, Protective, and Supportive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient,/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Analysis of movement while patient,/client wears device, using computer-assisted graphic imaging or videotape * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain



Page 195 of 234

* Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of ability to transfer * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs



Page 196 of 234

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of perceived exertion and dyspnea * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity, of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 1 to 12 months, patient/client will demonstrate a return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care



Page 197 of 234

6 to 87 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 87 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Delayed healing * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Nonunion of fractures and bone-lengthening procedures * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.



Page 198 of 234

Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals. and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved.



Page 199 of 234

* Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living ML) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction



Page 200 of 234

* Written or pictorial instruction Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is in * Energy expenditure is decreased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, inflammation, or restriction is reduced, *Level of supervision required for task performance is decreased. *Motor function (motor control and motor learning) is improved. * Need for assistive, adaptive, orthotic, protective, or supportive devices or equipment is decreased. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Joint integrity and mobility are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved.



Page 201 of 234

* Self-management of symptoms is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals



Page 202 of 234

* Ability to perform physical tasks related to self-care and home management including ADL and IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, and supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation



Page 203 of 234

* Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation



Page 204 of 234

* Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Edema, lymphedema, or effusion is reduced. * Joint stability is increased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity, and mobility are improved. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stress precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved.



Page 205 of 234

Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Iontophoresis * Neuromuscular electrical stimulation (NMES)



Page 206 of 234

* Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications resulting from soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Wound and soft tissue heating is enhanced. Specific Direct Interventions Physical agents include: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities include: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression documents, taping, total contact casting) * Continuous passive motion (CPM) * Tilt table or standing table * Traction (sustained, intermittent, or positional) Reexamination



Page 207 of 234

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups--may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with bony or soft tissue surgical procedures is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.



Page 208 of 234

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.



Page 209 of 234

Identified Risk Factors for Disability * Age * Anthropometric characteristics * Attitude * Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments * Habitual suboptimum body mechanics in work (job/school/play) and leisure activities and activities of daily living (ADL) * Heredity * Systemic diseases (eg, rheumatoid arthritis) * Lifestyle: - physical activity level (lack of regular exercise) - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Muscle tightness * Muscle weakness * Previous history of injury Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and bone trauma and (2) strategies to prevent or reduce trauma or the consequences of trauma * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs and sites (eg, scoliosis, athletic preparticipation, preemployment)



Page 210 of 234

* Workplace, home, and community ergonomic analysis and modification Impaired Gait, Locomotion, and Balance and Impaired Motor Function Secondary to Lower-Extremity Amputation This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations due to acute or longstanding lower extremity amputation. Patients/clients may have any one or a combination of the following: * Gait deviations or other mobility problems associated with recent amputation or effects of aging * Ill-fitting prosthesis or identified prosthetic needs INCLUDES patients/clients with: * Bilateral amputation * Congenital amputation (prosthetic needs only) joint contracture proximal to amputation * Need for postsurgical edema management * Residual limb revision * Wound care needs associated with surgical site EXCLUDES patients/clients with: * Congenital amputation and a need for developmental therapy * Ipsilateral hemiparesis ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM)



Page 211 of 234

coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 353 Nerve root and plexus disorders 353.6 Phantom limb (syndrome) 718 Other derangement of joint 718.4 Contracture of joint 718.45 Pelvic region and thigh 718.46 Lower leg 719 Other and unspecified disorders of joint 719.7 Difficulty in walking 755 Other congenital deformities of limb 755.3 Reduction deformities of lower limb 781 Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait Gait: ataxic, paralytic, spastic, staggering 897 Traumatic amputation of leg(s) (complete) (partial) 997 Complications affecting specified body systems, not elsewhere classified 997.6 Amputation stump complication Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development



Page 212 of 234

* Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition



Page 213 of 234

* Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include:



Page 214 of 234

Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Observation of chest movements and breathing patterns with activity * Palpation of pulses * Claudication time tests Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Arousal, Attention, and Cognition * Assessment of factors that influence motivation level * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) Assistive and Adaptive Devices



Page 215 of 234

* Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of patient/client or caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers. or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * IADL scales or indexes * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment, work (job/school/play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape



Page 216 of 234

* Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - determination of dynamic capabilities and limitations during specific work (job/school/play) activities - identification of essential functions of the job task or activity - identification of sources of actual or potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity



Page 217 of 234

* Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Gait, locomotion, and balance assessment instruments * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance profiles * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Integumentary integrity For wound: * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Assessment of response to manual provocation tests * Assessment of soft tissue swelling, inflammation, or restriction Motor Function (Motor Control and Motor Learning)



Page 218 of 234

* Assessment of dexterity, coordination, and agility Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Neuromotor Development and Sensory Integration * Assessment of dexterity, agility, and coordination Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movements * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales



Page 219 of 234

Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb tines, still photography, videotape, or visual analysis Prosthetic Requirements * Analysis of appropriate components of a prosthetic device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of the practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of residual limb or adjacent segment for range of motion (ROM), strength, skin integrity, and edema * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of environment



Page 220 of 234

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care in unfamiliar environments * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Assessment of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve



Page 221 of 234

goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 6 months, patient/client will demonstrate a return to premorbid or highest level of function in activities of daily living (ADL) and instrumental activities of daily living (IADL) and in community, work, and leisure activities. Expected Range of Number of Visits Per Episode of Care 15 to 45 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 15 to 45 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, contralateral hemiplegia, deconditioning) * Condition of contralateral leg * Patient/client motivation and adherence to the intervention program * Preexisting systemic conditions or diseases * Psychological factors



Page 222 of 234

* Psychological and socioeconomic stressors * Support provided by family unit * Wound healing complications (eg, infection drainage) Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care



Page 223 of 234

professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family), significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, caregivers. * Risk of recurrence of condition is reduced.



Page 224 of 234

* Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Energy expenditure is decreased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved.



Page 225 of 234

* Need for assistive devices is decreased. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Tolerance of positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining



Page 226 of 234

* Neuromuscular education or reeducation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct interventions * ADL training (eg, bed mobility, and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * Body mechanics training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money



Page 227 of 234

management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training Functional Training in Community and Work (Job/School/Play) integration or Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks. movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Performance of and independence in IADL is increased. * Safety is improved during performance of community, work (job/school/play) and leisure tasks and activities * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct interventions * Assistive and adaptive device and equipment training * Environmental, community,, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job Simulation * Leisure and plan. activity training * Organized functional training programs (eg, back schools, simulated environments and tasks)



Page 228 of 234

* Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training Manual Therapy Techniques including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Joint integrity and mobility are improved. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased, * Utilization and cost of health care services are decreased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct interventions * Connective tissue massage * Manual lymphatic drainage * Passive range of motion * Soft tissue mobilization and manipulation (eg, myofascial release) * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals



Page 229 of 234

* Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Loading on a body, part is decreased, * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Prosthetic fit is achieved. * Protection of body parts is increased. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)



Page 230 of 234

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct interventions * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications resulting from soft tissue and circulatory disorders are decreased.



Page 231 of 234

* Debridement of nonviable tissue is achieved. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which--for some patient/client diagnostic groups-may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optional return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with lower-extremity amputation is reduced. Safety of patient/client and caregivers is increased.



Page 232 of 234

* Self-care and home management activities, including activities of daily living (ADL)--and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL)--are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. * Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge



Page 233 of 234

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with, appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Age * Attitude * Decreased skin integrity * Decreased vascular integrity * Diabetes * Environmental hazards in home, community, and work (job/school/play) * Heredity * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - physical activity level - substance abuse (eg, smoking, alcohol, drugs) * Quality of skin care



Page 234 of 234

* Previous history of limb amputation Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise program,YMCA or YWCA programs) * Consultation (eg, senior centers) lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and amputation and (2) strategies to prevent amputation * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, elderly foot care clinics, senior centers, skilled nursing facility screening programs) * Workplace, home, and community ergonomic analysis and modification

Source Citation:"Musculoskeletal." Physical Therapy 77.n11 (Nov 1997): 1229(138). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 145

Neuromuscular. (includes related information)(Preferred Practice Patterns)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1371 (79). (34048 words)


The following patterns describe the elements of patient/client management provided by physical therapists -- examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Pattern D, "Impaired Motor and Sensory Function Associated With Peripheral Nerve Injury," also includes primary prevention/risk factor reduction strategies. This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor function associated with congenital or acquired disorders of the central nervous system in infancy, childhood, and adolescence. Patients/clients may have any one or a combination of the following: * Impaired affect * Impaired arousal and attention * Impaired balance * Impaired cognition * Impaired expressive or receptive communication * Impaired motor function (motor control and motor learning) * Impaired oromotor function * Impaired respiratory function * Impaired sensory integrity * Skeletal deficits



Page 2 of 145

INCLUDES patients/clients with: * Anoxia or hypoxia * Birth trauma * Brain anomalies * Cerebral palsy * Genetic syndromes that affect the central nervous system * Hydrocephalus * Infectious disease that affect the central nervous system (eg, meningitis, encephalitis) * Intracranial neurosurgical procedures * Meningocele * Myelocele * Myelocystoceles * Myelodysplasia * Myelomeningocele * Prematurity * Tethered cord * Traumatic brain injury * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Medical instability * Multisystem trauma * Spinal cord injury secondary to trauma * Tumor



Page 3 of 145

ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 036 Meningococcal infection 036.1 Meningococcal encephalitis 052 Chickenpox 052.0 Postvaricella encephalitis 055 Measles 055.0 Postmeasles encephalitis 056 Rubella 056.0 With neurological complications 072 Mumps 072.2 Mumps encephalitis 090 Congenital syphilis 090.4 Juvenile neurosyphilis 320 Bacterial meningitis 320.9 Meningitis due to unspecified bacterium 321 Meningitis due to other organisms 321.8 Meningititis due to other nonbacterial organisms classified elsewhere 322 Meningitis of unspecified cause 322.9 Meningitis, unspecified 323 Encephalitis, myelitis, and encephalomyelitis 323.4 Other encephalitis due to infection classified elsewhere 323.5 Encephalitis following immunization procedures 323.6 Postinfectious encephalitis 323.8 Other causes of encephalitis 323.9 Unspecified cause of encephalitis 331 Other cerebral degenerations 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 333 Other extrapyramidal disease and abnormal movement disorders 333.7 Symptomatic torsion dystonia Athetoid cerebral palsy [Vogt's disease]; double



Page 4 of 145

athetosis (syndrome) 343 Infantile cerebral palsy 345 Epilepsy 345.1 Generalized convulsive epilepsy 345.2 Petit mal status 345.3 Grand mal status 345.9 Epilepsy, unspecified 348 Other conditions of brain 348.1 Anoxic brain damage 348.3 Encephalopathy, unspecified 741 Spina bifida 742 Other congenital anomalies of nervous system 756 Other congenital musculoskeletal anomalies 756.1 Anomalies of spine 765 Disorders relating to short gestation and unspecified low birthweight 767 Birth trauma 767.0 Subdural and cerebral hemorrhage 767.9 Birth trauma unspecified 768 Intrauterine hypoxia and birth asphyxia 768.5 Severe birth asphyxia 768.6 Mild or moderate birth asphyxia 768.9 Unspecified birth asphyxia in liveborn infant 771 Infections specific to the perinatal period 771.2 Other congenital infections Congenital toxoplasmosis 780 General symptoms 780.3 Convulsions 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 800 Fracture of vault of skull 801 Fracture of base of skull 803 Other and unqualified skull fractures 804 Multiple fractures involving skull or face with other bones 850 Concussion 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drowning and nonfatal submersion Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation



Page 5 of 145

(early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity, * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support)



Page 6 of 145

Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of performance during established exercise protocols (eg, treadmills, ergometers, 6minute walk test, 3-minute step test) * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Assessment of level of consciousness * Assessment of level of recall (eg, short-term and long-term memory) * Assessment of orientation to time, person, and place * Screening for gross expressive (eg, verbalization) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment, work (job/school/play), and leisure activities * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family,



Page 7 of 145

significant others, caregivers, or other professionals (eg, educators, rehabilitation counselor, Workers' Compensation claims manager, employer) Cranial Nerve integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Body mechanics: * Measurement of height, weight, length, and girth * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin Joint Integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysts of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions *



Page 8 of 145

Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity) Neuromotor Development and Sensory integration * Analysis of age- and sex-appropriate development * Analysis of gait and posture * Analysis of involuntary movement * Analysis of reflex movement patterns * Analysis of sensory integration tests * Analysis of voluntary movement * Assessment of behavioral response * Assessment of dexterity, agility, and coordination * Assessment of postural, equilibrium, and righting reactions * Assessment of gross and fine motor skills * Assessment of motor function Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) including Muscle Length) * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex integrity * Assessment of developmentally appropriate reflexes over time * Assessment of normal reflexes (eg, deep tendon reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL and IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals (including educators) Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimation, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) deficits * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch,



Page 9 of 145

pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of chest wall mobility, expansion, and excursion * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will function with independence in home, school, work, and community environments, within the context of the disability. Depending on motor, perceptual, and cognitive deficits, patient/client will be completely independent or may need varying levels of assistance (eg, family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 6 to 90 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 90 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration



Page 10 of 145

of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Cumulative trauma * Deconditioning * Functional loss * Increases in postural deficits * Need for orthotic or adaptive equipment modification * Periods of rapid growth * Surgical intervention * Transition in lifestyle Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the



Page 11 of 145

plan of care. the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation. secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' * Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans



Page 12 of 145

* Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased.



Page 13 of 145

Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern for man include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Need for assistive and adaptive devices is decreased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk of recurrence of condition is reduced. * Risk, of secondary impairments is reduced.



Page 14 of 145

* Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Perceptual training * Posture awareness training * Strengthening: - active - active assistive - resistive



Page 15 of 145

* Stretching * Structured play or leisure activities Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, simulated environment and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Pay) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or



Page 16 of 145

reintegration and leisure tasks, movements, or activities is increased. * Performance of and independence in IADL are increased. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Organized functional training programs (simulated instruments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments is improved. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Joint mobilization * Manual traction



Page 17 of 145

* Passive range of motion * Soft tissue mobilization * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Independence in bed mobility, transfers, and gait is maximized. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Physical function and health status are improved. * Joint integrity and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Sense of well-being is improved. * Tolerance to positions and activities is improved. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)



Page 18 of 145

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compressive garments, corsets, slings, neck collars, serial casting, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Joint integrity and mobility are improved. * Muscle performance is increased. * Neuromuscular function is increased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions * Biofeedback * Neuromuscular electrical stimulation (NMES) Physical Agents and Mechanical Modalities Anticipated Goals * Tolerance to positions and activities is increased. Specific Direct interventions Mechanical modalities: * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the



Page 19 of 145

whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability to engage in age-specific, gender-specific, or sex-specific roles in a particu]ar social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers wether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability of caregivers to assist patient/client in functional activities and use of community resources is increased. * Health-related quality of life is improved. * Optimal return to role function (eg. worker, student. spouse. grandparent) is achieved. * Risk of disability associated with congenital or acquired disorders of the central nervous system is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention



Page 20 of 145

* Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man, indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation. leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes hate been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated with Acquired Nonprogressive Disorder of the Central Nervous System in Adulthood This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles. race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor and sensory function



Page 21 of 145

associated with acquired nonprogressive disorders of the central nervous system in adulthood. Patients/clients may have any one or a combination of the following: * Impaired affect * Impaired arousal and attention * Impaired balance * Impaired cognition * Impaired expressive or receptive communication * Impaired motor function (motor control and motor learning) * Impaired oromotor control * Impaired respiratory function * Impaired sensory integrity INCLUDES patients/clients with: * Aneurysm * Anoxia or hypoxia * Nonmalignant brain tumor * Cerebrovascular accident (stroke) * Infectious disease that affects the central nervous system * Intracranial neurosurigical procedures * Seizures * Traumatic brain injury * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Immature central nervous system * Malignant brain tumor



Page 22 of 145

* Medical instability * Multisystem trauma * Tumor ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 049 Other non-arthropod-borne viral diseases of the central nervous system 049.9 Unspecified non-arthropod-borne viral diseases of the central nervous system Viral encephalitis, not otherwise specified 322 Meningitis of unspecified cause 342 Hemiplegia and hemiparesis 348 Other conditions of brain 348.0 Cerebral cysts 348.1 Anoxic brain damage 431 Intracerebral hemorrhage 433 Occlusion and stenosis of precerebral arteries 434 Occlusion of cerebral arteries 435 Transient cerebral arteries 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 442 Other aneurysm 442.8 Of other specified artery 444 Arterial embolism and thrombosis 444.9 Of unspecified artery 447 Other disorders of arteries and arterioles 447.1 Stricture of artery 747 Other congenital anomalies of circulatory system 747.8 Other specified anomalies of circulatory system 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 854 Intracranial injury of other and unspecified nature Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem: stage of recovery (acute, subacute, chronic): phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age



Page 23 of 145

* Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level



Page 24 of 145

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Post History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report)



Page 25 of 145

* General health perception * Physical function (eg, mobility, sleep * patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity Anthropometric Characteristics



Page 26 of 145

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg. during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug theraphy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition * Assessment of factors that influence motivation * Assessment of level of consciousness * Assessment of level of recall (eg, short-term and long-term memory) * Assessment of orientation to time, person, place, and situation * Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration including IADL) * Analysis of adaptive skills



Page 27 of 145

* Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work, (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment, work (job/school/play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review reports provided by patient/client, family, significant others, caregivers, or other professionals (eg. rehabilitation counselor, Workers' Compensation claims manager, employer) Cranial Nerve Integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment



Page 28 of 145

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional. behavioral, and vocational status * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Body Mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion. and balance using electromyography (EMG), videotape, computer-assisted graphics, weight bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance characteristics Integumentary integrity For skin associated with integumentary disruption:



Page 29 of 145

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin Joint Integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk,, and limb movement * Analysis of myoelectric activity and neurophysiological integrity using electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG]. motor nerve conduction) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of autonomic responses to positional changes * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Assessment of sensorimotor integration * Motor assessment scales * Physical performance scales Muscle Performance (including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Electrophysiologic tests (eg, electromyography [EMG] and nerve conduction velocity [NCV])



Page 30 of 145

Neuromotor Development and Sensory Integration * Analysis of involuntary movement * Analysis of reflex movement patterns * Analysis of voluntary movement * Assessment of behavioral response * Assessment of dexterity, agility, and coordination * Assessment of postural, equilibrium, and righting reactions * Assessment of gross and fine motor skills * Assessment of motor function * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests



Page 31 of 145

* Assessment of pain and soreness with joint movement Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Assessment of muscle, joint, or soft tissue characteristics * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) * Electrophysiologic tests (eg, H-reflex) Self-Care and Home-Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment * Analysis of self-care performed in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity



Page 32 of 145

* Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability, of the condition; preexisting sytemic conditions or diseases; probability of prolonged impairment, functional limitation. or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home and community environments with maximal independence, within the context of the disability. Depending on residual motor, perceptual, and cognitive deficits, patient/client will be completely independent and demonstrate a return to premorbid level of function or may need varyiny levels of assistance (family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 10 to 60 This range represents the lower and upper limits of the number of physical therapist visits required



Page 33 of 145

to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 10 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Decline in functional independence * Development of complications or secondary impairments * Exacerbation of illness * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be quided by the alleviation of symptoms, and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/client, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.



Page 34 of 145

Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client. family significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professions, and interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources. Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved.



Page 35 of 145

* Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family significant others and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction



Page 36 of 145

* Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to Perform Physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased, * Motor function (motor control and motor learning) is improved. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary, impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased.



Page 37 of 145

* Tissue perfusion and oxygenation are enhanced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Aerobic endurance activities, using cycles, treadmills, steppers. Pulleys, weights, hydraulics, elastic resistance bands robotics. and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Gait, locomotion and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Perceptual training * Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights. hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL)



Page 38 of 145

Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation) * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability, to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Performance of and independence in IADL are increased. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities.



Page 39 of 145

* Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy * household chores, money management, driving a car or using public transportation) * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg. simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals



Page 40 of 145

* Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Performance of and independence in ADL and IADL are increased. * Pain is decreased. * Protection of body parts is increased. * Safety is improved. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, canes, crutches, walkers, wheelchair, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial/casts elastic wraps oxygen) Electrotherapeutic Modalities Anticipated Goals



Page 41 of 145

* Ability to perform physical tasks is increased. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. Specific Direct interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups-may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability of caregivers to assist patient/client in activities of daily living (ADL) and instrument activities of daily living (IADL) and solve new problems is improved. * Ability to solve problems enhances independence in task performance in varied environments. * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with acquired nonprogressive disorders of the central nervous system is reduced.



Page 42 of 145

* Safety of patient/client and caregivers is increased. * Self-care and home management activities, including ADL -- and work (job/school/play) and leisure activities, including IADL -- are performed safely, efficiently, and at a mammal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge



Page 43 of 145

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System in Adulthood This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor and sensory function associated with progressive disorders of the central nervous system in adulthood. Patients/clients may have any one or a combination of the following: * Exacerbation or remission of symptoms with treatment (eg, with radiation, chemotherapy) * Impaired affect * Impaired autonomic function * Impaired cognition * Impaired endurance * Impaired expressive or receptive communication * Impaired motor function * Impaired sensory integrity * Progressive loss of function



Page 44 of 145

INCLUDES patients/clients with: * Acquired immunodeficiency syndrome (AIDS) * Alcoholic ataxia * Alzheimer's disease * Amyotrophic lateral sclerosis * Basal ganglia disease * Cerebellar ataxia * Cerebellar disease * Huntington's disease * Idiopathic progressive cortical disease * Intracranial neurosurgical procedures * Malignant brain tumor * Multiple sclerosis * Parkinson's disease * Parkinsonian symptoms * Primary lateral palsy * Progressive muscular atrophy * Seizures * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Medical instability * Multisystem trauma * Poliomyelitis



Page 45 of 145

* Progressive nondemyelinating motor neuron diseases ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because die patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 042 Human immunodeficiency virus (HIV) disease 191 Malignant neoplasm of brain 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 331 Other cerebral degenerations 331.0 Alzheimer's disease 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.0 Other degenerative diseases of the basal ganglia 333.3 Tics of organic origin 333.4 Huntington's chorea 333.9 Other and unspecified extrapyramidal disease and abdominal movement disorders 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 334.3 Other cerebellar ataxia 334.8 Other spinocerebellar diseases 335 Anterior horn cell disease 335.2 motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 341 Other demyelinating diseases of central nervous system 341.8 Other demyelinating diseases of central nervous system Central demyelination of corpus callosum 341.9 Demyelinating disease of central nervous system, unspecified 348 Other conditions of brain 348.9 Unspecified condition of brain Through the examination (history, system review, and tests and measures). the physical therapist identifies impairments. functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History



Page 46 of 145

* Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist



Page 47 of 145

* Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Post Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitatizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent)



Page 48 of 145

* Social function (eg, social interaction, social activity, social support) Social Habits Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Screening for gross expressive eg, verbalization) deficits Assistive and Adaptive Devices * Analysis Of effects and benefits including energy conservation and expenditure) while



Page 49 of 145

patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, Or other professionals concerning use of or need for device Community and Work Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skins * Analysis of community, work job/school/play), and leisure activities * Analysis of community, work job/school/play), and leisure activities that are performed sing assistive, adaptive, orthotic, protective, supportive, or Prosthetic devices or equipment * Analyses of environment and work job/school/play) tasks * Assessment of functional capacity * Assessment of physiologic responses during community, work job/school/play), and leisure activities * Assessment of safety m community and work (job/school/play) environments * IADL scales or indexes * Questionnaires Completed bY and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care Professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) Cranial Nerve integrity * Assessment of gag reflex * Assessment Of Muscles innervated by the cranial nerves * Assessment of response to the following stimuli: - auditory



Page 50 of 145

- gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/school/play) Barriers * Analysis of physical space using photography or videotape * Assessment Of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred Postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments Body mechanics: * Determination of dynamic capabilities and limitations during specific work job/school/play) activities * Observation of performance of selected movements or activities videotape analysis of Performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis Of gait, locomotion, and balance on various terrain, in different physical environments, or in water * Analysis of wheelchair management and mobility



Page 51 of 145

* Assessment of safety * Gait, locomotion, and balance assessment instruments * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Motor Function (Motor Learning and Motor Control) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Assessment of sensorimotor integration * Motor assessment scales * Physical performance scales Muscle Performance including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCVI) Neuromotor Development and Sensory integration * Analysis of involuntary movements * Analysis of reflex movement patterns * Analysis of voluntary movement * Assessment of gross and fine motor skills * Assessment of oromotor function, phonation, and speech production



Page 52 of 145

* Assessment of postural reactions Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Assessment of muscle, joint, or soft tissue characteristics



Page 53 of 145

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Reflex integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care performed in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, tight touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be



Page 54 of 145

reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the Plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home, community, and work environments, within the context of the disability. Depending on the progression of motor, perceptual, and cognitive deficits, patient/client will need varying levels of assistance family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 6 to 50 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 50 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments



Page 55 of 145

* Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect)



Page 56 of 145

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' * Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.



Page 57 of 145

* Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home eference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Pain is decreased.



Page 58 of 145

* Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation



Page 59 of 145

* Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive. using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotic, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADLs and IADLs) is increased. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg. shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks)



Page 60 of 145

* Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job,/School/Play) Integration/ Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores,heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions



Page 61 of 145

* Connective tissue massage * Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity and mobility are improved. * Safety is improved.



Page 62 of 145

* Risk of secondary impairments is reduced. * Sense of well-being is improved. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls, and other devices) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Reexamination The physical therapist relies on reexamination,the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -maybe the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person. a physical action, activity or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention,and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Awareness and use of community resources are increased. * Awareness of and response of family and caregivers is increased to modified or add assistive and supportive devices necessary to maintain independence.



Page 63 of 145

* Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse grandparent) is achieved. * Risk of disability associated with progressive disorders of the central nervous system is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency. of physical therapist is acceptable to patient/client, family significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family significant others,and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.



Page 64 of 145

* Professional recommendations are integrated into home, community work (job/school/play), or leisure environment. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Peripheral Nerve Injury This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapist provide the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which has physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice and patient/client age, culture, gender role, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients who have functional limitations due to impaired motor and sensory function associated with peripheral nerve injury. Patients/clients may have one or more of the following: * Mobility deficits * Motor changes * Pain * Reflex changes * Sensory abnormalities INCLUDES patients/clients with:



Page 65 of 145

* Compression and entrapment neuropathies (eg. Erb's palsy, acute traumatic or pregnancyinduced carpal tunnel syndrome, cubital tunnel syndrome, radial tunnel syndrome, tarsal tunnel syndrome) * Traumatic and surgical nerve lesions (including macrotrauma and microtrauma) and surgical repairs (including neuropraxia, axonotmesis, neurotmesis) EXCLUDES patients/clients with: * Demyelinating disease * Radiculopathies, reflex sympathetic dystrophy syndrome, Bell's palsy, Horner's syndrome ICD-9 Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 350 Trigeminnal nerve disorders 350.1 Trigeminal neuralgia 352 Disorders of other cranial nerves 352.4 Disorders of accessory (11th) nerve 352.5 Disorders of hypogossal (12th) nerve 352.9 Unspecified disorder of cranial nerves 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.6 Phantom limb (syndrome) 354 Mononeuritis of upper limb and mononeuritis multiplex 354.2 Lesion of ulnar nerve 354.3 Lesion of radial nerve 355 Mononeuritis of lower limb and unspecified site 357 Inflammatory and toxic neuropathy 357.1 Polyneuropathy in collagen vascular disease Examination Through the examination (history, systems review, and tests and measures), the physical



Page 66 of 145

therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem: stage of recovery (acute, subacute, chronic); phase of rehabilitation (early intermediate, late, return to activity); home, community, or work (job/school/play) situation: and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist



Page 67 of 145

* Concerns or needs of patient/client who requires the service of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease including date of onset and course of events * Onset and pattern of symptoms * Patient/client family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the service of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary



Page 68 of 145

* Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations. surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg. memory reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction. social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking. drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play,], and leisure activities) Systems Review The system review man, include: Physiologic and anotomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures



Page 69 of 145

Test and measures for this pattern may include: Anthropometric Characteristics * Measurement of height, weight, length, and girth Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation. or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skins * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs



Page 70 of 145

* Review of reports provided by. patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety, in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress Body mechanics:



Page 71 of 145

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography, (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective. supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance characteristics * Identification of gait characteristics Integumentary Integrity For skin associated with integumentary disruption: * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) Joint Integrity and Mobility * Assessment of joint hypermobility and hypomobility * Assessment of the nature and quality of movement of the joint or body part during performance of specific movement tasks Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement



Page 72 of 145

* Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of dexterity, coordination, and agility * Assessment of motor control and motor learning * Electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG]. motor nerve conduction) * Motor assessment scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength. power, and endurance * Analysis of muscle strength. power, and endurance using manual muscle testing or dynamometry Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability, through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture



Page 73 of 145

* Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers. photographic or electronic devices. or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, deep tendon reflex) * Electrophysiologic tests (eg, H-reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of individual performing self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia. position sense) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence tile complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall



Page 74 of 145

physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical theraphy. During the prognostic process, the physical therapist develops tile plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency, of visits and duration of the episode of care man. vary, from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition: preexisting systematic conditions or diseases; probability of prolonged impairment, functional limitation. or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 4 to 8 months. patient/client win return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care 12 to 56 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patient/clients in this diagnostic group will achieve the goals and outcomes within 12 to 56 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to obtain job reclassification or redesign * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity, or severity of condition



Page 75 of 145

* Comorbidities * Lesion differential diagnosis -- neuropraxis, axonotmesis, or neurotmesis * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Quality of surgical intervention * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of rare, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that die diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings,diagnosis,and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined.



Page 76 of 145

Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client,family,significant others,and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (ADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational or leisure activities are improved.



Page 77 of 145

* Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern ma,%. include. in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Motor function (motor control and motor learning) is improved. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved.



Page 78 of 145

* Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Strength, power, and endurance are increased. * Weight-bearing status is improved. Specific Direct interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation. inhibition, and facilitation * Posture awareness training * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics. elastic resistance bands, robotics, and mechanical or electromechanical devices



Page 79 of 145

* Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. Safety is improved during performance of self-care and home * management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Organized functional training programs Functional Training in Community and Work (Job/School/Play) Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Performance of and independence in IADL are increased. Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Risk of recurrence of condition is reduced. * Utilization and cost of health care services are decreased.



Page 80 of 145

Specific Direct interventions * Assistive, adaptive, supportive, or protective device training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children. negotiating school environments) * Job coaching * Job simulation * Orthotic device training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased, * Motor function (motor control and motor learning) is improved. * Muscle spasms are reduced. * Pain is decreased. * Risk of secondary impairments is reduced. Ventilation, respiration gas exchange), and circulation are improved. Specific Direct Interventions * Passive range of motion * Soft tissue mobilization or manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals



Page 81 of 145

* Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Edema, lymphedema, or effusion is reduced. joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity, and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems. environmental controls, and other devices) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints)



Page 82 of 145

* Orthotic devices or equipment (eg, splints,. braces, shoe inserts. casts) * Protective devices or equipment (eg. braces, protective taping, cushions. helmets) * Supportive devices or equipment (eg. supportive taping, compression garments, corsets. slings. neck collars, serial casts. elastic wraps, oxyen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved, Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Pain is decreased.



Page 83 of 145

* Joint integrity and mobility are improved, * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg. pulsed ultrasound. pulsed electromagnetic fields) * Cryotherapy (eg. cold packs. ice massage) * Deep thermal modalities (eg, ultrasound. phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs. fluidotherapy) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also ma,.%, be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups--may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker. student, spouse, grandparent) is achieved. * Risk of disability associated with peripheral nerve injury is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and



Page 84 of 145

equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man. indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiologcal, psychological, or anatomical structure or function) and desired outcomes (described above). In



Page 85 of 145

consultation with appropriate individuals. the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client. caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability --is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability, by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Abnormal peripheral vascular conditions * Age * Altered sensibility * Anthropometric characteristics (eg, excessive weight, leg-length discrepancny body type) * Attitude * Habitual suboptimal body mechanics (eg, lifting, reaching) * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - muscle tightness or inflexibility (eg, pectoralis major, hamstring, and gastrocnemius-soleus muscles; spinal facets; glenohumeral joint) - physical activity level - physical work demands



Page 86 of 145

- psychosocial and socioeconomic stressors - substance abuse (eg, smoking, \alcohol, drugs) * Muscle weakness or imbalance (eg, trunk and hip, quadricep femoris, hamstring, rotator cuff and wrist muscles, finger flexors and extensors) * Design, equipment, or other barriers preventing optimal body, mechanics or posture * Previous history of injury or surgery affecting extremities, spine, posture, or body, mechanics (eg, recurrent lateral ankle sprains, persistent shoulder instability) * Systemic condition predisposing patient/client to contractile or noncontractile deficiency (eg, endocrine disorders, rheumatic diseases) * Underlying spinal dysfunction (eg, postural dysfunction) in home, community or work (job/school/play) environments Primary Preventive interventions * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors) and peripheral nerve lesions and (2) prevention strategies * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Motor Function and Sensory Integrity Associated With Acute or Chronic Polyneuropathies This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age. culture. gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group



Page 87 of 145

Patients/clients with functional limitations due to impaired motor and sensory function associated with acute or chronic polyneuropathies. Patients/clients ma,.%, have one or a combination of the following: * Autonomic nervous system dysfunction * Impaired sensory integrity * Impaired motor function (motor control and motor learning) * Skin and bone abnormalities INCLUDES patients/clients with: * Amputation * Axonal polyneuropathies (diabetic. renal, and alcoholic) * Guillain-Barre syndrome * Leprosy EXCLUDES patients/clients with: * Central nervous system lesions * Coma * Compression or traumatic neuropathies * Mixed central nervous system and peripheral lesions * Multisystem trauma * Poliomyelitis ICD-9-CM Codes As of press time. the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes. it is possible for individuals to belong to the group even though the codes man, not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision., Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 030 Leprosy 250 Diabetes mellitus 250.6 Diabetes with neurological manifestations 356 Hereditary and idiopathic peripheral neuropathy 356.4 Idiopathic progressive polyneuropathy 356.9 Unspecified 357 inflammatory and toxic neuropathy 357.2 Polyneuropathy in diabetes 357.4



Page 88 of 145

Polyneuropathy in other diseases classified elsewhere Uremia 357.5 Alcoholic polyneuropathy 357.7 Polyneuropathy due to other toxic agents Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions. social activities, and support systems Occupation/Employment * Current and prior community and * work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment



Page 89 of 145

* Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other,, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary



Page 90 of 145

* Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns. energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal



Page 91 of 145

* Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceivedexertion (RPE) scales, dyspnea scales. angina scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Claudication time tests Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy in determining the effects of other medical or health-related conditions,. during surgical procedures. after drug therapy) * Measurement of body fat composition, using calipers. underwater weighing tanks. or electrical impedance * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Arousal, Attention, and Cognition * Screening for level of cognition (eg, to determine ability to process commands to measure safety awareness) * Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device



Page 92 of 145

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective. supportive or prosthetic devices or equipment * Analysis of environment work (job/school/play), and leisure activities * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Measurement of physical space



Page 93 of 145

* Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its irherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity



Page 94 of 145

* Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance charactecristics Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin For wound: * Assessment for presence of blistering * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks



Page 95 of 145

* Assessment of joint hypermobility and hypomobility * Measurement of soft tissue restrictions Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk, and limb movement * Analysis of myoelectric activity and neurophysiological integrity using electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG], motor nerve conduction) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of postural, equilibrium, and righting reactions * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV]) Neuromotor Development and Sensory Integration * Assessment of dexterity, agility, and coordination * Assessment of gross and fine motor skills Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition



Page 96 of 145

* Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, deep tendon reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals



Page 97 of 145

Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp or dun discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment: potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development: and caregiver consistency or expertise. Prognosis Patient/client will be integrated into age-appropriate home, community, and work environments, within the context of the disability. Expected Range of Number of Visits Per Episode of Care 6 to 24 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 24 visits during a single



Page 98 of 145

continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Acute events related to the neuropathy (eg, infected ulcer) * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments (eg, progression of articular changes, muscle weakness, or sensory loss) * Development or progression of wound * Level of patient/client adherence to the intervention program * Mental competence of patient/client *Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Surgical intervention * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and



Page 99 of 145

prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals



Page 100 of 145

* Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference



Page 101 of 145

* Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Energy expenditure is decreased. * Gait, locomotion, and balance are improved. * Motor function (motor control and motor learning) is improved. * Need for assistive and adaptive devices is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk of recurrence of injury or condition is decreased. * Risk factors are reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics,



Page 102 of 145

elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Strengthening - active - active assistive - resistive,using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Safety when performing self-care and home management tasks and activities is improved. * Tolerance to positions and activities is increased Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training



Page 103 of 145

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Leisure and play activity * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training



Page 104 of 145

Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint comfort, alignment, and function are improved. * Joint integrity and mobility are improved.



Page 105 of 145

* Joint stability is increased. *Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Safety is improved. * Risk of secondary impairments is reduced. * Stresses precipitating or perpetuating injury are minimized. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Joint integrity and mobility are improved.



Page 106 of 145

* Muscle performance is increased. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, total contact casting) * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes



Page 107 of 145

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then- are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg. worker. student, spouse, grandparent) is achieved. * Risk and cost of hospitalization are reduced. * Risk of disability associated with acute or chronic polyneuropathies is reduced. * Safety of patient/client and caregivers is increased. * Safety, independence, and efficiency of functional mobility (eg. gait, wheelchair, transfers) are maximized. * Self-care and home management activities, including activities of daily living (ADL)--and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others and caregivers.



Page 108 of 145

Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment. pathology or impairment that may affect function or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/plan), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Spinal Cord This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation. and socioeconomic status. Patient/Client Diagnostic Group



Page 109 of 145

Patients/clients with functional limitations due to impaired motor function and sensation associated with nonprogressive disorders of the spinal cord at an,%- age. Patients/clients may have any one or a combination of the following: * Impaired balance * Impaired endurance * Impaired motor function (motor control and motor learning) * Impaired respiratory function * Impaired sensory integrity INCLUDES patients/clients with: * Benign spinal tumor * Complete and incomplete lesions * Infectious diseases affecting the spinal cord * Spinal compression secondary to osteomyelitis, spondylosis, herniated intervertebral disk. or degenerative joint disease * Spinal cord injury secondary to trauma * Spinal fusion and spinal neurological procedures EXCLUDES patients/clients with: * Amputation * Coma * Guillain-Barre syndrome * Malignant tumor * Meningocele * Medical instability * Multiple sclerosis, amyotrophic lateral sclerosis * Multiple system trauma * Myelocele * Myelomeningocele



Page 110 of 145

* Nerve root compression due to lumbar radiculopathy * Orthopedic or spinal instability with unstabilized spine * Progressive spinal cord injury or disease * Tethered cord CD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 192 Malignant neoplasm of other and unspecified parts of nervous system 192.2 Spinal cord Cauda equina 198 Secondary malignant neoplasm of other specified sites 198.3 Brain and spinal cord 225 Benign neoplasm of brain and other parts of nervous system 225.3 Spinal cord Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 239 Neoplasms of unspecified nature 239.7 Endocrine glands and other parts of nervous system 336 Other diseases of spinal cord 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia 344.8 Other specified paralytic syndromes 344.89 Other specified paralytic syndrome Brown-Sequard's syndrome 721 Spondylosis and allied disorders 721.1 Cervical spondylosis with myelopathy 721.4 Thoracic or lumbar spondylosis with myelopathy 721.9 Spondylosis of unspecified site 721.91 With myelopathy 722 Intervertebral disk disorders 722.7 Intervertebral disk disorder with myelopathy 730 Osteomyelitis, periostitis, and other infections involving bone 730.2 Unspecified osteomyelitis 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 806 Fracture of vertebral column with spinal cord injury 839 Other. multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.1 Cervical vertebra, open 839.2 Thoracic and lumbar vertebra, closed 839.3 Thoracic and lumbar vertebra, open 839.4 Other vertebra, closed 839.5 Other vertebra, open 839.6 Other location, closed 839.7 Other location, open 839.8 Multiple and ill-defined, closed 839.9 Multiple and ill-defined, open 952 Spinal cord injury without evidence of spinal bone injury 952.0 Cervical 952.1 Dorsal [thoracic] 952.2 Lumbar Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age: severity of the problem; stage of recovery (subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play)) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.



Page 111 of 145




Page 112 of 145

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a Physical therapist * Medications for other condition Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum



Page 113 of 145

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression. morale) * Role function (eg, worker, student, spouse, grandparent) * Social activity (eg. social interaction. social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-



Page 114 of 145

exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Pulse oximetry Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Assessment of height. weight. length. and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of environment, work (job/school/play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities



Page 115 of 145

* Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' * Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Computer-assisted motion analysis of patient/client at work (job/school/play) * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity



Page 116 of 145

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic. and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance profiles Integumentary Integrity * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin



Page 117 of 145

Joint integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG] and nerve conduction velocity [NCV]) Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition



Page 118 of 145

* Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain using questionnaires, graphics, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device



Page 119 of 145

Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of chest wall mobility, expansion, and excursion * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity, of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity, of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home and community environments with maximal independence, within the context of the disability.



Page 120 of 145

Depending on residual motor deficits. patient/client win become completely independent or will need varying levels of assistance (eg, family, caregiver, equipment) to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 4 to 150 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 4 to 150 visits during a single continous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency, or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention man be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all



Page 121 of 145

patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of * patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources



Page 122 of 145

Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment



Page 123 of 145

* Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Atelectasis is decreased. * Endurance is increased. * Energy expenditure is decreased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Osteogenic effects of exercise are maximized. * Performance of and independence in ADL arid IADL are increased. * Physical function and health status are improved. * Joint integrity and mobility are improved. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced.



Page 124 of 145

* Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching



Page 125 of 145

Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical task related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community, work (job/school/play) and leisure aft and activities * Risk of recurrence is decreased.



Page 126 of 145

* Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Leisure activity training * Organized functional training programs (eg, simulated environments and tasks) * Orthotic protective, or supportive device or equipment training * Posture awareness training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and



Page 127 of 145

Prosthetic) Anticipated Goals * Ability to perform physical task is increased. * Deformities are prevented. * Independence in bed mobility, transfers, and gait is maximized. * Joint stability is increased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Physical function and health status are improved. * Safety is improved. * Pressure areas (eg, pressure over bony prominence) are prevented. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, casts, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Anticipated Goals * Airway clearance is improved. * Cough is improved. * Disability associated with illness or injury is decreased.



Page 128 of 145

* Gas exchange is improved. * Independence in self-care for airway clearance techniques is increased. * Need for assistive device (mechanical ventilation) is decreased. * Physical function and health status are improved. * Risk of recurrence of condition is reduced. * Risk of secondary complications is reduced. * Utilization and cost of health care services are decreased. * Ventilation, respiration (gas exchange), and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions * Active cycle of breathing or forced expiratory technique * Assistive cough techniques * Assistive devices for airway clearance (eg, flutter valve) * Autogenic drainage * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Pain is decreased. * Risk of secondary impairments is reduced.



Page 129 of 145

Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Tolerance to positions and activities is increased. Specific Direct Interventions Mechanical modalities: * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action. activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then' are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability to participate in home, work (job/school/play), or leisure activities is increased. * Health-related quality of life is improved, Opportunities for completion of psychosocial development are optimized. * Optimal return to role function (eg. worker, student, spouse, grandparent) is achieved.



Page 130 of 145

* Risk and cost of hospitalization are reduced. * Risk of disability associated with nonprogressive disorders of the spinal cord is reduced. * Safety of patient/client and caregivers is increased. * Safety, independence, and efficiency of functional mobility (eg, gait, wheelchair. transfers) are maximized. * Self-care and home management activities, including activities of daily living (ADI) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed by patient/client and caregivers safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Sexual roles and function are resumed. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others. and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man, indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community



Page 131 of 145

adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care. periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers. environment, or task demands. Impaired Arousal, Range of Motion, Sensory Integrity, and Motor Control Associated With Coma, Near Coma, or Vegetative State This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice: and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients with impaired arousal, range of motion (ROM), sensation and motor control associated with coma, near coma, or persistent vegetative state at any age. Patients may have one or a combination of the following: * Autonomic nervous system dysfunction * Impaired sensory integrity * Impaired motor function (motor control and motor learning) * Skin and bone abnormalities INCLUDES patients with:



Page 132 of 145

* Anoxia * Cerebrovascular accident (stroke) * Infectious or inflammatory disease * Traumatic brain injury * Tumor EXCLUDES patients with: * Amputation * Medical instability * Multisystem trauma * Pneumonia ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 049 Other non-arthropod-borne viral diseases of the central nervous system 049.9 Unspecified non-arthropod-borne viral diseases of the central nervous system Viral encephalitis, not otherwise specified 322 Meningitis of unspecified cause 342 Hemiplegia and hemiparesis 342.0 Flaccid hemiplegia 348 Other conditions of brain 348.0 Cerebral cysts 348.1 Anoxic brain damage 431 Intracerebral hemorrhage 433 Occlusion and stenosis of precerebral arteries 433.0 Basilar artery 434 Occlusion of cerebral arteries 435 Transient cerebral ischemia 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 442 Other aneurysm 442.8 Of other specified artery 444 Arterial embolism and thrombosis 444.9 Of unspecified artery 447 Other disorders of arteries and arterioles 447.1 Stricture of artery 747 Other congenital anomalies of circulatory system 747.8 Other specified anomalies of circulatory system 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 850 Concussion 850.5 With loss of consciousness of unspecified duration 850.9 Concussion, unspecified 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 853.0 Without mention of open intracranial wound 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drowning and nonfatal submersion Examination



Page 133 of 145

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home. community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions,. social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition



Page 134 of 145

* Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal



Page 135 of 145

* Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style



Page 136 of 145

Test and Measures Tests and measures for this pattern may include, in alphabetical o Anthropometric Characteristics * Assessment of postures that aggravate or relieve edema, lymphedema, or effusion Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of level of consciousness Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of significant other, family, or caregiver ability to use and care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Review of reports provided by family, significant others, caregivers, or other professionals concerning use of or need for device Cranial Nerve Integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers



Page 137 of 145

* Measurement of physical space using photography or videotape * Physical inspection of the environment * Questionnaires completed b%. and interviews conducted with patient/client and others as appropriate Muscle Performance (Including Strength, Power, and Endurance) * Assessment of muscle tone Neuromotor Development and Sensory integration * Analysis of reflex movement patterns Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Asessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of family or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain and soreness with movement Posture * Observation of resting posture assumed in any position Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging



Page 138 of 145

* Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg. sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment to determine presence of cyanosis * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Management of airway secretions * Palpation of chest wall (eg. tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes. specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of



Page 139 of 145

prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient who continues in coma, near coma, or persistent vegetative state will have minimization of secondary impairments. Expected Range of Number of Visits Per Episode of Care 5 to 20 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients in this diagnostic group will achieve the goals and outcomes within 5 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Comorbidities * Development of complications or secondary impairments * Preexisting systemic conditions or diseases * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may, be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication,



Page 140 of 145

coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety, of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Community, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with family significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Family, significant other and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with family, significant others, caregivers, other health care professionals, and other interested persons * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals



Page 141 of 145

* Awareness and use of community resources by family, significant others and caregivers are improved * Decision making is enhanced regarding health of patient/client and use of health care resources by family significant other and * Disability associated with acute or chronic illness is reduced. * Intensity of care is decreased. * Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Physical function and health status are improved. * Progress is enhanced through the participation of family, significant others and caregivers. * Safety of patient/client, family, significant others, and caregivers is improved. * Risk of secondary impairment is reduced. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by family or caregivers in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced.



Page 142 of 145

* Tolerance to positions is increased. Specific Direct Interventions * Nueromuscular relaxation, inhibition, and facilitation * Sensory training or retraining * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Risk of secondary impairments is reduced. * Safety is improved during performance of self-care and home management tasks and activities. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, bathing) for caregiver * Assistive and adaptive device and equipment training for caregiver * Body mechanics training for caregiver * Orthotic, protective or supportive device or equipment training for caregiver Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Joint mobility and integrity are improved. * Risk of secondary impairments is reduced. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved



Page 143 of 145

Specific Direct Interventions * Adaptive devices or equipment (eg, hospital beds. seating systems) * Assistive devices or equipment (eg, wheelchairs) * Orthotic devices or equipment (eg, braces, splints) * Protective devices or equipment (eg, braces, helmets cushions, protective taping) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets,-neck collars, slings, supportive taping, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Risk of secondary complication is reduced. Specific Direct Interventions * Assistive devices for airway. clearance (eg, flutter valve) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg. maximum inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on reexamination. the process of performing selected tests and measures after the initial examination, to evaluate progress and to modified or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the



Page 144 of 145

whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment),primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic intervention and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Activities of daily living (ADL) are performed safely, efficiently, and at a maximal level of independence by caregivers. * Appropriate placement according to level of function is determined. * Disability associated with coma, near coma, or vegetative state is reduced. * Health-related quality of life is improved. * Potential for return to role function is maintained. * Safety of patient/client and caregivers is increased. * Family significant other, and caregiver understanding of personal and environmental factors that promote optimal health status is demonstrated. * Family significant other, and caregiver understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability and services provided are acceptable to family, significant others, and caregivers. * Administrative management of practice is acceptable to family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to family significant others, and caregivers. * Coordination and conformity of care are acceptable to family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to family significant others, and caregivers. Secondary Prevention * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased.



Page 145 of 145

* Family significant other, and caregiver adherence to the intervention program is maximized. * Family, significant others, and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: medical status, caregiver status, having environment, pathology or impairment that may affect function, or resources. * Professional recommendations are integrated into home and community environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Source Citation:"Neuromuscular." Physical Therapy 77.n11 (Nov 1997): 1371(79). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 188

Cardiopulmonary.(includes related information)(Preferred Practice Patterns)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1451 (104). (44288 words)


Preferred Practice Patterns: Cardiopulmonary The following patterns describe the elements of patient/client management provided by physical therapists -- examination (History, systems review, and tests and measures). evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Primary Prevention/Risk Factor Reduction for Cardiopulmonary Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with decreased maximum aerobic capacity who are at risk for developing cardiac disease, pulmonary disease, or both, based on well-accepted risk factor profiles that have been published in the literature. INCLUDES patients/clients who may have several of the following: * Diabetes * Family history of heart disease * Hypercholesterolemia or hyperlipidemia * Hypertension * Obesity * Significant smoking history EXCLUDES patients/clients with:



Page 2 of 188

* Known diagnosis of heart disease * Known diagnosis of pulmonary disease ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client dignostic group is defined by impairments functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 250 Diabetes mellitus 272 Disorders of lipoid metabolism 272.0 Pure hypercholesterolemia 278 Obesity and other hyperalimentation 278.0 Obesity 305 Nondependent abuse of drugs 305.1 Tobacco use disorder 401 Essential hypertension Factors Influencing Health Status and Contact With Health Services V17 Family history of certain chronic, disabling diseases V17.4 Other cardiovascular diseases Examination Through the examination (history, systems review, and measures) the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age



Page 3 of 188

* Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patients/ client's emotional response to the current clinical situation Functional Status and Activity Level



Page 4 of 188

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks



Page 5 of 188

Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, effect, cognition, lanquage, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and



Page 6 of 188

during and after activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Claudication time tests * interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of pulses * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment and work (job/school/play) tasks * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Observation of response to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics



Page 7 of 188

Ergonomics: * Assessment of safety in work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography. videotape. or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rules, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity and during exercise * Assessment of ability to clear airway * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity



Page 8 of 188

* Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption (VO.sub.2) studies * Palpation of pulses * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent. of loss of function social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the path" level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/client based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability If prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will demonstrate independence in an aerobic exercise program and be able to identify personal risk factors for cardiopulmonary disease and the methods he or she will use to reduce risk. Expected Range of Number of Visits Per Episode of Care 1 to 6 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within I to 6 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.



Page 9 of 188

Factors That May Modify Frequency of Visits * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioecomic stressors * Support provided by family unit intervention Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determined the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, organization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of client and use of health care resources by



Page 10 of 188

patient/client, family, significant others, and caregivers. Specific interventions * Communication (direct or indirect) * Coordination of care with client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of client management * Education plans * Referrals to other professionals or resources Patient/client-related instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Client knowledge of personal and environmental factors associated with the condition is increased. * Decision making is enhanced regarding health of client and use of health care resources by client. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by client in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching



Page 11 of 188

* Verbal instruction * Written or pictorial instruction Direct interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Physical function and health status are improved. * Physiologic response to increased oxygen demand is improved. * Strength, power, and endurance are increased. * Symptoms associated with increased oxygen demand are decreased. Specific Direct Interventions * Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Body mechanics and ergonomics training * Breathing exercises * Conditioning and reconditioning * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-care and Home Management (Including ADL and IADL) Anticipated Goals



Page 12 of 188

* Performance of and independence in ADL and IADL are increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Risk of recurrence of condition is reduced. Specific Direct interventions * Ergonomic stressor reduction training * Injury prevention or reduction training Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment ,primary or secondary prevention, and patient client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Health-related quality of life is enhanced. * Optimal role function (eg, worker, student, spouse, grandparent) is maintained. * Understanding of personal and environmental factors that promote optimal health status is demonstrated.



Page 13 of 188

* Understanding of prevention strategies is demonstrated. Client Satisfaction * Access, availability and services provided are acceptable to client. * Administrative management of practice is acceptable to client. * Clinical proficiency of physical therapist is acceptable to client. * Coordination and conformity of care are acceptable to client. * Interpersonal skills of physical therapist are acceptable to client, family, and significant others. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referml. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Aerobic Capacity and Endurance Secondary to Deconditioning Associated With Systemic Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with impaired aerobic capacity associated with systemic disorders that impair mobility or interfere with systemic response to increased oxygen demand. Patients/clients may have any one or a combination of the following: * Decreased ability. To perform endurance conditioning * Decreased independence in activities of daily living (ADL) or instrumental activities of daily living IADL)



Page 14 of 188

* Immediate prior history, of bed rest for more than 48 hours * Increased symptoms with increased activity * History of inactivity secondary. To systemic impairment INCLUDES patients/clients with: * Acquired immune deficiency syndrome (AIDS) * Cancer * Cardiopulmonary disorders * Chronic system failure * Multisystem impairments * Musculoskeletal disorders * Neuromuscular disorders EXCLUDES patients/clients with: * Acute cardiovascular pump failure * Acute respiratory failure * Airway clearance impairment * Mechanical ventilation ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to two preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations are not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases. Ninth Revision, Clinical Modification ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes add instructions regarding fifth-digit requirements. 042 Human immunodeficiency virus [HIV] disease Acquired immune deficiency sydrome [AIDS] 250 Diabetes mellitus 250.4 Diabetes with renal manifestations 250.8 Diabetes with other specified manifestations



Page 15 of 188

250.9 Diabetes with unspecified complications 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.0 Other degenerative diseases of the basal ganglia 333.3 Tics of organic origin 333.4 Huntington's chorea 333.9 Other and unspecified extrapyramidal disease and abnormal movement disorders 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 335 Anterior horn cell disease 335.2 motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 357 Inflammatory and toxic neuropathy 357.0 Acute infective polyneuritis Guillain-Barre syndrome 359 Muscular dystrophies and other myopathies 359.1 Hereditary progressive muscular dystrophy 443 Other peripheral vascular disease 443.9 Peripheral vascular disease, unspecified 482 Other bacterial pneumonia



Page 16 of 188

482.2 Pneumonia due to Hemophiluss influenzae 482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis 491.9 Unspecified chronic bronchitis 492 Emphysema 492.8 Other emphysema 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD], not otherwise specified 508 Respiratory conditions due to other and unspecified external agents 508.9 Respiratory conditions, due to unspecified external agent 513 Abscess of lung and mediastinum 513.0 Abscess of lung 514 Pulmonary congestion and hypostasis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy, 517 Lung involvement in conditions classified elsewhere 517.8 Lung involvement in other diseases classified elsewhere 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 519 Other diseases of respiratory system



Page 17 of 188

519.4 Disorders of diaphragm 711 Arthropathy associated with infections 712 Crystal arthropathies 713 Arthropathy associated with other disorders classified elsewhere 714 Rheumatoid arthritis and other inflammatory polyarthropaties 715 Osteoarthrosis and allied disorders 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities Procedure Codes 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 54 Other operations on abdominal region 54.9 Other operations of abdominal region 54.99 Other Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.



Page 18 of 188




Page 19 of 188

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular



Page 20 of 188

* Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes



Page 21 of 188

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Claudication time tests * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Palpation of pulses * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth * Observation and palpation of trunk and extremities at rest and during activity Arousal, Attention, and Cognition * Assessment of orientation to time, person, place, and situation * Screening for level of cognition (eg, to determine ability to process commands, to measure



Page 22 of 188

safety awareness) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client and caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers or other professionals concerning use of or need for device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of environment and work (job/school/play) tasks * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other health



Page 23 of 188

care professionals, or other interested persons (eg, rehabilitation counselor, Workers' * Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of safety in work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma,



Page 24 of 188

cumulative trauma, or repetitive stress * Videotape analysis of patient/client at work (job/school/play) Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Gait, locomotion, and balance profiles Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of soft tissue swelling, inflammation or restriction Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength * Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition



Page 25 of 188

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture girds, plumb lines, still photography, videotape, or visual analysis Prosthetic Requirements * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device



Page 26 of 188

Range of Motion (ROM) including Muscle Length) * Assessment of muscle, joint, or soft tissue characteristics Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computerassisted graphic imaging Self-Care and Home Management including ADL and IADL) * ADL scales or indexes * Analysis of adaptive skills * Analysis of environment and tasks * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care in unfamiliar environments * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of perceived exertion and dyspnea * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity



Page 27 of 188

* Assessment of chest wall mobility, expansion, and excursion * Assessment and classification of edema using volume and girth measurements * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of pulses * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing he diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 6 weeks, patient/client will demonstrate improved functional capacity and increased ability to perform activities of dad), living (ADL) and instrumental activities of daily living (IADL) without exacerbation of signs and symptoms, or patient/client will demonstrate an increase in muscle strength and endurance and an increase in exercise tolerance.



Page 28 of 188

Expected Range of Number of Visits Per Episode of Care 5 to 26 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 5 to 26 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. F o r clinical indications for the direct interventions, refer to Part One, Chapter 3.



Page 29 of 188

Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. * Resources are maximally utilized. Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased.



Page 30 of 188

* Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, f", significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregiver in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching



Page 31 of 188

* Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Physiologic response to increased oxygen demand is improved. * Strength, power, and endurance are increased. * Symptoms associated with increased oxygen demand are decreased. Specific Direct Interventions * Aerobic endurance activities using treadmill, ergometer, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Posture awareness training * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices



Page 32 of 188

* Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability, to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability, to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. Specific Direct Interventions * ADL training (eg, bed mobility, and transfer training, gait training locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy, household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device training Functional Training in Community and Work (Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. Specific Direct Interventions * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals



Page 33 of 188

* Ability to perform physical tasks is increased. * Performance of and independence in ADL and AIDL are increased. * Physical function and health status are improved. * Risk of secondary impairments is reduced. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats., seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.



Page 34 of 188

* Risk of disability associated with deconditioning associated with systemic disorders is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (AIDL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Level of patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.



Page 35 of 188

* Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes had been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity Associated With Airway Clearance Dysfunction This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, ace, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with impaired airway clearance, respiration (gas exchange), or ventilation accompanied by impaired aerobic capacity and impaired function. Patients/clients may have any one or a combination of the following: * Change in baseline breath sounds * Change in baseline chest radiograph * Dyspnea * Impaired respiratory function * Impaired gas exchange * Impaired performance in activities of daily living (ADL) or instrumental activities of daily living (IADL) * Increased work of breathing



Page 36 of 188

* Pulmonary infection, including frequent or recurring infections INCLUDES patients/clients with: * Acute lung disorders * Acute or chronic oxygen dependency * Bone marrow/cell transplants * Cardiothoracic surgery * Chronic obstructive pulmonary disease (COPD) * Solid-organ transplants (eg, heart, lung, kidney) * Tracheostomy or microtracheostomy EXCLUDES patients/clients with: * Age of fewer than 4 months * Mechanical ventilation * Multisystem failure * Respiratory failure ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instruction regarding fifth-digit requirements. 136 Other and unspecified infectious and parasitic diseases 136.3 Pneumocytosis Pneumonia due to Pneumocystis carinii 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 482 Other bacterial pneumonia 482.2 Pneumonia due to Hemophilus influenzae [H.influenzae] 482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis 491.8 Other chronic bronchitis 491.9 Unspecified chronic bronchitis 492 Emphysema 492.8 Other emphysema 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD], not otherwise specified 500 Coal workers' pneumoconiosis 501 Asbestosis 502 Pneumoconiosis due to other silica or silicates 503 Pneumoconiosis due to other inorganic dust 504 Pneumonopathy due to inhalation of other dust 505 Pneumoconiosis, unspecified 507 Pneumonitis due to solids and liquids 507.7 Due to inhalation of food or vomitus Aspiration pneumonia 508 Respiratory conditions due to other and



Page 37 of 188

unspecified external agents 508.9 Respiratory conditions due to unspecified external agent 510 Empyema 511 Pleurisy 513 Abscess of lung and mediastinum 513.0 Abscess of lung 514 Pulmonary congestion and hypostasis 515 Postinflammatory pulmonary fibrosis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 759 Other and unspecified congenital anomalies 759.3 Situs inversus Kartagener's syndrome or triad 770 Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory disease arising in the perinatal period Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified 786.5 Chest pain 786.52 Painful respiration 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion 996 Complications peculiar to certain specified procedures 996.0 Mechanical complication of cardiac device, implant, and graft 996.1 Mechanical complication of other vascular device, implant, and graft 996.2 Mechanical complication of nervous system device, implant, and graft 996.3 Mechanical complication of genitourinary device, implant, and graft 996.4 Mechanical complication of internal orthopedic device, implant, and graft 996.5 Mechanical complication of other specified prosthetic device, implant, and graft 996.8 Complications of transplanted organ 996.85 Bone marrow complications 997 Complications affecting specified body systems, not elsewhere classified 997.3 Respiratory complications Factors Influencing Health Status and Contact With Health Services V42 Organ or tissue replace by transplant V42.0 Kidney V42.2 Heart valve V42.3 Skin V42.4 Bone V42.6 Lung V42.7 Liver V42.8 Other specified organ or tissue V42.81 Bone marrow V42.82 Peripheral stem cells V42.83 Pancreas V42.89 Other Procedures 32 Excision of lung and bronchus 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 36 Operations on vessels of heart 36.1 Bypass anastomosis for heart revascularization 54 Other operations on abdominal region 54.9 Other operations of abdominal region 54.99 Other Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination. based on patient/client age; severity of the problem; stage of recovery acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or Work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may includes: General Demographics * Age



Page 38 of 188

* Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level



Page 39 of 188

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks



Page 40 of 188

Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity



Page 41 of 188

* Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Pulse oximetry * Tests and measures of pulmonary posture and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effussion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of patient/client and caregiver ability to care for device. * Assessment of safety during use of device * Review of reports provided by patient/client family, significant others, family, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills



Page 42 of 188

* Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of automic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) Cranial Nerve Integrity * Assessment of gag reflex * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with * patient/client and others as appropriate Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of sensation (eg, pain, temperature, tactile)



Page 43 of 188

* Assessment of nail beds For wound: * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of ecchymosis Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while Patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, still photography, videotape, or visual analysis Self-Care and Home Management (Including ADL and IADL)



Page 44 of 188

* ADL or IADL scales or indexes * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care in unfamiliar environment * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Review of daily activities log Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment and classification of edema using volume and girth measurements * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, diaphrugmatic motion) * Palpation of pulses



Page 45 of 188

* Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 6 weeks, one of the following will occur: * Patient/client will have an absence of secretions or will be able to clear secretions independently. * Chest radiograph will return to baseline. * Caregiver will be able to manage the secretions. Expected Range of Number of Visits Per Episode of Care 5 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of Patients/clients in this diagnostic group will achieve the goals and outcomes within 5 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning



Page 46 of 188

* Accessibility of resources * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions man, be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, or other professionals; * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified.



Page 47 of 188

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient,/client, family, significant others, and caregivers. * Disability associated with acute or chromic illnesses is reduced. * Functional independence activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcome are increased.



Page 48 of 188

* Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregiver in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Airway clearance is improved. * Atelectasis is decreased.



Page 49 of 188

* Energy expenditure is decreased. * Physical function and health status are improved. * Pyschologic response to increased oxygen demand is improved. * Quality and quantity of movement between and across body segments are improved * Risk of recurrence of condition is reduced. * Strength, power, and endurance are increased. * Tissue perfusion and oxygenation are improved, * Work of breathing is decreased. Specific Direct Interventions * Aerobic endurance activities using ergometers, treadmill, steppers, pulleys, weights, hydraulics, elastic resistance bands robotics, and mechanical or electromechanical devices * Balance and coordination training * Body, mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL)



Page 50 of 188

Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Safety is improved during performance of self-care and home management tasks and activities. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training,, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device training Functional Training in Community and Work (Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work job/school/play) integration and reintegration and leisure tasks. movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community and work (job/school/play) tasks and activities. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community. work job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Orthotic,. protective, or supportive device and equipment training



Page 51 of 188

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Joint integrity and mobility are improved. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk of secondary impairments is reduced. * Safety is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Cough is improved. * Exercise tolerance is improved. * Physical function and health status are improved. * Risk of recurrence of condition is reduced. * Ventilation, respiration (gas exchange), and circulation are improved. * Work of breathing is decreased.



Page 52 of 188

Specific Direct Interventions * Assistive cough techniques * Autogenic drainage * Breathing strategies (eg, training in paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Forced expiratory techniques * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with airway clearance dysfunction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are



Page 53 of 188

performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Level of patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of



Page 54 of 188

anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Aerobic Capacity and Endurance Associate With Cardiovascular Pump Dysfunction PATTERN D This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients who have impaired aerobic capacity associated with cardiovascular pump dysfunction and who may have one or a combination of the following: * Abnormal heart rate response to increased oxygen demand * Decreased ejection fraction (30%-50%) * Exercise-induced myocardial ischemia (1-2 mm ST segment, depression) * Functional capacity of less than or equal to 5 to 6 metabolic equivalent units (METs) * Hypertensive blood pressure response to increased oxygen demand * Nonmalignant arrhythmias * Symptomatic response to increased oxygen demand INCLUDES patients/clients with: * Angioplasty or atherectomy * Cardiomyopathy



Page 55 of 188

* Coronary artery bypass grafting * Coronary artery disease * Hypertensive heart disease * Uncomplicated myocardial infarction * Valvular heart disease EXCLUDES patients/clients with: * Age of fewer than 4 months * Airway clearance impairment * Heart failure * Mechanical ventilation ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 391 Rheumatic fever with heart involvement 394 Diseases of mitral valve 395 Diseases of aortic valve 396 Diseases of mitral and aortic valves 397 Diseases of other endocardial structures 398 Other rheumatic heart disease 402 Hypertensive heart disease 403 Hypertensive renal disease 404 Hypertensive heart and renal disease 410 Acute myocardial infarction 411 Other acute and subacute forms of ischemic heart disease 412 Old myocardial infarction 413 Angina pectoris 414 Other forms of chronic ischemic heart disease 416 Chronic pulmonary heart disease 416.0 Primary pulmonary hypertension 417 Other diseases of pulmonary circulation 417.0 Arteriovenous fistula of pulmonary vessels 422 Acute myocarditis 423 Other diseases of pericardium 423.2 Constrictive pericarditis 424 Other diseases of endocardium 424.0 Mitral valve disorders 425 Cardiomyopathy 426 Conduction disorders 426.0 Atrioventricular block, complete 426.1 Atrioventricular block, other and unspecified 427 Cardiac dysrhythmias 429 Ill-defined descriptions and complications of heart disease 429.0 Myocarditis, unspecified



Page 56 of 188

440 Atherosclerosis 441 Aortic aneurysm and dissection 443 Other peripheral vascular disease Procedures 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 36 Operations on vessels of heart 36.1 Bypass anastamosis for heart revascularization Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work job/school) activities Growth and Development * Hand and foot dominance



Page 57 of 188

* Developmental History Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition



Page 58 of 188

* Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review



Page 59 of 188

The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Claudication time tests * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Palpation of pulses * Performance or analysis of an electrocardiogram * Pulse oximetry



Page 60 of 188

* Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of body fat composition using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client and caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities



Page 61 of 188

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of environment and tasks * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of safety in work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs



Page 62 of 188

related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Videotape analysis of patient/client at work (job/school/play) Body Mechanics: * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Gait, locomotion, and balance profiles Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of pain and soreness * Assessment of soft tissue swelling, inflammation, or restriction Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or



Page 63 of 188

dynamometry * Assessment of muscle tone * Assessment of pain and soreness Neuromotor Development and Sensory integration * Analysis of reflex movement patterns * Assessment of behavioral response * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture



Page 64 of 188

* Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathologic reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL scales or indexes * Analysis of adaptive skills * Analysis of environment and tasks * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment and classification of edema through volume and girth measurements



Page 65 of 188

* Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of chest wall mobility, expansion, and excursion * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation of major vessels for bruits * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a



Page 66 of 188

high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 12 weeks, patient/client will have a functional capacity of greater than or equal to 6 metabolic equivalent units (METS), will recognize signs and symptoms of cardiovascular compromise, will be independent and safe with an aerobic exercise program, and will be able to identify his or her own risk factors for heart disease and the interventions required to modify those risk factors. Expected Range of Number of Visits Per Episode of Care 3 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit



Page 67 of 188

Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management



Page 68 of 188

* Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family. significant other, and caregiver knowledge and awareness of the diagnosis, prognosis. interventions., and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved.



Page 69 of 188

* Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregiver in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Physical function and health status are improved. * Physiologic response to increased oxygen demand is improved. * Strength, power, and endurance are increased. * Symptoms associated with increased oxygen demand are decreased. Specific Direct Interventions * Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning



Page 70 of 188

* Developmental activities training * Gait, locomotion, and balance training * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Safety is improved during self-care and home management tasks and activities. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * Injury prevention or reduction training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive devices and equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced.



Page 71 of 188

* Risk of recurrence is reduced. * Safety is improved during performance of community and work (job/school/play) tasks and activities. * Utilization and cost of health care services are decreased. Specific Direct interventions * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction * Injury prevention or reduction training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * job simulation * Assistive and adaptive device or equipment training * Orthotic, protective, or supportive device or equipment training Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prostheses (eg, artificial limbs)



Page 72 of 188

* Protective devices or equipment (eg, braces. protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Exercise tolerance is improved. * Risk of secondary complications is reduced. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct interventions * Assistive cough techniques * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on ree-xamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with cardiovascular pump dysfunction is reduced.



Page 73 of 188

* Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Level of patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge



Page 74 of 188

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient,/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Aerobic Capacity and Endurance Associated With Cardiovascular Pump Failure This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients who have impaired aerobic capacity associated with cardiovascular pump failure and who may have any one or a combination of the following: * Abnormal heart rate response to increased oxygen demand * Complex ventricular arrhythmias * Ejection fraction of less than 30% * Flat or falling blood pressure response to increased oxygen demand * Functional capacity of less than or equal to 4 or 5 metabolic equivalent units (METs) * Severe exercise-induced myocardial ischemia ([is greater than]2 mm ST segment, depression) * Symptomatic response to increased oxygen demand INCLUDES patients/clients with: * Atrioventricular block * Cardiogenic shock



Page 75 of 188

* Cardiomyopathy * Complicated myocardial infarction EXCLUDES patients/clients with: * Age of fewer than 4 months * Mechanical ventilation * Membrane oxygenator * Intra-aortic balloon pump support * Left ventricular assist device ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 391 Rheumatic fever with heart involvement 394 Diseases of mitral valve 395 Diseases of aortic valve 396 Diseases of mitral and aortic valves 397 Diseases of other endocardial structures 398 Other rheumatic heart disease 402 Hypertensive heart disease 403 Hypertensive renal disease 404 Hypertensive heart and renal disease 410 Acute myocardial infarction 411 Other acute and subacute forms of ischemic heart disease 412 Old myocardial infarction 413 Angina pectoris 414 Other forms of chronic ischemic heart disease 415 Acute pulmonary heart disease 416 Chronic pulmonary heart disease 416.0 Primary pulmonary hypertension 422 Acute myocarditis 423 Other diseases of pericardium 423.2 Constrictive pericarditis 424 Other diseases of endocardium 424.0 Mitral valve disorders 425 Cardiomyopathy 426 Conduction disorders 426.0 Atrioventricular block, complete 426.1 Atrioventricular block, other and unspecified 427 Cardiac dysrhythmias 428 Heart failure 428.0 Congestive heart failure 429 Ill-defined descriptions and complications of heart disease 429.0 Myocarditis, unspecified 440 Atherosclerosis 441 Aortic aneurysm and dissection 444 Arterial embolism and thrombosis



Page 76 of 188




Page 77 of 188

History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Post Medical/Surgical History * Cardiopulmonary



Page 78 of 188

* Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal



Page 79 of 188

* Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Claudication time tests * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Palpation of pulses * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)



Page 80 of 188

* Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client and caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of environment and tasks * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure



Page 81 of 188

activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of safety in work (job/school/play) environments Body Mechanics: * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility



Page 82 of 188

* Gait, locomotion, and balance profiles Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of pain and soreness Motor Function (Motor Control and Motor Learning) * Motor assessment scales * Physical performance scales * Analysis of gait, locomotion, and balance Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Neuromotor Development and Sensory Integration * Analysis of gait and posture * Analysis of reflex movement patterns * Assessment of behavioral response * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device



Page 83 of 188

* Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, still photography, video-tape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * ADL scales and indexes



Page 84 of 188

* Analysis of adaptive skills * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of environment and tasks * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment classification of edema through volume and girth measurements * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of chest wall mobility, expansion, and excursion * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation of major vessels for bruits



Page 85 of 188

* Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, and diaphragmatic motion) * Palpation of pulses * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 12 weeks, patient/client will have increased functional capacity; will be independent and safe with an aerobic exercise program; will be able to identify signs and symptoms of cardiac compromise and his or her own risk factors for heart disease and the interventions that modify those risks; and will demonstrate improved participation in activities of daily living (ADL) and instrumental activities of daily living (IADL) without exacerbation of signs and symptoms. Expected Range of Number of Visits Per Episode of Care 14 to 44 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 14 to 44 visits during a single



Page 86 of 188

continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased.



Page 87 of 188

* Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.



Page 88 of 188

* Disability, associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Demonstration by patient/client or caregiver in the appropriate environment * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals



Page 89 of 188

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Joint integrity and mobility are improved. * Performance of and independence in ADL and IADL are increased. * Physiologic response to increased oxygen demand is improved. * Safety is improved. * Self-management of symptoms is improved. * Strength, power, and endurance are increased. * Symptoms associated with increased oxygen demand are decreased. Specific Direct Interventions * Aerobic endurance activities * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Gait, locomotion, and balance training * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.



Page 90 of 188

* Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device and equipment training * Prosthetic device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is in * Safety is improved during performance of community and work (job/school/play) tasks and activities. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction * Injury prevention or reduction training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)



Page 91 of 188

* Job simulation * Orthotic, protective, and supportive device or equipment training * Prosthetic device or equipment training Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk of secondary impairments is reduced. * Safety is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure



Page 92 of 188

to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with cardiovascular pump failure is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention



Page 93 of 188

* Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Level of patient/client adherence to the intervention program is maximized, * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity and Endurance Associated With Ventilatory Pump Dysfunction This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/client Diagnostic Group Patients/clients with impaired respiration (gas exchange), ventilation, respiratory muscle performance (strength, power, endurance), and airway clearance accompanied by impaired



Page 94 of 188

aerobic capacity and functional limitation. Patients/clients may have any one or a combination of the following: * Abnormal respiratory rate and pattern * Change in baseline breath sounds * Decreased strength or endurance of ventilatory muscles * Decreased vital capacity or tidal volume * Dyspnea * Frequent or recurring pulmonary infection * Impaired cough * Impaired gas exchange * Impaired performance of activities of daily living (ADL) or instrumental activities of daily living (IADL) * Impaired posture * Impaired secretion clearance INCLUDES patients/clients with: * Acute or chronic oxygen dependency * Chronic obstructive pulmonary disease (COPD) * Diaphragmatic disorders * Intermittent negative pressure or assistive ventilatory support * Musculoskeletal disorders affecting ventilation * Neuromuscular disorders affecting ventilation * Status pre-lung transplant * Restrictive lung disease * Tracheostomy/microtracheostomy EXCLUDES patients/clients with: * Acute respiratory failure



Page 95 of 188

* Age of fewer than 4 months * Mechanical ventilator dependency, 24 hours per day ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 045 Acute poliomyelitis 192 Malignant neoplasm of other and unspecified parts of nervous system 192.2 Spinal cord Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.0 Other degenerative diseases of the basal ganglia 333.3 Tics of organic origin 333.4 Huntington's chorea 333.9 Other and unspecified extrapyramidal disease abnormal movement disorders 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 335 Anterior horn cell disease 335.2 Motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 343 Infantile cerebral palsy 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 357 Inflammatory and toxic neuropathy 357.0 Acute infective polyneuritis Guillain-Barre syndromes 359 Muscular dystrophies and other myopathies 359.1 Hereditary progressive muscular dystrophy 482 Other bacterial pneumonia



Page 96 of 188

482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis 491.8 Other chronic bronchitis 491.9 Unspecified chronic bronchitis 492 Emphysema 492.8 Other emphysema 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD], not otherwise specified 513 Abscess of lung and mediastinum 513.0 Abscess of lung 515 Postinflammatory pulmonary fibrosis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 519 Other diseases of respiratory system 519.4 Disorders of diaphragm 737 Curvature of spine 737.3 Kyphoscoliosis and scoliosis 770 Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory diseases arising in the perinatal period Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified 786.5 Chest, pain 786.52 Painful respiration 803 Other and unqualified skull fractures 850 Concussion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax



Page 97 of 188

861.21 Contusion 941 Burn of face, head, and neck 942 Burns of trunk 947 Burns of internal organs 947.1 Larynx, trachea, and lung 947.9 Unspecified site Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history



Page 98 of 188

Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition Concerns that led patient/client to seek the services of a physical therapist Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions



Page 99 of 188

* Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary



Page 100 of 188

* Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Palpation of pulses * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth



Page 101 of 188

Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Cranial Nerve Integrity * Assessment of gag reflex * Assessment of swallowing



Page 102 of 188

Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Integumentary Integrity For skin associated with integrumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds Muscle Performance (Including ;Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Neuromotor Development and Sensory Integration * Analysis of gait and posture * Assessment of behavioral response * Assessment of motor function (motor control and motor learning) * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device



Page 103 of 188

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Self-Care and Home Management (Including ADL and IADL) * ADL scales and indexes * Analysis of adaptive skills * Analysis of environment and tasks * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity



Page 104 of 188

* Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of chest wall mobility, expansion, and excursion * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation of major vessels for bruits * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis



Page 105 of 188

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 10 weeks, patient/client will have maximized ventilatory muscle strength, endurance, and aerobic capacity, as demonstrated by maximal ventilatory independence, absence of secretions, and maximal independence in activities of daily living (ADL) and instrumental activities of daily living (IADL). Expected Range of Number of Visits Per Episode of Care 10 to 65 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients clients in this diagnostic group will achieve the goals and outcomes within 10 to 65 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources



Page 106 of 188

* Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased, * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined.



Page 107 of 188

Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are * Patient/client knowledge of personal and environmental factors associate with the condition is increased. * Performance levels m employment, recreational, or leisure activities are improved.



Page 108 of 188

* Physical function and health status are improved. * Progress is enhanced through die participation of patient/client, family, sinificant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregiver in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise including Aerobic Conditioning) Anticipated Goals * Airway clearance is improved. * Atelectasis is decreased. * Ability to perform physical tasks related to self-care, home management, community and work job/school/play) integration or reintegration, and leisure activities is increased. * Endurance is increased. * Joint integrity and mobility are improved. * Need for ventilatory assistance is decreased.



Page 109 of 188

* Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Physiologic response to oxygen demand is improved. * Strength., power, and endurance of the ventilatory muscles are increased. * Symptoms associated with increased oxygen demand are decreased. * Work of breathing is decreased. Specific Direct interventions * Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.



Page 110 of 188

* Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety, is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device training Functional Training in Community and Work Job/school/play) Integration or Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community and work (job/school/play) tasks and activities. * Tolerance to positions and activities is increased. Specific Direct interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), and leisure task adaptation * IDL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device and equipment training Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adoptive, Orthotic, Protective, Supportive, and Prosthetic)



Page 111 of 188

Anticipated Goals * Ability to perform physical tasks is increased. joint integrity and mobility are improved. * Performance and independence in ADL and IADL are increased. * Physical function and health status are improved. * Tolerance to positions and activities is increased. Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Cough is improved. * Risk of recurrence of condition is prevented. * Risk of secondary complications is reduced. * Ventilation, respiration gas exchange), and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions * Active cycle of breathing/forced expiratory technique * Assistive cough techniques * Assistive devices for airway clearance (eg, flutter valve) * Autogenic drainage



Page 112 of 188

* Breathing strategies (eg, training in paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Forced expiratory techniques * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Physical Agents and Mechanical Modalities Anticipated Goals * Independence in airway clearance is increased. Specific Direct interventions Mechanical modalities: * Mechanical percussors * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups-may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved.



Page 113 of 188

* optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with ventilatory pump dysfunction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. * Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Level of patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or



Page 114 of 188

leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achivement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achived. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over die life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Ventilation With Mechanical Ventilation Secondary to Ventilatory Pump Dysfunction This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/client Diagnostic Group Patients/clients who are ventilator dependent with impaired ventilatory pump and decreased aerobic capacity and who may have associated impaired airway clearance. Patients/clients may have any one or a combination of the following: * Abnormal or adventitious breath sounds * Abnormal physiologic response to increased oxygen demand * Decreased strength or endurance of respiratory muscles * Airway clearance dysfunction secondary to artificial airway * Impaired performance of activities of daily living (ADL) or instrumental activities of daily living (IADL) INCLUDES patients/clients with (when not on mechanical ventilator): * Abnormal respiratory rate and tidal volume at rest



Page 115 of 188

* Dyspnea * Dyssynchronous or paradoxical breathing * Neuromuscular disorders * Progressive decrease in arterial oxygen pressure and increase in arterial carbon dioxide pressure * Ventilatory pump failure or chronic obstructive pulmonary disease (COPD) INCLUDES patients/clients with: * Mechanical ventilator dependency, 24 hours per day EXCLUDES patients/clients with: * Acute respiratory failure * Adult respiratory distress syndrome * Age of fewer than 4 months ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 045 Acute poliomyelitis 192 Malignant neoplasm of other and unspecified parts of nervous system 192.2 spinal cord Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 239 Neoplasms of unspecified nature 239.9 site unspecified 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.4 Huntington's chorea 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 335 Anterior horn disease 335.2 Motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 343 Infantile cerebral palsy 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 348 Other conditions of brain 348.1 Anoxic brain damage 357 Inflammatory and toxic neuropathy 357.0 Acute infective polyneuritis Guillain-Barre syndrome 359 Muscular dystrophies and other myopathies 359.1 Hereditary progressive muscle dystrophy 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432 Other and unspecified intracranial hemorrhage 434 Occlusion of cerebral arteries 434.1 Cerebral embolism 492 Emphysema 492.8 Other emphysema 493 Asthma 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD] 505 Pneumoconiosis,



Page 116 of 188

unspecified 515 Postinflammatory pulmonary fibrosis 518 Other diseases of lung 518 Other diseases of lung 518.81 Respiratory failure 519 Other diseases of respiratory system 519.4 Disorders of diaphragm 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.9 Dyspnea 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 941 Burn of face, head, and neck 942 Burn of trunk, 943 Burn of upper limb, except wrist and hand 944 Burn of wrist(s) and hand(s) 945 Burn of lower limb(s) 946 Burns of mutiple specified sites 947 Burn of internal organs 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 977 Poisoning by other and unspecified drugs and medicinal substances 977.9 Unspecified drug or medicinal substance Procedures 96 Nonoperative intubation and irrigation 96.7 other continuous mechanical ventilation Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems



Page 117 of 188

Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and totals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures



Page 118 of 188

* Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function(eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current)



Page 119 of 188

* Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of automic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Ausculation of the heart * Ausculation of the lungs * Interpretation of blood gas analysis or oxygen consumption (V[O.sub.2]) studies * Monitoring via telemetry during activity * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of edema through palpation and volume and girth measurements (eg, during



Page 120 of 188

pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) Assistive and Adaptive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Community and Work (Job/School/Play) Integration/ Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive,.or prosthetic devices and equipment * Analysis of environmental and (work job/school/play) tasks * Assessment of automic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work, and leisure activities * Assessment of safety in community and work (job/school/play) environments * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as



Page 121 of 188

appropriate * Review of reports provided by patient./client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) Cranial Nerve Integrity * Assessment of gag reflex * Assessment of muscle innervated by the cranial nerves * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in work (job/school/play) environments * Assessment of work (job/school/play) performance through batteries of tests * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Body Mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective,



Page 122 of 188

supportive, or prosthetic devices or equipment , * Assessment of automic responses to positional changes * Assessment of safety * Gait, locomotion, and balance profiles * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Integumentary Integrity For skin associated with integumentary description: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of tissue mobility, turgor, and texture Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movements Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength power, and endurance by manual testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device



Page 123 of 188

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practically and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptoms magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) * Assessment of postural, postural, equilibrium, and righting reactions Self-Care and Home Management (Including ADL and IADL) * ADL scales or indexes * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment



Page 124 of 188

* Analysis of self-care in unfamiliar environments * Assessment of ability to transfer * Assessment of automic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Ventilation Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of standard vital signs (eg, blood pressure, heart rate, and respiratory rate) at rest and during and after activity * Assessment of chest wall mobility, expansion, and excursion * Assessment of respiratory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([V[O.sub.2]) studies * Palpation of pulses * Pulse oximetry



Page 125 of 188

* Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 3 weeks,patient/client with acute reversible ventilatory pump failure will be weaned from mechanical ventilation and will demonstrate improved ventilatory muscle performance. Patient/client will show an absence of secretions or be able to independently clear secretions and win demonstrate independence in activities of daily living (ADL) and instrumental activities of daily living (IDL). Within 8 weeks, patient/client with prolonged ventilatory pump failure will be weaned from the mechanical ventilator and with demonstrate improved ventilatory muscle performance. Patient/client will show an absence of secretions or be able to clear independently or with caregiver assistance and will demonstrate independence in ADL and IADL. Patient/client with severe or chronic ventilatory failure with remain on mechanical ventilation and within 8 weeks will be able to perform ADL and IADL with caregiver assistance. Patient/client will show an absence of secretions or be able to clear secretions with caregiver assistance. Expected Range of Number of Visits Per Episode of Care 5 to 20 20 to 40 10 to 60 These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of



Page 126 of 188

patients/client in this diagnostic group will achieve the goals and outcomes within these ranges during a single continuous episode of care Frequency of visits and duration of the episode of care should be determined by die physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased.



Page 127 of 188

* Availability resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are * Decision making is enhanced regarding heath of patient/client and use of health care, resources by patient/client, family, significant others, and caregivers.



Page 128 of 188

* Disability associated with acute or chronic illness is reduced. * Functional independence in activities of that daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage:



Page 129 of 188

Therapeutic Exercise (including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Atelectasis is decreased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Need for assistive equipment or device (mechanical ventilator) is decreased. * Self-management of symptoms is improved. * Strength, power, and endurance of ventilatory muscles are increased. * Symptoms associated with increased oxygen demand are increased. * Tissue perfusion and oxygenation are increased. * Tolerance for positions is increased. * Work of breathing is decreased. Specific Direct Interventions * Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Motor function (motor control and motor learning) training or retraining * Neuromuscular reeducation * Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Sensory training or retraining



Page 130 of 188

* Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Performance of and independence in ADL and IADL are increased. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device and equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety, is improved during performance of community and work (job/school/play) tasks and activities.



Page 131 of 188

* Tolerance to positions and activities is increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Job simulation * Orthotic, protective, or supportive device and equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Muscle spasm is reduced. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Joint mobilization and manipulation * Passive range of motion * Soft tissue mobilization and manipulation Prescription, Application and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)



Page 132 of 188

Anticipated Goals * Ability to perform physical tasks is increased. * Motor function (motor control and motor learning) is improved. * Performance of and independence in ADL and IADL are increased. * Safety is improved. * Tolerance to positions and activities is increased. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamics splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen ) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Cough is improved. * Physical function and health status are improved. * Secondary complications are decreased. * Ventilation, respiration (gas exchange) and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions * Assistive cough techniques * Autogenic drainage * Chest percussion, vibration, and shaking



Page 133 of 188

* Breathing strategies (eg, paced breathing, pursed-lip breathing) * Forced expiratory techniques * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Muscle performance is increased. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) Physical Agents and Mechanical Modalities Anticipated Goals * Independence in airway clearance is increased. Specific Direct Interventions Mechanical modalities: * Mechanical percussors * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes



Page 134 of 188

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identities the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with ventilatory pump dysfunction is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced.



Page 135 of 188

Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goats and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Ventilation and Respiration (Gas Exchange, With Potential for Respiratory Failure This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with acute respiratory distress and impaired ventilatory pump and gas exchange, with potential for respiratory failure. Patients/clients may have one or a combination of the following: * Abnormal or adventitious breath sounds



Page 136 of 188

* Central signs of cyanosis * Dyspnea * Dyssynchronous or paradoxical breathing pattern at rest * Lethargy or confusion * Oxygen saturation levels of less than 92% at rest * Respiratory rate of greater than 32 at rest * Use of accessory muscles at rest INCLUDES patients/clients with: * Acute or chronic neuromuscular dysfunction or trauma * Acute pulmonary disease * Asthma * Chronic obstructive pulmonary disease (COPD) * Cystic fibrosis * Pneumonia * Thoracic trauma EXCLUDES patients/clients with: * Age of fewer than 4 months * Mechanical ventilation ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 277.6 Other diseases of circulating enzymes Alpha 1-antitrypsin deficiency



Page 137 of 188

482 Other bacterial pneumonia 482.2 Pneumonia due to Hemophilus influenzae [H.influenzae] 482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis 491.8 Other chronic bronchitis 491.9 Unspecified chronic bronchitis 492 Emphysema 492.8 Other emphysema Emphysema (lung or pulmonary), not otherwise specified 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD] 513 Abscess of lung and mediastinum 513.0 Abscess of lung 514 Pulmonary congestion and hypostasis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.5 Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 519 Other diseases of respiratory system 519.4 Disorders of diaphragm 770 Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory disease arising in perinatal period Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified 786.5 Chest pain 786.52 Painful respiration 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion 997 Complications affecting specified body systems, not elsewhere classified 997.3 Respiratory complication Procedures 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 54 Other operations on abdominal wall 54.9 Other operations of abdominal region 54.99 Other Examination



Page 138 of 188

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition



Page 139 of 188

* Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic



Page 140 of 188

* Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular



Page 141 of 188

Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Auscultation of major vessels for bruits * Monitoring via telemetry during activity * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation Cranial Nerve Integrity * Assessment of gag reflex



Page 142 of 188

* Assessment of swallowing Ergonomics and Body Mechanics * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of safety in work (job/school/play) environments Gait, Locomotion, and Balance * Analysis of wheelchair management and mobility * Assessment of autonomic responses to positional changes * Assessment of safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds Joint Integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of pain and soreness Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping) * Assessment of autonomic responses to positional changes Muscle Performance (including Strength, Power, and Endurance)



Page 143 of 188

* Analysis of functional muscle strength, power, and endurance * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position Reflex integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL)



Page 144 of 188

* Analysis of adaptive skills * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Assessment of ability to transfer Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to protect the airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of chest wall mobility, expansion, and excursion * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation of major vessels for bruits * Auscultation and mediate percussion of the lungs * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of



Page 145 of 188

establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 72 hours, patient/client will have adequate gas exchange, with ventilatory parameters indicating ability to ventilate independently, or patient/client will be placed on mechanical ventilation. Expected Range of Number of Visits Per Episode of Care 1 to 9 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 1 to 9 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That may Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition



Page 146 of 188

* Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management



Page 147 of 188

* Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and



Page 148 of 188

caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family,significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Atelectasis is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Need for assistive device (mechanical ventilation) is decreased, * Quality and quantity of movement between and across body segments are improved. Specific Direct Interventions * Breathing exercises and ventilatory muscle training



Page 149 of 188

* Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Strengthening active active assistive resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, home household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Quality and quantity of movement between and across body segments are improved. Specific Direct interventions * Joint mobilization and manipulation



Page 150 of 188

* Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved with decreased dyspnea. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Protective devices or equipment (eg, braces, protective taping, cushions. helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Cough is improved. * Need for assistive device (mechanical ventilation) is decreased. * Ventilation, respiration (gas exchange), and circulation is improved.



Page 151 of 188

* Work of breathing is decreased. Specific Direct interventions * Assistive cough techniques * Autogenic drainage * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Forced expiratory techniques * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment) primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with potential for respiratory failure is reduced. * Safety of patient/client and caregivers is increased.



Page 152 of 188

* Self-care and home management activities, including activities of daily living (ADL) -- and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge



Page 153 of 188

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Ventilation and Respiration (Gas Exchange) With Mechanical Ventilation Secondary to Respiratory Failure This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients who are ventilator dependent with severely impaired gas exchange and impaired ventilatory pump associated with airway clearance impairment. Patients/clients may have any one or a combination of the following: * Abnormal or adventitious breath sounds * Abnormal chest radiograph * Airway clearance dysfunction * Impaired respiration (gas exchange) INCLUDES patients/clients with (when not on ventilator): * Abnormal respiratory rate at rest * Dyssynchronous or paradoxical breathing * Inability to maintain arterial oxygen pressure (Pa[O.sub.2]) when receiving supplemental oxygen * Progressive rise in arterial carbon dioxide pressure (Pa[CO.sub.2])



Page 154 of 188

* Severe dyspnea INCLUDES patients/clients with: * Acute respiratory failure * Adult respiratory distress syndrome * Cardiothoratic surgery * Multisystem failure * Severe pneumonia * Thoracic trauma * Transplant rejection, infection, or failure EXCLUDES patients/clients with: * Age of fewer than 4 months * Cardiovascular pump failure ICD-9-CM Codes As of press time, the Listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 136 Other and unspecified infectious and parasitic diseases 136.3 Pneumocystosis Pneumonia due to pneumocystis carinii 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 286 Coagulation defects 286.6 Defribrination syndrome Diffuse or disseminated intravascular coagulation [DIC syndrome] 348 Other conditions of brain 348.1 Anoxic brain damage 415 Acute Pulmonary heart disease 415.1 Pulmonary embolism and infarction 480 Viral pneumonia 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] 482 Other bacterial pneumonia 483 Pneumonia due to other specified organism 484 Pneumonia in infectious diseases classified elsewhere 485 Bronchopneunonia, organism unspecified 486 Pneumonia, organism unspecified 491 Chronic bronchitis 493 Asthma 495 Extrinsic allergic alveolitis 495.7 "Ventilation" pneumonitis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD] 507 Pneumonitis due to solids and liquids 507 Due to inhalation of food or vomitus Aspiration pneumonia 511 Pleurisy 511.8 Other specified forms of effusion, except tuberculous Hemothorax 512 Pneumothorax 512.8 Other spontaneous pneumothorax 513 Abscess of lung and mediastinum 514 Pulmonary congestion and hypostasis Pulmonary edema, not otherwise specified 517 Lung involvement in conditions classified



Page 155 of 188

elsewhere 518 Other diseases of lung 518.5 Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome 518.8 Other diseases of lung 518.81 Respiratory failure 518.82 Other pulmonary insufficiency, not elsewhere classified Acute respiratory distress 770 Other respiratory conditions of fetus and newborn 770.4 Primary atelactasis 770.7 Chronic respiratory diseases aarising in the perinatal period Bronchopulmonary dysplasia 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage, following injury 854 Intracnial injury of other and unspecified nature 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion 959 Injury, other and unspecified 996 Complications peculiar to certain specified procedures 996.0 Mechanical complication of cardiac device, implant, and graft 996.1 Mechanical complication of other vascular device, implant, and graft 996.2 Mechanical complication of nervous system device, implant, and graft 996.3 Mechanical complication of genitourinary device, implant, and graft 996.4 Mechanical complication of internal orthopedic device, implant, and graft 996.5 Mechanical complication of other specified prosthetic device, implant, and graft 996.8 Complications of transplanted organ 996.85 Bone marrow Factors influencing Health Status and Contact With Health Services V42 Organ or tissue replaced by transplant V42.0 Kidney V42.1 Heart V42.4 Bone V42.6 Lung V42.7 Liver V42.8 Other specified organ or tissue V42.81 Bone marrow Procedures 32 Excision of lung and bronchus 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 36 Operations on vessels of heart 36.1 Bypass anastomosis for heart revascularization 54 Other operations on abdominal region 54.9 Other operations of abdominal region 54.99 Other 96 Nonoperative intubation and irrigation 96.7 Other continuous mechanical ventilation Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, facility, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History



Page 156 of 188

* Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical



Page 157 of 188

therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobolity, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)



Page 158 of 188

* Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceivedexertion (RPE) scales, dyspnea scales,anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs * Monitoring via telemetry during activity * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics



Page 159 of 188

Anthropometric Characteristics * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of level of consciousness * Assessment of orientation to time, person, place, and situation * Screening for gross expressive (eg, verbalization) deficits * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device Integumentary integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile)



Page 160 of 188

* Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobolity turgor and texture Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movements * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of pain and soreness Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping) * Assessment of autonomic responses to positional changes Muscle Performance including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance by manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pain and soreness Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effect; and benefits including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care



Page 161 of 188

* Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Posture * Analysis of resting posture in any position Range of Motion (ROM) (Including Muscle Length) * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photograpbic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-care and Home Management (Including ADL and IADL) * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care in unfamiliar environments * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity



Page 162 of 188

* Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise * Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, * dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of cough and sputum * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Palpation of chest wall (eg, tactile, fremitus pain, diaphragmatic motion)



Page 163 of 188

* Palpation of pulses * Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 72 hours, patient/client with acute reversible respiratory failure will be weaned from mechanical ventilation and will show an absence of secretions or be able to clear secretions independently, or caregiver will be able to manage the secretions and the chest radiograph will show significant improvement. Patient/client win demonstrate independence in activities of daily living (ADL) and instrumental activities of daily living (IADL). Within 3 weeks, patient/client with prolonged respiratory failure will be weaned from mechanical ventilation and will show an absence of secretions or be able to clear secretions independently or with caregiver assistance. The chest radiograph will be clear, return to baseline, or show clearance of the acute process. Patient/client will demonstrate independence in ADL or IADL. Patient/client with severe or chronic respiratory failure will remain mechanically ventilated indefinitely and within 4 to 6 weeks will demonstrate ability to clear secretions independently or with caregiver assistance. Patient/client will show improved participation in ADL and IADL. Expected Range of Number of Visits Per Episode of Care



Page 164 of 188

3 to 9 10 to 25 10 to 45 These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within these ranges during a single continuous episode of care Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care of That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by



Page 165 of 188

the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals



Page 166 of 188

* Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily, living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, no, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Demonstration by patient/client or caregivers in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Verbal instruction * Written or pictorial instruction



Page 167 of 188

Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Atelactasis is decreased. * Endurance is increased. * Energy expenditure is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Need for assistive device (mechanical ventilation) is decreased. * Physiologic response to increased oxygen demand is improved. * Tissue perfusion and oxygenation are increased. * Work of breathing is decreased. Specific Direct Interventions * Aerobic endurance activities * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Neuromuscular relaxation, inhibition, and facilitation * Strengthening - active - active assistive - resistive * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL)



Page 168 of 188

Anticipated Goals * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * Orthotic, protective, or supportive device training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented.



Page 169 of 188

* Loading on a body part is decreased. * Protection of body parts is increased. * Safety is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Ventilation, respiration (gas exchange), and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions * Assistive cough techniques * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation) Re examination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic



Page 170 of 188

groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with respiratory failure is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.



Page 171 of 188

Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity and Endurance Secondary to Respiratory Failure in the Neonate This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group



Page 172 of 188

Patients who are neonates or in early infancy (eg, up to 4 months of age) who have impaired gas exchange and ventilatory pump related to prematurity; postmaturity; congenital heart, lung, or diaphragm abnormalities; infection; complications of medical management; or impairments secondary to other systemic dysfunctions. These patients often require mechanical ventilation and may have any one or a combination of the following, on or off the ventilator: * Apnea and bradycardia * Cyanosis * Impaired airway clearance * Impaired cough * Impaired respiration (gas exchange) * Increased work of breathing * Paradoxical and abnormal breathing pattern * Physiologic intolerance of routine care INCLUDES patients with: * Abdominal/thoracic surgery * Bronchopulmonary dysplasia * Congenital anomalies * Hyaline membrane disease * Intermittent or continuous ventilatory support * Meconium aspiration syndrome * Neurovascular disorders * Pneumonia EXCLUDES patients with: * Age of more than 4 months ICD- 9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.



Page 173 of 188

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 508 Respiratory condition due to unspecified and external agents 508.9 Respiratory condition due to unspecified external agent 514 Pulmonary congestion and hypostasis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 553 Other hernia of abdominal cavity without mention of obstruction or gangrene 553.3 Diaphragmatic hernia 769 Respiratory distress syndrome Hyaline membrane disease (pulmonary) 770 Other respiratory conditions of fetus and newborn 770.1 Meconium aspiration syndrome 770.6 Transitory tachypnea of newborn 770.7 Chronic respiratory disease arising in the perinatal period Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary Language * Race/ethnicity * Sex Social History



Page 174 of 188

* Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (ML) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical



Page 175 of 188

therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)



Page 176 of 188

* Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) * Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary, * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Aerobic Capacity and Endurance * Assessment of ability to control body temperature * Assessment of autonomic responses to positional changes * Assessment of signs of infant respiratory distress (eg, sternal and intercostal retractions, nasal flaring, paradoxical breathing pattern, expiratory grunting, cyanosis, pallor, apnea, bradycardia, head bobbing) at rest, during activity (eg, routine care, evaluation, and treatment), and during recovery * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Auscultation of the heart * Auscultation of the lungs



Page 177 of 188

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Monitoring via telemetry during activity * Performance or analysis of an electrocardiogram * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of level of consciousness Cranial Nerve integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Physical inspection of the environment



Page 178 of 188

Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of nail beds * Assessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment of ecchymosis Motor Function (Motor Control and Motor Learning) * Motor assessment scales * Analysis of head, trunk, and limb movement * Assessment of autonomic responses to positional changes Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Assessment of muscle tone * Assessment of pain and soreness Neuromotor Development and Sensory integration * Analysis of age-appropriate and sex-appropriate development * Analysis of reflex movement patterns * Assessment of behavioral response



Page 179 of 188

* Assessment of motor function (motor control and motor learning) * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests Posture * Analysis of resting posture in any position Reflex Integrity * Assessment of developmentally appropriate reflexes over time * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) * Assessment of postural, postural, equilibrium, and righting reactions Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest and during activity, either on or off mechanical ventilation



Page 180 of 188

* Assessment of ability to clear airway * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of cardiopulmonary response to performance of * ADL (eg, feeding) * Assessment of cough and sputum * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of chest wa]l mobility, expansion, and excursion * Assessment of ventilatory muscle strength, power, and endurance * Assessment of cyanosis * Auscultation of the heart * Auscultation and mediate percussion of the lungs interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies * Palpation of chest wall (eg, tactile, fremitus, pain, diaphragmatic motion) * Pulse oximetry * Tests and measures of pulmonary function and ventilatory mechanics Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity



Page 181 of 188

of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite of multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Within 6 to 12 months, patient will achieve developmental milestones appropriate to adjusted age (based on prematurity). Within 6 months, patient will be weaned from the ventilator if applicable) and from supplemental oxygen. Caregiver will be able to manage the secretions. Expected Range of Number of Visits Per Episode of Care 16 to 84 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients in this diagnostic group will achieve the goals and outcomes within 16 to 84 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors of the family * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional



Page 182 of 188

limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased * Available resources are maximally utilized. * Care is coordinated with family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews



Page 183 of 188

* Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources by family, significant others, and caregivers are improved. * Decision making is enhanced regarding health of patient/client and the use of health care resources by family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Family and caregiver knowledge of personal and environmental factors associated with the condition is increased. * Physical function and health status are improved. * Progress is enhanced through the participation of family, significant others, and caregivers. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching



Page 184 of 188

* Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Atelectasis is decreased. * Endurance is increased. * Physical function is improved. * Physiologic response to increased oxygen demand is improved. * Quality and quantity of movement between and across body segments are improved. * Strength and endurance are increased. * Tissue perfusion and oxygenation are increased. Specific Direct Interventions * Balance and coordination training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education * Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Sensory training * Strengthening



Page 185 of 188

- active - active assistive * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Risk of secondary impairments is reduced. * Safety is improved during performance of self-care and home management tasks and activities. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, bathing) for caregiver * Assistive and adaptive device and equipment training for caregiver * Body mechanics training for caregiver * Orthotic, protective, or supportive device or equipment training for caregiver Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Joint mobilization and manipulation * Passive range of motion * Soft tissue mobilization and manipulation Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented.



Page 186 of 188

* Protection of body parts is increased. * Safety is improved. * Tolerance to positions and activities is increased. Specific Direct Interventions * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Cough is improved. * Risk of secondary complications is reduced. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to, respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent



Page 187 of 188

manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Developmental delays associated with functional limitations and disability are reduced. * Risk of disability associated with respiratory failure is reduced. * Safety of patient/client and caregivers is increased. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to family, significant others, and caregivers. * Administrative management of practice is acceptable to family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to family, significant others, and caregivers. * Coordination and conformity of care are acceptable to family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Family and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status; community adaptation; leisure activities; living environment; pathology or impairment that may affect function; or home or work (job/school/play) settings. * Professional recommendations are integrated into home and community environments. * Utilization and cost of health care services are decreased.



Page 188 of 188

Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Source Citation:"Cardiopulmonary." Physical Therapy 77.n11 (Nov 1997): 1451(104). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 114

Integumentary. (skin)(includes related information)(Preferred Practice Patterns)(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1557 (62). (26320 words)


Preferred Practice Patterns: Integumentary The following patterns describe the elements of patient/client management provided by physical therapists -- examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Pattern A: Primary Prevention/Risk Factor Reduction for Integumentary Disorders 7A-1 Pattern B: Impaired Integumentary Integrity Secondary to Superficial Skin Involvement 7B-1 Pattern C: Impaired Integumentary Integrity Secondary to Partial-Thickness Skin Involvement and Scar Formation 7C-1 Pattern D: Impaired Integumentary Integrity Secondary to Full-Thickness Skin Involvement and Scar Formation 7D-1 Pattern E: Impaired Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone 7E-1 Pattern F: Impaired Anthropometric Dimensions Secondary to Lymphatic System Disorders 7F-1 Primary Prevention/Risk Factor Reduction for Integumentary Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with a potential risk for disruption in the integument. Patients/clients may have any one or a combination of the following: * Edema



Page 2 of 114

* Inflammation * Integument repaired by primary intention * Ischemia * Low or moderate risk assessment score (eg, for pressure, insensitivity) * Pain * Prior scar INCLUDES patients/clients at any stage with: * Amputation * Central nervous system disorder * Congestive heart failure * Diabetes * Obesity * Spinal cord involvement * Surgery * Vascular disease EXCLUDES patients/clients with: * Flaps * Grafts ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 250 Diabetes mellitus 277 Other and unspecified disorders of metabolism 277.6 Other deficiencies of circulating enzymes Hereditary angioedema 278 Obesity and other hyperalimentation 278.0 Obesity 320 Bacterial meningitis 322 Meningitis of unspecified cause



Page 3 of 114

322.9 Meningitis, unspecified 323 Encephalitis, myelitis, and encephalomyelitis 331 Other cerebral degenerations 331.7 Cerebral degeneration in diseases classified elsewhere 331.9 Cerebral degeneration, unspecified 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.2 Myoclonus 334 Spinocerebellar disease 334.0 Friedreich's ataxia 334.1 Hereditary spastic paraplegia 334.2 Primary cerebellar degeneration 334.9 Spinocerebellar disease, unspecified 335 Anterior horn cell disease 336 Other diseases of spinal cord 336.0 Syringomyelia and syringobulbia 336.1 Vascular myelopathies 336.9 Unspecified disease of spinal cord 337 Disorders of the autonomic nervous system 340 Multiple sclerosis 341 Other demyelinating diseases of central nervous system 342 Hemiplegia and hemiparesis 343 Infantile cerebral palsy 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia 344.3 Monoplegia of lower limb 353 Nerve root and plexus disorders 353.9 Unspecified nerve root and plexus disorder 357 Inflammatory and toxic neuropathy 357.2 Polyneuropathy in diabetes 357.3 Polyneuropathy in malignant disease 357.4 Polyneuropathy in other diseases classified elsewhere 357.6 Polyneuropathy due to drugs 428 Heart failure 428.0 Congestive heart failure 435 Transient cerebral ischemia Cerebrovascular insufficiency (acute) with transient focal neurological signs and symptoms; insufficiency of carotid artery 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 440 Atherosclerosis 443 Other peripheral vascular disease 443.0 Raynaud's syndrome 443.1 Thromboangiitis obliterans [Buerger's disease] 443.9 Peripheral vascular disease, unspecified 454 Varicose veins of lower extremities 457 Noninfectious disorders of lymphatic channels 457.0 Postmastectomy lymphedema syndrome 457.1 Other lymphedema 459 Other disorders of circulatory system 459.1 Postphlebitic syndrome 459.8 Other specified disorders of circulatory system 459.81 Venous (peripheral) insufficiency, unspecified 459.9 Unspecified circulatory system disorder 581 Nephrotic syndrome 581.9 Nephrotic syndrome with unspecified pathological lesion in kidney Nephritis with edema, not otherwise specified 593 Other disorders of kidney and ureter 593.8 Other specified disorders of kidney and ureter 593.81 Vascular disorders of kidney 686 Other local infections of skin and subcutaneous tissue 686.9 Unspecified local infection of skin and subcutaneous tissue 701 Other hypertrophic and atrophic conditions of skin 701.4 Keloid scar Hypertrophic scar 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 716 Other and unspecified arthropathies 716.6 Unspecified monoarthritis 719 Other and unspecified disorders of joint 719.4 Pain in joint 728 Disorders of muscle, ligament, and fascia 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.5 Pain in limb 757 Congenital anomalies of the integument 757.0 Hereditary edema of legs 782 Symptoms involving skin and other integumentary tissue 782.0 Disturbance of skin sensation 782.3 Edema 895 Traumatic amputation of toe(s) (complete) (partial) 895.0 Without mention of complication 896 Traumatic amputation of foot (complete) (partial) 896.2 Bilateral, without mention of complication 897 Traumatic amputation of leg(s) (complete) (partial) 897.0 Unilateral, below knee, without mention of complication 897.2 Unilateral, at or above knee, without mention of complication 897.4 Unilateral, level not specified, without mention of complication 897.6 Bilateral [any level], without mention of complication 995.1 Angioneurotic edema Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.



Page 4 of 114




Page 5 of 114

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular



Page 6 of 114

* Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Integumentary Integrity For skin associated with integumentary disruption:



Page 7 of 114

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, itch, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment of ecchymosis * Assessment of scar tissue (cicatrix), including banding, pliability sensation, and texture Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain



Page 8 of 114

* Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that night be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 1 to 3 weeks, patient/client or caregiver will be independent in skin inspection. Patient/client will demonstrate knowledge of disease-preventing behavior and will demonstrate knowledge of risk factors of integumentary disruption and methods to modify those risk factors. Expected Range of Number of Visits Per Episode of Care 1 to 6 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in



Page 9 of 114

this diagnostic group will achieve the goals and outcomes within 1 to 6 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Modify Frequency of Visits * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppresion (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of



Page 10 of 114

symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of client and use of health care resources by patient/client, family, significant others, and caregivers. Specific Interventions * Communication (direct or indirect) * Coordination of care with client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of client management * Education plans * Referrals to other professionals or resources Patient/client-related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of client and use of health care resources by client. * Client knowledge of personal and environmental factors associated with the condition is increased.



Page 11 of 114

* Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by client in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise including Aerobic Conditioning) Anticipated Goals * Joint integrity and mobility are improved. * Nutrient delivery to tissue is increased. * Physiologic response to increased oxygen demand is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Sensory awareness is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Breathing exercises



Page 12 of 114

* Posture awareness training Functional Training in Self-Care and Home Management (Including (ADL and IADL) Anticipated Goals * Ability to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (Job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. Specific Direct Interventions * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) Manual Therapy Techniques including Mobilization and Manipulation) Anticipated Goals * Integumentary integrity is improved. * Pain is decreased.



Page 13 of 114

* Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Protection of body parts is increased. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)



Page 14 of 114

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment. * Optimal role function (eg, worker, student, spouse, grandparent) is maintained. * Health-related quality of life is enhanced. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of prevention strategies is demonstrated. Client Satisfaction * Access, availability, and services provided are acceptable to client. * Administrative management of practice is acceptable to client. * Clinical proficiency of physical therapist is acceptable to client. * Coordination and conformity of care are acceptable to client. * Interpersonal skills of physical therapist are acceptable to client, family, and significant others. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides



Page 15 of 114

for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the fife span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Integumentary Integrity Secondary to Superficial Skin Involvement PATTERN B This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/client Diagnostic Group Patients/clients with superficial skin involvement. Patients/clients may have any one or a combination of the following: * Burns (first degree) * Contusion * Dermopathy * Neuropathic ulcers (grade) * Pressure ulcers (stage I) * Vascular disease (eg, venous, arterial, diabetic) INCLUDES patients/clients with: * Cellulitis * Dermatitis EXCLUDES patients/clients with: * Any break in skin integrity * Frostbite



Page 16 of 114

ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 250 Diabetes mellitus 454 varicose veins of lower extremities 454.1 With inflammation 690 Erythematosquainous dermatosis 691 Atopic dermatitis and related conditions 692 Contact dermatitis and other eczema 692.7 Due to solar radiation 692.71 Sunburn 700 Corns and callosities 707 Chronic ulcer of skin 707.0 Decubitus ulcer 707.1 Ulcer of lower limbs, except decubitus 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.8 Other bone involvement in diseases classified elsewhere 782 Symptoms involving skin and other integumentary tissue 782.2 Localized superficial swelling, mass, or lump 782.7 Spontaneous ecchymoses 782.8 Changes in skin texture 920 Contusion of face, scalp, and neck, except eye(s) 922 Contusion of trunk 922.0 Breast 922.1 Chest wall 922.2 Abdominal wall 922.31 Back 922.32 Buttock 922.33 Interscapular region 922.8 Multiple sites of trunk 923 Contusion of upper limb 923.0 Shoulder and upper arm 923.1 Elbow and forearm 923.2 Wrist and hand(s), except finger(s) alone 923.3 Finger 923.8 Multiple sites of upper limb 924 Contusion of lower limb and of other unspecified sites 924.0 Hip and thigh 924.1 Knee and lower leg 924.2 Ankle and foot, excluding toe(s) 924.3 Toe 924.4 Multiple sites of lower limb 942 Burn of trunk 942.1 Erythema [first degree] 943 Burn of upper limb, except wrist and hand 943.1 Erythema [first degree] 944 Burn of wrist(s) and hand(s) 944.1 Erythema [first degree] 945 Burn of lower limb (s) 945.1 Erythema [first degree] 946 Burns of multiple specified sites 946.1 Erythema [first degree] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.1 Erythema [first degree] Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairment, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age



Page 17 of 114

* Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional



Page 18 of 114

response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Post History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Geritourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions



Page 19 of 114

Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behaviorl health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth * measurements (eg, during pregnancy, in determining the effects of other medical or health-



Page 20 of 114

related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition * Assessment of level of recall (eg, short- and long-term memory) Assistive and Adaptive Devices * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Assessment of patient/client and caregiver ability to care for device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound:



Page 21 of 114

* Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment for signs of infection * Assessment of activities, devices, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of burn * Assessment of ecchymosis * Assessment of pigment (color) * Assessment of sensation (eg, pain, temperature, (tactile) * Assessment of shape and size of skin involvement Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practically and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain and soreness Range of Motion (ROM) (Including Muscle Length)



Page 22 of 114

* Analysis of ROM using goniometers, tape measures, flexible rulers, inchnometers, photographic or electronic devices, or computer-assisted graphic imaging Sensory Integrity * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capilary refill time * Assessment of standard vital signs (eg, blood pressure, hearth rate, respiratory rate) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 2 weeks, patient/client will show resolution of skin involvement. Expected Range of Number of Visits Per Episode of Care 1 to 6 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 1 to 6 visits during a single



Page 23 of 114

continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home heath aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to * the intervention program * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability of optimization patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and



Page 24 of 114

prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized * Care is coordinated with patient/client, family significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and die use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' * Compensation claims manager, (employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals



Page 25 of 114

* Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of that living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairment is reduced. * Safety of patient/client family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program



Page 26 of 114

* Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. * Pain is decreased. * Postural control is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Utilization and cost of health care services are decreased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training



Page 27 of 114

* Posture awareness training Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Assistive and adaptive device or equipment training IADL training (eg, maintaining a home,



Page 28 of 114

shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Protection of body parts is increased. * Pressure areas (eg, pressure over bony prominence) are prevented.



Page 29 of 114

* Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, braces, shoe inserts, casts, splints, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Risk factors for infection are reduced. * Risk of secondary, impairments is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound and soft tissue healing is enhanced. * Wound size is reduced. Specific Direct Interventions * Dressings (eg, wound coverings) * Orthotic, protective, and supportive devices * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities



Page 30 of 114

Anticipated Goals * Complications are reduced. * Pain is decreased. * Risk of secondary, impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue heating is enhanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, and total contact casting) * Tilt table or standing table



Page 31 of 114

Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with superficial skin involvement is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.



Page 32 of 114

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.



Page 33 of 114

Patient/Client Diagnostic Group Patients/clients with partial-thickness skin involvement. Patients/clients may have any one or a combination of the following: * Burns (second degree) * Dermatologic disorders * Hematoma * Neuropathic ulcers (grade 1) * Pressure ulcers (stage II) * Prior scar * Surgical wounds * Traumatic injury * Vascular ulcers (eg, venous, arterial, diabetic) INCLUDES patients/clients at any stage with: * Epidermolysis bullosa * Immature scar * Neoplasms (including Kaposi's sarcoma) * Pemphigus vulgaris * Status post-spinal cord injury * Toxic epidermal necrolyzing syndrome (Stevens-Johnson syndrome) EXCLUDES patients/clients with: * A total body surface area (TBSA) involvement of more than 25% in adults and more than 20% in children who are medically unstable * Acute amputation * Frostbite * Injury secondary to trauma (eg, multiple fractures, amputations, electricity-related injuries) ICD-9-CM Codes



Page 34 of 114

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 031 Diseases due to other mycobacteria 031.1 Cutaneous 216 Benign neoplasm of skin 216.5 Skin of trunk, except scrotum 216.6 Skin of upper limb, including shoulder 216.7 Skin of lower limb, including hip 232 Carcinoma in situ of skin 232.5 skin of trunk, except scrotum 232.6 Skin of upper limb, including shoulder 232.7 skin of lower limb, including hip 239 Neoplasms of unspecified nature 239.2 Bone, soft tissue, and skin 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 682 Other cellulitis and abscess 686 Other local infections of skin and subcutaneous tissue 694 Bullous dermatoses 694.5 Pemphigoid 695 Erythematous conditions 695.1 Erythema multiforme 695.4 Lupus erythematosus 696 Psoriasis and similar disorders 696.1 other psoriasis 701 Other hypertrophic and atrophic conditions of skin 701.0 Circumscribed scleroderma 701.3 Striae atrophicae Atrophy blanche (of Milian) 701.4 Keloid scar 707 Chronic ulcer of skin 707.0 Decubitus ulcer



Page 35 of 114

707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 709.3 Degenerative skin disorders 757 Congenital anomalies of the integument 911 Superficial injury of trunk 911.0 Abrasion or friction burn without mention of infection 911.1 Abrasion or friction bum, infected 911.2 Blister without mention of infection 911.3 Blister, infected 912 Superficial injury of shoulder and upper arm 912.0 Abrasion or friction burn without mention of infection 912.1 Abrasion or friction bum, infected 912.2 Blister without mention of infection 912.3 Blister, infected 913 Superficial injury of elbow, forearm, and wrist 913.0 Abrasion or friction burn without mention of infection 913.1 Abrasion or friction burn, infected 913.2 Blister without mention of infection 913.3 Blister, infected 914 Superficial injury of hand(s), except finger(s) alone 914.0 Abrasion or friction burn without mention of infection 914.1 Abrasion or friction burn, infected 914.2 Blister without mention of infection 914.3 Blister, infected 915 Superficial injury of finger(s) 915.0 Abrasion or friction burn without mention of



Page 36 of 114

infection 915.1 Abrasion or friction burn, infected 915.2 Blister without mention of infection 915.3 Blister, infected 916 Superficial injury of hip, thigh, leg, and ankle 916.0 Abrasion or friction burn without mention of infection 916.1 Abrasion or friction burn, infected 916.2 Blister without mention of infection 916.3 Blister, infected 917 Superficial injury of foot and toe(s) 917.0 Abrasion or friction burn without mention of infection 917.1 Abrasion or friction burn, infected 917.2 Blister without mention of infection 917.3 Blister, infected 942 Burn of trunk 942.2 Blisters, epidermal loss [second degree] 943 Burn of upper limb, except wrist and hand 943.2 Epidermal loss [second degree] 944 Burn of wrist(s) and hand(s) 944.2 Blisters, epidermal loss [second degree] 945 Burn of lower limb(s) 945.2 Blisters, epidermal loss [second degree] 946 Burns of multiple specified sites 946.2 Blisters, epidermal loss [second degree] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.2 Blisters, epidermal loss [second degree] Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age;



Page 37 of 114

severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events



Page 38 of 114

* Onset and pattern of symptoms * Patient/client, family, significant other, * and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal



Page 39 of 114

* Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anotomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during



Page 40 of 114

pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition * Assessment of level of recall (eg, short-term and long-term memory) Assistive and Adaptive Devices * Assessment of patient/client and caregiver ability to care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of nail beds * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound:



Page 41 of 114

* Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment for signs of infection * Assessment of burn * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of bleeding * Assessment of pigment (color) * Assessment of scar tissue cicatrix), including banding, pliability, sensation, and texture * Assessment of scar tissue mobility, turgor, and texture * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of wound contraction, drainage location, odor, shape, size, and depth (eg, linear, tracing, photography) * Assessment of wound tissue, including epithelium, granulation, necrosis, slough, texture, and turgor * Assessment of ecchymosis Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device



Page 42 of 114

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain and soreness Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis



Page 43 of 114

Over the course of 4 weeks, patient/client will achieve wound closure. Expected Range of Number of Visits Per Episode of Care 4 to 40 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 4 to 40 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the



Page 44 of 114

plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences



Page 45 of 114

* Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions



Page 46 of 114

* Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved, * Pain is decreased. * Postural control is improved, * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased.



Page 47 of 114

* Utilization and cost of health care services are decreased, * Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training * Posture awareness training * Strengthening Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.



Page 48 of 114

* Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased, Specific Direct Interventions * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased.



Page 49 of 114

* Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominences) are prevented * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are improved. * Risk factors for infection are reduced.



Page 50 of 114

* Risk of secondary impairments is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement -- selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic Modalities) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical Agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Complications are reduced. * Pain is decreased.



Page 51 of 114

* Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, and total contact casting) * Tilt table or standing table Re examination



Page 52 of 114

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with partial-thickness skin involvement and scar tissue is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.



Page 53 of 114

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goats (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Integumentary Integrity Secondary to Full-Thickness Skin Involvement and Scar Formation PATTERN D This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and



Page 54 of 114

standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with full-thickness involvement. Patients/clients may have any one or a combination of the following: * Burns * Dermatologic disorders * Hematoma * Lymphostatic ulcers * Necrotizing fasciitis * Neuropathic ulcers (grade 2) * Pressure ulcer (stage 3) * Prior scar * Vascular ulcers (eg, venous, arterial, diabetic) INCLUDES patients/clients at any stage with: * Abscess * Frostbite * Immature, hypertrophic, or keloid scar * Neoplasm * Surgical wound * Toxic epidermal necrolysis (Stevens-Johnson syndrome) EXCLUDES patients/clients with: * Amputations * Crushing injury * Electricity-related injury * Lymphedema



Page 55 of 114

* Traumatic wound ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 031 Diseases due to other mycobacteria 031.1 Cutaneous 036 Meningococcal infection 036.1 Meningococcal encephalitis 040 Other bacterial diseases 040.0 Gas gangrene 172 Malignant melanoma of skin 172.5 Trunk, except scrotum 172.6 Upper limb, including shoulder 172.7 Lower limb, including hip 172.8 Other specific sites of skin 173 Other malignant neoplasm of skin 173.5 Skin of trunk, except scrotum 173.6 Skin of upper limb, including shoulder 173.7 Skin of lower limb, including hip 173.8 Other specified sites of skin 176 Kaposi's sarcoma 176.0 Skin 216 Benign neoplasm of skin 232 Carcinoma in situ of skin 239 Neoplasms of unspecified nature 443 Other peripheral vascular disease 443.1 Thromboangiitis obliterans [Buerger's disease] 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 680 Carbuncle and furuncle 680.2 Trunk



Page 56 of 114

680.3 Upper arm and forearm 680.4 Hand 680.5 Buttock 680.6 Leg, except foot 680.7 Foot 681 Cellulitis and abscess of finger and toe 681.0 Finger 681.1 Toe 682 Other cellulitis and abscess 682.0 Face 682.2 Trunk 682.3 Upper arm and forearm 682.4 Hand, except fingers and thumb 682.5 Buttock 682.6 Leg, except foot 682.7 Foot, except toes 686 Other local infections of skin and subcutaneous tissue 686.0 Pyoderma 686.1 Pyogenic granuloma 686.8 Other specified local infections of skin and subcutaneous tissue 694 Bullous dermatoses 695 Erythematous conditions 695.1 Erythema multiforme 695.4 Lupus erythematosus 701 Other hypertrophic and atrophic conditions of skin 701.0 Circumscribed scleroderma 701.4 Keloid scar 701.5 Other abnormal granulation tissue 707 Chronic ulcer of skin 707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin



Page 57 of 114

709.3 Degenerative skin disorders 941 Burn of face, head, and neck 941.3 Full-thickness skin loss [third degree, not otherwise specified] 942 Burn of trunk 942.3 Full-thickness skin loss [third degree, not otherwise specified) 943 Burn of upper limb, except wrist and hand 943.3 Full-thickness skin loss [third degree, not otherwise specified] 944 Burn of wrist(s) and hand (s) 944.3 Full-thickness skin loss [third degree, not otherwise specified] 945 Burn of lower limb(s) 945.3 Full-thickness, skin loss [third degree, not otherwise specified] 946 Burns of multiple specified sites 946.3 Full-thickness skin loss [third degree, not otherwise specified] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.3 Full-thickness skin loss [third degree, not otherwise specified] Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors



Page 58 of 114

* Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist



Page 59 of 114

* Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Post History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent)



Page 60 of 114

* Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition * Assessment of level of recall (eg, short-term and long-term memory) Assistive and Adaptive Devices * Analysis of patient/client and caregiver ability to care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition



Page 61 of 114

* Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the scar or that may produce additional trauma * Assessment of burn * Assessment of bleeding * Assessment of ecchymosis * Assessment for presence of hair growth * Assessment of pigment (color)



Page 62 of 114

* Assessment of scar mobility, turgor, and texture * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of wound contraction, drainage, location, odor, shape, size, depth (eg, linear, tracing, photography), tunneling, and undermining * Assessment of wound tissue, including epithelium, granulation, necrosis, slough, and texture Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain and soreness Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation



Page 63 of 114

* Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Wound Over the course of 4 to 12 weeks, one of the following will occur: * Wound will be clean and stable. * Wound will be prepared for closure. * Wound will be closed. Scar Over the course of 6 to 12 months, scar will be mature. Expected Range of Number of Visits Per Episode of Care 12 to 60



Page 64 of 114

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 12 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive * pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [IHV/AIDS), cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional



Page 65 of 114

limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews



Page 66 of 114

* Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction



Page 67 of 114

* Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Pain is decreased. * Postural control is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Utilization and cost of health care services are decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength is increased. * Tolerance to positions and activities is increased.



Page 68 of 114

* Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training * Posture awareness training * Strengthening Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to recognize and intiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.



Page 69 of 114

* Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a time, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Manual lymphatic drainage * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and



Page 70 of 114

Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominences) are prevented. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restricted is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets)



Page 71 of 114

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are improved. * Risk factors for infection are reduced. * Risk of secondary impairment is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement -- selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic * Modalities) * Orthotic, protective, and supportive devices



Page 72 of 114

* Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical Agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Complications are reduced. * Edema, lymphedema, or effusion is decreased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Electrical muscle Stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents:



Page 73 of 114

* Athermal modalities (eg, pulsed ultrasound, pulsed radio frequency energy) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot * packs, fluidotherapy) Mechanical modalities: * Continuous passive motion (CPM) * Compression therapies (eg, all compression devices, compression bandaging, compression garments, taping, and total contact casting) * Tilt table or standing table Re examination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with full-thickness skin involvement and scar formation is reduced. * Safety of patient/client and caregivers is increased.



Page 74 of 114

* Self-care and home management activities, including activities of daily living (IADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge



Page 75 of 114

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with subcutaneous tissue involvement that may extend into underlying tissue; patients/clients may have any one or a combination of the following: * Abscess * Hematoma * Necrotizing fasciitis * Neuropathic ulcers (grades 3, 4, 5) * Pressure ulcers (stage 4) * Surgical wounds * Vascular ulcers (eg, venous, diabetic) INCLUDES patients/clients with: * Acute amputation * Burn



Page 76 of 114

* Chronic surgical wound * Electrical burns * Frostbite * Kaposi's sarcoma * Lymphostatic ulcer * Neoplasm * Subcutaneous arterial ulcer * Surgical wound EXCLUDES patients/clients with: * Lymphedema ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 036 Meningococcal infection 036.2 Meningococcemia 171 Malignant neoplasm of connective and other soft tissue 171.2 Upper limb, including shoulder 171.3 Lower limb, including hip 171.5 Abdomen 171.6 Pelvis 171.8 Other specified sites of connective and other soft tissue 172 Malignant melanoma of skin 172.5 Trunk, excluding scrotum 172.6 Upper limb,includingshoulder 172.7 Lower limb, including hip 172.8 Other specific sites of skin 173 Other malignant neoplasm of skin 173.5 Skin of trunk, except scrotum 173.6 Skin of upper limb, including shoulder 173.7 Skin of lower limb, including hip 173.8 Other specified sites of skin 176 Kaposi's sarcoma 176.0 skin 176.1 Soft tissue 215 Other benign neoplasm of connective and other soft tissue 215.2 Upper limb,including shoulder 215.3 Lower limb, including hip 215.6 Pelvis 239 Neoplasms of unspecified nature 239.2 Bone, soft tissue, and skin 440 Atherosclerosis 440.2 Of native arteries of the extremities 440.24 Atherosclerosis of the extremities with gangrene 443 Other peripheral vascular disease 443.1 Thromboangiitis obliterans [Buerger's disease] 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 674 Other and unspecified complications of the perperium, not elsewhere classified 674.1 Disruption of cesarean wound 680 Carbuncle and furuncle 680.2 Trunk 680.3 Upper arm and forearm 680.4 Hand 680.5 Buttock 680.6 Leg, except foot 680.7 Foot 681 Cellulitis and abscess of finger and toe 681.0 Finger 686 Other local infections of skin and subcutaneous tissue 686.8 Other specified local infections of skin and subcutaneous tissue 707 Chronic ulcer of skin 707.0 Decubitus ulcer 707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 710 Diffuse diseases of connective



Page 77 of 114

tissue 710.0 Systemic lupus erythematosus 710.1 Systemic sclerosis 710.3 Dermatomyositis 880 Open wound of shoulder and upper arm 881 Open wound of elbow, forearm, and wrist 882 Open wound of hand except figer(s) alone 883 Open wound of finger(s) 884 Multiple and unspecified open wound of upper limb 885 Traumatic amputation of thumb (complete) (partial) 886 Traumatic amputation of other finger(s) (complete) (partial) 887 Traumatic amputation of arm and hand (complete) (partial) 890 Open wound of hip and thigh 891 Open wound of knee, leg [except thigh], and ankle 892 Open wound of foot except toe(s) alone 893 Open wound of toe(s) 894 Multiple and unspecified open wound of lower limb 895 Traumatic amputation of toe(s) (complete) (partial) 896 Traumatic amputation of foot (complete) (partial) 897 Traumatic amputation of leg(s ) (complete) (partial) 927 Crushing injury of upper limb 928 Crushing injury of lower limb 929 Crushing injury of multiple and unspecified sites 941 Burn of face, head, and neck 941.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 941.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 942 Burn of trunk 942.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 942.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 943 Burn of upper limb, except wrist and hand 943.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 943.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 944 Burn of wrist(s) and hand(s) 944.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 944.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 946 Burns of multiple specified sites 946.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 946.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 948 Burns classified according to extent of body surface involved 991 Effects of reduced temperature 991.1 Frostbite of hand 991.2 Frostbite of foot 991.3 Frostbite of other and unspecified sites 991.4 Immersion foot 991.5 Chilblains 998 Other complications of procedures, not elsewhere classified 998.3 Disruption of operation wound Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity



Page 78 of 114

* Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions



Page 79 of 114

Medications * Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue)



Page 80 of 114

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk and extremities at rest and during activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of level of recall (eg, short-term and long-term memory)



Page 81 of 114

Assistive and Adaptive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of dermatitis (eg, rush, fungus) * Assessment for presence of hair growth * Assessment of activities and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin) * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Asessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for presence of hair and nail growth * Assessment for signs of infection



Page 82 of 114

* Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of bleeding * Assessment of ecchymosis * Assessment of exposed anatomical structures * Assessment of pigment (color) * Assessment of scar mobility, turgor, and texture * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture * Assessment of sensation (eg, pain, protective, temperature, tactile) * Assessment of wound contraction, drainage, location, odor, shape, size, depth (eg, linear, tracing, photography), tunneling and undermining * Assessment of wound tissue, including epithelium, granulation, mobility, necrosis, slough, texture, and turgor Joint integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device



Page 83 of 114

Pain * Assessment of pain and soreness Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, fight touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) * Palpation of pulses Evaluation., Diagnosis, and Prognosis The physical therapist performs an evaluation makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpretion examination data. The prognosis is the determination of the optimal level of improvement that might be answer and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or midtisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatonxic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis



Page 84 of 114

Wound Over the course of 4 to 16 weeks, one of the following will occur: * Wound will be clean and stable. * Wound will be prepared for closure. * Wound will be closed. Scar Over the course of 4 to 16 weeks, immature scar will be evident. Expected Range of Number of Visits Per Episode of Care 12 to 112 12 to 112 These ranges represents the lower and upper limits of the number of physical therapist visits required to achieve the anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 12 to 112 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive * Pulmonary disease, renal disease, cerebrovascular accident) * Imununosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Intrusion beyond tissue-protective surface (eg, fascial plane, peritenon, periosteum) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status



Page 85 of 114

* Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes remediation of functional bmitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management



Page 86 of 114

* Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) * Discharge planting * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/client-related instruction Anticipated Goals * Ability. to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chromic illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and



Page 87 of 114

caregivers. * Risk, of recurrence of condition is reduced. * Risk of secondary, impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. joint integrity and mobility are improved. * Pain is decreased. * Postural control is improved. * Preoperative and postoperative complication are reduced. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairment is reduced.



Page 88 of 114

* Safety is impaired. * Self-management of symptoms is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Breathing exercises * Strengthening * Gait, locomotion, and balance training * Posture awareness training Functional Training in Self-care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training



Page 89 of 114

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work job/school/play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques including Mobilization and Manipulation) Anticipated Goals * Ability, to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased.



Page 90 of 114

Specific Direct interventions * Connective tissue massage * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved * Joint integrity and mobility are improved joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominence)are prevented * Prosthetic fit is achieved. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Utilization and cost of health care services are decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased.



Page 91 of 114

* Weight-bearing status is improved. Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, solints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, stings, neck collars, serial casts, elastic wraps) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are unproved. * Risk factors for infection are reduced. * Risk of secondary improvement is reduced. * Tissue perfussion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings



Page 92 of 114

* Debridement-selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic Modalities) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphederna, or effusion is decreased. joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairment is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased.



Page 93 of 114

* Debridement of nonviable tissue is achieved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairment is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed radio frequency stimulation) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatie lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, all compression devices, compression bandaging, compression garments, taping, and total contact casting) * Continuous passive motion (CPM) * Tilt table or standing table Re examination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify, or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations



Page 94 of 114

for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability), associated with skin involvement extending into fascia, muscle, or bone is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living * ADL -- and work (job/school/play) and leisure activities, including instrumental activities of daily living * (ADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent finger function limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinically proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced.



Page 95 of 114

Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, giving environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendation are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological. psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals. the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The participated goals and the desired outcomes hate been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. N"en discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. F()r patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Impaired Anthropometric Dimensions Secondary to Lympathic System Disorders This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/client Diagnostic Group Patients/clients with lymphatic system involvement. Patients/ clients may have any one or a combination of the following: * Acquired immune deficiency syndrome (AIDS) * Lymphedema



Page 96 of 114

* Status postcancer * Status postinfection * Status posttrauma * Vascular/lymphatic malfunction INCLUDES patients/clients with: * Amputation with lymphedema * Filariasis (elephantiasis) * Multiple abdominal surgeries * Postradiation status * Status post-lymph node dissection in the groin or abdomen * Status post-axillary lymph node dissection * Reconstructive surgery EXCLUDES patients/clients with: * Acute traumatic edema * Acute surgical edema * Congestive heart failure * Deep vein thrombosis (DVT) * Dependent edema * Lymphangiosarcoma * Lymphangitis ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.



Page 97 of 114

040 Other bacterial diseases 040.0 Gas gangrene malignant edema) 176 Kaposi's sarcoma 176.5 Lymph nodes 457 Noninfectious disorders of lymphatic channels 457.0 Postmastectomy lymphedema syndrome 457.1 Other lymphedema 457.8 Other noninfectious disorders of lymphatic channels 457.9 Unspecified noninfectious disorder of lymphatic channels 646 Other complications of pregnancy not elsewhere classified 646.1 Edema or excessive weight gain in pregnancy, without mention of hypertension 683 Acute lymphadenitis 757 Congenital anomalies of the integument 757.0 Hereditary edema of legs 782 Symptoms involving skin and other integumentary tissue 782.8 Changes in skin texture 995 Certain adverse effects not elsewhere classified 995.1 Angioneurotic edema Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex



Page 98 of 114

Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems Occupation/Employment * Current and prior community and work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * Living environment and community characteristics * Projected discharge destinations History of Current Condition * Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) * Sleep patterns and positions Medications



Page 99 of 114

* Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)



Page 100 of 114

* Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Tests and measures for this pattern may include, in alphabetical order: Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth observation and palpation of trunk and extremities at rest and during activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)



Page 101 of 114

* Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * Analysis of effects and benefits including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client and caregiver ability to care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Gait, Locomotion, and Balance * Assessment of safety * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin, signs of cellulitis, or infection) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture (eg, dry, flaky, cracked skin) For the wound: * Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment of drainage Joint integrity and Mobility * Assessment of pain and soreness



Page 102 of 114

Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of muscle soreness Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Sensory integrity including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) * Assessment of receptive (eg, vision, hearing) abilities Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity



Page 103 of 114

* Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 1 to 8 weeks: Patient/client with mild lymphedema (less than 3-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Patient/client with moderate lymphedema (3- to 5-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Patient/client with severe lymphedema (5-plus-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Management of lymphatic involvement may he required over the life span. Expected Range of Number of Visits Per Episode of Care 5 to 7 7 to 14 14-20



Page 104 of 114

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve the anticipated goals and desired outcomes. It is anticipated that 80% of patients/ clients in this diagnostic group will achieve the goals and outcomes within these ranges during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Hardening, fibrosis of limb tissue * Immunosuppression (eg, human * Immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Lymphatic ulceration * Multilimb involvement * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Presence of wound * Support provided by family unit Intervention



Page 105 of 114

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' * Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management



Page 106 of 114

* Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved.



Page 107 of 114

* Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct Intervention for this may include, in order of preferred usage: Therapeutic Exercise including Aerobic Conditioning) Anticipated Goals * Aerobic capacity is increased. * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved, * Pain is decreased. * Postural control is improved. * Risk of recurrence is reduced. * Risk factors are reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved.



Page 108 of 114

* Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength is increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Gait, locomotion, and balance training * Posture awareness training * Strengthening Functional Training in Self-Care and Home Management (Including (ADL and IADL) Anticipated Goals * Ability to recognize and initiate treatment of a recurrence is improved through increased selfmanagement of symptoms. * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Orthotic, protective, or supportive device or equipment training



Page 109 of 114

Functional Training in Community and Work (Job/School/Play) integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integr-ation and reintegration and leisure tasks, movements, or activities is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary. impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Manual lymphatic drainage



Page 110 of 114

* Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominence) are prevented, * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling. inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)



Page 111 of 114

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, longhandled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Protective devices or equipment (eg, braces, cushions, protective taping, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wrap, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Joint integrity and mobility are improved. * Muscle performance is increased.. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enchanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is decreased.



Page 112 of 114

* Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Compression therapies (eg, all compression devices, compression bandaging, compression garments) * Continuous passive motion (CPM) * Cryotherapy (eg, cold packs, ice massage) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices compression bandaging, compression garments, taping, and total contact casting) * Continuous passive motion (CPM) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify, or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life spain. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optional return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with lymphatic system disorders is reduced. * Safety of patient/client and caregivers is increased.



Page 113 of 114

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode



Page 114 of 114

of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status,

Source Citation:"Integumentary." Physical Therapy 77.n11 (Nov 1997): 1557(62). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 9

Glossary.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1620(5). (3036 words)


Activities of daily living (ADL) The self-care, communication, and mobility skills (eg, bed mobility, transfers, ambulation, dressing, grooming, bathing, eating, and toileting) required for independence in everyday living. Adaptive devices A variety of implements or equipment used to aid patients/clients in performing movements, tasks, or activities. Adaptive devices include raised toilet seats, seating systems, environmental controls, and other devices. Aerobic activity/conditioning The performance of therapeutic exercise and activities to increase endurance. Aerobic capacity A measure of the ability to perform work or participate in activity over time using the body's oxygen uptake and delivery and energy release mechanisms. Airway clearance techniques A broad group of activities used to manage or prevent consequences of acute and chronic lung diseases and impairment, including those associated with surgery. Anthropometric characteristics Human body measurements such as height, weight, girth, and body fat composition. Arthrokinematic Describing the motion of a joint without regard to the forces producing that motion or resulting from it; describing the structure and shape of joint surfaces. Assessment The measurement or quantification of a variable or the placement of a value on something. Assessment should not be confused with examination or evaluation. Assistive devices A variety of implements or equipment used to aid patients/clients in performing tasks or movements. Assistive devices include crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, and static and dynamic splints. Auscultation The act of listening to internal body sounds (eg, heart, lungs). Autogenic drainage Airway clearance through the patient's/client's own efforts (eg, coughing). Back school A structured educational program about low back problems, usually offered to a group of patients/clients. Balance The ability to maintain the body in equilibrium with gravity both statically (eg, while stationary) and dynamically (eg, while walking).



Page 2 of 9

Barriers -- environmental, home, and work (job/school/ play) The physical impediments that keep patients/clients from functioning optimally in their surroundings, including safety hazards (eg, throw rugs, slippery surfaces), access problems (eg, narrow doors, high steps), and home or office design difficulties (eg, excessive distance to negotiate, multistory environment). Biofeedback A training technique that enables an individual to gain some element of voluntary control over muscular or autonomic nervous system functions using a device that produces auditory or visual stimuli. Body mechanics The interrelationships of the muscles and joints as they maintain or adjust posture in response to environmental forces. Cardiovascular pump Structures responsible for maintaining cardiac output, including the cardiac muscle, valves, arterial smooth muscle, and venous smooth muscle. Cardiovascular pump dysfunction Abnormalities of the cardiac muscles, valves, conduction, or circulation that interrupt or interfere with cardiac output or circulation. Cicatrix Scar; the fibrous tissue replacing the normal tissues destroyed by injury or disease. Clients Individuals who are not necessarily sick or injured but who can benefit from a physical therapist's consultation, professional advice, or services. Clients are also businesses, school systems, and others to whom physical therapists offer services. Cognition The act or process of knowing, including both awareness and judgment. Community and work (job/school/play) integration or reintegration The process of assuming or resuming roles in the community or at work. Compression therapy Treatment using devices or techniques that decrease the density of a part of the body through the application of pressure. Continuous passive motion (CPM) The use of a device that allows a joint (eg, the knee) to he exercised without the involvement of the patient/client, often in the early postoperative period. Contrast bath The immersion of an extremity in alternating hot and cold water. Cosmesis A concern in rehabilitation, especially regarding surgical operations or burns, for the appearance of the patient/client. Cryotherapy Therapeutic application of cold (eg, ice). Debridement Excision of contused and necrotic tissue from the surface of a wound. Autolytic: selfdebridement, that is, removal of contused or necrotic tissue through the action of enzymes in the tissue. Sharp: debridement using a sharp instrument. Deficit A lack or deficiency. Developmental: The difference between expected and actual (lower) performance in an aspect of development (eg, motor, communication, social). Developmental delay The failure to reach expected age-specific performance in one or more areas of development (eg, motor, sensory-perceptual).



Page 3 of 9

Disability The inability to engage in age-specific, gender-related, and sex-specific roles in a particular social context and physical environment. Discharge The process of discontinuing interventions included in a single episode of care, occurring when the anticipated goals and desired outcomes have been met. Other indicators for discharge: The patient/client declines to continue care, the patient/client is unable to continue to progress toward goals because of medical or psychosocial complications, or the physical therapist determines that the patient/client will no longer benefit from physical therapy. Dynamometry Measurement of the degree of muscle power. Electrical potential The amount of electrical energy residing in specific tissues. Electrical stimulation Intervention through the application of electricity. Electrophysiologic testing The process of examining and recording the electrical responses of the body. Electromyography (EMG) The examining and recording of the electrical activity of a muscle. Electrotherapeutic modalities A broad group of agents that use electricity to produce a therapeutic effect. Endurance The ability of a muscle to sustain forces or to repeatedly generate forces. Episode of care All patient/client management activities provided, directed, or supervised by the physical therapist, from initial contact through discharge. Ergonomics The relationship among the worker, the work that is done, the tasks and activities inherent in that work, and the environment in which the work is performed. Ergonomics uses scientific and engineering principles to improve the safety, efficiency, and quality of movement involved in work. Evaluation A dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination. Examination The process of obtaining a history, performing relevant systems reviews, and selecting and administering specific tests and measures. Fluidotherapy "Dry whirlpool"; the application of dry heat through a fluidotherapy machine. Force plate An embedded plate used to measure the force that a person exerts when walking. Function Those activities identified by an individual as essential to support physical, social, and psychological well-being and to create a personal sense of meaningful living. Functional limitation Restriction of the ability to perform a physical action, activity, or task in an efficient, typically expected efficient, or competent manner. Functional muscle testing Performance-based muscle assessment in particular positions



Page 4 of 9

simulating functional tasks and activities and usually under specific test conditions. Gait The manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed. Goniometry Measurement of the angle of a joint or a series of joints. History An account of past and present health status that includes the identification of complaints and provides the initial source of information about the patient/client. The history also suggests the individual's ability to benefit from physical therapy services. Hydrotherapy Intervention using water. Impairment A loss or abnormality of physiological, psychological, or anatomical structure or function. Secondary: Impairments that originate from other, preexisting impairments. Instrumental activities of daily living (IADL) Activities -- such as shopping, cooking, home chores, heavy household chores, managing money, and structured play for infants and children -- that are important components of maintaining independent living. Intervention The purposeful and skilled interaction of the physical therapist with the patient/client, and, when appropriate, with other individuals involved in care, using various methods and techniques to produce changes in the condition. Iontophoresis Introduction of ions into tissues by means of electric current. Locomotion The ability to move from place to place. Manipulation A passive therapeutic movement, usually of small amplitude and high velocity at the end of the available range of motion. Manual therapy A broad group of skilled hand movements used by the physical therapist to mobilize soft tissues and joints for the purpose of modulating pain, increasing range of motion, reducing or eliminating soft tissue inflammation, inducing relaxation, improving contractile and noncontractile tissue extensibility, and improving pulmonary function. Mechanical modalities A broad group of agents that use distraction, approximation, or compression to produce a therapeutic effect. Mobilization A passive therapeutic movement at the end of the available range of motion at variable amplitudes and speed. Modality A broad group of agents that may include thermal, acoustic, radiant, mechanical, or electrical energy to produce physiologic changes in tissues for therapeutic purposes. Motor control The ability of the central nervous system to control or direct the neuromotor system in purposeful movement and postural adjustment by selective allocation of muscle tension across appropriate joint segments. Motor deficit Lack or deficiency of normal motor function (motor control and motor function) that may be the result of pathology or other disorder. Weaknesses, paralysis, abnormal movement



Page 5 of 9

patterns, abnormal timing, coordination, clumsiness, involuntary movements, or abnormal postures may be manifestations of impaired motor function (motor control and motor learning). Motor function (motor control and motor learning) The ability to learn or demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns. Fine: Refers to relatively delicate movements, such as using a fork and tying a shoelace. Gross: Refers to larger-scale movements, such as assuming an upright position and carrying a bag. Motor learning A set of processes associated with practice or experience leading to relatively permanent changes in the capability for producing skilled action. Muscle tone The velocity-dependent resistance to stretch that muscle exhibits. Orthotic devices Devices to support weak or ineffective joints or muscles, such as splints, braces, shoe inserts, and casts. Outcomes Outcomes are the results of patient/client management. They relate to remediation of functional limitation and disability, primary or secondary prevention, and optimization of patient/client satisfaction. Outcomes Analysis A systematic examination of patient/client outcomes in relation to selected patient/client variables (eg, age, sex, diagnosis, interventions performed); outcomes analysis may be used in quality assessment, economic analysis of practice, and other processes. Oxygen saturation the degree to which oxygen is present in a particular cell, tissue, organ, or system. Palpation Examination using the hands (eg, palpation of muscle spasm, palpation of the thoracic cage). Paraffin bath A superficial thermal modality using paraffin wax and mineral oil. Patients individuals who are the recipients of physical therapy and direct intervention. Percussion (diagnostic) A procedure in which the clinician taps a body part manually or with an instrument to estimate its density. Phototherapy Intervention using the application of fight. Physical agent A form of thermal, acoustic, or radiant energy that is applied to tissues in a systematic manner to achieve a therapeutic effect; a therapeutic modality used to treat physical impairments. Physical function Fundamental component of health status describing the state of those sensory and motor skills necessary for mobility, work, and recreation. Physical therapist A person who is a graduate of an accredited physical therapist education program and is licensed to practice physical therapy. Physical therapist assistant A person who is a graduate of an accredited physical therapist



Page 6 of 9

assistant education program and who assists the physical therapist in the provision of physical therapy. The physical therapist assistant may perform physical therapy procedures and related tasks that have been selected and delegated by the supervising physical therapist. Physical therapy aide A nonlicensed worker, trained under the direction of a physical therapist, who performs designated routine physical therapy tasks. Plan of care Statements that specify the anticipated long-term and short-term goals and the desired outcomes, predicted level of optimal improvement, specific interventions to be used, duration and frequency of the intervention required to reach the goals and outcomes, and criteria for discharge. Pulmonary postural drainage Placing the body in a position that uses gravity to drain fluid from the lungs. Posture The alignment and positioning of the body in relation to gravity, center of mass, and basis of support. Power The ability to perform work over time. Prevention Activities that are directed toward slowing or stopping the occurrence of both mental and physical illness and disease, minimizing the effects of a disease or impairment on disability, or reducing the severity or duration of an illness. Primary: Prevention of the development of disease in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts. Secondary: Efforts to decrease the duration of illness, reduce severity of diseases, and limit sequelae through early diagnosis and prompt intervention. Tertiary: Efforts to limit the degree of disability and promote rehabilitation and restoration of function in patients/clients with chronic and irreversible diseases. Primary care The provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of personal health care needs, developing a sustained partnership with patients/clients, and practicing in the context of family and community. [Defining Primary Care: An Interim Report. Washington, DC: Institute of Medicine, National Academy Press; 1995] Prognosis: The determination of the level of optimal improvement that might be attained by the patient/client and the amount of time needed to reach that level. Proprioception The reception of stimuli from within the body (eg, from muscles and tendons); includes position sense (the awareness of the joints at rest) and kinesthesia (the awareness of movement). Prosthesis An artificial device, often mechanical or electrical, used to replace a missing part of the body. Protective devices External supports to protect weak or ineffective joints or muscles. Protective devices include braces, protective taping, cushions, and helmets. Range of motion (ROM) (including muscle length) The space, distance, or angle through which movement occurs at a joint or a series of joints. Reexamination The process by which patient/client status is updated following the initial



Page 7 of 9

examination (because of new clinical indications, failure to respond to interventions, or failure to establish progress from baseline data) Referral A recommendation that a patient/client seek service from another health care provider or resource. Screening Determining the need for further examination or consultation by a physical therapist or for referral to another health professional. Cognitive screening: Brief assessment of the patient's/client's thinking process (eg, ability to process commands). Self-care The set of activities that comprise daily living, such as bed mobility, transfers, ambulation, dressing, grooming, bathing, eating, and toileting. Sensory Having to do with sensations or the senses; including peripheral sensory processing (eg, sensitivity to touch) and cortical sensory processing (eg, two-point and sharp/dull discrimination). Sensory integration The ability to integrate information from the environment to produce normal movement. Serial casting A process in which the patient is recasted over a period of time, typically to achieve increased range of motion of a particular body part. Splinting Support of a body segment through application of an external device. Static: Customized and prefabricated splints, inhibitory casts, and spinal and other braces that are designed to maintain joints in a desired position. Dynamic: Customized and prefabricated supports that allow for or control motion while providing support. Strength Force-generating capacity of muscle. Strengthening Active: A form of strength-building exercise in which the physical therapist applies resistance through the range of motion of active movement. Assistive: A form of strength-building exercise in which the physical therapist assists the patient/client through the available range of motion. Resistive: Any form of active exercise in which a dynamic or static muscular contraction is resisted by an outside force. The external force may be applied manually or mechanically. Supportive devices External supports to protect weak or ineffective joints or muscles. Supportive devices include supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, and oxygen. Transcutaneous electrical nerve stimulation (TENS) The use of electrical energy to stimulate cutaneous and peripheral nerves via electrodes on the skin's surface. Tests and measures Specific standardized methods and techniques used to gather data about the patient/client after the history and systems review have been performed. Therapeutic exercise A broad range of activities intended to improve strength, range of motion (including muscle length), cardiovascular fitness, or flexibility or to otherwise increase a person's functional capacity. Thermistor An electrical resistor that uses a a semiconductor whose resistance varies sharply in a known manner with the ambient temperature; used in determining temperature.



Page 8 of 9

Thermotherapy intervention through the application of heat, causing vasodilation to enhance the healing process. Traction The therapeutic use of manual or mechanical tension created by a pulling force to produce a combination of distraction and gliding to relieve pain and increase tissue flexibility. Transfer The process of relocating a body from one object or surface to another (eg, getting into or out of bed, moving from a wheelchair to a chair). Treatment The sum of all interventions provided by the physical therapist to a patient/client during an episode of care. Ultrasound A diagnostic or therapeutic technique using high-frequency sound waves to produce heat. Pulsed ultrasound: The application of therapeutic ultrasound using predetermined interrupted frequencies. Ultraviolet A form of radiant energy using fight rays with wavelengths beyond the violet end of the visible spectrum. Vasopneumatic compression device A device to decrease edema by using compressive forces that are applied to the body part. Ventilatory pump Thoracic skeleton and skeletal muscles and their innervation responsible for ventilation. The muscles include the diaphragm; the intercostal, scalene, and stern-ocleidomastoid muscles; accessory muscles of ventilation; and the abdominal, triangular, and quadratus lumborum muscles. Ventilatory pump dysfunction Abnormalities of the thoracic skeleton, respiratory muscles, airways, or lungs that interrupt or interfere with the work of breathing or ventilation. Vestibular Describing the sense of balance located in the inner ear. Visual analog scale A tool used in a pain examination that allows the patient/client to indicate degree of pain by pointing to a visual representation of pain intensity. Volume measurement The amount of fluid that has been displaced from a container (of any size) following the introduction of part or all of the body. Wellness concepts that embrace positive health behaviors (eg, exercise, nutrition, stress reduction). Work conditioning An intensive, work-related, goal-oriented conditioning program designed specifically to restore systemic neuromusculoskeletal functions (eg, strength, endurance, movement, flexibility, motor control) and cardiopulmonary functions. The objective of the work conditioning program is to restore physical capacity and function to enable the patient/client to return to work. Work hardening Highly structured, goal-oriented, individualized treatment program designed to return the client to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. Work hardening addresses issues of productivity, safety, physical tolerances, and worker behaviors.



Page 9 of 9

Wound care Procedures used to achieve a clean wound bed, promote a moist environment or facilitate autolytic debridement, or absorb excessive exudation from a wound complex.

Source Citation:"Glossary." Physical Therapy 77.n11 (Nov 1997): 1620(5). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 8

Standards of practice for physical therapy and the accompanying criteria.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1625 (4). (1849 words)


PREAMBLE The physical therapy profession is committed to providing an optimum level of service delivery and to striving for excellence in practice. The House of Delegates of the American Physical Therapy Association, as the formal body that represents the profession, attests to this commitment by adopting and promoting the following Standards of Practice for Physical Therapy. These Standards of Practice for Physical Theraphy are the profession's statement of conditions and performances that are essential for provision of high-quality physical therapy. The Standards provide a foundation for assessment of physical therapy practice. I. LEGAL/ETHICAL CONSIDERATIONS A. Legal Considerations The physical therapist complies with all the legal requirements of jurisdictions regulating the practice of physical therapy. The physical therapist assistant complies with all the legal requirements of jurisdictions regulating the work of the assistant. B. Ethical Considerations The physical therapist practices according to the Code of Ethics of the American Physical Therapy Association. The physical therapist assistant complies with the Standards of Ethical Conduct for the Physical Therapist Assistant of the American Physical Therapy Association. II. ADMINISTRATION OF THE PHYSICAL THERAPY SERVICE A. Statement of Mission, Purposes, and Goals The physical therapy service has a statement of mission, purposes, and goals that reflects the needs and interests of the individuals served, the physical therapy personnel affiliated with the service, and the community. Criteria The statement: * Defines the scope and limitations of the service.



Page 2 of 8

* Lists the goals and objectives of the service. * Is reviewed annually. B. Organizational Plan The physical therapy service has a written organizational plan. Criteria The plan: * Describes relationships within the service and, where the physical therapy service is part of a larger organization, between the physical therapy service and other components of the organization. * Ensures that the service is directed by a physical therapist. * Defines supervisory structures within the service. * Reflects current personnel functions. C. Policies and Procedures The physical therapy service has written policies and procedures that reflect the operation of the service and that are consistent with the mission, purposes, and goals of the service. Criteria The policies and procedures, which are reviewed regularly and revised as necessary, address pertinent information including (but not limited to) the following: * Clinical education. * Clinical research. * Interdisciplinary collaboration. * Criteria for access to, initiation of, continuation of, referral of, and termination of care. * Equipment maintenance. * Environmental safety. * Fiscal management. * Infection control. * Job/position descriptions. * Competency assessment.



Page 3 of 8

* Medical emergencies. * Patient/client care policies and protocols. * Patient/client rights. * Personnel-related policies. * Quality/performance improvement. * Documentation. * Staff orientation. The policies and procedures meet the requirements of state law and external agencies. D. Administration A physical therapist is responsible for the direction of the physical therapy service. Criteria The director: * Ensures compliance with local, state, and federal requirements. * Ensures compliance with current APTA documents, including Standards of Practice for Physical Therapy, Guide for Professional Conduct, and Guide for Conduct of the Affiliate Member * Ensures that services provided are consistent with the mission, purposes, and goals of the service. * Ensures that services are provided in accordance with established policies and procedures. * Reviews and updates policies and procedures. * Provides training that assures continued competence of physical therapy support personnel * Provides for continuous in-service training on safety issues and for periodic safety inspection of equipment by qualified individuals. E. Fiscal Management The director of the physical therapy service, in consultation with staff and appropriate administrative personnel, is responsible for planning for, and allocation of, resources. Fiscal planning and management of the service is based on sound accounting principles. Criteria The fiscal management plan includes: * Preparation and monitoring of a budget that provides for optimum use of resources. * Accurate recording and reporting of financial information.



Page 4 of 8

* Conformance with legal requirements. * Cost-effective utilization of resources. * A fee schedule that is consistent with cost of services and that is within customary norms of fairness and reasonableness. F. Quality/Performance Improvement The physical therapy service has a written plan for continuous improvement of the performance of services provided. Criteria The plan: * Provides evidence of ongoing review and evaluation of the service. * Provides a mechanism for documentation of performance improvement. * Is consistent with requirements of external agencies, if applicable. G. Staffing The physical therapy personnel affiliated with the physical therapy service have demonstrated competence and are sufficient to achieve the mission, purposes, and goals of the service. Criteria The service: * Meets all legal requirements regarding licensure and/or certification of appropriate personnel. * Provides staff expertise that is appropriate to the patient/clients served. * Provides for appropriate staff-to-patient/client ratios. * Provides for appropriate ratios of support staff to professional staff. H. Staff Development The physical therapy service has a written plan that provides for appropriate and ongoing staff development. Criteria The plan: * Provides for consideration of self-assessments, individual goal setting, and organization needs in directing continuing education and learning activities. * Includes strategies for long-term learning and professional development. I. Physical Setting The physical setting is designed to provide a safe and accessible environment that facilitates fulfillment of the mission and achievement of the purposes and goals of the physical therapy



Page 5 of 8

service. The equipment is safe and sufficient to achieve the purposes and goals of physical therapy. Criteria The physical setting: * Meets all applicable legal requirements for health and safety. * Meets space needs appropriate for the number and type of patients/clients served. The equipment: * Meets all applicable legal requirements for health and safety. * Is inspected routinely. J. Interdisciplinary Collaboration The physical therapy service collaborates with all appropriate disciplines. Criteria The collaboration includes: * An interdisciplinary team approach to patient/client care. * Interdisciplinary patient/client and family education. * Interdisciplinary staff development and continuing education. III. PROVISION OF SERVICES A. Informed Consent The physical therapist has sole responsibility for providing information to the patient/client and for obtaining the patient's/client's informed consent in accordance with jurisdictional law before initiating physical therapy. Criteria The information provided to the patien/client should include the following: * A clear description of the proposed intervention/treatment. * A statement of material (decisional) risks associated with the proposed intervaention/treatment. * A statement of expected benefits of the proposed intervention/treatment. * A comparison of the benefits and risks possible both with and without intervention/treatment. * An explanation of reasonable alternatives to the recommended intervention/treatment. Informed consent requires: * Consent by a competent adult.



Page 6 of 8

* Consent by a parent/legal guardian as the surrogate decision maker when the adult patient/client is not competent or when the patient/client is a minor The patient's/client's acknowledgment of understanding and consent before the intervention/treatment proceeds. B. Initial Examination and Evaluation The physical therapist performs and documents an initial examination and evaluates the results to identify problems and determine the diagnosis prior to intervention/treatment. Criteria The examination: * Is documented, dated, and signed by the physical therapist who performed the examination. * Identifies the physical therapy needs of the patient/client. * Incorporates appropriate objective tests and measures to facilitate outcome measurement. * Documents sufficient data to establish a plan of care. * May result in recommendations for additional services to meet the needs of the patient/client. C. Plan of Care The physical therapist establishes and provides a plan of care for the individual based on the results of the examination and evaluation and on patient/client needs. The physical therapist involves the patient/client and appropriate others in the planning, implementation, and assessment of the intervention/treatment program. The physical therapist, in consultation with appropriate disciplines, plans for discharge of the patient/client taking into consideration goal achievement, and provides for appropriate follow-up or referral. Criteria The plan of care includes: * Realistic goals and expected functional outcomes. * Intervention/treatment, including its frequency and duration. * Documentation that is dated and signed by the physical therapist who established the plan of care. D. Intervention/Treatment The physical therapist provides, or delegates and supervises, the physical therapy intervention/treatment consistent with the results of the examination and evaluation and plan of care. The physical therapist documents, on an ongoing basis, services provided, responses to services,



Page 7 of 8

and changes in status relative to the plan of care. Criteria The intervention/treatment is: * Provided under the ongoing personal care or supervision of the physical therapist. * Provided in such a way that delegated responsibilities are commensurate with the qualifications and legal limitations of the physical therapy personnel involved in the intervention/treatment. * Altered in accordance with changes in individual response or status. * Provided at a level that is consistent with current physical therapy practice. * Interdisciplinary when necessary to meet the needs of the patient/client. Documentation of the services provided includes: * Date and signature of the physical therapist and/or of the physical therapist assistant when permissible by law. E. Reexamination and Reevaluation The physical therapist reexamines and reevaluates the individual continually and modifies or discontinues the plan of care accordingly. Criteria The physical therapist: * Periodically documents, dates, and signs the patient/client reexamination and modifications of the plan of care. F. Discharge/Discontinuation of Treatment or Intervention The physical therapist discharges the patient/client from physical therapy intervention/treatment when the goals or projected outcomes for the patient/client have been met. Physical therapy intervention/treatment shall be discontinued when the goals are achieved, the patient/ client declines to continue care, the patient/client is unable to continue, or the physical therapist determines that intervention/treatment is no longer warranted. Criteria Discharge documentation shall include: * The patient's/client's status at discharge and functional outcomes/goals achieved. * Dating and signing of the discharge summary by the physical therapist * When a patient/client is discharged prior to goal achievement, the patient's/client's status and the rationale for discontinuation. IV. EDUCATION The physical therapist is responsible for individual professional development. The physical



Page 8 of 8

therapist assistant is responsible for individual career development. The physical therapist participates in the education of physical therapist students, physical therapist assistant students, and students in other health professions. The physical therapist assistant participates in the education of physical therapist assistant students and other student health professionals. The physical therapist educates and provides consultation to consumers and the general public regarding the purposes and benefits of physical therapy. The physical therapist educates and provides consultation to consumers and the general public regarding the roles of the physical therapist and the physical therapist assistant. Criteria The physical therapist educates and provides consultation to consumers and the general public regarding the roles of the physical therapist, the physical therapist assistant, and other support personnel. V. RESEARCH The physical therapist applies research findings to practice and encourages, participates in, and promotes activities that establish the outcomes of physical therapist patient/client management. The physical therapist supports collaborative and interdisciplinary research. VI. COMMUNITY RESPONSIBILITY The physical therapist demonstrates community responsibility by participating in community and community agency activities, educating the public, formulating public policy, or providing pro bono physical therapy services. Criteria The physical therapist demonstrates community responsibility by participating in community and community agency activities; educating the public, including prevention and health promotion activities; formulating public polity; or providing pro bono physical therapy services.

Source Citation:"Standards of practice for physical therapy and the accompanying criteria." Physical Therapy 77.n11 (Nov 1997): 1625(4). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 2

Code of ethics.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1628(1). (173 words)


PREAMBLE This Code of Ethics sets forth ethical principles for the physical therapy profession. Members of this profession are responsible for maintaining and promoting ethical practice. This Code of Ethics, adopted by the American Physical Therapy Association, shall be binding on physical therapists who are members of the Association. Principle 1 Physical therapists respect the rights and dignity of all individuals. Principle 2 Physical therapists comply with the laws and regulations governing the practice of physical therapy. Principle 3 Physical therapists accept responsibility for the exercise of sound judgment. Principle 4 Physical therapists maintain and promote high standards for physical therapy practice, education, and research. Principle 5 Physical therapists seek remuneration for their services that is deserved and reasonable. Principle 6 Physical therapists provide accurate information to the consumer about the profession and about those services they provide. Principle 7 Physical therapists accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Principle 8



Page 2 of 2

Physical therapists participate in efforts to address the health needs of the public.

Source Citation:"Code of ethics." Physical Therapy 77.n11 (Nov 1997): 1628(1). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 7

Guide for professional conduct.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1629(3). (2136 words)


PURPOSE This Guide for Professional Conduct (Guide) is intended to serve physical therapists who are members of the American Physical Therapy Association (Association) in interpreting the Code of Ethics (Code) and matters of professional conduct. The Guide provides guidelines by which physical therapists may determine the propriety of their conduct. The Code and the Guide apply to all physical therapists who are Association members. These guidelines are subject to changes as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public. This Guide is subject to monitoring and timely revision by the judicial Committee of the Association. INTERPRETING ETHICAL PRINCIPLES The interpretations expressed in this Guide are not to be considered all inclusive of situations that could evolve under a specific principle of the Code but reflect the opinions, decisions, and advice of the judicial Committee. While the statements of ethical principles apply universally, specific circumstances determine their appropriate application. Input related to current interpretations, or to situations requiring interpretation, is encouraged from Association members. PRINCIPLE I Physical therapists respect the rights and dignity of an individuals. 1.1 Attitudes of Physical Therapists A. Physical therapists shall recognize that each individual is different from all other individuals and shall respect and be responsive to those differences. B. Physical therapists are to be guided at all times by concern for the physical, psychological, and socioeconomic welfare of those individuals entrusted to their care. C. Physical therapists shall not engage in conduct that constitutes harassment or abuse of, or discrimination against, colleagues, associates, or others. 1.2 Confidential Information A. Information relating to the physical therapist/patient relationship is confidential and may not be communicated to a third party not involved in that patient's care without the prior written consent of the patient, subject to applicable law. B. Information derived from component-sponsored peer review shall be held confidential by the reviewer unless written permission to release the information is obtained from the physical therapist who was reviewed. C. Information derived from the working relationships of physical therapists shall be held confidential by all parties. D. Information may be disclosed to appropriate authorities when it is necessary to protect the welfare of an individual or the community. Such disclosure shall be in accordance with applicable law.



Page 2 of 7

1.3 Patient Relations Physical therapists shall not engage in any sexual relation ship or activity, whether consensual or nonconsensual, with any patient while a physical therapist/patient relationship exists. 1.4 Informed Consent Physical therapists shall obtain patient informed consent before treatment. PRINCIPLE 2 Physical therapists comply with the laws and regulations governing the practice of physical therapy. 2.1 Professional Practice Physical therapists shall provide consultation, evaluation, treatment, and preventive care, in accordance with the laws and regulations of the jurisdiction(s) in which they practice. PRINCIPLE 3 Physical therapists accept responsibility for the exercise of sound judgment. 3.1 Acceptance of Responsibility A. Upon accepting an individual for provision of physical therapy services, physical therapists shall assume the responsibility for evaluating that individual; planning, implementing, and supervising the therapeutic program; reevaluating and changing that program; and maintaining adequate records of the case, including progress reports. B. When the individual's needs are beyond the scope of the physical therapist's expertise, or when additional services are indicated, the individual shall be so informed and assisted in identifying a qualified provider. C. Regardless of practice setting, physical therapists shall maintain the ability to make independent judgments. D. The physical therapist shall not provide physical therapy services to a patient while under the influence of a substance that impairs his or her ability to do so safely. 3.2 Delegation of Responsibility A. Physical therapists shall not delegate to a less qualified person any activity which requires the unique skill, knowledge, and judgment of the physical therapist. B. The primary responsibility for physical therapy care rendered by supportive personnel rests with the supervising physical therapist. Adequate supervision requires, at a minimum, that a supervising physical therapist perform the following activities: 1. Designate or establish channels of written and oral communication. 2. Interpret available information concerning the individual under care. 3. Provide initial evaluation. 4. Develop plan of care, including short- and longterm goals.



Page 3 of 7

5. Select and delegate appropriate tasks of plan of care. 6. Assess competence of supportive personnel to perform assigned tasks. 7. Direct and supervise supportive personnel in delegated tasks. 8. Identify and document precautions, special problems, contraindications, goals, anticipated progress, and plans for reevaluation. 9. Reevaluate, adjust plan of care when necessary, perform final evaluation, and establish followup plan. 3.3 Provision of Services A. Physical therapists shall recognize the individual's freedom of choice in selection of physical therapy services. B. Physical therapists' professional practices and their adherence to ethical principles of the Association shall take preference over business practices. Provisions of services for personal financial gain rather than for the need of the individual receiving the services are unethical. C. When physical therapists judge that an individual will no longer benefit from their services, they shall so inform the individual receiving the services. Physical therapists shall avoid overutilization of their services. D. In the event of elective termination of a physical therapist/patient relationship by the physical therapist, the therapist should take steps to transfer the care of the patient, as appropriate, to another provider. 3.4 Referral Relationships In a referral situation where the referring practitioner prescribes a treatment program, alteration of that program or extension of physical therapy services beyond that program should be undertaken in consultation with the referring practitioner. 3.5 Practice Arrangements A. Participation in a business, partnership, corporation, or other entity does not exempt the physical therapist, whether employer, partner, or stockholder, either individually or collectively, from the obligation of promoting and maintaining the ethical principles of the Association. B. Physical therapists shall advise their employer(s) of any employer practice which causes a physical therapist to be in conflict with the ethical principles of the Association. Physical therapist employees shall attempt to rectify aspects of their employment which are in conflict with the ethical principles of the Association. PRINCIPLE 4 Physical therapists maintain and promote high standards for physical therapy practice, education, and research. 4.1 Continued Education A. Physical therapists shall participate in educational activities which enhance their basic knowledge and provide new knowledge. B. Whenever physical therapists provide continuing education, they shall ensure that course content, objectives, and responsibilities of the instructional faculty are accurately reflected in the promotion of the course.



Page 4 of 7

4.2 Review and Self Assessment A. Physical therapists shall provide for utilization review of their services. B. Physical therapists shall demonstrate their commitment to quality assurance by peer review and self-assessment. 4.3 Research A. Physical therapists shall support research activities that contribute knowledge for improved patient care. B. Physical therapists engaged in research shall ensure: 1. the consent of subjects; 2. confidentiality of the data on individual subjects and the personal identities of the subjects; 3. well-being of all subjects in compliance with facility regulations and laws of the jurisdiction in which the research is conducted; 4. the absence of fraud and plagiarism; 5. full disclosure of support received; 6. appropriate acknowledgment of individuals making a contribution to the research; 7. that animal subjects used in research are treated humanely and in compliance with facility regulations and laws of the jurisdiction in which the research experimentation is conducted. C. Physical therapists shall report to appropriate authorities any acts in the conduct or presentation of research that appear unethical or illegal. 4.4 Education A. Physical therapists shall support quality education in academic and clinical settings. B. Physical therapists functioning in the educational role are responsible to the students, the academic institutions and the clinical settings for promoting ethical conduct in educational activities. Whenever possible, the educator shall ensure: 1. the rights of students in the academic and clinical setting; 2. appropriate confidentiality of personal information; 3. professional conduct toward the student during the academic and clinical educational processes; 4. assignment to clinical settings prepared to give the student a learning experience. C. Clinical educators are responsible for reporting to the academic program student conduct which appears to be unethical or illegal. PRINCIPLE 5 Physical therapists seek remuneration for their services that is deserved and reasonable. 5.1 Fiscally Sound Remuneration



Page 5 of 7

A. Physical therapists shall never place their own financial interest above the welfare of individuals under their care. B. Fees for physical therapy services should be reasonable for the service performed, considering the setting in which it is provided, practice costs in the geographic area, judgment of other organizations, and other relevant factors. C. Physical therapists should attempt to ensure that providers, agencies, or other employers adopt physical therapy fee schedules that are reasonable and that encourage access to necessary services. 5.2 Business Practices/Fee Arrangements A. Physical therapists shall not: 1. directly or indirectly request, receive, or participate in the dividing, transferring, assigning, rebating of an unearned fee. 2. profit by means of a credit or other valuable consideration, such as an unearned commission, discount, or gratuity in connection with furnishing of physical therapy services. B. Unless laws impose restrictions to the contrary, physical therapists who provide physical therapy services in a business entity may pool fees and moneys received. Physical therapists may divide or apportion these fees and moneys in accordance with the business agreement. C. Physical therapists may enter into agreements with organizations to provide physical therapy services if such agreements do not violate the ethical principles of the Association. 5.3 Endorsement of Equipment or Services A. Physical therapists shall not use influence upon individuals under their care or their families for utilization of equipment or services based upon the direct or indirect financial interest of the physical therapist in such equipment or services. Realizing that these individuals will normally rely on the physical therapists' advice, their best interest must always be maintained as well as their right of free choice relating to the use of any equipment or service. While it cannot be considered unethical for physical therapists to own or have a financial interest in equipment companies, or services, they must act in accordance with law and nub full disclosure of their interest whenever such companies or services become the source of equipment or services for individuals under their care. B. Physical therapists may be remunerated for endorsement or advertisement of equipment or services to the lay public, physical therapists, or other health professionals provided they disclose any financial interest in the production, sale, or distribution of said equipment or services. C. In endorsing or adverting equipment or services, physical therapists shall use sound professional judgment and shall not give the appearance of Association endorsement. 5.4 Gifts and Other Considerations A. Physical therapists shall not accept nor offer gifts or other considerations with obligatory conditions attached. B. Physical therapists shall not accept or offer gifts or other considerations that affect or give an objective appearance of affecting their professional judgment. PRINCIPLE 6 Physical therapists provide accurate information to the consumer about the profession and about those services they provide. 6.1 Information about the Profession Physical therapists shall endeavor to educate the public to an awareness of the physical therapy



Page 6 of 7

profession through such means as publication of articles and participation in seminars, lectures, and civic programs. 6.2 Information about Services A. Information given to the public shall emphasize that individual problems cannot be treated without individualized evaluation and plans/programs of care. B. Physical therapists may advertise their services to the public. C. Physical therapists shall not use, or participate in the use of, any form of communication containing a false, plagiarized, fraudulent, misleading, deceptive, unfair, or sensational statement or claim. D. A paid advertisement shall be identified as such unless it is apparent from the context that it is a paid advertisement. PRINCIPLE 7 Physical therapists accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. 7.1 Consumer Protection A. Physical therapists shall report any conduct which appears to be unethical, incompetent or illegal. B. Physical therapists may not participate in any arrangements in which patients are exploited due to the referring sources enhancing their personal incomes as a result of referring for, prescribing, or recommending physical therapy. C. Physical therapists shall be obligated to safeguard the public from underutilization or overutilization of physical therapy services. 7.2 Disclosure The physical therapist shall disclose to the patient if the referring practitioner derives compensation from the provision of physical therapy. The physical therapist shall ensure that the individual has freedom of choice in selecting a provider of physical therapy. PRINCIPLE 8 Physical therapists participate in efforts to address the health needs of the public. 8.1 Pro Bono Service Physical therapists should render pro bono publico (reduced or no fee) services to patients lacking the ability to pay for services, as each physical therapist's practice permits.

Source Citation:"Guide for professional conduct." Physical Therapy 77.n11 (Nov 1997): 1629 (3). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .




Page 7 of 7




Page 1 of 1

Standards of ethical conduct for the physical therapist assistant.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1632(1). (141 words)


PREAMBLE Physical therapist assistants are responsible for maintaining and promoting high standards of conduct. These Standards of Ethical Conduct for the Physical Therapist Assistant shall be binding on physical therapist assistants who are affiliate members of the Association. STANDARD 1 Physical therapist assistants provide services under the supervision of a physical therapist. STANDARD 2 Physical therapist assistants respect the rights and dignity of all individuals. STANDARD 3 Physical therapist assistants maintain and promote high standards in the provision of services, giving the welfare of the patients their highest regard. STANDARD 4 Physical therapist assistants provide services within the limits of the law. STANDARD 5 Physical therapist assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. STANDARD 6 Physical therapist assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts.

Source Citation:"Standards of ethical conduct for the physical therapist assistant." Physical Therapy 77.n11 (Nov 1997): 1632(1). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 4

Guide for the conduct of the affiliate member.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1632(2). (959 words)


PURPOSE This Guide is intended to serve physical therapist assistants who are affiliate members of the American Physical Therapy Association in the interpretation of the Standards of Ethical Conduct for the Physical Therapist Assistant, providing guidelines by which they may determine the propriety of their conduct. These guidelines are subject to change as new patterns of health care delivery are developed and accepted by the professional community and the public. This Guide is subject to monitoring and timely revision by the judicial Committee of the Association. INTERPRETING STANDARDS The interpretations expressed in this Guide are not to be considered all inclusive of situations that could evolve under a specific standard of the Standards of Ethical Conductor the Physical Therapist Assistant but reflect the opinions, decisions, and advice of the Judicial Committee. While the statements of ethical standards apply universally, specific circumstances determine their appropriate application. Input related to current interpretations, or to situations requiring interpretation, is encouraged from APTA members. STANDARD 1 Physical therapist assistants provide services under the supervision of a physical therapist. 1.1 Supervisory Relationships Physical therapist assistants shall work under the supervision and direction of a physical therapist who is properly credentialed in the jurisdiction in which the physical therapist assistant practices. 1.2 Performance of Service A. Physical therapist assistants may not initiate or alter a treatment program without prior evaluation by and approval of the supervising physical therapist. B. Physical therapist assistants may modify a specific treatment procedure in accordance with changes in patient status. C. Physical therapist assistants may not interpret data beyond the scope of their physical therapist assistant education. D. Physical therapist assistants may respond to inquiries regarding patient status to appropriate parties within the protocol established by a supervising physical therapist. E. Physical therapist assistants shall refer inquiries regarding patient prognosis to a supervising physical therapist. STANDARD 2 Physical therapist assistants respect the rights and dignity of all individuals.



Page 2 of 4

2.1 Attitudes of Physical Therapist Assistants A. Physical therapist assistants shall recognize that each individual is different from all other individuals and respect and be responsive to those differences. B. Physical therapist assistants shall be guided at all times by concern for the dignity and welfare of those patients entrusted to their care. C. Physical therapist assistants shall not engage in conduct that constitutes harassment or abuse of, or discrimination against, colleagues, associates, or others, 2.2 Request for Release of Information Physical therapist assistants shall refer all requests for release of confidential information to the supervising physical therapist. 2.3 Protection of Privacy Physical therapist assistants must treat as confidential all information relating to the personal conditions and affairs of the persons whom they serve. 2.4 Patient Relations Physical therapist assistants shall not engage in any sexual relationship or activity, whether consensual or nonconsensual, with any patient while a physical therapist assistant/patient relationship exits. STANDARD 3 Physical therapist assistants maintain and promote high standards in the provision of services, giving the welfare of patients their highest regard. 3.1 Information About Services A. Physical therapist assistants may provide consumers with information regarding provision of services within the protocol established by a supervising physical therapist. B. Physical therapist assistants may not use or participate in the use of, any form of communication containing a false, fraudulent, misleading, deceptive, unfair, or sensational statement or claim. 3.2 Organizational Employment Physical therapist assistants shall advise their employer(s) of any employer practice which causes them to be in conflict with the Standards of Ethical Conduct for the Physical Therapist Assistant. 3.3 Endorsement of Equipment Physical therapist assistants may not endorse equipment or exercise influence on patients or families to purchase or lease equipment except as directed by a physical therapist acting in accord with the stipulation in paragraph 5.3.a. of the Guide for Professional Conduct.



Page 3 of 4

3.4 Financial Consideration Physical therapist assistants shall never place their own financial interest above the welfare of their patients. 3.5 Exploitation of Patients Physical therapist assistants shall not participate in any arrangements in which patients are exploited. Such arrangements include situations where referring for, delegating, prescribing, or recommending physical therapy services. STANDARD 4 Physical therapist assistants provide services within the limits of the law. 4.1 Supervisory Relationships Physical therapist assistant shall comply with all aspects of law. Regardless of the content of any law, physical therapists assistants shall provide services only under the supervision and direction of a physical therapist who is properly credentialed in the jurisdiction in which the physical therapist assistant practices. 4.2 Representation Physical therapist assistants shall not hold themselves out as physical therapists. STANDARD 5 Physical therapist assistants make the most those judgments that are commensurate with their qualifications as physical therapist assistants. 5.1 Patient Treatment A. Physical therapist assistants shall report all untoward patient responses to a surprising physical therapist. 5.2 Patient Safety A. Physical therapist assistants may refuse to carry out treatment procedures that they believe to be not in the best interest of the patient. B. The physical therapist assistant shall not provide physical therapy services to a patient while under the influence of a substance that impairs his or her ability to do so safely. 5.3 Qualifications Physical therapist assistants may not carry out any procedure that they are not qualified to provide. 5.4 Discontinuance of Treatment Program Physical therapist assistants shall discontinue immediately any treatment procedures which in their judgment appear to be harmful to the patient. 5.5 Continued Education



Page 4 of 4

Physical therapist assistants shall continue participation in var ious types of educational activities which enhance their skills and knowledge and provide new skills and knowledge. STANDARD 6 Physical therapist assistants accept the responsibility to pro tect the public and the profession from unethical, income tent, or illegal acts. 6.1 Consumer Protection Physical therapist assistants shall report any conduct which appears to be unethical or illegal.

Source Citation:"Guide for the conduct of the affiliate member." Physical Therapy 77.n11 (Nov 1997): 1632(2). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .





Page 1 of 5

Guidelines for physical therapy documentation.(Guide to Physical Therapy Practice).Physical Therapy 77.n11 (Nov 1997): pp1634(3). (1628 words)


PREAMBLE The American Physical Therapy Association (APTA) is committed to meeting the physical therapy needs of society, to meeting the needs and interests of its members, and to developing and improving the art and science of physical therapy, including practice, education, and research. To help meet these responsibilities, the APTA Board of Directors has approved the following guidelines for physical therapy documentation. It is recognized that these guidelines do not reflect all of the unique documentation requirements associated with the many specialty areas within the physical therapy profession. Applicable for both handwritten and electronic documentation systems, these guidelines are intended to be used as a foundation for the development of more specific documentation guidelines in specialty areas, while at the same time providing guidance for the physical therapy profession across all practice settings. OPERATIONAL DEFINITIONS Guidelines: APTA defines "guidelines" as approved, non-binding statements of advice. Documentation: Any entry into the client record, such as: consultation report, initial examination report, progress note, flow sheet/checklist that identifies the care/service provided, reexamination, or summation of care. Authentication: The process used to verify that an entry is complete, accurate, and final. Indications of authentication can include original written signatures and computer signatures" on secured electronic record systems only. I. GENERAL GUIDELINES A. All documentation must comply with the applicable jurisdictional/regulatory requirements. 1. All handwritten entries shall be made in ink and will include original signatures. Electronic entries should be made with appropriate security and confidentiality provisions. 2. Informed consent: As required by the APTA Standards of Practice for Physical Therapy and the Accompanying Criteria 2.1 The physical therapist has sole responsibility for providing information to the patient and for obtaining the patient's informed consent in accordance with jurisdictional law before initiating physical therapy. 2.2 Those deemed competent to give consent are competent adults. When the adult is not competent, and in the case of minors, a parent or legal guardian consents as the surrogate decision maker. 2.3 THe information provided to the patient should include the following: (a) a clear description of the treatment ordered or recommended, (b) material (decisional) risks associated with the proposed treatment, (c) expected benefits of treatment, (d) comparison of the benefits and risks possible with and without treatment, and (e) reasonable alternatives to the recommended treatment. The physical therapist should solicit questions from



Page 2 of 5

the patient and provide answers. The patient should be asked to acknowledge understanding and consent before treatment proceeds. Examples of ways in which to accomplish this documentation: Ex 2.3.1 Signature of patient/ guardian on long or short consent form. Ex 2.3.2 Notation/entry of what was explained by the physical therapist or the physical therapist assistant in the official record. Ex 2.3.3 Filing of a completed consent checklist signed by the patient. 3. Charting errors should be corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record. 4. Identification. 4.1 Include patient's full name and identification number, if applicable, on all official documents. 4.2 All entries must be dated and authenticated with the provider's full name and appropriate designation (eg, PT, PTA). 4.3 Documentation by students (SPT/SPTA) shall be authenticated by a licensed physical therapist. 4.4 Documentation by graduates (GPT/GPTA) or others pending receipt of an unrestricted license shall be authenticated by a licensed physical therapist. 5. Documentation should include the manner in which physical therapy services are initiated. Examples include: Ex 5.1 Self-referral/direct access. Ex 5.2 Attachment of the referral/consultation request by a qualified practitioner. Ex 5.3 File copy of correspondence to referral source as acknowledgment of the referral. II. INITIAL EXAMINATION AND EVALUATION/CONSULTATION A. Documentation is required at the outset of each episode of physical therapy care. B. Elements include: 1. Obtaining a history and identifying risk factors: 1. 1 History of the presenting problem, current complaints, and precautions (including onset date). 1.2 Pertinent diagnoses and medical history. 1.3 Demographic characteristics, including pertinent psychological, social, and environmental factors. 1.4 Prior or concurrent services related to the current episode of physical therapy care. 1.5 Comorbidities that may affect goals and treatment plan. 1.6 Statement of patient's knowledge of problem. 1.7 Goals of patient (and family members, or significant others, if appropriate). 2. Selecting and administering tests and measures to determine patient status in a number of areas. The following is a partial list of these areas, with illustrative tests and measures: 2.1 Arousal, mentation, and cognition Examples include objective findings related, but not limited, to the following areas: Ex 2.1.1 Level of consciousness Ex 2.1.2 Ability to process commands Ex 2.1.3 Alertness Ex 2.1.4 Gross expressive and receptive language deficits 2.2 Neuromotor development and sensory integration Examples include objective findings related, but not limited, to the following areas: Ex 2.2.1 Gross and fine motor skills Ex 2.2.2 Reflex and movement patterns Ex 2.2.3 Dexterity, agility, and coordination 2.3 Range of motion



Page 3 of 5

Examples include objective findings related, but not limited, to the following areas: Ex 2.3.1 Extent of joint motion Ex 2.3.1 Pain and soreness of surrounding soft tissue Ex 2.3.2 Muscle length and flexibility 2.4 Muscle performance Examples include objective findings related, but not limited, to the following areas: Ex 2.4.1 Strength Ex 2.4.2 Power Ex 2.4.3 Endurance 2.5 Ventilation, respiration, and circulation Examples include objective findings related, but not limited, to the following areas: Ex 2.5.1 Vital signs Ex 2.5.2 Breathing patterns Ex 2.5.3 Heart sounds 2.6 Posture Examples include objective findings related, but not limited, to the following areas: Ex 2.6.1 Static posture Ex 2.6.2 Dynamic posture 2.7 Gait, locomotion, and balance Examples include objective findings related, but not limited, to the following areas: Ex 2.7.1 Characteristics of gait Ex 2.7.2 Functional ambulation Ex 2.7.3 Characteristics of balance 2.8 Self-care and home management status Examples include objective findings related, but not limited, to the following areas: Ex 2.8.1 Activities of daily living Ex 2.8.2 Functional capacity Ex 2.8.3 Static and dynamic strength 2.9 Community and work (job/school/play) integration/reintegration. Ex 2.9.1 Instrumental activities of daily living Ex 2.9.3 Functional capacity Ex 2.9.3 Adaptive skills 3. Evaluation (a dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination). 4. Diagnosis (a label encompassing a cluster of signs and symptoms, syndromes, or categories that reflects the information obtained for the examination). 5. Coals. 5.1 Patient (and family members or significant others, if appropriate) is involved in establishing goals. 5.2 All goals are stated in measurable terms. 5.3 Goals arc linked to problems identified in the examination. 5.4 Short- and long-term goals are established when applicable may include potential for achieving goals). 6. Intervention plan or recommendation requirements: 6.1 Shall be related to realistic goals and expected functional outcomes. 6.2 Should include frequency and duration to achieve the stated goals. 6.3 Should include patient and



Page 4 of 5

family/caregiver educational goals. 6.4 Should involve appropriate collaboration and coordination of care with other professionals/services. 7. Authentication and appropriate designation of physical therapist. III. DOCUMENTATION OF THE CONTINUUM OF CARE A. Intervention or service provided. 1 . Documentation is required for each patient visit/encounter. Authentication is required for every note by the physical therapist or the physical therapist assistant providing the service under the supervision of the physical therapist. Examples include: Ex 1.1 Checklist Ex 1.2 Flow sheet Ex 1.3 Graph Ex 1.4 Narrative 2. Elements may include: 2.1 Identification of specific interventions provided. 2.2 Equipment provided. B. Patient status, progress, or regression. 1. Documentation is required for every visit/encounter. Authentication is required for every note by the physical therapist or the physical therapist assistant providing the service under the supervision of the physical therapist. 2. Elements may include: 2.1 Subjective status of patient. 2.2 Changes in objective and measurable findings as they relate to existing goals. 2.3 Adverse reaction to treatment. 2.4 Progression/regression of existing therapeutic regimen, including patient education and adherence. 2.5 Communication/consultation with providers/patient/family/significant other. 2.6 Authentication and appropriate designation of either a physical therapist or a physical therapist assistant. C. Reexamination and Reevaluation 1. Documentation is required monthly for patients seen at intervals of a month of less; if the patient is seen less frequently, documentation is required for every visit or encounter. 2. Elements include: 2.1 Documentation of elements as identified in III.B.2.1 through III.B.2.5 to update patient's status. 2.2 Interpretation of findings and, when indicated, revision of goals. 2.3 When indicated, revision of treatment plan, as directly correlated with documented goals. 2.4 Authentication and appropriate designation of physical therapist. IV. SUMMATION OF CARE A. Documentation is required following conclusion of the current episode in the physical therapy care sequence. B. Elements include: 1. Reason for discontinuation of service. Examples include: Ex 1.1 Satisfactory goal achievement. Ex 1.2 Patient declines to continue care. Ex 1.3 Patient is unable to continue to work toward goals due to medical or psychosocial complications. 2. Current physical/functional status. 3. Degree of goal achievement and reasons for goals not being achieved. 4. Discharge plan that includes written and verbal communication related to the patient's continuing care. Examples include: Ex 4.1 Home program. Ex 4.2 Referrals for additional services. Ex 4.3 Recommendations for follow-up physical therapy care. Ex 4.4 Family and caregiver training. Ex 4.5 Equipment provided. 5. Authentication and appropriate designation of physical therapist. References



Page 5 of 5

[1.] Direction, Delegation and Supervision in Physical Therapy Services. HOD 06-96-30-4) [2.] Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1996. [3.] Glossary of Terms Related to Information Security. Schamburg, Ill: Computer-Based Patient Record Institute; 1996 [4.] Guidelines for Establishing Information Security Policies at Organizations Using ComputerBased Patient Records. Schamburg, Ill: Computer-Based Patient Record Institute; 1995. Adopted by the Board of Directors March 1997 Amended March 1993, June 1993, November 1994, March 1995, March 1997

Source Citation:"Guidelines for physical therapy documentation." Physical Therapy 77.n11 (Nov 1997): 1634(3). Expanded Academic ASAP. Gale. University of Florida. 21 Nov. 2008 .




Guidelines to Physical Therapist Practice APTA [1]

Recommend Documents