How and Why Was the Guide Developed?

During the early 1990s, state legislative bodies began to request that health care professionals develop practice parameters. In February 1992, at the request of one of the American Physical Therapy Association's (APTA) state components, APTA's Board of Directors embarked on a process to determine whether practice parameters could be delineated for the profession of physical therapy. The Board initiated development of a document that would describe physical therapist practice-content and processes--both for members of the physical therapy profession and for health care policy makers and third-party payers.

The initial foundation for the document was laid by the Board-appointed Task Force on Practice Parameters, whose work led to the appointment of the Task Force to Review Practice Parameters and Taxonomy. The deliberations of these task forces and the materials that they produced resulted in the Board's development of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management ("Volume I").[1] This document was approved in March 1995 by the Board. In June 1995, APTA's House of Delegates approved the conceptual framework on which Volume I was based and endorsed the Board's plan to develop Volume II using a process of expert consensus. Volume I was published in the August 1995 issue of Physical Therapy. Volume II was to be "composed of descriptions of preferred physical therapist practice for patient groupings defined by common physical therapist management:" [Report to the 1997 House of Delegates, Processes to Describe Physical Therapy Care for Specific Patient Conditions, RC 32-95]

A Board-appointed Project Advisory Group and a Board Oversight Committee were charged to lead the Volume II project. The members of the Project Advisory Group were chosen on the basis of the following criteria:

* Broad knowledge of physical therapy

* Understanding of clinical policy development

* Familiarity with research in physical therapy

* Recognized decision-making abilities

In June 1995, the Project Advisory Group and the Board Oversight Committee met to refine the project design. That September, the Committee selected 24 physical therapists to serve on one: of four panels: cardiopulmonary, integumentary, musculoskeletal, and neuromuscular. Each Project Advisory Group member was assigned as a liaison to one of the panels. Criteria for selection of panel members included the following:

* Experience in the subject area

* Knowledge of physical therapy literature

* Understanding of research and the use of data

* Expertise in documentation

* Experience in peer review

* Knowledge of broad areas of physical therapy

* Recognized ability to work with groups and reach a consensus

* Openness to a variety of treatment philosophies

* Willingness to commit to the entire project

Consideration also was given to creating panels whose collective clinical experience would represent a wide range of patient/client age groups and practice settings.

Between October 1995 and September 1996, the panels developed preferred practice patterns that were subsequently reviewed by more than 200 select reviewers. In addition, each pattern was reviewed by APTA's Risk Management Committee, by physical therapists with reimbursement expertise, by APTA's Reimbursement Department, and by APTA's legal counsel. In December 1996, revised drafts of the patterns were sent for broad-based review to more than 600 reviewers, to APTA chapter and section presidents, to APTA members with risk management and reimbursement expertise, and to other select reviewers. Input from the general membership was obtained during open forums at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1996 and 1997.

In early 1997, Volume I and Volume II became Part One and Part Two of a single document ("the Guide"). Revisions were made to Part One to reflect Part Two. In March 1997, the Board of Directors approved the draft of Part Two; in June 1997, the House of Delegates approved the conceptual framework on which Part Two is based. The first edition of the Guide was published in the November 1997 issue of Physical Therapy.[2]

In 1998 and 1999, revisions were made to the Guide based on (1) input from both the general membership and the leadership of APTA and (2) changes in House of Delegates policies. These revisions were published in Physical Therapy.[3,4] During this period, the Association developed forms (Appendix 6) to be used in clinical practice (both inpatient and outpatient settings) for documenting the five elements of patient/client management that are described in the Guide: examination, evaluation, diagnosis, prognosis (including plan of care), and interventions. In addition, a patient/client satisfaction assessment was developed for inclusion in the Guide (Appendix 7).[5]

In 1998, APTA began development of Part Three of the Guide to catalog the armamentarium of tests and measures that are used by physical therapists in the examination of patients/clients and in the documentation of patient/client management outcomes. (This part of the Guide, intended as a reference work, is available on CD-ROM only.) One task force was charged by APTA's Board to examine the available literature pertaining to tests and measures that are used in the assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. Another task force was charged to retrieve and review the available literature on tests and measures of health status, health-related quality of life, and patient/client satisfaction.

The two task forces met throughout 1999 and 2000 to search the peer-reviewed literature and develop a comprehensive list of tests and measures that are used in physical therapist practice. Field reviews were conducted, using APTA's Board, all APTA components (sections and state chapters), a sample of clinical specialists certified by the American Board of Physical Therapy Specialties (ABPTS), and APTA's general membership. Presentations of the work-in-progress were made at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1999 and 2000.

To complete their charge to catalog the armamentarium of tests and measures that are used in physical therapist practice, the two task forces refined the template for documenting the history and systems review components of examination and for documenting intervention, based on the essential data elements of patient/client management described in the Guide. The template (Appendix 6) was reviewed by all APTA components (sections and state chapters), a sample of clinical specialists certified by ABPTS, and APTA's general membership.

Also throughout 1999 and 2000, Board-appointed Project Editors revised Part One and Part Two of the Guide to reflect input from the general membership, the Task Force on Development of Part Three of the Guide to Physical Therapist Practice (Second Edition), and the leadership of APTA and to refine and clarify terminology and definitions used in the Guide.

Purposes of the Guide

APTA developed the Guide to Physical Therapist Practice as a resource not only for physical therapist clinicians, educators, researchers, and students, but for health care policy makers, administrators, managed care providers, third-party payers, and other professionals.

The Guide serves the following purposes:

1. To describe physical therapist practice in general, using the disablement model as the basis.

2. To describe the roles of physical therapists in primary, secondary, and tertiary care; in prevention; and in the promotion of health, wellness, and fitness.

3. To describe the settings in which physical therapists practice.

4. To standardize terminology used in and related to physical therapist practice.

5. To delineate the tests and measures and the interventions that are used in physical therapist practice.

6. To delineate preferred practice patterns that will help physical therapists (a) improve quality of care, (b) enhance the positive outcomes of physical therapy services, (c) enhance patient/client satisfaction, (d) promote appropriate utilization of health care services, (e) increase efficiency and reduce unwarranted variation in the provision of services, and (f) diminish the economic burden of disablement through prevention and the promotion of health, wellness, and fitness initiatives.

The Guide does not provide specific protocols for treatments, nor are the practice patterns contained in the Guide intended to serve as clinical guidelines. Clinical guidelines usually are based on a comprehensive search and systematic evaluation of peer-reviewed literature. The Institute of Medicine has defined clinical guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [emphasis added]."[6,7] The Guide was developed using expert consensus to identify common features of patient/client management for selected patient/client diagnostic groups. The Guide is a first step toward the development of clinical guidelines in that it provides patient/client diagnostic classifications and identities the array of current options for care.

The preferred practice patterns identify the breadth of physical therapist practice. They are the boundaries within which the physical therapist may select and implement any of a number of clinical alternatives based on consideration of a wide variety of factors, including individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. The Guide is not intended to set forth the standard of care for which a physical therapist may be legally responsible in any specific case.

Future Development of the Guide

The Guide to Physical Therapist Practice is an evolving document that will be systematically revised as the physical therapy profession's knowledge base, scientific literature, and outcomes research develop and as examination and intervention strategies change. The Guide is the structure on which scientific evidence will be fastened, and, in turn, the evidence will reshape the structure.

Notification of revisions will be published annually in Physical Therapy and will be posted on APTA's Web site (www.apta.org).

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References

[1] A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management. Plays Ther. 1995;75:707-764.

[2] Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650.

[3] Guide to Physical Therapist Practice. Revisions. Phys Ther. 1999;623-629.

[4] Guide to Physical Therapist Practice. Revisions. Phys Ther. 1999;1078-1081.

[5] Goldstein MS, Elliott SD, Guccione AA. The development of an instrument to measure satisfaction with physical therapy. Phys Ther. 2000;80:853-863.

[6] Field M, Lohr K, eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: Institute of Medicine, National Academy Press; 1990.

[7] Field M, Lohr K, eds. Guidelines for Clinical Practice: From Development to Use. Washington, DC: Institute of Medicine, National Academy Press; 1992.