A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy

A Guide to Physical Therapist Practice. Volume I:
A Description of Patient Management
[A Guide to Physical Therapist Practice. Volume One: A Description of Patient Management.
Pbys Ther. 1995;75:R.1
Table of Contents
Preface ............................................................... 709
Chapter One: Management of Physical Therapy
..........................................................
Patients 711
............................................
Physical Therapists 711
...........................
Definition of Physical Therapy 711
...............................
Physical Therapist Practice 712
...................... ................
Practice Settings .
. 712
....................................................
Primary Care 712
..............................
Secondary and Tertiary Care 713
Patient Management .....................
.
.
.............. 713
I. Examination ............................................. 714
.............................................
A. The History 714
......................................
B. Systems Review 715
C. Tests, Measures. and Data Generated ....... 715
I1. Evaluation ............................................ 715
.................................................
I11. Diagnosis 715
.................................................
IV. Prognosis 716
v. ~ntervention......................................... 716
.................................
A. Direct Intervention 716
........................
B. Patient-related Instruction 716
C. Coordination. Communication. and
.......................................
Documentation 716
Additional Professional Activities of the Physical
Therapist ....................................................... 716
I. Prevention and Wellness (including Health
Promotion) ..............................................
717
. .............................................
I1 Consultation 717
.................................................
1
1
1. Screening 717
................................................
.
IV Education 718
..........................................
V. Critical Inquiry 718
VI. Administration .......................................... 718
Physical Therapy Services:Direction and
....................
Supervision of Support Personnel 718
.............................................
Support Personnel 719
........................
I. Physical Therapist Assistants 719
..............................
I1. Physical Therapy Aides 719
...........................
.
I11 Other Support Personnel 719
References ........................................................ 719
Chapter Two: Examinations Provided by
........................................
Physical Therapists 720
Aerobic Capacity or Endurance Examination ....... 720
Anthropometric Characteristics Examination ........ 721
Arousal, Mentation. and Cognition Examination ... 722
Assistive, Adaptive, Supportive, and Protective
......................................
Devices Examination 722
Community or Work Reintegration Examination
(including Instrumental Activities of Daily
Living) .......................................................... 723
Cranial Nerve Integrity Examination .................... 724
Environmental. Home. or Work Barriers
Examination .................................................. 725
Ergonomics or Body Mechanics Examination ....... 725
............................
Gait and Balance Examination 727
...................
Integumentary Integrity Examination 727
..............
Joint Integrity and Mobility Examination 728
..............................
Motor Function Examination 729
Muscle Performance Examination (including
Strength. Power. and Endurance) .................... 730
Neuromotor Development and Sensory
.................................
Integration Examination 731
....................
Orthotic Requirements Examination 731
..............................................
Pain Examination 732
Posture Examination .......................................... 733
..................
Prosthetic Requirements Examination 734
Range of Motion Examination (including Muscle
.........................................................
Length) 734
Reflex Integrity Examination .............................. 735
Self-care and Home-Management Examination
(including Activities of Daily Living and
.............
Instrumental Activities of Daily Living) 736
Sensory Integrity Examination (including
......................
Proprioception and Kinesthesia) 737
Ventilation. Respiration. and Circulation
Examination ................................................ 737
Chapter Three: Interventions Provided by
Physical Therapists ........................................ 739
......................................................
Intervention 739
I. Direct Intervention ...................................... 739
...........................
.
1
1 Patient-related Instruction 740
1
1
1. Coordination. Communication. and
..........................................
Documentation 740
Therapeutic Exercise (including Aerobic
..............................................
Conditioning) 741
Functional Training in Self Care and Home
Management (including Activities of Daily
Living and Instrumental Activities of Daily
..........................................................
Living) 742
Functional Training in Community or Work
Reintegration (including Instrumental Activities
of Daily Living. Work Hardening. and Work
Physical Therapy / Volume 75. Number 8 / August 1995

................................................
Conditioning) 742
Manual Therapy Techniques (including
.......................
Mobilization and Manipulation) 743
Prescription. Fabrication. and Application of
Assistive. Adaptive. Supportive. and Protective
..................................
Devices and Equipment 744
Airway Clearance Techniques ............................. 744
...........................
Debridement and Wound Care 745
..........
Physical Agents and Mechanical Modalities 746
Physical Therapy/ Volume 75. Number 8/August 1995
Electrotherapeutic Modalities .......................... 746
Patient-related Instruction .................................. 747
Appendices ................................................... 749
Appendix I. A Glossary of Operational Definitions
in Physical Therapy ..............................
.
. ..... 749
Appendix I1. Code of Ethics and Guide for
Professional Conduct ..................................... 757
Appendix I11. Guidelines for Physical Therapy
Documentation............................................... 762

A Guide to Physical Therapist
Practice, Volume I: A Description
of Patient Management
Physical therapy is a dynamic profession with an established theoretical base
and widespread clinical applications,particularly in the preservation, develop-
ment, and restoration of maximum physical function. Physical therapists seek to
prevent injury, impairments,functionallimitations, and disability;to maintain
and promote fitness, health, and quality of life; and to ensure availability,acces-
sibility, and excellence in the delivery of physical therapy services to the patient.
As essential participants in the health care delivery system, physical therapists
assume leadership roles in prevention and health maintenance programs, in the
provision of rehabilitation services, and in professional and communityorganiza-
tions. They also play important roles in developing health policy and appropri-
ate standards for the various elements of physical therapy practice. Physical
therapists help nearly a million Americans daily to restore health, alleviate pain,
and prevent the onset and progression of impairments, functionallimitations,
and disability. The benefits of rehabilitation and physical therapy services are
well documented, and services are covered in nearly all federal, state, and pri-
vate insurance plans.
The American Physical Therapy Association (APTA), the national organization
representing the profession of physical therapy, believes it to be critically impor-
tant that those outside the profession understand the role of physical therapists
in the health care system and the unique services they provide. As clinicians,
physical therapists examine patients, identdy potential and existing problems,
perform evaluations,establish a diagnosis, set forth a prognosis, provide inter-
ventions (those practices and procedures used by the physical therapist in treat-
ing and instructing patients), evaluate the success of those interventions,and
moddy treatment to effect the desired outcomes. Physical therapy includes not
only those services provided by physical therapists but also those rendered
under their direction and supervision.
The APTA is committed to informing consumers, federal and state governments,
and third-party payers of the benefits of physical therapy and, more specifically,
of the relationship of the patient's health status after treatment to the services
that the therapist has provided. The Association actively supports outcomes
research and strongly endorses all efforts to develop appropriate systems to
measure the results of physical therapy patient management.
A Guide to Physical TherapistPractice is a two-volume description of general
physical therapy patient management developed by the APTA to give readers a
thorough understanding of the contributionsthat physical therapists bring to
Physical Therapy / Volume 75, Number 8/August 1995

health care. VolumeI: A Description of Patient Management,focuses first on
physical therapists as health professionals, describing their approach to patient
management in Chapter One. Chapter Two details 23 examinations that physical
therapists often perform and includes an overview of each examination, clinical
indications that may prompt its use, a list of the general tests and measures that
may be atiministered, and data that may be generated. Chapter Three details the
interventions (treatments) that physical therapists frequently provide. An over-
view for each intervention is given, followed by a listing of the modes in which
the intervention may be applied. Clinical indications for selecting the interven-
tion are described and its expected benefits listed. Finally, three appendices are
presented: a glossary, the APTA Code of Ethics and Guidefor Ptofssional Con-
duct,and the APTA Guidelinesfor Physical T?m-apyDocumentation.[Volume
I t Preferred Practice Patterns,will be keyed to defined impairments and ICD-9
codes ancl is in the process of being developed.]
A Guide to Physical 7h;berapistPractice serves two purposes: 1) to provide a
guide to the domain of accepted physical therapy practice and 2) to facilitate the
development of preferred practice patterns that will reduce unwarranted varia-
tion in the provision of physical therapy treatments, improve the quality of phys-
ical therapy, enhance consumer satisfaction,promote appropriate utilization of
health care services, and reduce costs. This document is intended to be used as
a reference by health care policymakers, administrators,managed care provid-
ers, third-party payers, physical therapists, and other health care professionals.
The material presented describes the generally accepted elements of physical
therapy patient management. Decisions about the appropriateness of treatment
are made by the physical therapist in light of the patient's needs and the profes-
sion's code of ethics, standards of practice, and practice patterns. The physical
therapist considers the influence of culture, gender, race, age, socioeconomic
status, and sexual orientation when providing services to a patient, while adher-
ing to APTA policy on nondiscrimination.
The American Physical Therapy Association recommends that federal and state
governments and other entities that provide insurance reimbursement for physi-
cal therapy services require that these services be provided only by or under the
direction of a physical therapist. The use of any physical therapy examination or
intervention, unless provided by a physical therapist or under the direction or
supervision of a physical therapist, is not physical therapy, nor should it be
represented or reimbursed as such.

Chapter One:
Management of Physical Therapy Patients
This chapter introduces physical thera-
pists, describes their qualifications,
defines the field of physical therapy,
details the elements of physical thera-
pist practice, and discusses the roles of
physical therapists in the provision of
primary, secondary, and tertiary care.
Physical therapists are professionals
involved in the examination, evalua-
tion, treatment, and prevention of
neuromuscular, musculoskeletal, car-
diovascular,and pulmonary disorders
that produce movement impairments,
disabilities, and functional limitations.
As members of primary care teams or
as providers of specialty care, physical
therapists help patients to improve
function, alleviate pain, and prevent
the onset of disease or disability.
Chapter One also lists the settings in
which physical therapists practice and
describes the professional activities in
which they are involved, which in-
clude patient management (examina-
tion, evaluation, diagnosis, prognosis,
and intervention), prevention and
wellness (including health promotion),
consultation, screening, education,
critical inquiry, and administration.
The chapter eoncludes with a discus-
sion of support personnel.
Pt,ysical Therapists
Physical tb~rapists
are professionally
educated at the college or university
level and are required to be licensed
in the states(s) in which they practice.
Graduates from 1960 to the present
have successfully completed profes-
sional programs of physical therapy
accredited by the APTA's Cornmission
on Accreditation in Physical Therapy
Education (CAPTE). Graduates from
1926to 1959completed physical ther-
apy curricula approved by appropriate
accreditation bodies.
Physical therapists interact and prac-
tice in collaboration with a variety of
health professionals, including physi-
cians, dentists, podiatrists, nurses,
social workers, occupational thera-
pists, speech and language patholo-
gists, and others. As responsible health
professionals, physical therapists ac-
knowledge the need to educate and
inform other health professionals,
government agencies, insurers, and
the consumer public about the ser-
vices they offer and their effective and
cost-efficient delivery.
Physical therapists provide patients
with services at the preventive, acute,
and rehabilitativestages directed to-
ward achieving increased functional
independence and decreased func-
tional impairment. They provide pre-
ventive care that forestallsor prevents
functional decline and the need for
more intense care. Through timely and
appropriate intervention, they fre-
quently reduce or eliminate the need
for costlier forms of care such as sur-
gery and may also shorten or even
eliminate institutional stays.
Definition of Physical Therapy
The current Model Definition of Physi-
cal Therapy for State Practice Acts was
adopted by the APTA Board of Direc-
tors in March 1993and revised in
March 1995:
Physical therapy, which is the care
and servicesprovided by or under the
direction and supenrision of a physical
therapist, includes:
1) Examining patients with impair-
ments,functional limitations,and
disability or other health-related
conditions in order to determine a
diagnosis,prognosis, and interven-
tion; examinations include, but are
aerobic capacity or endurance
anthropometric characteristics
arousal, mentation, and
cognition
assistive, adaptive, supportive,
and protective devices
community or work
reintegration
cranial nerve integrity
environmental, home, or work
barriers
ergonomics or body mechanics
gait and balance
integumentary integrity
joint integrity and mobility
motor function
muscle performance
neuromotor development and
sensory integration
orthotic requirements
pain
posture
prosthetic requirements
range of motion
reflex integrity
self care and home management
sensory integrity
ventilation, respiration, and
circulation
2) Alleviating impairments andfunc-
tional limitations by designing,
implementing, and modthing
therapeutic intauentions that in-
clude, but are not limited to, the
following:
therapeutic exercise (including
aerobic conditioning)
functional training in self care
and home management (includ-
ing activities of daily living and
instrumental activities of daily
living)
functional training in community
or work reintegration activities
(including instrumental activities
of daily living, work hardening,
and work conditioning)
not limited to, thefollowing:
Physical Therapy /Volume 75, Number 8/August 1995

manual therapy techniques (in-
cluding mobilization and
manipulation)
prescription, fabrication, and
application of assistive, adap-
tive, supportive, and protective
devices and equipment
airway clearance techniques
debridement and wound care
physical agents and mechanical
modalities
electrotherapeutic modalities
patient-related instruction
3) Pmazting injury, impimzents,
functional limitations,and disabil-
ity, including thepromotion and
maintenance offitness, health,
and quality of life in all age
populntiorts.
4) Engaging in consultation, educa-
tion, and mearch.
Physical Therapist Practice
Physical therapists are committed to
offering necessary, appropriate, and
highquality health services.They
provide these services to patients
(individuals who are sick or injured)
and clients(individualswho are not
necessarily sick or injured but who
can benefit from physical therapy
services, eg, a person with a chronic
disability, a person wishing to prevent
a loss of function). In addition, physi-
cal therapists offer selected services
(eg, screening) to individuals,busi-
nesses, school systems, and others
also termed clients.Physical therapists
also provide wellness initiatives, in-
cluding health promotion and educa-
tion, that stimulate the public to en-
gage in healthy behavior.
Physical therapists provide services to
patients with impairments, functional
limitations, disability, or change in
physical function and health status
resulting from injury, disease, or other
causes. Impaimzents are losses or
abnormalities of physiological, psycho-
logical, or anatomical structure or
function. Functional limitationsare
restrictions of the ability to perform a
physical action, activity, or task in an
efficient, typically expected, or compe-
tent manner. Disability is the inability
to engage in age- and sex-specific
roles in a particular social context and
physical environment. Physical func-
tion, which is a fundamental compo-
nent of health status, describes the
state of those sensory and motor slulls
necessary for mobility, work, and
recreation. Health status, which is part
of well-being, describes an individual
in terms of physical, mental, affective,
and social function.
Practice Settings
Physical therapists practice in a broad
range of inpatient, outpatient, and
community settings, including, but not
limited to, the following:
hospitals
homes
physical therapy office practices
rehabilitation facilities
subacute care facilities
skilled nursing or extended care
facilities
hospices
schools (preschool, primary, and
secondary)
corporate or industrial health
centers
work or occupational
environments
athletic training facilities
sports injury treatment centers
fitness centers
education or research centers
PtSmary Cam
Physical therapists have major roles to
play in the provision of primary care,
recently defined as fol1ows:l
Primary care is the provision of inte-
grated, accessible health care sm'ces
by clinicianswho are accountablefor
addressing a large majority ofperonal
health care needs,developing a sus-
tainedpattndipwith patients, and
practicing in the context offamily and
community.
In recent years a number of organiza-
tions, including the Institute of Medi-
cine, have examined the delivery of
primary care services in the United
States.The APTA endorses the con-
cepts of primary care set forth by the
Institute of Medicine's Committee on
the Future of Primary Care,l which
include the following:
Recognition that 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
practitioners
Rejection of the "gatekeeper"
concept because of its pejorative
connotation that the role of the
primary care practitioner is to
manage costs and, for the most
part, to keep the "gate" closed
Awareness that primary care is
not limited to the "first contact"
or point of entry into the health
care system
Emphasis on the comprehen-
siveness o
f a primary care
program
Recognition of the important
role of family and community in
the provision of primary care,
and recognition that caregivers
and care-receivers function
within, and are dependent on, a
wide range of societal and envi-
ronmental factors
Physical therapists are involved in the
examination, treatment, and preven-
tion of neuromusculoskeletal disorders
and are well positioned to provide
those services as members of primary
care teams. On a daily basis, physical
therapists practicing at acute, rehabili-
tative, and preventive stages of care
assist individuals in restoring health,
alleviating pain, and preventing the
onset of disease or disability. They
play roles in the acute, chronic, pre-
vention, and wellness areas. A number
of studies indicate that the assumption
by physical therapists of a primary
care role is an efficient use of health
care resources.
Physical therapists provide a broad
range of neuromusculoskeletal health
services from entry to discharge, in-
cluding screening, triage, examination,
referral, intervention, coordination of
care, and education and prevention.
For acute neuromusculoskeletal disor-
ders, the triage and initial examination
is the appropriate responsibility of a
physical therapist. The primary care
team functions more efficiently with
Physical Therapy /Volume 75, Number 8/August 1995 712/ 67

physical therapists who recognize
neuromusculoskeletal disorders, per-
form examinations, and treat or refer
without delay (eg, physical therapists
providing immediate pain reduction
and programs for strengthening,flexi-
bility, endurance, postural alignment,
instruction in activities of daily living,
and work modification for patients
with low back pain). These actions
result in more efficient and effective
patient care and more appropriate use
of other members of the primary care
team. The efficiency and cost effective-
ness of physical therapy in this context
is well documented. With physical
therapists functioning in a primary
care role and delivering early interven-
tion for work-related musculoskeletal
injuries, time lost due to injuries has
been dramatically reduced.
For certain chronic conditions, physi-
cal 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.Through
community-based agencies, physical
therapists coordinate and integrate
provision of services to individuals
with chronic neuromusculoskeletal
disorders,including a vast array of
postural, muscular, joint, and func-
tional problems in patients with osteo-
porosis of the spine or hips.
The practice of physical therapists in
industrial or workplace settings illus-
trates another key element of primary
care. In these settings, physical thera-
pists manage the care provided to
employees and prevent injury by
designing or redesigning the work
environment.The services provided
by physical therapists focus on both
the individual and the environment to
ensure comprehensive and appropri-
ate intervention. These practices have
been documented to be both cost-
and clinically effective.
Secondary and Tertiary Cam
Physical therapists play major roles in
secondary and tertiary care as well.
Patients with neuromuscular, muscule
skeletal, cardiovascular, pulmonary,
integumentary,or other disorders
frequently are seen initially by another
health practitioner and then referred to
physical therapists for secondary care.
Physical therapists provide secondary
care in a wide range of settings,from
hospitals to preschools.
Physical therapists provide tertiary care
services in highly specialized,com-
plex, and technologically based set-
tings (eg, a heart or lung transplant
service,a bum unit). They are also
tertiary-care practitioners when sup-
plying specialized services (eg, to
patients with a spinal cord lesion, to
individuals who have suffered closed-
head trauma) following referral from
clinicianssuch as physicians, dentists,
and nurse practitioners.
Patient Management
A schema describing the physical
therapist's approach to patient man-
agement is presented below in Figure
1.As the figure demonstrates, the
physical therapist integrates five ele-
ments of care in a manner designed to
maximize the patient's outcome,which
may be conceptualized as either
patient-related (eg, satisfactionwith
care) or associated with service deliv-
ery (eg, efficacy and efficiency). In
many cases the physical therapist
offers all five elements of care before
an outcome is reached, but outcomes
may result from the rendering of even
a single element, such as the examina-
tion, or two to four elements (eg,
examination, evaluation,diagnosis,
and prognosis but no intervention).
Examination is the process of obtain-
ing a patient history, performing rele-
vant systems reviews, and selecting
and administeringspecific tests and
measures to obtain data. (Frequently,
physical therapists will perform one or
more ~examinations,
which are any
examinations that take place after the
initial examination is completed. A
reexamination gives the physical
therapist the opportunity to evaluate
the patient's progress and to mod^ or
adapt the patient management process
as necessary.)
Evaluation is a dynamic process in
which the physical therapist makes
EVALUATION
DIAGNOSIS
v
PROGNOSIS
INTERVENTION -
,
Figure 1. 7he elements of physical therapistpatient management leading to opti-
mal outcome.
!

clinical judgments based on data gath-
ered during the examination. Diagno-
sis is both the process and the end
result of evaluating information ob-
tained from the patient examination,
which the physical therapist then
organizes into defined clusters, syn-
dromes, or categories to help deter-
mine the most appropriate interven-
tion strategies for each patient.
Pmgnosis is the determination of the
level of maximal improvement that
might be attained and the time re-
quired to reach that level; it may also
include predictions of improvement at
various intervals during therapy. Inter-
vention is the purposeful and skilled
interaction of the physical therapist
with the patient, using various meth-
ods and techniques to produce
changes in the patient's condition
consistent with the diagnosis and
prognosis.
After analyzing all relevant information
that has been gathered from the his-
tory and systems reviews, the physical
therapist decides what groups of tests
and measures should be included in
the exarnination of the patient. The
physical therapist will decide to use
one, more than one, or portions of
several .$pec$c examinations (detailed
in Chapter Two) as part of the exami-
nation. As the examination progresses,
the physical therapist may determine
that there are additional problems
present that were not uncovered by
the history and systems review and
conclude that other specfic examina-
tions (in Chapter Two) or portions of
specific examinationswill need to be
performed to obtain sufficient data to
make an evaluation,render a diagno-
sis, fomi a prognosis, and choose
interventions. In addition, as described
below, the physical therapist may
reexamine at any stage of the patient
management process. Because physi-
cal therapy is most often an ongoing
process delivered over a period of
weeks rather than at a single visit,
physical therapists rely on re-
examinations to modify or redirect the
patient management process and to
evaluate outcomes that have been
predicted. In actuality,the re-
examination has an important quality
assurance component, as it allows the
physical therapist to focus on both the
elements of physical therapy manage-
ment and the outcomes of care.
At each step of the management pro-
cess the physical therapist considers
the possible patient outcomes. Out-
come is the result of physical therapy
management and is expressed in five
areas: prevention and management of
symptom madestation, consequences
of disease (impairment,disability,
andor role limitation), cost-benefit
analysis, health-related quality of life,
and patient satisfaction.Because the
physical therapist projects an outcome
that reflects the needs of the patient, a
successful outcome includes improved
or maintained physical function when
possible, a slowing of functional de-
cline where the status quo cannot be
maintained, andor an expression by
the patient that the outcome is
desirable.
During the initial history taking, the
physical therapist identifies the pa-
tient's expectations for therapeutic
interventions, perceptions about the
clinical situation,and goals and de-
sired outcomes. The physical therapist
considers whether these are realistic in
the context of the examinationfind-
ings. In setting forth a diagnosis,mak-
ing a prognosis, and choosing inter-
ventions, the physical therapist also
considers potential patient outcomes;
eg, what outcome is likely given this
patient's diagnosis?The physical thera-
pist may use a re-examination to see
whether predicted outcomes are rea-
sonable and then m o d e them as
necessary. Ideally, the physical thera-
pist also engages in outcomes analysis;
ie, he or she systematically examines
the outcomes of care in relation to
selected patient variables (eg, age, sex,
diagnosis, interventions performed)
and develops statistical reports for
internal or external use.
I. Examination. The exarnination,
which is an investigation, is the first
step in the management process. It
has three components:
obtaining a patient history
performing relevant systems
reviews
selecting and administering spe-
cific tests and measures
The examination is a required element
prior to any intervention and is per-
formed for all patients. The physical
therapist selects components of spe-
cific examinationsdescribed in Chap-
ter Two based on the purpose of the
patient's visit to the physical therapist,
the complexity of the patient's condi-
tion(~),
and the evolving impression
formed by the physical therapist dur-
ing the examination.The examination
may therefore be as brief or lengthy as
necessary. For example, the physical
therapist may conclude from the pa-
tient history and systems review that
further testing and management by the
physical therapist is not required
andor that the patient should be
referred to another health care practi-
tioner. Conversely, the physical thera-
pist may decide that a full examination
is necessary and then select appropri-
ate tests and measures to be adminis-
tered. The range of tests and measures
may include those selected from any
or all of the specific examinations
listed in Chapter Two, depending on
the complexity of the patient's prob-
lems and the directions taken by the
physical therapist in the clinical
decision-making process. It should be
noted that at some point after com-
pleting the initial examination, the
physical therapist may conclude that a
second examination (re-examination)
is indicated (because of new clinical
indications,failure of the patient to
respond to interventions, etc) and
proceed to perform it as described
above.
A. The History. The patient history is
an account of past and present health
status. It includes the identificationof
complaints and provides the initial
source of information about the pa-
tient; it also suggests the patient's
ability to benefit from physical therapy
services. The patient history provides
information that enables the therapist
to identlfy health-risk factors, health
restoration and prevention needs, and
co-existing health problems that have
implications for physical therapy inter-
vention. It is commonly conducted by
gathering data from the patient, family,
Physical Therapy /Volume 75,Number

signhcant others, caregivers, and
other interested persons; by consulting
with other members of the health care
team; and by reviewing the medical
record. In conducting the history, the
physical therapist encourages patients
to express their expected outcomes,
which may be used in the process of
establishing goals and intended
outcomes.
The process of taking a history to
identlfy specific information about the
patient may include, but is not limited
to, the following:
interviewing
administering a questionnaire
consulting with other health
professionals
reviewing available records
Data generated from a history may
include, but are not limited to, the
following:
needs or concerns that led an
individual to seek the services
of a physical therapist
the patient's expectations for
therapeutic interventions and
perceptions about his/her clini-
cal situation
prior functional status in self-
care and home-management
activities (activities of daily liv-
ing and instrumental activities of
daily living)
current community or work
activities
prior hospitalizations, surgeries,
and pre-existing medical and
other health-related conditions
medications
level of fitness
health risks (eg, family history,
diet, alcohol consumption,
smoking, stress)
incontinence, bowel and blad-
der problems
obstetric history
projected discharge designation
8
.
Systems Review.The systems
review is a brief or limited exarnina-
tion to provide additionalinformation
about the patient's general health that
will help the physical therapist to
formulate a diagnosis and select an
intervention program. The systems
review also assists the physical thera-
pist in ident~fying
possible health
problems that require consultation
with or referral to another health care
provider.
Data generated from a systems review
that may affectsubsequent examina-
tion(~)and intervention(s) include the
following:
physiologic and anatomic status
cardiopulmonary response dur-
ing rest and activity
neuromusculoskeletal physio-
logic responses during rest and
activity
somatosensory integrity
newly identified or recently
emerging signs or symptoms
communication skills and cogni-
tive status
emotional status
C. Tests, Measures, and Data
Generated.Tests and measures are
procedures or sets of procedures used
to obtain data. After concluding the
systems review, the physical therapist
examines the patient more closely and
selectstests and measures from one or
more specific examinationsto elicit
additional information. Before, during,
and after administering the tests and
measures, physical therapists will
frequently apply their hands to the
patient to gauge responses, to assess
physical status, and to obtain a more
specific understanding of the patient's
condition and diagnosticand thera-
peutic requirements.
judgments) based on the data gath-
ered from the examination.Factors
that influence the complexity of the
examination and the evaluation pro-
cess include the clinical findings,ex-
tent of loss of function, social consid-
erations, and the patient's overall
physical function and health status.
Thus, the physical therapist's evalua-
tion reflects the severity of the current
problem, the stability of the patient's
condition,the presence of pre-existing
conditions, and the possibility of mul-
tiple sites or systems involvement.
Physical therapists also consider the
l&l of the patient's impairment(s)
and the possibility of prolonged im-
pairment, functional limitations, and
disability, as well as the patient's social
supports, living environment, and
potential discharge destination.Fre-
quently, the physical therapist's evalu-
ation will indicate that a second exam-
ination (reexamination) is necessary,
which would then be conducted as
detailed in the section entitled "I.
Examination" above.
111. 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 patient examination and
organizing it into clusters, syndromes,
or categories.The purpose of the
diagnosis is to guide the physical
therapist in determining the most
appropriate intervention strategy for
each patient. In the event that the
diagnostic process does not yield an
identifiable cluster, syndrome, or cate-
gory, intervention may be guided by
the alleviation of symptoms and reme-
diation of deficits.Alternatively, the
physical therapist may determine that
a re-examination is in order and pro-
ceed accordingly. The diagnostic pro-
cess includes the following:
"
developmental history
social interactions, activities, and Tests and measures commonly per- obtaining relevant history
formed by physical therapists and the performing systems review
support systems
nutrition and hydration resulting data generated are discussed selecting and administering spe-
sleep patterns in the specific examinations presented cific tests and measures
skin integrity in Chapter Two. interpreting all data
organizing the data
family and caregiver resources
living environment and commu- 11. Evaluation. Physical therapists
nity characteristics perform evaluations (make clinical
70 / 715 Physical Therapy/ Volume 75, Number 8/August 1995

In carrying out the diagnosticprocess,
physical therapists may need to obtain
additional information (including diag-
nostic labels) from other health profes-
sionals. In addition, as the diagnostic
process continues, physical therapists
may identlfy findings that should be
shared with other health professionals,
including referral sources, to ensure
optimal patient care. If the diagnostic
process reveals findings that are out-
side the scope of the physical thera-
pist's knowledge, experience, or ex-
pertise, the physical therapist should
then refer the patient to an appropri-
ate practitioner.
IV. Prognosis. Prognosis is the deter-
mination of the level of maximal im-
provement that might be attained by
the patient and the amount of time
needed to reach that level; it may also
include a prediction of the levels of
improvementthat may be reached at
various intervals during the course of
therapy. The physical therapist makes
prognoses for recovery from impair-
ment, functional limitation,and dis-
ability; for return to role fulfillment;
and for other outcomes, including
prevention and management of symp-
tom manifestations.When the physical
therapist determines that physical
therapy intervention would be likely
to produce desirable outcomes, the
appropriate intervention is imple-
mented. When the physical therapist
considers physical therapy intervention
unlikely to be beneficial, the physical
therapist discussesthose findings and
conclusions with the individuals con-
cerned, and there is no further physi-
cal therapy intervention.
V. Intervention. Intenention is the
purposeful and skilled interaction of
the physical therapist with the patient
and, if appropriate, other individuals
involved in the patient's care, using
various methods and techniques to
produce changes in the patient's con-
dition consistent with the diagnosis
and prognosis. Decisions about inter-
vention are contingent on the timely
monitoriilg of the patient's response
and the progress made toward achiev-
ing outcomes. There are three inter-
vention components:
direct intervention
coordination, communication,
and documentation
A. Direct Intervention.Physical thera-
pists select, apply, or modlfy one or
more interventionsbased on the data
gathered from the initial examination.
Based on the results of the interven-
tion(~),
the physical therapist may
decide that a re-examination is neces-
sary, a decision that may lead to the
use of ddferent interventionsor, alter-
natively, the discontinuationof treat-
ment. Chapter Three details several
interventions commonly selected by
the physical therapist:
therapeutic exercise (including
aerobic conditioning)
functional training in self care
and home management activities
(including activities of daily liv-
ing and instrumental activities of
daily living)
functional training in community
or work reintegration (including
instrumental activities of daily
living, work hardening, and
work conditioning)
manual therapy techniques (in-
cluding mobilization and
manipulation)
prescription, fabrication, and
application of assistive, adap-
tive, supportive, and protective
devices and equipment
airway clearance techniques
debridement and wound care
physical agents and mechanical
modalities
electrotherapeutic modalities
Factors that influence the complexity
of the intervention and the decision-
rnalung process may include the
following:
severity of the current problem
stability of the patient's
condition
pre-existing conditions
level(s) of impairment(s1
probability of prolonged impair-
ment, functional limitations, and
disability
social supports and living
environment
multiple sites or systems
involvement
overall physical function and
health status
cognitive status
potential discharge destination
B. Patient-related Instmction.The
physical therapist uses patient-related
instruction to educate not only the
patient but also families and other
caregivers about the patient's current
condition, treatment plan, and future
transition to home, work, or commu-
nity roles. The physical therapist may
include information and training in
maintenance activities as well as pri-
mary and secondary prevention in the
instruction program.
C. Coordination,Communication,
and Documentation.These processes
ensure that the patient receives appro-
priate, coordinated, comprehensive,
and cost-effective services between
admission and discharge. The services
include, but are not limited to, the
following:
patient care conferences
communications (telephone, fax,
etc)
documentation of all elements
of patient management
coordination of care with pa-
tients, significant others, family
members, and other health
professionals
record reviews
discharge planning
Documentation should follow the
APTA Guidelinesfor Physical Theram
Documentation (Appendix 111).
Additional Professional Activitks
of the Physical Therapist
Physical therapists also participate
actively in the following activities:
prevention and wellness (includ-
ing health promotion)
consultation
screening
education
critical inquiry
administration
Physical Therapy/ Volume 75, Number 8/August 1995

I. Prevention and Wellness (Includ-
ing Health Promotion).Physical
therapists have successfully integrated
prevention, wellness, and the promo-
tion of positive health behavior into
physical therapy practice to reduce
injury, impairment,and disability
among their patients. These initiatives
have decreased costs by achieving and
restoring functionalcapacity, minimiz-
ing limitations due to congenital and
acquired diseases, maintaining health
(because sustaining a level of function
may prevent further deterioration or
future illness), and providing appropri-
ate environmental adaptations to en-
hance independent function.
For example, physical therapists are
heavily involved in preventing and
treating low back pain, a disorder that
afflicts dlions of Americans and is the
most common disabilityfor those
under 45 years of age. The majority of
such injuries are work related. The
annual cost of this disability exceeds
$10billion, but cost savings realized
through physical therapy programs
aimed at preventing injury in the work
site, which may include back schools,
workplace redesign, strengthening,
stretching,endurance exercise, and
postural training, have been
sigtxficant.2-5
Older adults are prime candidates for
preventive interventions by physical
therapists: Laboratory and clinical
studies have shown that bone mass
increases in response to mechanical
strain and exercise, and that exercise
can reduce the incidence of wrist and
hip fractures from falls, for which
older women are particularly at
ljsk.6-13
Cardiac and pulmonary rehabilitation,
which are offered to the elderly as
well as to younger patients, have also
proven to be of great value. Short,
contained exercise and education
programs decrease hospital costs,
health care visits, and related ex-
penses. Individuals with chronic ob-
structive pulmonary disease can de-
crease their hospital costs by 50%
per year through pulmonary
rehabilitation.14-16
Physical therapists initiate numerous
other prevention and wellness pro-
grams aimed at both individual pa-
tients and the communityto curtail
tobacco, alcohol, and other drug use,
prevent head injury (through the use
of helmets), and reduce domestic
violence (by reporting suspected abu-
sive behavior). Prevention of strains
and sprains has generated consider-
able cost savings.17-'9 In industry,
physical therapists help to prevent
job-related disabilities, including repet-
itive motion injuries. Finally, physical
therapists participate in obstetrical
care, where cardiovascular condition-
ing and instruction in posture for
women both before and after child-
birth have been shown to decrease
infant morbidity and maternal disabil-
ity and dysfunction.20,21
11. Consultation. Consultation is a
service provided by a physical thera-
pist to render a professional or expert
opinion or advice. Consultants apply
highly specialized knowledge and
skillsto identlfy problems, recommend
solutions,or produce some specified
outcome or product in a given amount
of time on behalf of a patient or client.
Patient-relatedconsultation is a ser-
vice provided by a physical therapist
at the request of a patient, health care
practitioner, or health care organiza-
tion either to evaluate the quality of
physical therapy services being pro-
vided or to recommend physical ther-
apy services that are needed; it does
not involve actual treatment.
Client-relatedconsultation is a sewice
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 engage
include:
responding to a request for a
second opinion
advising a referring practitioner
about the indications for
intervention
advising employers about the
requirements of the Americans
with Disabilities Act (ADA)
instructing employers about pre-
placement in accordance with
provisions of the ADA
educating other health practitio-
ners (eg, in injury prevention)
performing environmental as-
sessments to minimize the risk
of falls
conducting a program to deter-
mine the suitability of employ-
ees for specific job assignments
examining school environments
and recommending changes to
improve accessibility for stu-
dents with disabilities
developing programs that evalu-
ate the effectiveness of an inter-
vention plan in reducing work-
related injuries
working with employees, labor
unions, and government agen-
cies to develop injury reduction
and safety programs
participating at the local, state,
and federal levels in policymak-
ing for physical therapy services
providing expert legal opinion
111. Scrreening.Screening is the brief
process of determining the need for
further examination or consultation by
a physical therapist or for referral to
another health care practitioner.
Screeningis based on a problem-
focused, systematiccollection and
analysis of data to: 1) iden* individ-
uals at risk in order to provide primary
prevention, 2) identlfy those in need
of physical therapy intervention or
other rehabilitative services, and 3)
ascertain the presence of positive
findings that require attention by an-
other health care practitioner in order
to provide secondary or tertiary pre-
vention. Generally, candidates for
screening are not patients currently
receiving physical therapy sewices.
Examples of screening activities in
include:
identifying children who may
need an examination for idio-
pathic scoliosis
identifying risk factors in the
workplace
Physical Therapy / Volume 75, Number 8/ August 1995

pre-performance testing of indi-
viduals active in sports
identifying an individual's life-
style factors (eg, exercise, stress,
weight) that may lead to in-
creased risk for serious health
problems
identifying elderly individuals in
a community center or nursing
home who are at high risk for
slipping, tripping, or falling
IV. Education.Education is the pro-
cess 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 as an element of
intervention, examples of educational
activities in which physical therapists
engage include:
planning and conducting pro-
grams for the public to increase
its awareness of issues in which
physical therapists have
expertise
planning and conducting pro-
grams for local, state, and fed-
eral health agencies
planning and conducting aca-
demic and continuing clinical
education programs for physical
therapists, other health care pro-
viders, and students
V. CriticalInquiry. Critical inquiry is
the process of applying the principles
of scientific methods to read and inter-
pret professional literature;participate
in, plan, and conduct research; and
analyze patient care outcomes, new
concepts, and findings.
Examples of critical inquiry activities in
include:
analyzing and applying research
findings to patient management
and. client programs
evaluating the efficacy of both
new and established
technologies
participating in, planning, and
conducting clinical, basic, or
applied research
disseminating the results of
research
VI. Administration. Administration is
the skilled process of planning, direct-
ing, organizing, and managing human,
technical, environmental, and financial
resources effectively and efficiently,
including the management by individ-
ual physical therapists of resources for
their patients' care as well as the man-
aging of organizational resources.
Examples of administration activities in
include:
supervising physical therapist
assistants, physical therapy
aides, and other support
personnel
managing staff resources, includ-
ing the acquisition and develop-
ment of clinical expertise and
leadership abilities
monitoring quality of care and
clinical productivity
budgeting for physical therapy
services
developing, implementing, and
reviewing strategic plans and
marketing programs
Physical Therapy Sewiees:
Direction and Supervision of
Support Pemonnel
Direction and supervision are essential
to the provision of quality physical
therapy services. The degree of direc-
tion and supervision necessary for
ensuring quality physical therapy ser-
vices depends on many factors, in-
cluding the education, experience, and
responsibilitiesof the personnel in-
volved, the organizational structure in
which the physical therapy services
are provided, and applicable state law.
The physical therapist who directs a
physical therapy service has qualifica-
tions based on education andexperi-
ence in the field of physical therapy
and has accepted the responsibilities
inherent in being a supervisor. The
director of a physical therapy service:
1) establishes guidelines and proce-
dures that delineate the functions and
responsibilities of all levels of physical
therapy personnel in the service and
the supervisory relationships inherent
in the functions of the service and the
organization; 2) ensures that the objec-
tives of the service are efficiently and
effectively achieved within the frame-
work of the stated purpose of the
organization and in accordance with
safe physical therapy practice; and 3)
interprets administrativepolicies, acts
as a liaison between line staff and
administration, and fosters the profes-
sional growth of the staff.
Written practice and performance
criteria are available for all levels o
f
physical therapy personnel in a physi-
cal therapy service. Regularly sched-
uled performance appraisals are con-
ducted by the supervising physical
therapist based on these standards of
practice and performance criteria.
Delegated responsibilities are com-
mensurate with the qualifications,
including experience, education, and
training, of the individuals to whom
the responsibilities are being assigned
and must be in accordance with appli-
cable state law. When the physical
therapist delegates patient care re-
sponsibilitiesto physical therapist
assistants or other support personnel,
that physical therapist is responsible
for supervising the physical therapy
program. Regardless of the setting in
which the service is given, the follow-
ing responsibilities are borne solely by
the physical therapist:
interpretation of referrals when
available
initial examination, problem
identification, and diagnosis for
physical therapy
development or modification of
a plan of care that is based on
the initial examination and that
includes the physical therapy
treatment goals
determination of which tasks
require the expertise and
decision-making capacity of the
physical therapist and must be
personally rendered by the
physical therapist, and which
tasks may be delegated
delegation and instruction of the
services to be rendered by the
physical therapist assistant or
other support personnel, includ-
ing, but not limited to, specific

treatment program, precautions,
special problems, and contra-
indicated procedures
timely review of treatment docu-
mentation, re-examination of the
patient and the patient's treat-
ment goals, and revision of the
plan of care when indicated
establishment of the discharge
plan and documentation of dis-
charge summary or status
Support Personnel
I. Physical TherapistAssistants.
The physical therapist assistant is an
educated health care provider who
assists the physical therapist in provid-
ing physical therapy. The physical
therapist assistant is a graduate of a
physical therapist assistant associate
degree program accredited by an
agency recognized by the Secretary of
the United States Department of Edu-
cation or the Council on Postsecond-
ary Accreditation.
The supervising physical therapist is
directly responsible for the actions of
the physical therapist assistant. The
physical therapist assistant performs
physical therapy procedures and re-
lated tasks that have been selected
and delegated by the supervising
physical therapist. Where permitted by
law, the physical therapist assistant
also carries out routine operational
functions, including supervising the
physical therapy aide and document-
ing treatment progress. The ability of
the physical therapist assistant to per-
form the selected and delegated tasks
is assessed on an ongoing basis by the
supervising physical therapist. The
physical therapist assistant may m o d e
a specific treatment procedure in ac-
cordance with changes in patient
status within the scope of the estab-
lished treatment plan.
therapist or, in accordance with the
law, by a physical therapist assistant.
The physical therapist is directly re-
sponsible for the actions of the physi-
cal therapy aide. The physical therapy
aide provides support services in the
physical therapy service,both patient-
related and non-patient-relatedduties.
When providing direct physical ther-
apy services to patients, the physical
therapy aide functions only with the
continuous on-site supervision of the
physical therapist or, where allowable
by law andlor regulation,the physical
therapist assistant. The requirement for
continuous on-site supervision man-
dates the presence of the physical
therapist or physical therapist assistant
in the immediate area and their in-
volvement in appropriate aspects of
each treatment session in which a
component of treatment is delegated
to a physical therapy aide.
111. Other Support Personnel. When
other personnel (eg, exercise physiol-
ogists, athletic trainers, massage thera-
pists) work within the supervision of a
physical therapy service they should
be employed under their appropriate
titles. Any involvement in patient care
activities should be within the limits of
their education, in accord with appli-
cable laws and regulations, and at the
discretion of the physical therapist.
However, if they function as an exten-
sion of the physical therapist's license,
their title and all provided services
must be in accordance with state and
federal laws and regulations. (In all
situations in which the physical thera-
pist delegates activities to other sup-
port personnel, physical therapists
must recognize their legal responsibil-
ity and liability for such delegation.)
References
4. Klaber MoffettJA, Chase SM, Portek I, En-
nis JR. A controlled, prospective study to eval-
uate the effectiveness of a back school in the
relief of chronic low back pain. Spine.
1986;11:120-122.
5. Bigos SJ, Battie MC. Acute care to prevent
back disability. Clin Orthop. 1987;221:
121-130.
6. Judge JO, Lindsey C, Underwood M, Win-
semius D. Balance improvements in older
women: effects of exercise training. Phys Iher.
1993;73:254-265.
7. Rutherford OM. The role of exercise in the
prevention of osteoporosis. Physiotherapy.
1990;76:522-526.
8. Nelson ME, Fisher EC, Dilmanian FA, et al.
A one-year walking program and increased
dietary calcium in post-menopausal women:
effects on bone. Am J Clin Nutr.
1991;53:1304-1311.
9. Osteoporosis:Cause, Treatment, Prevention
U
S Dept of Health and Human Services Publi-
cation No. (NIH) 86-2226. Bethesda, MD: Na-
tional Institute of Arthritis and Musculoskeletal
and Skin Diseases; 1986.
10. Whedon GC. Interrelation of physical ac-
tivity and nutrition on bone mass. In: White
PL, Mondeika T, eds. Diet and Erercise: Syn-
ergism in Health Maintenance. Chicago, 1
1
1
:
American Medical Association; 1982:99.
11. Jacobsen PC, Beaver W, Grubb SA, et al.
Bone density in women: college athletes and
older athletic women. J Orthop Res.
1984;2:328-332.
12. Nilsson BE, Westlin NE. Bone density in
athletes. Clin Orthop. 1971;77:179-182.
13. Chow RK, HarrisonJE, Brown CF, et al.
Physical fitness effect on bone mass in post-
menopausal women. Arch Phys Med Rehabil.
1986;67:231-234.
14. Ades PA, Huang D, Weaver SO. Cardiac
rehabilitation participation predicts lower re-
hospitalization costs. Am Heart J.
1992;123:195-200.
15. Busch AJ, McClements JD. Effects of a su-
pervised home exercise program on patients
with severe chronic obstructive pulmonary
disease. Phys Iher. 1988;68:469-474.
16. Hudson LD, Tyler ML, Petty T. Hospital-
ization needs during an outpatient rehabilita-
tion program for severe chronic airway ob-
struction. Chest. 1976;70:606-610.
17. Dinchin M, Woolf 0,Kaplan L, Floman Y.
Secondary prevention of low-back pain: a
clinical trial. Spine. 1990;15:1317-1319.
18. Ryden LA, Molgaard CA, Bobbitr SL. Ben-
efits of a back care and lighr duty health pro-
motion program in a hospital setting.J Com-
munity Health. 1988;13:222-230.
19. Wood PJ. Design and evaluation of a
back injury prevention program within a geri-
atric hospital. Spine. 1987;12:77-81.
1. Donaldson M, Yordy K, Vanselow N. 20. Clapp JF. The course of labor after endur-
11. Physical TherapyAides. The Defrning Primary Care: An Interim Repott. ance exercise during pregnancy. Am J Obstet
physical therapy aide is a nonlicensed Washington, DC: National Academy Press; Gynecol. 1990;163:1799-1805.
1994. 21. Lokey EA, Tran ZV, Wells CL, et al. Effects
worker who is specificallytrained
2, Hazard RG, Fenwick JW, Kalisch SM, et al, of physical exercise On pregnancy outcomes:
under the direction a physical Functional restoration with behavioral a meta-analyticreview. Med Sci Sports &WC.
pist. The physical therapy aide per- support: a one-year prospective study of pa- 19'91;23:1234-1239.
formsdesignated routine tasks related tien's: with chronic low back pain. Spine.
1989;14:157-161.
the a therapy 3. Kellet KM, Kellett DA, Nordholm LA. Ef-
service delegated by the physical fects of an exercise program on sick leave
due to back pain. Phys Iher. 1991;71:285293.
74/ 719 Physical Therapy / Volume 75, Number 8/ August 1995

Chapter Two:
Examinations Provided by Physical Therapists
The physical therapist's patient man-
agement process of examination, eval-
uation, diagnosis, prognosis, and inter-
vention has been described in Chapter
One. Twenty-threeexaminations that
the physical therapist may select are
detailed in Chapter Two; other exami-
nations not described in h s chapter
may also be used in patient manage-
ment. Depending on the data gener-
ated during the history and systems
review, the physical therapist may use
one or more of these examinations, in
whole or in part. For example, in
examining a patient with impairments
and disabilities resulting from a brain
injury, the physical therapist may de-
cide to peiform part or all of several
examinations,based on the pattern of
involvement in the individual patient.
Thus, the physical therapist should
individualize the selection of examina-
tions rather than choose them solely
on the patient's presenting diagnosis
(eg, brain injury).
For each of the examinations, four
areas are discussed:
Overview-Provides an intro-
duction to the examination.
Clinical Indications-Lists ex-
amples of the functional limita-
tions, impairments, disabilities,
or special requirements that may
prompt the physical therapist to
conduct the examination.
Tests and Measures-Lists
general methods and techniques
used in conducting the
examination.
Data Generated-Describes the
information collected from the
tests and measures.
Other information that may be re-
quired for the examination includes,
but is not limited to, clinical findings
of other health professionals; results of
diagnostic imaging,clinical laboratory,
and electrophysiologicstudies; federal,
state, and local work surveillanceand
safety reports and announcements;
and observations of family members,
significant others, caregivers, and
other interested persons.
A physical therapy examination or
intervention, unless performed by a
physical therapist, is not physical ther-
apy nor should it be represented or
reimbursed as such.
Aerobic Capacity or Endurance
Examination
Overview.Ambic capacity,pow,
and endurance are all measures of 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 employs tests
ranging from simple determinations of
heart rate, blood pressure, and respira-
tory rate to complex calculationsof
oxygen consumption and carbon
dioxide production to determine the
appropriateness of an individual's
response to increased oxygen de-
mand. Monitoring responses at rest
and during activity can indicate the
degree and severity of impairment,
iden* cardiopulmonary deficits that
produce functional limitations, and
indicate that other tests and specific
therapeutic interventions are needed.
The aerobic capacity or endumce
examination produces information
used to identlfy the possible or actual
cause(s) of difficulties during the pa-
tient's performance of essential every-
day activities, leisure pursuits, and
work tasks. Selection of specific tests
and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a diag-
nosis, a prognosis, and the selection of
appropriate interventions.
Clinical Indications. An aerobic
capacity or endurance examination is
appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that speclfy minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
or work reintegration, or leisure
tasks and movements:
weakness
shortness of breath
dizziness
palpitation
tightness of the chest wall
lack of mobility
lack of endurance
abnormalities in movement,
flexibility, or strength
edema of the lower
extremities
referred pain (angina) indica-
tive of cardiac ischemia
ischemic pain in the extremi-
ties (claudication)
inability to perform specific
movement tasks
abnormalities of heart rate,
blood pressure, respiratory
rate or pattern of breathing,
and/or heart muscle function

Testsand Measures. Tests and
measures for performing an aerobic
capacity or endurance examination
include,but are not limited to:
obtainment of standard vital
signs (blood pressure, heart and
respiratory rate) at rest, during
activity, and during recovery
auscultation of heart sounds
auscultation of the lungs
auscultation of major vessels for
bruits
palpation of pulses
performance of an
electrocardiogram
performance of pulse oximetry
performance of tests of pulmo-
nary function and ventilatory
mechanics
performance of gas analysis or
oxygen consumption studies
observation of chest movements
and breathing patterns with
activity
performance of claudication
time tests
assessment of patient's perfor-
mance during established exer-
cise protocols (eg, treadmill,
ergometer, 6-minute walk test,
3-minute step test)
monitoring of the patient by
telemetry during activity
assessment of perceived exer-
tion or dyspnea during activity
using a visual analog scale
Data Generated. Data generated
may include, but are not limited to:
description of peripheral vascu-
lar integrity
report of vital signs (blood pres-
sure, heart and respiration rate)
at rest, during, and after activity
list of activities that aggravate or
relieve symptoms
physical exertion scale grading
and/or dyspnea assessment with
activity
report of oxygen saturation with
activity
report of ventilatory volumes
and flow at rest and after activ-
ity (including comparison of
actual to predicted)
report of inspiratory and expira-
tory muscle force before and
after activity (including compari-
son of actual to predicted)
maximum oxygen consumption
(including comparison of actual
to predicted)
oxygen consumption for particu-
lar activity (including compari-
son of actual to predicted)
respiratory quotient
anaerobic threshold
description of chest movement
and breathing patterns with
activity
report of any arrhythmias at rest
and during activity
report of symptoms limiting
activity
Anthropometric Characteristics
Examination
Overview.Anthropometric character-
&ticsdescribe human body measure-
ments such as height, weight, girth,
and body fat composition. The physi-
cal therapist uses the anthropometric
characteristicsexamination to test for
muscle atrophy, gauge the extent of
edema, and establish a baseline to
allow patients to be compared to
national norms on such variables as
weight and body-fat composition.An
anthropometriccharacteristics exami-
nation may lead to a recommendation
that other examinationsbe performed,
such as an aerobic capacity or endur-
ance examination.
The anthropometric characteristics
examination produces information to
idenhfy the possible or actual cause($
of difficultiesduring the patient's per-
formance of essential everyday activi-
ties, leisure pursuits, and work tasks.
Selection of specific tests and mea-
sures will depend on the findings of
the patient history and systems review.
The examination may require testing
while the patient performs specific
activities. The examinationwill lead to
an evaluation,a diagnosis,a progno-
sis, and the determination of appropri-
ate interventions.
ClinicalIndications.An anthropo-
metric characteristics examination is
Suspected or identified pathol-
ogy, injury, or developmental
delay that prevents normal per-
formance of daily activities, in-
cluding self care, home manage-
ment, community or work
reintegration, and leisure
that specify minimum capacity
for performance
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
biomechanical and arthroki-
nematic limitations
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
movement tasks
effusion or edema (including
edema during pregnancy)
muscle atrophy
suspected onset of
lymphedema
Tests and Measums. Tests and
measures for performing an anthropo-
metric characteristicsexamination
include, but are not limited to:
measurement of height, weight,
and girth
measurement of body-fat com-
position, using calipers, under-
water weighing tanks, or electri-
cal impedance
classification of edema through
volumetrics and girth

observation and palpation of an
extremity or part at rest and dur-
ing activity
assessment of activities and pos-
tures that aggravate or relieve
edema
assessment of edema (eg, during
pregnancy, in determining the
effects of other medical or
health-related conditions, during
surgical procedures, after drug
therapy)
Data Generated.Data generated
height in feet and inches or
centimeters
weight in pounds or kilograms
girths of extremities and chest
and lengths of extremities in
inches or centimeters
body fat (as a percentage of
mass or in inches or
centimeters)
volumetric displacement in liters
a list of activities and postures
that aggravate or relieve edema
integrity of lymphatic system
Arousal, Mentation, and
Cognition Examination
Ovwiew. Amusal is the stimulation
to action or to physiologic readiness
for activity. Mentation is a mechanism
of thought or mental activity. Cogni-
tion is the act or process of knowing,
including both awareness and judg-
ment. Tht: physical therapist uses the
arousal, mentation, and cognition
examination to assess the patient's
responsiveness;orientation to time,
person, and place; and ability to fol-
low directions. The examination
guides the physical therapist in select-
ing interventionsby indicating
whether the patient has the cognitive
ability to participate in the care
process.
The arousal, mentation, and cognition
examinationproduces information
used in identifying the possible or
actual cause($ of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
tion will lead to an evaluation,a
diagnosis,a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. An arousal,
mentation, and cognition examination
is appropriate in the presence of:
leisure
for performance
pain
weakness
lack of mobility
lack of endurance
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial or temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
somatosensory deficit
gait deficit(s) and
disturbances
postural deficits
nematic limitations
impaired balance or frequent
falling
learning
impaired sensation
movement tasks
change in baseline status of
arousal, mentation, cognition
Tests and Measures. Tests and
measures for performing an arousal,
mentation, and cognition examination
include, but are not limited to:
determination of patient's level
of consciousness
determination of patient's level
of recall
determination of patient's orien-
tation to time, person, and place
cognitive screening (eg, to de-
termine ability to process com-
mands, to measure safety
awareness)
screening for gross expressive
and receptive deficits
assessment of arousal, menta-
tion, and cognition using stan-
dardized instruments
level of arousal, mentation, or
cognition deficits
difference between predicted
and actual performance
variation over time of arousal,
mentation, or cognition deficits
scores on standardized instru-
ments for measuring arousal,
mentation, and cognition
Assistive, Adaptive, Supportive,
and Protective Devices
Examination
Overview. Assistive, adaptive, support-
ive, and protective devices are a variety
of implements or equipment used to
aid individuals in performing tasks or
movements. Rssirstive deuices,which
include crutches and canes, involve
rather simple technologies; adaptive
devices, which include such technolo-
gies as a wheelchair and the long-
handed reacher, are generally more
complex. Supportive devices include
taping, compression garments, corsets,
and neck collars, while protective
devices include braces and helmets.
The physical therapist uses the assis-
tive, adaptive, supportive, and protec-
tive devices examination to determine
whether an individual might benefit
from such a device or, where one is

already in use, to determine how well
the patient performs with it.
The assistive,adaptive, supportive,
and protective devices examination
produces information used in identify-
ing the possible or actual cause(s) of
difficultiesduring the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures wiU
depend on the findings of the patient
history and systems review. The exarn-
ination may require testing while the
patient performs specfic activities.The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the de-
termination of appropriate
interventions.
Clinical Indications. An assistive,
adaptive, supportive, and protective
devices examination is appropriate in
the presence of:
the normal performance of daily
leisure
for performance
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbance(s)
nematic limitations
falling
movement tasks
learning
impaired sensation
integumentary deficits
incontinence, bowel, and
bladder difficulty
lymphedema
Testsand Measures. Tests or mea-
sures for performing an assistive,
adaptive, supportive, and protective
devices examination include, but are
not limited to:
analysis of the potential to re-
mediate impairments, functional
limitations, or disabilities using
an assistive, adaptive, support-
ive, or protective device
observation of the individual
using the device for intended
effects and benefits and ability
to use the device
review of reports provided by
the patient, significant others,
family, and caregivers
analysis of alignment and fit of
the device and inspection of
related changes in skin
condition
assessment of appropriate com-
ponents of the device
assessment of safety while using
the device
videotape analysis of the patient
or client using the device
computer-assisted analysis of
motion
deviations and malfunctions that
can be corrected or alleviated
by an assistive, adaptive, sup-
portive, or protective device
alignment of anatomical parts
with the device
safety and effectiveness of the
device in providing protection,
promoting stability, or improv-
ing performance of tasks and
activities
expressions of comfort, cosme-
sis, and effectiveness using the
device
ability to use the device and
understanding of its appropriate
use
level of compliance with use of
the device
Community or Wo&
Reintegration Examination
(Including lnstnrmental Activities
of Daily Living)
Overview. Community or m
r
k reinte-
gration is the process of resuming
one's role(s) in the community or at
work. The physical therapist uses the
community or work reintegration
examination to make an informed
judgment as to whether an individual
is currently prepared to resume com-
munity or work roles or to determine
when and how such reintegration
might occur. The physical therapist
also uses this examination to deter-
mine whether an individual is a candi-
date for a work hardening or work
conditioning program.
The community or work reintegration
used in identdjmg the possible or
actual cause(s) of difficultiesduring
tests and measures wiU depend on the
forms specific activities.The examina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
Clinical Indications. A community or
work reintegration examination is
activities, including community
or work reintegration or leisure
tasks and movements
for performance

tempting to perform community
or work reintegration or leisure
pain
weakness
lack of mobility
lack of endurance
gait deficitGI and
disturbances
postural deficits
abnormalities in movements,
nematic limitations
falling
learning
impaired sensation
incontinence, bowel and
bladder difficulty
Testsand Measures. General tests
and measures for performing a com-
munity or work reintegration examina-
tion include, but are not limited to:
performing work tasks and com-
munity and leisure activities
review of reports provided by
the individual, family members,
significant other, or caregiver
administering questionnaires
and conducting interviews with
the patient and other interested
persons
application of instrumental activ-
ities of daily living measurement
scales and performance batteries
for community, work, and lei-
sure activities
measurement of physiologic re-
sponses during community,
work, and leisure activities
review of daily activities logs
measurement of static and dy-
namic strength
application of functional rating
scales
measurement of functional
capacity
assessment of appropriateness
of assistive, adaptive, support-
ive, and protective devices
analysis of environment and job
tasks
analysis of mentation and
cognition
analysis of adaptive skills
levels of strength, flexibility, and
endurance
effort in specific movement tasks
gross and fine motor function
physical, functional, behavioral,
and vocational status
work-related systemic neuro-
musculoskeletal restoration
needs
vital signs and physiologic re-
sponse during community or
work reintegration and leisure
activities
presence or absence of menta-
tion and cognition deficits
level of adaptive skills
Cranial Nerve Integrity
Examination
Overview.A cranial n e m is one of
twelve paired nerves (eg, olfactory,
optic) that emerge from or enter the
brain. The cranial nerve integrity ex-
amination has somatic, visceral, affer-
ent, and efferent components. The
physical therapist uses the cranial
nerve integrity examination to localize
a dysfunction in the brain stem and to
iden* cranial nerves that merit an
in-depth examination.The physical
therapist uses a number of cranial
nerve tests to assess the patient's sen-
sory and motor functions,such as
taste, smell, and facial expression.
analysis of aerobic capacity or
endurance during community, The cranial nerve integrity examina-
tion produces information used to
work, and leisure activities
assessment of dexterity and
identlfy the possible or actual cause(s)
coordination
of difficulties during the patient's per-
formance of essential everyday activi-
ties, leisure pursuits, and work tasks.
Selection of specific tests and mea-
sures will depend on the findings of
the patient history and systems review.
The examination may require testing
while the patient performs specfic
activities.The examinationwill lead to
an evaluation, a diagnosis, a progno-
sis, and the determination of appropri-
ate interventions.
ClinicalIndications. A cranial nerve
integrity examination is appropriate in
the presence of:
leisure
for performance
pain
weakness
lack of mobility
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial and temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
somatosensory deficit
falling
learning
impaired sensation
movement tasks
Tests and Measures.Tests and
measures for performing a cranial
nerve integrity examination include,
but are not limited to:

performance of tests of:
touch
pain
temperature
vision
vestibular sensibility
auditory sensibility
taste
smell
assessment of muscles inner-
vated by the cranial nerves
description of eye movements
amount of constriction and dila-
tion of pupils
visual deficits
pain, touch, temperature
localization
gross auditory acuity
equilibrium responses
characteristics of swallowing
integrity o
f gag reflexes
degree of loss of taste
degree of loss of function in
muscles innervated by the cra-
nial nerves
Envimnmental, Home, or Work
Bammets
Examination
Overview.Environmental, home, and
work barrim are the physical impedi-
ments that keep individualsfrom func-
tioning optimally in their surround-
ings. The physical therapist uses the
environmental, home, or work barriers
examination to iden@ any of a vari-
ety of possible impediments, including
safety hazards (eg, throw rugs, slip-
pery surfaces), access problems (eg,
narrow doors, high steps), and home
or office design (eg, excessive dis-
tances to negotiate, multiple-story
environment). The physical therapist
uses this examination, often in con-
junction with elements of the ergo-
nomics or body mechanics examina-
tion, to suggest modifications to the
environment (eg, grab bars in the
shower, ramps, raised toilet seats,
increased lighting) that will permit the
patient or client to improve function-
ing in the home, workplace, or other
settings.
The environmental, home, or work
barriers examination produces infor-
mation used in iden*ing the possible
or actual cause(s) of difficulties during
and work tasks. Selection of specfic
ClinicalIndications.An environmen-
tal, home, or work barriers examina-
tion is appropriate in the presence of:
leisure
for performance
pain
weakness
lack of mobility
lack of endurance
gait deficit(s1 and
disturbances
postural deficits
nematic limitations
falling
learning
impaired sensation
bladder difficulty
movement tasks
Testsand Measures.Tests and
measures for performing an environ-
mental, home, or work barriers exarni-
nation include, but are not limited to:
assessment of present and po-
tential barriers
physical inspection of the
environment
conducting interviews and ad-
ministering questionnaires
off-site
analysis of physical space using
photography or videotape
measureihent of physical space
ergonomic analysis of an indi-
vidual's home, workplace, or
other customary environment
may include, but are not limited to: 11
a list of space limitations and
other barriers, including their
dimensions, that limit an indi-
vidual's ability to perform spe-
cific movement tasks during
home, work, and leisure
activities
degree of compliance with stan-
dards set forth in the Americans
with Disabilities Act
recommendations for elimina-
tion of environmental barriers
a list of adaptations, additions,
or modifications that would en-
hance patient safety
Ergonomics or Body Mechanics
Examination
Overview.E?gonomics is the study of
the relationships between people,
work, and the work environment,
using scienthc and engineering princi-
ples to improve those relationships.
Body mechanics describes the interre-
lationships of the muscles and joints as
they maintain or adjust posture in
response to environmental forces. The
physical therapist uses the ergonomics
or body mechanics examination to
examine the work environment on
behalf of patients or clients to deter-
mine the potential for trauma to result
from inappropriate workplace design.
The ergonomics or body mechanics
examination may be conducted after a
work injury or as a preventive mea-
sure, particularly when an individual is
Physical Therapiy/ Volume 75, Number 8/ August 1995

returning to the work environment
after an extended absence.
The ergonomics or body mechanics
used in identlfylng the possible or
acmal cause(s) of dificulties during
ClinicalIndications.An ergonomics
or body mechanics examination is
or work reintegration, and lei-
sure tasks and movements
for performance
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
ab~lormalities
in movement,
nematic limitations
mclvement tasks
falling
learning
impaired sensation
abnormal body alignment and
movement patterns
frequent injury
Tests and Measures.Tests and
measures for performing an ergonom-
ics examination include, but are not
limited to:
ergonomic analysis of job tasks
or activities to assess the
following:
essential functions of the job
task or activity
work postures required to
perform the job task or
activity
joint range of motion used to
perform the job task or
activity
strength required in the work
postures necessary to perform
the job task or activity
repetition/work/rest cycling
during the job task or activity
sources of potential trauma
vibration
tools, devices, or equipment
used
endurance required to per-
form aerobic endurance
activities
assessment of work hardening
or work conditioning, including
identification of needs related to
administration of batteries of
work performance
review of safety and accident
reports
assessment of dexterity and
coordination
performing selected movements
or activities
determination of dynamic capa-
bilities and limitations during
specific work activities
video analysis of the patient or
client at work
computer-assisted motion analy-
sis of the patient or client at
work
Tests and measures for performing a
body mechanics examination include,
but are not limited to:
measurement of height, weight,
and girth
performing selected movements
or activities
determination of dynamic capa-
bilities and limitations during
specific work activities
videotape analysis of the patient
or client performing selected
movements or activities
computer-assisted motion analy-
sis of the patient or client per-
forming selected movements or
activities
height in feet and inches or
meters and centimeters
weight in pounds or kilograms
girths of extremities and chest
amount of dficulty experienced
or pain expressed during the
performance of specific job
tasks or activities
a list of potential and actual er-
gonomic stressors
body alignment, timing, and se-
quencing of component move-
ments during specific job tasks
or activities
levels of strength, flexibility, and
endurance
level of effort in specific move-
ment tasks
levels of gross and fine motor
function
safety records and accident
reports
level of work performance
work-related systemic neuro-
musculoskeletal restoration
needs

temporal and spatial characteris-
tics of movements during job
tasks or activities
Gait and Balance Examination
Overview. Gaitis the manner in
which a person walks, characterized
by rhythm, cadence, step, stride, and
speed. Balance is the ability to main-
tain the body in equilibrium with
gravity both statically (eg, while sta-
tionary) and dynamically (eg, while
walking). The physical therapist uses
the gait and balance examination to
investigate disturbances in gait and
balance because they frequently lead
to decreased mobility, a decline in
functional independence, and an in-
creased risk of falls. Gait and balance
problems often involve dficulty in
integrating sensory, motor, and neural
processes. The physical therapist also
uses the gait and balance examination
to determine whether the patient is a
candidate for an assistive, adaptive,
supportive, or protective device.
The gait and balance examination
produces ~nformation
used in identify-
ing the possible or actual cause(s) of
dficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the de-
termination of appropriate
interventions.
ClinicalIndications.A gait and bal-
ance examination is appropriate in the
presence of:
leisure
for performance
tempting to ~erform
self care,
pain
weakness
lack of mobility
lack of endurance
gait deficitcs) and
disturbances
postural deficits
nematic limitations
falling
learning
impaired sensation
bladder difficulty
inability to participate in
athletics
Tests and Measums. Tests and
measures for performing a gait and
balance examination include, but are
not limited to:
identification of gait
characteristics
identification and quantification
of static and dynamic balance
characteristics
analysis of biomechanical, ar-
throkinematic, and other spatial
and temporal characteristics of
gait and balance with and with-
out the use of assistive, adap-
tive, supportive, or protective
devices
analysis of gait on various ter-
rains, in different physical envi-
ronments, and in water
administration of functional am-
bulation profiles
videotape analysis of patient's
movement to assess gait or
balance
EMG analysis of patient's move-
ment to assess gait or balance
computer-assisted analysis of
patient's movement
application of gait analysis rat-
ing scales
assessment of safety awareness
ergonomic analysis of gait
application of mechanical and
electrical weight-bearing scales
and force plates
qualitative and quantitative de-
scriptions of gait and balance
gait cycle, gait deviations, and
the safety and quality of gait
over time in different environ-
ments and on a variety of
surfaces
safety and quality of gait and
the gait cycle over time using
assistive, adaptive, supportive,
or protective devices
a list of surfaces and elevations
patient is able to negotiate
number ratings from standard-
ized gait testing instruments
charts and videos that reflect
gait pattern changes over time
a list of patient activities that
aggravate or diminish difficulties
with gait
patient's perception of gait
problems
level of safety awareness
weight-bearing ability, including
standardized measures of
weight-bearing in pounds or
kilograms
analysis of spatial and temporal
characteristics of gait and bal- Integumentary Integrffy
ance using kinematic, kinetic,
Examination
-
and electromyographic (EMG)
f ~ ^ + ^
Overview.Integumentary integrityis
LCZiLZi
application of balance and gait
the health of the skin, including its
ability to serve as a barrier to environ-
analysis rating scales
mental threats (eg, bacteria, parasites).
The physical therapist uses an integu-

A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy

A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy

Recommended

Recommended

More Related Content

Similar to A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy

Similar to A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy (20)

More from Dawn Cook

More from Dawn Cook (20)

Recently uploaded

Recently uploaded (20)

A Guide To Physical Therapist Practice. Volume I A Description Of Patient Management Table Of Contents Chapter One Management Of Physical Therapy