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1995; 75:707-764.PHYS THER.Description of Patient ManagementA Guide to Physical Therapist Practice, Volume I: A

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Guide to Physical Therapist Practice. Volume I:Description of Patient Management[A Guide to Physical Therapist Practice Volume One: A Description of Patient ManagementPbys Ther 1995;75:R 1

Table of ontentsPreface 709Chapter One Management of Physical Therapyatients 71 1

hysical Therapists 71 1efinition of Physical Therapy 71 1hysical Therapist Practice 712ractice Settings 71 2rimary Care 71 2econdary and Tertiary Care 713Patient Management 713I Examination 714

The History 714Systems Review 715

C Tests, Measures. and Data Generated 715I1 Evaluation 71511 Diagnosis 715V Prognosis 716

~ntervention 716Direct Intervention 716Patient-related Instruction 716

C Coordination. Communication. andocumentation 716

Additional Professional Activities of the PhysicalTherapist 716I Prevention and Wellness including Health

Promotion) 171 Consultation 71711 Screening 717V Education 718

Critical Inquiry 718V Administration 718

Physical Therapy Services: Direction andupervision of Support Personnel 718

upport Personnel 719Physical Therapist Assistants 7191 Physical Therapy Aides 71911 Other Support Personnel 719

References 719Chapter Two Examinations Provided byhysical Therapists 720Aerobic Capacity or Endurance Examination 720Anthropometric Characteristics Examination 721Arousal, Mentation. and Cognition Examination 722Assistive, Adaptive, Supportive, and Protective

evices Examination 722

Community or Work Reintegration Examinationincluding Instrumental Activities of Daily

Living) 723Cranial Nerve Integrity Examination 724Environmental. Home. or Work Barriers

Examination 725Ergonomics or Body Mechanics Examination 725

ait and Balance Examination 727ntegumentary Integrity Examination 727oint Integrity and Mobility Examination 728

otor Function Examination 729Muscle Performance Examination including

Strength. Power. and Endurance) 730Neuromotor Development and Sensory

ntegration Examination 731rthotic Requirements Examination 731ain Examination 732

Posture Examination 733rosthetic Requirements Examination 734

Range of Motion Examination including Muscleength) 734

Reflex Integrity Examination 735Self-care and Home-Management Examination

including Activities of Daily Living andnstrumental Activities of Daily Living) 736

Sensory Integrity Examination includingroprioception and Kinesthesia) 737

Ventilation. Respiration. and CirculationExamination 737Chapter Three Interventions Provided byPhysical Therapists 739

ntervention 739I Direct Intervention 7391 Patient-related Instruction 740111 Coordination. Communication. and

ocumentation 740Therapeutic Exercise including Aerobic

onditioning) 741Functional Training in Self Care and Home

Management including Activities of DailyLiving and Instrumental Activities of Daily

iving) 742Functional Training in Community or Work

Reintegration including Instrumental Activitiesof Daily Living. Work Hardening. and Work

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onditioning) 742Manual Therapy Techniques including

obilization and Manipulation) 743Prescription. Fabrication. and Application of

Assistive. Adaptive. Supportive. and Protectiveevices and Equipment 744

Airway Clearance Techniques 744ebridement and Wound Care 745hysical Agents and Mechanical Modalities 746

Physical Therapy Volume 75 Number 8 /August 1995

Electrotherapeutic ModalitiesPatient-related InstructionppendicesAppendix I A Glossary of Operational Definitions

in Physical TherapyAppendix I1 Code of Ethics and Guide for

Professional Conduct 7Appendix I11 Guidelines for Physical Therapy

Documentation 7

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A Guide to Physical TherapistPractice Volume I: A Descriptiono Patient Management

Physical therapy is a dynamic profession with an established theoretical baseand widespread clinical applications, particularly in the preservation, develop-ment, and restoration of maximum physical function. Physical therapists seek toprevent injury, impairments, functional limitations, and disability; to maintainand 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.A s essential participants in the health care delivery system, physical therapistsassume leadership roles in prevention and health maintenance programs, in theprovision of rehabilitation services, and in professional and community organiza-tions. They also play important roles in developing health policy and appropri-ate standards for the various elements of physical therapy practice. Physicaltherapists help nearly a million Americans daily to restore health, alleviate pain,and prevent the onset and progression of impairments, functional limitations,and disability. The benefits of rehabilitation and physical therapy services arewell documented, and services are covered in nearly all federal, state, and pri-vate insurance plans.The American Physical Therapy Association (APTA), the national organizationrepresenting the profession of physical therapy, believes it to be critically impor-tant that those outside the profession understand the role of physical therapistsin 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, andmoddy treatment to effect the desired outcomes. Physical therapy includes notonly those services provided by physical therapists but also those renderedunder 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 servicesthat the therapist has provided. The Association actively supports outcomesresearch and strongly endorses all efforts to develop appropriate systems tomeasure the results of physical therapy patient management.

uide o hysical Therapist ractice is a two-volume description of generalphysical therapy patient management developed by the APTA to give readers athorough understanding of the contributions that physical therapists bring to

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health care. Volume A Description of Patient Management focuses first onphysical therapists as health professionals, describing their approach to patientmanagement in Chapter One. Chapter Two details 3 examinations that physicaltherapists often perform and includes an overview of each examination, clinicalindications that may prompt its use, a list of the general tests and measures thatmay be atiministered, and data that may be generated. Chapter Three details theinterventions (treatments) that physical therapists frequently provide. n over-view for each intervention is given, followed by a listing of the modes in whichthe intervention may be applied. Clinical indications for selecting the interven-tion are described and its expected benefits listed. Finally, three appendices arepresented: a glossary, the APTA Code of Ethics and Guide or Ptofssional Con-duct and the APTA Guidelines or Physical T?m-apyDocumentation. [Volume

t Preferred Practice Patterns will be keyed to defined impairments and ICD-9codes ancl is in the process of being developed.]A Guide to Physical 7h;berapistPractice serves two purposes: 1) to provide aguide to the domain of accepted physical therapy practice and 2 to facilitate thedevelopment 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 ofhealth care services, and reduce costs. This document is intended to be used asa 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 physicaltherapy patient management. Decisions about the appropriateness of treatmentare 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 physicaltherapist considers the influence of culture, gender, race, age, socioeconomicstatus, 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 stategovernments and other entities that provide insurance reimbursement for physi-cal therapy services require that these services be provided only by or under thedirection of a physical therapist. The use of any physical therapy examination orintervention, unless provided by a physical therapist or under the direction orsupervision of a physical therapist, is not physical therapy, nor should it berepresented or reimbursed as such.

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Chapter OneManagement 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 ofphysical therapists in the provision ofprimary, secondary, and tertiary care.Physical therapists are professionalsinvolved in the examination, evalua-tion, treatment, and prevention ofneuromuscular, musculoskeletal, car-diovascular, and pulmonary disordersthat produce movement impairments,disabilities, and functional limitations.s members of primary care teams or

as providers of specialty care, physicaltherapists help patients to improvefunction, alleviate pain, and preventthe onset of disease or disability.Chapter One also lists the settings inwhich physical therapists practice anddescribes the professional activities inwhich they are involved, which in-clude patient management (examina-tion, evaluation, diagnosis, prognosis,and intervention), prevention andwellness (including health promotion),consultation, screening, education,critical inquiry, and administration.The chapter eoncludes with a discus-sion of support personnel.Pt ysical TherapistsPhysical tb~rapists re professionallyeducated at the college or universitylevel and are required to be licensedin the states(s) in which they practice.Graduates from 1960 to the presenthave successfully completed profes-sional programs of physical therapyaccredited by the APTA s Cornmissionon Accreditation in Physical TherapyEducation (CAPTE). Graduates from1926 to 1959 completed physical ther-apy curricula approved by appropriateaccreditation bodies.

Physical therapists interact and prac-tice in collaboration with a variety ofhealth professionals, including physi-cians, dentists, podiatrists, nurses,social workers, occupational thera-pists, speech and language patholo-gists, and others. s responsible healthprofessionals, physical therapists ac-knowledge the need to educate andinform other health professionals,government agencies, insurers, andthe consumer public about the ser-vices they offer and their effective andcost-efficient delivery.Physical therapists provide patientswith services at the preventive, acute,and rehabilitative stages directed to-ward achieving increased functionalindependence and decreased func-tional impairment. They provide pre-ventive care that forestalls or preventsfunctional decline and the need formore intense care. Through timely andappropriate intervention, they fre-quently reduce or eliminate the needfor costlier forms of care such as sur-gery and may also shorten or eveneliminate institutional stays.Definition of Physical TherapyThe current Model Definition of Physi-cal Therapy for State Practice Acts wasadopted by the APTA Board of Direc-tors in March 1993 and revised inMarch 1995:Physical therapy which is the careand services provided y or under thedirection and supenrision of a physicaltherapist includes:1 Examining patients wit impair-

ments functional limitations anddisability or other health-relatedconditions in order to determine adiagnosis prognosis and interven-tion; examinations include but are

aerobic capacity or enduranceanthropometric characteristicsarousal, mentation, andcognitionassistive, adaptive, supportive,and protective devicescommunity or workreintegrationcranial nerve integrityenvironmental, home, or workbarriersergonomics or body mechanicsgait and balanceintegumentary integrityjoint integrity and mobilitymotor functionmuscle performanceneuromotor development andsensory integrationorthotic requirementspainpostureprosthetic requirementsrange of motionreflex integrityself care and home managementsensory integrityventilation, respiration, andcirculation

2) Alleviating impairments and func-tional limitations y designingimplementing and modthingtherapeutic intauentions that in-clude but are not limited to thefollowing:

therapeutic exercise (includingaerobic conditioning)functional training in self careand home management (includ-ing activities of daily living andinstrumental activities of dailyliving)functional training in communityor work reintegration activities(including instrumental activitiesof daily living, work hardening,and work conditioning)

not limited to the following:Physical Therapy /Volume 75, Number 8 /August 1995

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manual therapy techniques (in-cluding mobilization andmanipulation)prescription, fabrication, andapplication of assistive, adap-tive, supportive, and protectivedevices and equipmentairway clearance techniquesdebridement and wound carephysical agents and mechanicalmodalitieselectrotherapeutic modalitiespatient-related instruction

3 Pmazting injury, impimzents,functional limitations, and disabil-ity, including the promotion andmaintenance offitness, health,and quality of life in all agepopulntiorts.

4 Engaging in consultation, educa-tion, and mearch.

Physical Therapist PracticePhysical therapists are committed tooffering necessary, appropriate, andhighquality health services. Theyprovide these services to patients(individuals who are sick or injured)and clients (individuals who are notnecessarily sick or injured but whocan benefit from physical therapyservices, eg, a person with a chronicdisability, a person wishing to preventa loss of function). In addition, physi-cal therapists offer selected services(eg, screening) to individuals, busi-nesses, school systems, and othersalso termed clients. Physical therapistsalso provide wellness initiatives, in-cluding health promotion and educa-tion, that stimulate the public to en-gage in healthy behavior.Physical therapists provide services topatients with impairments, functionallimitations, disability, or change inphysical function and health statusresulting from injury, disease, or othercauses. Impaimzents are losses orabnormalities of physiological, psycho-logical, or anatomical structure orfunction. Functional limitationsarerestrictions of the ability to perform aphysical action, activity, or task in anefficient, typically expected, or compe-tent manner. Disability is the inability

to engage n age- and sex-specificroles in a particular social context andphysical environment. Physical func-tion, which is a fundamental compo-nent of health status, describes thestate of those sensory and motor slullsnecessary for mobility, work, andrecreation. Health status, which is partof well-being, describes an individualin terms of physical, mental, affective,and social function.Practice SettingsPhysical therapists practice in a broadrange of inpatient, outpatient, andcommunity settings, including, but notlimited to, the following:

hospitalshomesphysical therapy office practicesrehabilitation facilitiessubacute care facilitiesskilled nursing or extended carefacilitieshospicesschools (preschool, primary, andsecondary)corporate or industrial healthcenterswork o r occupationalenvironmentsathletic training facilitiessports injury treatment centersfitness centerseducation or research centers

PtSmary amPhysical therapists have major roles toplay in the provision of primary care,recently defined as fol1ows:l

Primary care is the provision of inte-grated, accessible health care sm cesby clinicianswho are accountableforaddressing a large majority of peronalhealth care needs,developing a sustainedpattndip with patients, andpracticing in the context of family andcommunity.

In recent years a number of organiza-tions, including the Institute of Medi-cine, have examined the delivery ofprimary care services n the UnitedStates. The APTA endorses the con-cepts of primary care set forth by theInstitute of Medicine's Committee onthe Future of Primary Care,l whichinclude the following:

Recognition that primary carecan encompass a myriad ofneeds that go well beyond thecapabilities and competenciesof individual caregivers andthat require the involvementand interaction of variedpractitionersRejection of the gatekeeperconcept because of its pejoraticonnotation that the role of theprimary care practitioner is tomanage costs and, for the mospart, to keep the gate closedAwareness that primary care isnot limited to the first contactor point of entry into the healtcare systemEmphasis on the comprehen-siveness of a primary careprogramRecognition of the importantrole of family and community the provision of primary care,and recognition that caregiversand care-receivers functionwithin, and are dependent on,wide range of societal and envronmental factors

Physical therapists are involved in theexamination, treatment, and preven-tion of neuromusculoskeletal disordeand are well positioned to providethose services as members of primarycare teams. On a daily basis, physicatherapists practicing at acute, rehabilitative, and preventive stages of careassist individuals in restoring health,alleviating pain, and preventing theonset of disease or disability. Theyplay roles in the acute, chronic, pre-vention, and wellness areas. A numbof studies indicate that the assumptioby physical therapists of a primarycare role is an efficient use of healthcare resources.Physical therapists provide a broadrange of neuromusculoskeletal healthservices from entry to discharge, in-cluding screening, triage, examinatioreferral, intervention, coordination ofcare, and education and prevention.For acute neuromusculoskeletal disorders, the triage and initial examinatiois the appropriate responsibility of aphysical therapist. The primary careteam functions more efficiently with

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clinical judgments based on data gath-ered during the examination. Diagno-sis is both the process and the endresult of evaluating information ob-tained from the patient examination,which the physical therapist thenorganizes 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 thelevel of maximal improvement thatmight be attained and the time re-quired to reach that level; it may alsoinclude predictions of improvement atvarious intervals during therapy. Inter-vention is the purposeful and skilledinteraction of the physical therapistwith the patient, using various meth-ods and techniques to producechanges in the patient s conditionconsistent with the diagnosis andprognosis.After analyzing all relevant informationthat has been gathered from the his-tory and systems reviews, the physicaltherapist decides what groups of testsand measures should be included inthe exarnination of the patient. Thephysical therapist will decide to useone, more than one, or portions ofseveral . pec c examinations (detailedin Chapter Two) as part of the exami-nation. s the examination progresses,the physical therapist may determinethat there are additional problemspresent that were not uncovered bythe history and systems review andconclude that other specfic examina-tions (in Chapter Two) or portions ofspecific examinations will need to beperformed to obtain sufficient data tomake an evaluation, render a diagno-sis, fomi a prognosis, and chooseinterventions. In addition, as describedbelow, the physical therapist mayreexamine at any stage of the patientmanagement process. Because physi-cal therapy is most often an ongoingprocess delivered over a period ofweeks rather than at a single visit,physical therapists rely on re-examinations to modify or redirect thepatient management process and toevaluate outcomes that have beenpredicted. In actuality, the re-examination has an important qualityassurance component, as it allows the

physical therapist to focus on both theelements of physical therapy manage-ment and the outcomes of care.t each step of the management pro-

cess the physical therapist considersthe possible patient outcomes. Out-come is the result of physical therapymanagement and is expressed in fiveareas: prevention and management ofsymptom madestation, consequencesof disease (impairment, disability,andor role limitation), cost-benefitanalysis, health-related quality of life,and patient satisfaction. Because thephysical therapist projects an outcomethat reflects the needs of the patient, asuccessful outcome includes improvedor maintained physical function whenpossible, a slowing of functional de-cline where the status quo cannot bemaintained, an dor an expression bythe patient that the outcome isdesirable.During the initial history taking, thephysical therapist identifies the pa-tient s expectations for therapeuticinterventions, perceptions about theclinical situation, and goals and de-sired outcomes. The physical therapistconsiders whether these are realistic inthe context of the examination find-ings. In setting forth a diagnosis, mak-ing a prognosis, and choosing inter-ventions, the physical therapist alsoconsiders potential patient outcomes;eg, what outcome is likely given thispatient s diagnosis? The physical thera-pist may use a re-examination to seewhether predicted outcomes are rea-sonable and then m o d e them asnecessary. Ideally, the physical thera-pist also engages in outcomes analysis;ie, he or she systematically examinesthe outcomes of care in relation toselected patient variables (eg, age, sex,diagnosis, interventions performed)and develops statistical reports forinternal or external use.I Examination The exarnination,which is an investigation, is the firststep in the management process. Ithas three components:

obtaining a patient historyperforming relevant systemsreviews

selecting and administering spcific tests and measures

The examination is a required elemprior to any intervention and is per-formed for all patients. The physicatherapist selects components of spe-cific examinations described in Chater Two based on the purpose of thpatient s visit to the physical therapithe complexity of the patient s condtion (~) , nd the evolving impressionformed by the physical therapist during the examination. The examinatiomay therefore be as brief or lengthynecessary. For example, the physicatherapist may conclude from the pa-tient history and systems review thafurther testing and management by tphysical therapist is not requiredandor that the patient should bereferred to another health care practtioner. Conversely, the physical therpist may decide that a full examinatis necessary and then select approprate tests and measures to be adminitered. The range of tests and measurmay include those selected from anyor all of the specific examinationslisted in Chapter Two, depending onthe complexity of the patient s prob-lems and the directions taken by thephysical therapist in the clinicaldecision-making process. It should bnoted that at some point after com-pleting the initial examination, thephysical therapist may conclude thatsecond examination (re-examinationis indicated (because of new clinicalindications, failure of the patient torespond to interventions, etc) andproceed to perform it as describedabove.A The History The patient history ian account of past and present healtstatus. It includes the identification ocomplaints and provides the initialsource of information about the pa-tient; it also suggests the patient sability to benefit from physical theraservices. The patient history provideinformation that enables the therapisto identlfy health-risk factors, healthrestoration and prevention needs, anco-existing health problems that havimplications for physical therapy intevention. It is commonly conducted bgathering data from the patient, fami

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signhcant others, caregivers, andother interested persons; by consultingwith other members of the health careteam; and by reviewing the medicalrecord. In conducting the history, thephysical therapist encourages patientsto express their expected outcomes,which may be used in the process ofestablishing goals and intendedoutcomes.The process of taking a history toidentlfy specific information about thepatient may include, but is not limitedto, the following:

interviewingadministering a questionnaireconsulting with other healthprofessionalsreviewing available records

Data generated from a history mayinclude, but are not limited to, thefollowing:

needs or concerns that led anindividual to seek the servicesof a physical therapistthe patient's expectations fortherapeutic interventions andperceptions about his/her clini-cal situationprior functional status in self-care and home-managementactivities (activities of daily liv-ing and instrumental activities ofdaily living)current community or workactivitiesprior hospitalizations, surgeries,and pre-existing medical andother health-related conditionsmedicationslevel of fitnesshealth risks (eg, family history,diet, alcohol consumption,smoking, stress)incontinence, bowel and blad-der problemsobstetric history

projected discharge designation8 ystems Review.The systemsreview is a brief or limited exarnina-tion to provide additional informationabout the patient's general health thatwill help the physical therapist toformulate a diagnosis and select anintervention program. The systemsreview also assists the physical thera-pist in ident~fying ossible healthproblems that require consultationwith or referral to another health careprovider.Data generated from a systems reviewthat may affect subsequent examina-tion(~) nd intervention(s) include thefollowing:

physiologic and anatomic statuscardiopulmonary response dur-ing rest and activityneuromusculoskeletal physio-logic responses during rest andactivitysomatosensory integritynewly identified or recentlyemerging signs or symptomscommunication skills and cogni-tive statusemotional status

C Tests Measures and DataGenerated. Tests and measures areprocedures or sets of procedures usedto obtain data. After concluding thesystems review, the physical therapistexamines the patient more closely andselects tests and measures from one ormore specific examinations to elicitadditional information. Before, during,and after administering the tests andmeasures, physical therapists willfrequently apply their hands to thepatient to gauge responses, to assessphysical status, and to obtain a morespecific understanding of the patient'scondition and diagnostic and thera-peutic requirements.

judgments) based on the data gath-ered from the examination. Factorsthat influence the complexity of theexamination and the evaluation pro-cess include the clinical findings, ex-tent of loss of function, social consid-erations, and the patient's overallphysical function and health status.Thus, the physical therapist's evalua-tion reflects the severity of the currentproblem, the stability of the patient'scondition, the presence of pre-existingconditions, and the possibility of mul-tiple sites or systems involvement.Physical therapists also consider thel&l of the patient's impairment(s)and the possibility of prolonged impairment, functional limitations, anddisability, as well as the patient's socialsupports, living environment, andpotential 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 asdetailed in the section entitled I.Examination above.111 Diagnosis A diagnosis is a labelencompassing a cluster of signs andsymptoms, syndromes, or categories. Itis the decision reached as a result ofthe diagnostic process, which includesevaluating the information obtainedduring the patient examination andorganizing it into clusters, syndromes,or categories. The purpose of thediagnosis is to guide the physicaltherapist in determining the mostappropriate intervention strategy foreach patient. In the event that thediagnostic process does not yield anidentifiable cluster, syndrome, or cate-gory, intervention may be guided bythe alleviation of symptoms and reme-diation of deficits. Alternatively, thephysical therapist may determine thata 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 historyformed by physical therapists and the performing systems reviewsupport systemsnutrition and hydration resulting data generated are discussed selecting and administering spe-sleep patterns in the specific examinations presented cific tests and measuresskin integrity in Chapter Two. interpreting all dataorganizing the datafamily and caregiver resourcesliving environment and commu- 11 Evaluation Physical therapistsnity characteristics perform evaluations (make clinical

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In carrying out the diagnostic process,physical therapists may need to obtainadditional information (including diag-nostic labels) from other health profes-sionals. In addition, as the diagnosticprocess continues, physical therapistsmay identlfy findings that should beshared with other health professionals,including referral sources, to ensureoptimal patient care. If the diagnosticprocess reveals findings that are out-side the scope of the physical thera-pist s knowledge, experience, or ex-pertise, the physical therapist shouldthen 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 bythe patient and the amount of timeneeded to reach that level; it may alsoinclude a prediction of the levels ofimprovement that may be reached atvarious intervals during the course oftherapy. The physical therapist makesprognoses for recovery from impair-ment, functional limitation, and dis-ability; for return to role fulfillment;and for other outcomes, includingprevention and management of symp-tom manifestations. When the physicaltherapist determines that physicaltherapy intervention would be likelyto produce desirable outcomes, theappropriate intervention is imple-mented. When the physical therapistconsiders physical therapy interventionunlikely to be beneficial, the physicaltherapist discusses those findings andconclusions with the individuals con-cerned, and there is no further physi-cal therapy intervention.V Intervention Intenention is thepurposeful and skilled interaction ofthe physical therapist with the patientand, if appropriate, other individualsinvolved in the patient s care, usingvarious methods and techniques toproduce changes in the patient s con-dition consistent with the diagnosisand prognosis. Decisions about inter-vention are contingent on the timelymonitoriilg of the patient s responseand the progress made toward achiev-ing outcomes. There are three inter-vention components:

direct interventionpatient-related instructioncoordination, communication,and documentation

A. Direct Intervention.Physical thera-pists select, apply, or modlfy one ormore interventions based on the datagathered from the initial examination.Based on the results of the interven-tion(~), he physical therapist maydecide that a re-examination is neces-sary, a decision that may lead to theuse of ddferent interventions or, alter-natively, the discontinuation of treat-ment. Chapter Three details severalinterventions commonly selected bythe physical therapist:

therapeutic exercise (includingaerobic conditioning)functional training in self careand home management activities(including activities of daily liv-ing and instrumental activities ofdaily living)functional training in communityor work reintegration (includinginstrumental activities of dailyliving, work hardening, andwork conditioning)manual therapy techniques (in-cluding mobilization andmanipulation)prescription, fabrication, andapplication of assistive, adap-tive, supportive, and protectivedevices and equipmentairway clearance techniquesdebridement and wound carephysical agents and mechanicalmodalitieselectrotherapeutic modalitiespatient-related instruction

Factors that influence the complexityof the intervention and the decision-rnalung process may include thefollowing:

severity of the current problemstability of the patient sconditionpre-existing conditionslevel(s) of impairment(s1probability of prolonged impair-ment, functional limitations, anddisabilitysocial supports and livingenvironment

multiple sites or systemsinvolvementoverall physical function andhealth statuscognitive statuspotential discharge destination

B Patient-related Instmction.Thephysical therapist uses patient-relatedinstruction to educate not only thepatient but also families and othercaregivers about the patient s currentcondition, treatment plan, and futuretransition to home, work, or commu-nity roles. The physical therapist mayinclude information and training inmaintenance activities as well as pri-mary and secondary prevention in thinstruction program.C. Coordination Communicationand Documentation.These processeensure that the patient receives appropriate, coordinated, comprehensive,and cost-effective services betweenadmission and discharge. The serviceinclude, but are not limited to, thefollowing:

patient care conferencescommunications (te lephone, faetc)documentation of all elementsof patient managementcoordination of care with pa-tients, significant others, familymembers, and other healthprofessionalsrecord reviewsdischarge planning

Documentation should follow thePT Guidelines for Physical Theramocumentation (Appendix 111).

Additional Professional Activitkso the Physical TherapistPhysical therapists also participateactively in the following activities:

prevention and wellness (including health promotion)consultationscreeningeducationcritical inquiryadministration



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I. Prevention and Wellness Includ-ing Health Promotion). Physicaltherapists have successfully integratedprevention, wellness, and the promo-tion of positive health behavior intophysical therapy practice to reduceinjury, impairment, and disabilityamong their patients. These initiativeshave decreased costs by achieving andrestoring functional capacity, minimiz-ing limitations due to congenital andacquired diseases, maintaining health(because sustaining a level of functionmay prevent further deterioration orfuture illness), and providing appropri-ate environmental adaptations to en-hance independent function.For example, physical therapists areheavily involved in preventing andtreating low back pain, a disorder thatafflicts d l i o n s of Americans and is themost common disability for thoseunder 5 years of age. The majority ofsuch injuries are work related. Theannual cost of this disability exceeds

10 billion, but cost savings realizedthrough physical therapy programsaimed at preventing injury in the worksite, which may include back schools,workplace redesign, strengthening,stretching, endurance exercise, andpostural training, have beensigtxficant.2-5Older adults are prime candidates forpreventive interventions by physicaltherapists: Laboratory and clinicalstudies have shown that bone massincreases in response to mechanicalstrain and exercise, and that exercisecan reduce the incidence of wrist andhip fractures from falls, for whicholder women are particularly atljsk.6-13Cardiac and pulmonary rehabilitation,which are offered to the elderly aswell as to younger patients, have alsoproven to be of great value. Short,contained exercise and educationprograms 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 pulmonaryrehabilitation. 4-16

Physical therapists initiate numerousother prevention and wellness pro-grams aimed at both individual pa-tients and the community to curtailtobacco, alcohol, and other drug use,prevent head injury (through the useof helmets), and reduce domesticviolence (by reporting suspected abu-sive behavior). Prevention of strainsand sprains has generated consider-able cost savings.17-'9 In industry,physical therapists help to preventjob-related disabilities, including repet-itive motion injuries. Finally, physicaltherapists participate in obstetricalcare, where cardiovascular condition-ing and instruction in posture forwomen both before and after child-birth have been shown to decreaseinfant morbidity and maternal disabil-ity and dysfunction.20,2111 Consultation. Consultation is aservice provided by a physical thera-pist to render a professional or expertopinion or advice. Consultants applyhighly specialized knowledge andskills to identlfy problems, recommendsolutions, or produce some specifiedoutcome or product in a given amountof time on behalf of a patient or client.Patient related consultation is a ser-vice provided by a physical therapistat the request of a patient, health carepractitioner, or health care organiza-tion either to evaluate the quality ofphysical therapy services being pro-vided or to recommend physical ther-apy services that are needed; it doesnot involve actual treatment.Client related consultation is a sewiceprovided by a physical therapist at therequest of an individual, business,school, government agency, or otherorganization.Examples of consultation activities inwhich physical therapists engageinclude:

responding to a request for asecond opinionadvising a referring practitionerabout the indications forintervention

advising employers about therequirements of the Americanswith Disabilities Act (ADA)instructing employers about pre-placement in accordance withprovisions of the ADAeducating other health practitio-ners (eg, in injury prevention)performing environmental as-sessments to minimize the riskof fallsconducting a program to deter-mine the suitability of employ-ees for specific job assignmentsexamining school environmentsand recommending changes toimprove accessibility for stu-dents with disabilitiesdeveloping programs that evalu-ate the effectiveness of an inter-vention plan in reducing work-related injuriesworking with employees, laborunions, and government agen-cies to develop injury reductionand safety programsparticipating at the local, state,and federal levels in policymak-ing for physical therapy servicesproviding expert legal opinion

111 Scrreening. Screening is the briefprocess of determining the need forfurther examination or consultation bya physical therapist or for referral toanother health care practitioner.Screening is based on a problem-focused, systematic collection andanalysis of data to: 1) iden* individ-uals at risk in order to provide primaryprevention, 2) identlfy those in needof physical therapy intervention orother rehabilitative services, and 3ascertain the presence of positivefindings that require attention by an-other health care practitioner in orderto provide secondary or tertiary pre-vention. Generally, candidates forscreening are not patients currentlyreceiving physical therapy sewices.Examples of screening activities inwhich physical therapists engageinclude:

identifying children who mayneed an examination for idio-pathic scoliosisidentifying risk factors in theworkplace

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pre-performance testing of indi-viduals active in sportsidentifying an individual s life-style factors (eg, exercise, stress,weight) that may lead to in-creased risk for serious healthproblemsidentifying elderly individuals ina community center or nursinghome who are at high risk forslipping, tripping, or falling

IV Education Education is the pro-cess of imparting information or skillsand instructing by precept, example,and experience so that individualsacquire knowledge, master skills, ordevelop competence. In addition toinstructing patients as an element ofintervention, examples of educationalactivities in which physical therapistsengage include:

planning and conducting pro-grams for the public to increaseits awareness of issues in whichphysical therapists haveexpertiseplanning and conducting pro-grams for local, state, and fed-eral health agenciesplanning and conducting aca-demic and continuing clinicaleducation programs for physicaltherapists, other health care pro-viders, and students

V Critical Inquiry Critical inquiry isthe process of applying the principlesof scientific methods to read and inter-pret professional literature; participatein, plan, and conduct research; andanalyze patient care outcomes, newconcepts, and findings.Examples of critical inquiry activities inwhich physical therapists engageinclude:

analyzing and applying researchfindings to patient managementand. client programsevaluating the efficacy of bothnew and establishedtechnologiesparticipating in, planning, andconducting clinical, basic, orapplied researchdisseminating the results ofresearch

VI Administration Administration isthe skilled process of planning, direct-ing, organizing, and managing human,technical, environmental, and financialresources effectively and efficiently,including the management by individ-ual physical therapists of resources fortheir patients care s well as the man-aging of organizational resources.Examples of administration activities inwhich physical therapists engageinclude:

supervising physical therapistassistants, physical therapyaides, and other supportpersonnelmanaging staff resources, includ-ing the acquisition and develop-ment of clinical expertise andleadership abilitiesmonitoring quality of care andclinical productivitybudgeting for physical therapyservicesdeveloping, implementing, a ndreviewing strategic plans andmarketing programs

Physical Therapy Sewiees:Direction and Supervision ofSupport PemonnelDirection and supervision are essentialto the provision of quality physicaltherapy services. The degree of direc-tion and supervision necessary forensuring quality physical therapy ser-vices depends on many factors, in-cluding the education, experience, andresponsibilities of the personnel in-volved, the organizational structure inwhich the physical therapy servicesare provided, and applicable state law.The physical therapist who directs aphysical therapy service has qualifica-tions based on education an dexperi-ence in the field of physical therapyand has accepted the responsibilitiesinherent in being a supervisor. Thedirector of a physical therapy service:1) establishes guidelines and proce-dures that delineate the functions andresponsibilities of all levels of physicaltherapy personnel in the service andthe supervisory relationships inherentin the functions of the service and the

organization; 2 ensures that the objetives of the service are efficiently andeffectively achieved within the framework of the stated purpose of theorganization and in accordance withsafe physical therapy practice; and 3interprets administrative policies, actsas a liaison between line staff andadministration, and fosters the professional growth of the staff.Written practice and performancecriteria are available for all levels ofphysical therapy personnel in a physcal therapy service. Regularly sched-uled performance appraisals are conducted by the supervising physicaltherapist based on these standards ofpractice and performance criteria.Delegated responsibilities are com-mensurate with the qualifications,including experience, education, andtraining, of the individuals to whomthe responsibilities are being assigneand must be in accordance with appcable state law. When the physicaltherapist delegates patient care re-sponsibilities to physical therapistassistants or other support personnelthat physical therapist is responsiblefor supervising the physical therapyprogram. Regardless of the setting inwhich the service is given, the following responsibilities are borne solely bthe physical therapist:

interpretation of referrals whenavailableinitial examination, problemidentification, and diagnosis fophysical therapydevelopment or modification oa plan of care that is based onthe initial examination and thaincludes the physical therapytreatment goalsdetermination of which tasksrequire the expertise anddecision-making capacity of thphysical therapist and must bepersonally rendered by thephysical therapist, and whichtasks may be delegateddelegation and instruction of thservices to be rendered by thephysical therapist assistant orother suppor t personnel, incluing, but not limited to, specific



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treatment program, precautions,special problems, and contra-indicated procedurestimely review of treatment docu-mentation, re-examination of thepatient and the patient s treat-ment goals, and revision of theplan of care when indicatedestablishment of the dischargeplan and documentation of dis-charge summary or status

Support PersonnelI Physical Therapist AssistantsThe physical therapist assistant is aneducated health care provider whoassists the physical therapist in provid-ing physical therapy. The physicaltherapist assistant is a graduate of aphysical therapist assistant associatedegree program accredited by anagency recognized by the Secretary ofthe United States Department of Edu-cation or the Council on Postsecond-ary Accreditation.The supervising physical therapist isdirectly responsible for the actions ofthe physical therapist assistant. Thephysical therapist assistant performsphysical therapy procedures and re-lated tasks that have been selectedand delegated by the supervisingphysical therapist. Where permitted bylaw, the physical therapist assistantalso carries out routine operationalfunctions, including supervising thephysical therapy aide and document-ing treatment progress. The ability ofthe physical therapist assistant to per-form the selected and delegated tasksis assessed on an ongoing basis by thesupervising physical therapist. Thephysical therapist assistant may m o d ea specific treatment procedure in ac-cordance with changes in patientstatus within the scope of the estab-lished treatment plan.

therapist or, in accordance with thelaw, by a physical therapist assistant.The physical therapist is directly re-sponsible for the actions of the physi-cal therapy aide. The physical therapyaide provides support services in thephysical therapy service, both patient-related and non-patient-related duties.When providing direct physical ther-apy services to patients, the physicaltherapy aide functions only with thecontinuous on-site supervision of thephysical therapist or, where allowableby law andlor regulation, the physicaltherapist assistant. The requirement forcontinuous on-site supervision man-dates the presence of the physicaltherapist or physical therapist assistantin the immediate area and their in-volvement in appropriate aspects ofeach treatment session in which acomponent of treatment is delegatedto a physical therapy aide.111 Other Support Personnel Whenother personnel (eg, exercise physiol-ogists, athletic trainers, massage thera-pists) work within the supervision of aphysical therapy service they shouldbe employed under their appropriatetitles. Any involvement in patient careactivities should be within the limits oftheir education, in accord with appli-cable laws and regulations, and at thediscretion of the physical therapist.However, if they function as an exten-sion of the physical therapist s license,their title and all provided servicesmust be in accordance with state andfederal laws and regulations. (In allsituations in which the physical thera-pist delegates activities to other sup-port personnel, physical therapistsmust recognize their legal responsibil-ity and liability for such delegation.)

References

4. Klaber Moffett JA, Chase SM, Portek I, En-nis JR. A controlled, prospective study to eval-uate the effectiveness of a back school in therelief of chronic low back pain. Spine.1986;11:120-122.5. Bigos SJ, Battie MC. Acute care to preventback disability. Clin Orthop. 1987;221:121-130.6. Judge JO, Lindsey C, Underwood M, Win-semius D. Balance improvements in olderwomen: effects of exercise training. Phys Iher.1993;73:254-265.7. Rutherford OM. The role of exercise in theprevention of osteoporosis. Physiotherapy.1990;76:522-526.8. Nelson ME, Fisher EC, Dilmanian FA, et al.A one-year walking program and increaseddietary calcium in post-menopausal women:effects on bone. Am J Clin Nutr.1991;53:1304-1311.9. Osteoporosis: Cause Treatment PreventionUS Dept of Health and Human Services Publi-cation No. (NIH) 86-2226. Bethesda, MD: Na-tional Institute of Arthritis and Musculoskeletaland Skin Diseases; 1986.10. Whedon GC. Interrelation of physical ac-tivity and nutrition on bone mass. In: WhitePL, Mondeika T, eds. Diet and Erercise: Syn-ergism in Health Maintenance. Chicago, 111American Medical Association; 1982:99.11. Jacobsen PC, Beaver W, Grubb SA, et al.Bone density in women: college athletes andolder athletic women. J Orthop Res.1984;2:328-332.12. Nilsson BE, Westlin NE. Bone density inathletes. Clin Orthop. 1971;77:179-182.13. Chow RK Harrison JE, 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. Cardiacrehabilitation participation predicts lower re-hospitalization costs. Am Heart J1992;123:195-200.15. Busch AJ, McClements JD. Effects of a su-pervised home exercise program on patientswith severe chronic obstructive pulmonarydisease. 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: aclinical 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 aback 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 Therapy Aides The Defrning Primary Care: An Interim Repott. ance exercise during pregnancy. Am Obstetphysical 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. Effectsworker who is specifically trained 2, Hazard RG, Fenwick JW, Kalisch SM, et al, of physical exerciseOn pregnancy outcomes:under the direction a physical Functional restoration with behavioral a meta-analytic review. 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 leavedue to back pain. Phys Iher. 1991;71:285293.74 7 9 Physical Therapy Volume 75 Number 8 August 1995



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Chapter TwoExaminations Provided by Physical Therapists

Th e physical therapist s patient man-agement process of examination, eval-uation, diagnosis, prognosis, and inter-vention has been described in ChapterOne. Twenty-three examinations thatthe physical therapist may select aredetailed in Chapter Two; other exami-nations not described in h s haptermay also be used in patient manage-ment. Depending on the data gener-ated during the history and systemsreview, the physical therapist may useon e or m ore of these examinations, inwhole or in part. For example, inexamining a patient with impairmentsand disabilities resulting from a b raininjury, the physical therapist may de-cide to peiform part o r all of severalexaminations, based on the pattern ofinvolvement in the individual patient.Thus, the physical therapist shouldindividualize the selection of exam ina-tions rather than choose them solelyon the patient s presenting diagnosis(eg, brain injury).For each of the examinations, fourareas are discussed:

Overview-Provides an intro-duction to the exam ination.C li ni ca l Indications-Lists ex-amples of the functional limita-tions, im pairmen ts, disabilities,or special requirements that mayprompt the physical therapist toconduct the exam ination.Tests and Measures-Listsgeneral methods and techniquesused in conducting theexamination.Data Generated-Describes theinformation collected from thetests an d m easures.

Other information that may be re-quired for the examination includes,but is not limited to, clinical findingsof other health professionals; results ofdiagnostic imag ing, clinical labora tory,

and electrophysiologic studies; federal,state, and local work surveillance andsafety reports and announcements;and observations of family mem bers,significant others, caregivers, andother interested persons.A physical therapy exam ination orintervention, unless performed by aphysical therapist, is not physical ther-apy nor should it be represented orreimbursed as such.Aerobic Capacity or EnduranceExaminationOverview.A m bi c capacity,p o wand end urance are all measures of theability to perform w ork or participatein activity over time using the body soxygen uptake, delivery, and energyrelease mechanisms. During activity,the physical therapist employs testsranging from simple determinations ofheart rate, blood pressure, and respira-tory rate to com plex calcu lations ofoxygen consumption and carbondioxide production to determine theappropriaten ess of an individual sresponse to increased oxygen de-mand. Monitoring responses at restand during activity can indicate thedegree and severity of impairment,iden* cardiopulm onary deficits thatproduce functional limitations, andindicate that other tests and specifictherapeutic interventions are needed.The aerobic capacity or en d u m c eexamination produce s informationused t o identlfy the possible or actualcause(s) of difficulties during th e pa-tient s performan ce of essential every-day activities, leisure pursuits, an dwork tasks Selection of specific testsand measures will depe nd o n thefindings of the patient history andsystems review. The examination mayrequire testing while the patient per-forms sp ecific activities. Th e exam ina-

tion will lead to an evaluation, a diag-nosis, a prognosis, and t he selection oappropriate interventions.Clinical Indications An aerobiccapacity or endurance examination isappropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, o r de-velopmental delay that preventsnormal performance of dailyactivities, including self care,hom e management, communityor work reintegration, andleisureRequirements of employmentthat speclfy minimum capacityfor performanceA need to initiate or change aprevention or wellness programExpectations or indications ofone or more of the followingimpairments or functional limitations experienced when at-tempting t o perform self care,home management, communityor w ork reintegration, or leisuretasks and movements:

weaknessshortness of breathdizzinesspalpitationtightness of the chest walllack of mobilitylack of enduranceabnormalities in m ovement,flexibility, or strengthedema of the lowerextremitiesreferred pain (angina) indica-tive of cardiac ischemiaischemic pain in the extremi-ties (claudication)inability to perform specificmovement tasksabnormalities of heart rate,blood pressure, respiratoryrate or pattern of breathing,and/or heart muscle function

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observation and palpation of anextremity or part at rest and dur-ing activityassessment of activities and pos-tures that aggravate or relieveedemaassessment of edema (eg, duringpregnancy, in determining theeffects of other medical orhealth-related conditions, duringsurgical procedures, after drugtherapy)

Data Generated.Data generatedmay include, but are not limited to:

height in feet and inches orcentimetersweight in pounds or kilogramsgirths of extremities and chestand lengths of extremities ininches or centimetersbody fat (as a percentage ofmass or in inches orcentimeters)volumetric displacement in litersa list of activities and posturesthat aggravate or relieve edemaintegrity of lymphatic system

Arousal Mentation andCognition ExaminationOvwiew. Amusal is the stimulationto action or to physiologic readinessfor activity. Mentation is a mechanismof thought or mental activity. Cogni-tion is the act or process of knowing,including both awareness and judg-ment. Tht: physical therapist uses thearousal, mentation, and cognitionexamination to assess the patient'sresponsiveness; orientation to time,person, and place; and ability to fol-low directions. The examinationguides the physical therapist in select-ing interventions by indicatingwhether the patient has the cognitiveability to participate in the careprocess.The arousal, mentation, and cognitionexamination produces informationused in identifying the possible oractual cause( of difficulties duringthe patient's performance of essentialeveryday activities, leisure pursuits,and work tasks. Selection of specifictests and measures will depend on the

findings of the patient history andsystems review. The examination mayrequire testing while the patient per-forms specific activities. The examina-tion will lead to n evaluation, adiagnosis, a prognosis, and the deter-mination of appropriate interventions.Clinical Indications. An arousal,mentation, and cognition examinationis appropriate in the presence of:

Physical disability, impaired sen-sorimotor function, pain, or de-velopmental delay that preventsnormal performance of dailyactivities, including self care,home management, communityor work reintegration, andleisureRequirements of employmentthat specify minimum capacityfor performanceExpectations or indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to perform self care,home management, communityor work reintegration, or leisuretasks and movements:

painweaknesslack of mobilitylack of endurancemotor deficits (eg, weakness;paralysis; uncoordination; ab-normal spatial or temporalpatterns of movement; tone;spasticity; flaccidity; andpathological reflexes)somatosensory deficitgait deficit(s) anddisturbancespostural deficitsabnormalities in movement,flexibility, or strengthbiomechanical and arthroki-nematic limitationsimpaired balance or frequentfallingimpaired motor function andlearningimpaired sensationinability to perform specificmovement tasksinadequate circulation, recur-rent ischemia, or claudication

change in baseline status ofarousal, mentation, cognition

estsand Measures. Tests andmeasures for performing an arousal,mentation, and cognition examinationinclude, but are not limited to:

determination of patient's levelof consciousnessdetermination of patient's levelof recalldetermination of patient's orientation to time, person, and placcognitive screening (eg, to de-termine ability to process com-mands, to measure safetyawareness)screening for gross expressiveand receptive deficitsassessment of arousal, menta-tion, and cognition using stan-dardized instruments

Data Generated. Data generatedmay include, but are not limited to:

level of arousal, mentation, orcognition deficitsdifference between predictedand actual performancevariation over time of arousal,mentation, or cognition deficitsscores on standardized instru-ments for measuring arousal,mentation, and cognition

Assistive Adaptive Supportiveand Protective DevicesExaminationOverview. Assistive adaptive supporive and protective devices are a varietyof implements or equipment used toaid individuals in performing tasks ormovements. Rssirstive deuices whichinclude crutches and canes, involverather simple technologies; adaptivedevices which include such technolo-gies as a wheelchair and the long-handed reacher, are generally morecomplex. Supportive devices includetaping, compression garments, corsetsand neck collars, while protectivedevices include braces and helmets.The physical therapist uses the assis-tive, adaptive, supportive, and protec-tive devices examination to determinewhether an individual might benefitfrom such a device or, where one is

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Expectations or indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to perform communityor work reintegration or leisuretasks and movements:

painweaknesslack of mobilitylack of endurancegait deficitGI anddisturbancespostural deficitsabnormalities in movements,flexibility, or strengthbiomechanical and arthroki-nematic limitationsimpaired balance or frequentfallingimpaired motor function andlearningimpaired sensationinadequate circulation, recur-rent ischemia, or claudicationincontinence, bowel andbladder difficulty

Tests and Measures General testsand measures for performing a com-munity or work reintegration examina-tion include, but are not limited to:

observation of the individualperforming work tasks and com-munity and leisure activitiesreview of reports provided bythe individual, family members,significant other, or caregiveradministering questionnairesand conducting interviews withthe patient and other interestedpersonsapplication of instrumental activ-ities of daily living measurementscales and performance batteriesfor community, work, and lei-sure activitiesmeasurement of physiologic re-sponses during community,work, and leisure activitiesreview of daily activities logsmeasurement of static and dy-namic strength

application of functional ratingscalesmeasurement of functionalcapacityassessment of appropriatenessof assistive, adaptive, support-ive, and protective devicesanalysis of environment and jobtasksanalysis of mentation andcognitionanalysis of adaptive skills

Data Generated Data generatedmay include, but are not limited to:

levels of strength, flexibility, andenduranceeffort in specific movement tasksaerobic capacity or endurancegross and fine motor functiondifference between predictedand actual performancephysical, functional, behavioral,and vocational statuswork-related systemic neuro-musculoskeletal restorationneedsvital signs and physiologic re-sponse during community orwork reintegration and leisureactivitiespresence or absence of menta-tion and cognition deficitslevel of adaptive skills

Cranial Nerve IntegrityExaminationOverview A cr ni l n m s one oftwelve paired nerves (eg, olfactory,optic) that emerge from or enter thebrain. The cranial nerve integrity ex-amination has somatic, visceral, affer-ent, and efferent components. Thephysical therapist uses the cranialnerve integrity examination to localizea dysfunction in the brain stem and toiden* cranial nerves that merit anin-depth examination. The physicaltherapist uses a number of cranialnerve tests to assess the patient s sen-sory and motor functions, such astaste, smell, and facial expression.

analysis of aerobic capacity orendurance during community, The cranial nerve integrity examina-tion produces information used towork, and leisure activitiesassessment of dexterity and identlfy the possible or actual cause(s)coordination of difficulties during the patient s per-

formance of essential everyday activities, leisure pursuits, and work tasks.Selection of specific tests and mea-sures will depend on the findings ofthe patient history and systems revieThe examination may require testingwhile the patient performs specficactivities. The examination will lead an evaluation, a diagnosis, a progno-sis, and the determination of approprate interventions.Clinical Indications A cranial nerveintegrity examination is appropriate ithe presence of:

Physical disability, impaired sesorimotor function, pain, or developmental delay that preventnormal performance of dailyactivities, including self care,home management, communityor work reintegration, andleisureRequirements of employmentthat specify minimum capacityfor performanceExpectations or indications ofone or more of the followingimpairments or functional limittions experienced when at-tempting to perform self care,home management, communityor work reintegration, or leisurtasks and movements:

painweaknesslack of mobilitymotor deficits (eg, weaknessparalysis; uncoordination; abnormal spatial and temporalpatterns of movement; tone;spasticity; flaccidity; andpathological reflexes)somatosensory deficitabnormalities in movement,flexibility, or strengthimpaired balance or frequenfallingimpaired motor function andlearningimpaired sensationinability to perform specificmovement tasks

Tests and Measures Tests andmeasures for performing a cranialnerve integrity examination include,but are not limited to:

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performance of tests of:touchpaintemperaturevisionvestibular sensibilityauditory sensibilitytastesmell

assessment of muscles inner-vated by the cranial nervesData Generated. Data generatedmay include, but are not limited to:

difference between predictedand actual performancedescription of eye movementsamount of constriction and dila-tion of pupilsvisual deficitspain, touch, temperaturelocalizationgross auditory acuityequilibrium responsescharacteristics of swallowingintegrity of gag reflexesdegree of loss of tastedegree of loss of function inmuscles innervated by the cra-nial nerves

Envimnmen tal Home or WorkBammetsExaminationOverview.Environmental home andwor b rrim are the physical impedi-ments that keep individuals from func-tioning optimally in their surround-ings. The physical therapist uses theenvironmental, home, or work barriersexamination to iden@ any of a vari-ety of possible impediments, includingsafety hazards (eg, throw rugs, slip-pery surfaces), access problems (eg,narrow doors, high steps), and homeor office design (eg, excessive dis-tances to negotiate, multiple-storyenvironment). The physical therapistuses this examination, often in con-junction with elements of the ergo-nomics or body mechanics examina-tion, to suggest modifications to theenvironment (eg, grab bars in theshower, ramps, raised toilet seats,increased lighting) that will permit thepatient or client to improve function-ing in the home, workplace, or othersettings.

The environmental, home, or workbarriers examination produces infor-mation used in iden*ing the possibleor actual cause(s) of difficulties duringthe patient s performance of essentialeveryday activities, leisure pursuits,and work tasks. Selection of specfictests and measures will depend on thefindings of the patient history andsystems review. The examination mayrequire testing while the patient per-forms specific activities. The examina-tion will lead to an evaluation, adiagnosis, a prognosis, and the deter-mination of appropriate interventions.Clinical Indications.An environmen-tal, home, o r work barriers examina-tion is appropriate in the presence of:

Physical disability, impaired sen-sorimotor function, pain, or de-velopmental delay that preventsnormal performance of dailyactivities, including self care,home management, communityor work reintegration, andleisureRequirements of employmentthat specify minimum capacityfor performanceExpectations or indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to perform self care,home management, communityor work reintegration, or leisuretasks a nd movements:

painweaknesslack of mobilitylack of endurancegait deficit(s1 anddisturbancespostural deficitsabnormalities in movement ,flexibility, or strengthbiomechanical and arthroki-nematic limitationsimpaired balance or frequentfallingimpaired motor function andlearningimpaired sensationincontinence, bowel, andbladder difficultyinability to perform specificmovement tasks

Tests and Measures. Tests andmeasures for performing an environ-mental, home, or work barriers exarni-nation include, but are not limited to:

assessment of present and po-tential barriersphysical inspection of theenvironmentconducting interviews and ad-ministering questionnairesoff-siteanalysis of physical space usingphotography or videotapemeasureihent of physical spaceergonomic analysis of an indi-vidual s home, workplace, orother customary environment

Data Generated.Data generatedmay include, but are not limited to:

a list of space limitations andother barriers, including theirdimensions, that limit an indi-vidual s ability to perform spe-cific movement tasks duringhome, work, and leisureactivitiesdegree of compliance with stan-dards set forth in the Americanswith Disabilities Actrecommendations for elimina-tion of environmental barriersa list of adaptations, additions,or modifications that would en-hance patient safety

Ergonomics or ody MechanicsExaminationOverview.E?gonomics is the study ofthe 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 asthey maintain or adjust posture inresponse to environmental forces. Thephysical therapist uses the ergonomicsor body mechanics examination toexamine the work environment onbehalf of patients or clients to deter-mine the potential for trauma to resultfrom inappropriate workplace design.The ergonomics or body mechanicsexamination may be conducted after awork injury or as a preventive mea-sure, particularly when an individual is

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returning to the work environmentafter an extended absence.The ergonomics or body mechanicsexamination produces informationused in identlfylng the possible oracmal cause(s) of dificulties duringthe patient s performance of essentialeveryday activities, leisure pursuits,and work tasks. Selection of specifictests and measures will depend on thefindings of the patient history andsystems review. The examination mayrequire testing while the patient per-forms specific activities. The examina-tion will lead to an evaluation, adiagnosis, a prognosis, and the deter-mination of appropriate interventions.Clinical Indications An ergonomicsor body mechanics examination isappropriate in the presence of:

Physical disability, impaired sen-sorimotor function, pain, or de-velopmental delay that preventsnormal performance of dailyactivities, including self care,home management, communityor work reintegration, and lei-sure tasks and movementsRequirements of employmentthat specify minimum capacityfor performanceA need to initiate or change aprevention or wellness programExpectations or indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to perform self care,home management, communityor work reintegration, or leisuretasks and movements:

painweaknesslack of mobilitylack of endurancegait deficit(s) anddisturbancespostural deficitsab~lormalitiesn movement,flexibility, or strengthbiomechanical and arthroki-nematic limitationsinability to perform specificmclvement tasksimpaired balance or frequentfalling

impaired motor function andlearningimpaired sensationabnormal body alignment andmovement patternsinadequate circulation, recur-rent ischemia, or claudicationfrequent injury

ests and Measures Tests andmeasures for performing an ergonom-ics examination include, but are notlimited to:

ergonomic analysis of job tasksor activities to assess thefollowing:

essential functions of the jobtask or activitywork postures required toperform the job task oractivityjoint range of motion used toperform the job task oractivitystrength required in the workpostures necessary to performthe job task or activityrepetition/work/rest cyclingduring the job task or activitysources of potential traumavibrationtools, devices, or equipmentusedendurance required to per-form aerobic enduranceactivities

assessment of work hardeningor work conditioning, includingidentification of needs related tophysical, functional, behavioral,and vocational statusadministration of batteries ofwork performancereview of safety and accidentreportsassessment of dexterity andcoordinationobservation of the individualperforming selected movementsor activitiesdetermination of dynamic capa-bilities and limitations duringspecific work activitiesvideo analysis of the patient orclient at work

computer-assisted motion analy-sis of the patient or client atwork

Tests and measures for performing abody mechanics examination include,but are not limited to:

measurement of height, weight,and girthobservation of the individualperforming selected movementsor activitiesdetermination of dynamic capa-bilities and limitations duringspecific work activitiesvideotape analysis of the patientor client performing selectedmovements or activitiescomputer-assisted motion analy-sis of the patient or client per-forming selected movements oractivities


height in feet and inches ormeters and centimetersweight in pounds or kilogramsgirths of extremities and chestamount of dficulty experiencedor pain expressed during theperformance of specific jobtasks or activitiesa list of potential and actual er-gonomic stressorsbody alignment, timing, and se-quencing of component move-ments during specific job tasksor activitieslevels of strength, flexibility, andendurancelevel of effort in specific move-ment tasksaerobic capacity or endurancelevels of gross and fine motorfunctiondifference between predictedand actual performancesafety records and accidentreportsphysical, functional, behavioral,and vocational statuslevel of work performancework-related systemic neuro-musculoskeletal restorationneeds



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temporal and spatial characteris-tics of movements during jobtasks or activities

Gait and Balance ExaminationOverview Gait is the manner inwhich a person walks, characterizedby rhythm, cadence, step, stride, andspeed. alance is the ability to main-tain the body in equilibrium withgravity both statically (eg, while sta-tionary) and dynamically (eg, whilewalking). The physical therapist usesthe gait and balance examination toinvestigate disturbances in gait andbalance because they frequently leadto decreased mobility, a decline infunctional independence, and an in-creased risk of falls. Gait and balanceproblems often involve dficulty inintegrating sensory, motor, and neuralprocesses. The physical therapist alsouses the gait and balance examinationto determine whether the patient is acandidate for an assistive, adaptive,supportive, or protective device.The gait and balance examinationproduces ~nformation sed in identifying the possible or actual cause(s) ofdficulties during the patient s perfor-mance of essential everyday activities,leisure pursuits, and work tasks. Selec-tion of specific tests and measures willdepend on the findings of the patienthistory and systems review. The exam-ination may require testing while thepatient performs specific activities. Theexamination will lead to an evaluation,a diagnosis, a prognosis, and the de-termination of appropriateinterventions.Clinical Indications A gait and bal-ance examination is appropriate in thepresence of:

Physical disability, impaired sen-sorimotor function, pain, or de-velopmental delay that preventsnormal performance of dailyactivities, including self care,home management, communityor work reintegration, andleisureRequirements of employmentthat specify minimum capacityfor performance

A need to initiate or change aprevention or wellness programExpectations or indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to ~er fo rmelf care,home management, communityor work reintegration, or leisuretasks and movements:

painweaknesslack of mobilitylack of endurancegait deficitcs) anddisturbancespostural deficitsabnormalities in movement,flexibility, or strengthbiomechanical and arthroki-nematic limitationsimpaired balance or frequentfallingimpaired motor function andlearningimpaired sensationinadequate circulation, recur-rent ischemia, or claudicationincontinence, bowel, andbladder difficultyinability to participate inathletics

Tests and Measums Tests andmeasures for performing a gait andbalance examination include, but arenot limited to:

identification of gaitcharacteristicsidentification and quantificationof static and dynamic balancecharacteristicsanalysis of biomechanical, ar-throkinematic, and other spatialand temporal characteristics ofgait and balance with and with-out the use of assistive, adap-tive, supportive, or protectivedevices

analysis of gait on various ter-rains, in different physical envi-ronments, and in wateradministration of functional am-bulation profilesvideotape analysis of patient smovement to assess gait orbalanceEMG analysis of patient s move-ment to assess gait or balancecomputer-assisted analysis ofpatient s movementapplication of gait analysis rat-ing scalesassessment of safety awarenessergonomic analysis of gaitapplication of mechanical andelectrical weight-bearing scalesand force plates


qualitative and quantitative de-scriptions of gait and balancegait cycle, gait deviations, andthe safety and quality of gaitover time in different environ-ments and on a variety ofsurfacessafety and quality of gait andthe gait cycle over time usingassistive, adaptive, supportive,or protective devicesa list of surfaces and elevationspatient is able to negotiatenumber ratings from standard-ized gait testing instrumentscharts and videos that reflectgait pattern changes over timea list of patient activities thataggravate or diminish difficultieswith gaitpatient s perception of gaitproblemslevel of safety awarenessweight-bearing ability, includingstandardized measures ofweight-bearing in pounds orkilograms

analysis of spatial and temporalcharacteristics of gait and bal- Integumentary Integrffyance using kinematic, kinetic, Examinationand electromyographic (EMG)f ~ ^ ^ Overview Integumentary integrity isL ZiLZiapplication of balance and gait the health of the skin, including itsability to serve as a barrier to environ-analysis rating scales mental threats (eg, bacteria, parasites).

The physical therapist uses an integu-

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mentary integrity examination to as-sess the effects of a wide variety ofproblems that result in skin and sub-cutaneous changes, including pressureand vascular insufficiency ulcers, burnsand other traumas, as well as a num-txr of diseases (eg, connective tissuedisorders). The integumentary integrityexamination s also used to obtainmore information about circulationthrough inspection of the skin or thenail beds.The integumentary integrity examina-tion produces information used inidentlfying the possible or actualcause(s) of difficulties during the pa-tient s performance of essential every-day activities, leisure pursuits, andwork tasks. Selection of specific testsand measures will depend on thefindings of the patient history andsystems review. The examination mayrequire testing while the patient per-forms specific activities. The examina-tion will lead to an evaluation, a diag-nosis, a prognosis, and thedetermination of appropriateinterventions.Clinical Indications An integumen-tary integrity examination is appropri-ate in the presence of:

Suspected or identified pathol-ogy, injury, or developmentaldelay that prevents normal per-formance of daily activities, in-cluding self care, home manage-ment, community or workreintegration, and leisureRequirements of employmentthat specify specific minimumcapacity for performance

need to initiate or change aprevention or wellness programExpectations o r indications ofone or more of the followingimpairments or functional limita-tions experienced when at-tempting to perform self care,home management, communityor work reintegration, or leisuretasks and movements:

painweaknesslack of mobilitylack of endurance

gait deficit(s1 anddisturbancespostural deficitsabnormalities in movement,flexibility, or strengthbiomechanical and arthroki-nematic limitationsimpaired balance or frequentfallingimpaired motor function andlearningimpaired sensationinadequate circulation, recur-rent ischemia, or claudicationincontinence, bowel andbladder difficultyloss of integumentary integrityinability t

1995-Guide to Physical Therapist Practice, Volume I-707-64

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