Musculoskeletal.

The following patterns describe the elements of patient/client management provided by physical therapists -- examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Each pattern also describes primary prevention/risk factor reduction strategies for the specific patient/client diagnostic group.

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients at risk of bone demineralization, with or without clinical signs of osteological involvement.

INCLUDES patients/clients with:

* Activity-induced hormonal changes * Certain medications (eg, steroids) * Joint immobilization * Known high risk (eg, based on sex, ethnicity, age, lifestyle, menstrual or hormonal changes related to hysterectomy or menopause) * Nutritional deficiency * Prolonged non-weight-bearing state

EXCLUDES patients/clients with:

* Acute fractures * Neoplasms of the bone * Osteogenesis imperfecta * Paget's disease

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

344 other paralytic syndromes 334.0 Quadriplegia and quadriparesis 344.1 Paraplegia

714 Rheumatoid arthritis and other inflammatory polyarthropathies

719 Other and unspecified disorders of joint 719.5 Stiffness of joint, not elsewhere classified 719.7 Difficulty in walking 719.8 Other specified disorders of joint (calcification of joint),

722 Intervertebral disk disorders 722.4 Degeneration of cervical intervertebral disk 722.5 Degeneration of thoracic or lumbar intervertebral disk 722.6 Degeneration of intervertebral disk, site unspecified

728 Disorders of muscle, ligament, and fascia 728.2 muscular wasting and disuse atrophy, not elsewhere classified

729 Other disorders of soft tissues 729.9 Other unspecified disorders of soft tissue

733 Other disorders of bone and cartilage 733.0 Osteoporosis

737 Curvature of spine 737.3 Kyphoscoliosis and scoliosis 737.4 Curvature of spine associated with other conditions

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age * Primary language * Race/ethnicity * Sex

Social History

* Cultural beliefs and behaviors * Family and caregiver resources * Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance * Developmental history

Living Environment

* Living environment and community characteristics * Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist * Concerns or needs of patient/client who requires the services of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease, including date of onset and course of events * Onset and pattern of symptoms * Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist * Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions * Prior medications

Past Medical/Surgical History

* Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support)

Social Habits (Post and Current)

* Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

Anthropometric Characteristics

* Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance * Measurement of height, weight, length, and girth

Community and Work (Job/School/Play) Integration or Reintegration

(Including IADL)

* Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment and work (job/school/play) tasks * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Ergonomics and Body Mechanics

* Functional capacity, evaluation, including:

- postures required to perform task or activity - strength required in the work postures necessary to perform the work (job/school/play) task or activity

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of joint hypermobility and hypomobility * Assessment of pain and soreness

Motor Function (Motor Control and Motor Learning)

* Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of dexterity, coordination, and agility

Muscle Performance including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

Orthotic, Protective, and Supportive Devices

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

Posture

* Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, stiff photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

Self-Care and Home Management (Including ADL and IADL)

* Analysis of self-care and home management activities * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing he diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Through lifestyle modification, patient/client at risk of low bone density will maintain bone mineral density above fracture threshold.

Through lifestyle modification, patient/client with identified low bone density will reverse the demineralization process and achieve bone mineral density above fracture threshold.

Expected Range of Number of Visits Per Episode of Care

3 to 18 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Modify Frequency of Visits

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of client and use of health care resources by client, family, significant others, and caregivers.

Specific Interventions

* Communication (direct or indirect)

* Coordination of care with client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of client management

* Education plans

* Referrals to other professionals or resources

Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of client and use of health care resources by client.

* Client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Utilization and cost of health care services are decreased.

Specific interventions

* Computer-assisted instruction

* Demonstration by client in the appropriate environment

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Endurance is increased.

* Osteogenic effects of exercise are maximized.

* Postural control is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises

* Conditioning

* Motor function (motor control and motor learning) training

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights,

hydraulics, elastic resistance bands, robotics, and mechanical

or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including Activities

of Daily Living [ADL] and Instrumental Activities of Doily Living [IADL])

Anticipated Goals

* Performance of and independence in ADL and IADL are increased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, toileting)

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

Functional Training in Community and Work (Job/School/Play) integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Performance of and independence in IADL are increased.

Specific Direct Interventions

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Deformities are prevented.

* Optimal joint alignment is achieved.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, compression, garment, corsets, slings, neck collars, serial casts, elastic wraps, oxygen)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, elastic wraps, oxygen)

Outcomes

At each step of patient/client management, the physical therapist considers the desired outcomes. Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Consequences of falls are reduced.

* Health-related quality of life is enhanced.

* Optimal role function (eg, worker, student, spouse, grandparent) is maintained.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of prevention strategies is demonstrated.

Client Satisfaction

* Access, availability, and services provided are acceptable to client.

* Administrative management of practice is acceptable to client.

* Clinical proficiency of physical therapist is acceptable to client.

* Coordination and conformity of care are acceptable to client.

* Interpersonal skills of physical therapist are acceptable to client, family, and significant others.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the fife span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type)

* Attitude

* Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments

* Endocrine or hormonal status

* Habitual suboptimal body mechanics

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal

deconditioning

- nutritional status (eg, calcium and vitamin D intake)

- physical activity level

- physical work job/school/play) demands

- psychosocial and socioeconomic stressors

- substance abuse (eg, smoking, alcohol, drugs)

* Medication history

* Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors)

* Muscle weakness or imbalance (eg, trunk and hip muscles)

* Previous history of injury or surgery affecting spine, posture, or body mechanics

* Systematic condition predisposing patient/client to spinal pain with radiculopathy

* Underlying spinal dysfunction (eg, postural dysfunction) in home, community, and work (job/school/play) tasks and activities

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and demineralization and (2) strategies to prevent demineralization

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, scoliosis, athletic preparticipation, preemployment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Posture

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitation secondary to impaired posture with one or more of the following:

* Associated muscle weakness or imbalance

* Associated pain

* Structural or functional deviation from normal posture

* Suboptimal joint mobility

INCLUDES patients/clients with:

* Appendicular postural deficits

* Cumulative effects of poor habitual posture in addition to poor work-related posture

* Pregnancy-related postural changes

* Scoliosis or other excessive spinal curvature

EXCLUDES patients/clients with:

* Neuromuscular disorders or disease (eg, spina bifida)

* Radicular signs

* Spinal stabilization (fusion or rodding), less than 1 year postsurgery

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because die patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

524 Dentofacial anomalies, including malocclusion

524.6 Temporomandibular joint disorders 718 Other derangement of joint

718.8 Other joint derangement, not elsewhere classified 719 Other and unspecified disorders of joint

719.5 Stiffness of joint, not elsewhere classified

719.7 Difficulty in walking 722 Intervertebral disk disorders

722.4 Degeneration of cervical intervertebral disk

722.5 Degeneration of thoracic or lumbar intervertebral disk

722.6 Degeneration of intervertebral disk, site unspecified 723 Other disorders of cervical region

723.1 Cervicalgia 724 Other and unspecified disorders of back

724.2 Lumbago

Low back pain, low back syndrome, lumbalgia

724.9 Back disorders, other unspecified

Ankylosis of spine, not otherwise specified;

compression of spinal nerve root, not elsewhere

classified; spinal disorders, not otherwise specified 728 Disorders of muscle, ligament, and fascia

728.2 Muscular wasting and disuse atrophy, not elsewhere classified

728.8 Other disorders of muscle, ligament, and fascia 729 Other disorders of soft tissues

729.9 Other and unspecified disorders of soft tissue 733 Other disorders of bone and cartilage

733.0 Osteoporosis 737 Curvature of spine

737.1 Kyphosis (acquired)

737.2 Lordosis (acquired)

737.3 Kyphoscoliosis and scoliosis 738 Other acquired deformity

738.4 Acquired spondylolisthesis 756 Other congenital musculoskeletal anomalies

756.1 Anomalies of spine 781 Symptoms involving nervous and musculoskeletal systems

781.2 Abnormality of gait

Gait: ataxic, paralytic, spastic, staggering

781.9 Other symptoms including nervous and musculoskelatal systems Abnormal posture

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Anthropometric Characteristics

* Measurement of height, weight, length, and girth

Assistive and Adaptive Devices

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of environment and work (job/school/play) tasks

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of dexterity and coordination

* Assessment of safety in community and work (job/school/play) environments

* Assessment of work (job/school/play) performance through batteries of tests

* Computer-assisted motion analysis of patient/client at work

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or

activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- assessment of workstation

- computer-assisted motion analysis during performance of

- selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress

* Functional capacity evaluation, including:

- endurance required to perform aerobic endurance activities

- joint range of motion (ROM) used to perform task or activity

- postures required to perform task or activity

- strength required in the work postures necessary to perform task or activity

* Videotape analysis of patient/client at work

Body mechanics:

* Computer-assisted motion analysis of the performance of selected movements or activities

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Observation of performance of selected movements or activities

* Videotape analysis of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, or supportive devices

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Assessment of safety

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of joint hypermobility and hypomobility

* Assessment of pain and soreness

* Assessment of response to manual provocation tests

* Assessment of soft tissue swelling, inflammation, or restriction

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain and soreness with joint movement

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

Self-Care and Home Management (Including ADL and IADL)

* Analysis of self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Sensory integrity (Including Proprioception and Kinesthesia)

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 12 months, patient/client will demonstrate the ability to maintain preferred posture during various activities (activities of daily living [ADL]; instrumental activities of daily living [IADL]; and community, work, and leisure activities).

Expected Range of Number of Visits Per Episode of Care

6 to 20

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency

of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary, impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint and soft tissue swelling, inflammation, or restriction is reduced.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Quality and quantity of movement between and across body segments are improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices)

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved when performing self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

Functional Training in Community and Work (Job/school/play) Integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Safety is improved during performance of community and work (job/school/play) tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* Injury prevention or reduction training

* job coaching

* job simulation

* Organized functional training programs (eg, back schools, simulated environments and tasks)

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Joint integrity and mobility are improved.

* Motor function (motor control and motor learning) is improved.

* Muscle spasm is reduced.

* Pain is decreased.

* Quality and quantity of movement between and across body segments are improved.

* Risk of secondary impairments is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Connective tissue massage

* Joint mobilization and manipulation

* Manual traction

* Passive range of motion

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Deformities are prevented.

* Edema, lymphedema, or effusion is reduced.

* Gait, locomotion, and balance are improved.

* Joint stability is increased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is improved.

* Optimal joint alignment is achieved.

* Physical function and health status are improved.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, compression garment, corsets, slings, neck collars, serial casts, elastic wraps, oxygen)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Muscle performance is increased.

* Pain is decreased. joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

Specific Direct Interventions

* Biofeedback

* Electrical muscle stimulation

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Joint integrity and mobility are

* Risk of secondary impairments is

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

Physical agents:

* Cryotherapy (eg, cold pack, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)

Mechanical modalities:

* Traction (sustained, intermittent, or positional)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment),primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with postural dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL)--and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional [imitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Age-related somatosensory changes

* Attitude

* Habitual suboptimal body mechanics

* Habitual suboptimal posture

* Inflexibility

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal

deconditioning

- physical activity level and demand

- substance abuse (eg, smoking, alcohol, drugs)

* Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors)

* Muscle weakness or imbalance (eg, trunk and hip muscles)

* Physical demands of work (job/school/play)

* Suboptimal particular extensibilty

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg, retirement centers, senior centers, assisted-living centers)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and posture and (2) strategies to prevent impaired posture

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, school scoliosis screening program, programs identifying those with postural dyscontrol tendencies)

* Workplace, home, and community ergonomic analysis and modification

Impaired Muscle Performance

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitations secondary to impaired muscle performance.

INCLUDES patients/clients with:

* Cardiovascular insufficiency

* Disuse atrophy secondary to prolonged bed rest, congestive heart failure, chronic obstructive pulmonary disease (COPD), pneumonia

* Dysfunction of the pelvic-floor musculature

* Muscle weakness due to immobilization or lack of activity

* Renal disease

* Vascular insufficiency,

EXCLUDES patients/clients with:

* Amputation

* Primary capsular restriction

* Primary joint arthroplasty

* Primary localized inflammation

* Recent bony and surgical soft tissue procedures

* Recent fracture

* Upper and lower motor neuron disease

ICD-9-CM-Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

359 Muscular dystrophies and other myopathies 359.9 Myopathy, unspecified 410 Acute myocardial infarction 428 Heart failure 428.0 Congestive heart failure 443 Other peripheral vascular disease 482 Other bacterial pneumonia 492 Emphysema 492.8 Other emphysema 496 Chronic airway obstruction, not elsewhere classifed Chronic: obstructive pulmonary disease (COPD), not otherwise specfied 618 Genital prolapse 618.8 Other specified genital prolapse Incompetence or weakening of pelvic fundus; relaxation of vaginal outlet or pelvis 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 719 Other and unspecified disorders of joint 719.7 Difficulty in walking 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 733 Other disorders of bone and cartilage 733.0 osteoporosis 733.1 Pathologic fracture 739 Nonallopathic lesions. not elsewhere classified 780 General symptoms 780.7 Malaise and fatigue 781 Symptoms involving nervous and musculoskeletal systems 781.0 Abnormal involuntary movements 781.2 Abnormality of gait Gait ataxic, paralytic, spastic, staggering 781.3 Lack of coordination Ataxia, not otherwise specified; muscular incoordination 781.4 Transient paralysis of limb 781.9 Other symptoms involving nervous and musculoskeletal systems Abnormal posture 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 799 Other ill-defined and unknown causes of morbidity and mortality 799.3 Debility, unspecified

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and

* preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales Assessment of performance during established exercise protocols eg, using treadmill, ergometer, 6- minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity

Assistive and Adaptive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability), through use of device Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work (job/school/play) through batteries of tests * Assessment of workstation * Determination of dynamic capabilities and limitations during specific work job/school/play) activities

Body mechanics: * Observation of performance of selected movements or activities

Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of autonomic responses to positional changes * Assessment of safety

Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during the performance of specific movement tasks * Assessment of joint hypermobdity and hypomobility * Assessment of pain and soreness

Muscle Performance including Strength, Power and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV)

Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of muscle soreness * Assessment of pain and soreness with joint movement * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture * Analysis of resting posture in any position

Range of Motion (ROM) including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

Self-Care and Home Management (Including ADL and IADL) * Analysis of adaptive skills * Analysis of environment and work (job/school/play) tasks * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, and supportive devices and equipment * Assessment of ability to transfer * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Sensory integrity including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, fight touch, pressure)

Ventilation, Respiration (Gas Exchange), and Circulation * Analysis of thoracoabdominal movements and breathing patterns at rest and during activity or exercise * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of chest wall mobility, expansion, and excursion * Assessment of perceived exertion and dyspnea * Assessment of phonation * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of ventilatory muscle strength, power, and endurance * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion)

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Over the course of 2 to 10 months, patient/client will demonstrate a return to premorbid or highest level of function.

Expected Range of Number of Visits Per Episode of Care

6 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify

Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals * Accountability for services is increased. * Available resources are maximally, utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding tile health of patient/client and use of health care resources by patient/client, family significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined.

Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources

Patient/Client-related Instruction

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

Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Motor function (motor control and motor learning) is improved.

* Pain decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Quality and quantity of movement between and across body segments are unproved.

* Risk factors are reduced.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home-Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Performance of and independence m ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device or equipment training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Functional Training in Community and Work (Job/School/Play) Integration or

Reintegration (Including IADL, Work

Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased,

* Costs to work-related injury or disability are reduced.

* Safety is improved during performance of community and work tasks and activities.

* Tolerance to position

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Assistive and adaptive device and equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* Injury prevention or reduction training

* Job coaching

* Job simulation

* Leisure and play activity training

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Deformities are prevented.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint integrity and mobility are improved.

* Joint stability is increased.

* Level of supervision required for task performance is decreased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is improved.

* Optimal joint alignment is achieved.

* Overall independence is increased.

* Physical function and health status are improved.

* Protection of body parts is increased.

* Safety is improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, canes, crutches, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splits, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, helmets, cushions, protective taping)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Complications are reduced.

* Edema, lymphedema, or lymphedema, is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, and restriction are reduced.

* Wound and soft tissue healing is enhanced.

Specific Direct Interventions

* Biofeedback

* Electrical muscle stimulation

* Functional electrical stimulation (FES)

* Neuromuscular electrical stimulation (NMES)

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased.

* Complications from soft tissue and circulatory disorders are decreased.

* Edema, effusion, or lymphedema is reduced.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, and restriction are reduced.

* Tolerance to positions and activities is increased.

Specific Direct interventions

Physical agents:

* Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields)

* Cryotherapy (eg, cold packs, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage)

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities:

* Compression therapies eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, total contact casting)

* Tilt table or standing table

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of fife is improved.

* Optimal return to role function (eg,

* worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with muscle performance dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status,

Primary Prevention/risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type)

* Attitude

* Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments

* Habitual suboptimal posture or body mechanics (eg, scapular retraction, forward-head position, hyperextension of the knees)

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal

deconditioning

- physical activity level

- physical work demands

- psychosocial and socioeconomic stressors

- substance abuse (eg, smoking, alcohol, drugs)

* Musculotendinous tightness or inflexibitity (eg, Achilles tendon, hamstring muscles, pectoral muscles)

* Musculotendinous weakness or imbalance (eg, quadriceps femoris. hamstring, rhomboid, lower trapezius, pectoral muscles)

* Previous history. of injury or surgery affecting posture or body mechanics (eg, shoulder injury resulting in forearm compensation, foot pain resulting in knee or hip compensation)

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise program, youth activity programs)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and inflammatory conditions and (2) strategies to prevent these conditions

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, athletic preparticipation, preemployment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Joint Mobility, Motor Function, Muscle Performance, and

Range of Motion Associated Wit Capsular Restriction

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitations as a primary result of capsular restriction following prolonged joint immobilization. Patients/clients may have one or both of the following:

* Decreased range of motion

* Pain

INCLUDES patients/clients with:

* External supports or protective devices

* Protective muscle guarding

EXCLUDES patients/clients with:

* Impaired reflex integrity or lack of voluntary movement

* Immobility as a primary result of prolonged bed rest

* Joint hemarthrosis, active sepsis, or deep vein thrombosis

* Traumatic wounds or burns not associated with prolonged immobilization

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

337 Disorders of the autonomic nervous system 337.2 Reflex sympathetic dystrophy 354 Mononeuritis of upper limb and mononeuritis multiplex 354.4 Causalgia of upper limb 524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.5 Unspecified polyarthropathy or polyarthritis 716.9 Arthropathy, unspecified

Inflammation of joint, not otherwise specified

718 Other derangement of joint 718.8 Other joint derangement, not elsewhere classified 719 Other and unspecified disorders of joint 719.7 Difficulty in walking 719.8 Other specified disorders of joint Calcification of joint 726 Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.10 Disorders of bursae and tendons in shoulder region, unspecified 726.2 Other affections of shoulder region, not elsewhere classified 726.9 Unspecified enthesopathy 726.90 Enthesopathy of unspecified site

Tendinitis

727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 727.6 Rupture of tendon, nontraumatic 727.61 complete rupture of rotator cuff 727.8 Other disorders of synovium, tendon, and bursa 727.91 Contracture of tendon (sheath) Short Achilles tendon (acquired) 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.6 Contracture of palmar fascia Dupuytren's contracture 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 729 Other disorders of soft tissue 729.8 Other musculoskeletal symptoms referable to limbs 729.81 swelling of limb 730 Osteomyelitis, periostitis and other infections involving bone 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 733.8 Malunion and nonunion of fractures 733.82 Nonunion of fracture 802 Fracture of face bones 805 Fracture of vertebral column without mention of spinal cord injury 808 Fracture of pelvis 811 Fracture of scapula 812 Fracture of humerus 812.4 Lower end, closed

Distal end of bumerus, elbow

813 Fracture of radius and ulna 813.4 Lower end, closed 813.41 Colles'fracture 813.5 Lower end, open 813.51 Colles'fracture 814 Fracture of carpal bone(s) 814.0 Closed 815 Fracture of metacarpal bone(s) 816 Fracture of one or more phalanges of hand 820 Fracture of neck of femur 821 Fracture of other and unspecified parts of femur 822 Fracture of patella 823 Fracture of tibia and fibula 824 Fracture of woe 825 Fracture of one or more tarsal and metatarsal bones 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff capsule) 879 Open wound of other and unspecified sites, except limbs 998 Other complications of procedures, not elsewhere classifed 998.5 Postoperative infection

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goats for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (ADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, lanquage, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device

* Videotape analysis of patient/client using device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of environment and work (job/school/play) tasks

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics:

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Assessment of safety

* Identification and quantification of gait characteristics

Joint Integrity and Mobility

* Assessment of soft tissue swelling, inflammation, or restriction

* Assessment of joint hypermobility and hypomobility

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Electrophysiologic tests (eg, electromyography [EMG])

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain and soreness with joint movement

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of multisegmental movement

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

Self-Care and Home Management (Including ADL and IADL)

* Analysis of self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Sensory Integrity (Including Proprioception and Kinesthesia)

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure)

Ventilation, Respiration (Gas Exchange), and Circulation

* Palpation of pulses

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also man, include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Over the course of 4 months, patient/client will demonstrate a return to premorbid or highest level of function.

Expected Range of Number of Visits Per Episode of Care

6 to 36

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 36 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Delayed healing

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint and soft tissue swelling, inflammation, or restriction is reduced.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Quality and quantity of movement between and across body segments are improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

Functional Training in Community and Work Job/School/Play) integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Safety is improved during performance of community, work (job/school/play), or leisure tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Environmental, community, work (job/school/play). or leisure task adaptation

* Ergonomic stressor reduction training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving car or using public transportation, structured play for infants and children, negotiating school environments)

* Injury prevention or reduction training

* Job coaching

* Job simulation

* Organized functional training programs (eg. back schools, simulated environments and tasks)

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Joint integrity and mobility are improved.

* Muscle spasm is reduced.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Quality and quantity of movement between and across body segments is improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Connective tissue massage

* Joint mobilization and manipulation

* Manual traction

* Passive range of motion

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Deformities are prevented.

* Gait, locomotion, and balance are improved.

* Edema, lymphedema, or effusion is reduced.

* Joint integrity and mobility are improved.

* Joint stability is increased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is improved.

* Optimal joint alignment is achieved.

* Physical function and health status are improved.

* Protection of body parts is increased.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Stresses precipitating injury are decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, plastic wraps)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Complications are reduced.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

Specific Direct Interventions

* Biofeedback

* Electrical muscle stimulation

* Iontophoresis

* Neuromuscular electrical stimulation (NMES)

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased:

* Complications resulting from soft tissue and circulatory disorders are decreased.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning is improved.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

Physical agents:

* Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields)

* Cryotherapy (eg, cold pack, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Hydrotherapy (eg, whirlpool tanks, contrast baths, pulsatile lavage)

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)

Mechanical modalities:

* Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting)

* Continuous passive motion (CPM)

* Traction (sustained, intermittent, or positional)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with capsular restriction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL)-and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safety, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status,

Primary Prevention/Risk Factor Reduction Strategies

Prima prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Attitude

* Cognitive status (eg, sufficient to understand risk reduction processes)

* Heredity

* Lifestyle:

- general physical condition

- physical activity level

- substance abuse (eg, smoking, alcohol, drugs)

* Overly conservative medical management

* Pain tolerance

* Vascular integrity, including faster or slower metabolic or healing rates

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise program, youth activity programs)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors, diet) and capsular restriction and (2) strategies to prevent related impairments.

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, athletic preparticipation, preemployment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated

With Ligament or Other Connective Tissue Disorders

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitation due to ligamentous sprain or musculotendinous strain. Patients/clients may have any one or a combination of the following:

* Joint subluxation or dislocation

* Muscle guarding or weakness

* Swelling (edema) or effusion

INCLUDES patients/clients with:

* Ligamentous, cartilaginous, capsular, or fascial sprain

* Muscle and tendon strain

EXCLUDES patients with:

* Fractures

* Neurological dysfunction (upper motor neuron or lower motor neuron lesions)

* Open wounds and recent associated surgical procedures

* Radiculopathy, with or without spinal pain

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders

717 Internal derangement of knee 717.7 Chondromalacia of patella 717.8 Other internal derangement of knee 717.9 Unspecified internal derangement of knee 718.8 Other joint derangement, not elsewhere classified Instability of joint

718 Other derangement of joint

719 Other and unspecified disorders of joint

719.0 Effusion of joint 719.5 Stiffness of joint, not elsewhere classified

724 Other and unspecified disorders of back 724.2 Lumbago Low, back pain, Low, back syndrome, lumbalgia 724.3 Sciatica 724.9 Other unspecified back disorders Ankylosis of spine, not otherwise specified; compression of spinal nerve root, not elsewhere classified; spinal disorder not otherwise specified

726 Peripheral enthesopathies and allied syndromes 726.1 Rotator cuff syndrome of shoulder and allied disorders

728 Disorders of muscle, ligament, and fascia 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle

729 Other an unspecified disorders of soft tissue 729.9 Other disorders of soft tissue Imbalance of posture

830 Dislocation of jaw

831 Dislocation of shoulder

832 Dislocation of elbow

833 Dislocation of wrist

836 Dislocation of knee

837 Dislocation of ankle

838 Dislocation of foot

839 Other, multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.8 Multiple and ill-defined, closed Arm;back; hand; multiple locations; except fingers or toes; other ill-defined locations; unspecified location

840 Sprains and strains of shoulder and upper arm

841 Sprains and strains of elbow and forearm

842 Sprains and strains of wrist and hand

843 Sprains and strains of hip and thigh

844 Sprains and strains of knee and leg

845 Sprains and strains of ankle and foot

846 Sprains and strains of sacroiliac region

847 Sprains and strains of other and unspecified parts of back

848 Other and ill-defined sprains and strains 848.1 Jaw 848.3 Ribs 848.4 Sternum 848.5 Pelvis Symphysis pubis

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals, for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work (job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary.

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

Assistive and Adaptive Devices

* Analysis of alignment and fit of device and inspection of related changes in skin condition

* Analysis of appropriate components of device

* Analysis of patient/client and caregiver ability to care for device

* Analysis of the potential to remediate impairment, functional limitation, or disability, through use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device

* Videotape analysis of patient/client using device

Community and Work (Job/School/Play) integration or Reintegration (Including IADL)

* Analysis of environment and work (job/school/play) tasks

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Observation of response to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

Ergonomics and Body Mechanics Ergonomics:

* Analysis of performance of selected tasks or activities

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- assessment of workstation

- computer-assisted motion analysis of performance of selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress

* Functional capacity evaluation, including:

- endurance required to perform aerobic endurance activities

- joint range of motion (ROM) used to perform task or activity

- postures required to perform task or activity

- strength required in the work postures necessary to perform task or activity

* Observation of performance of selected movements or activities

* Videotape analysis of patient/client at work

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Assessment of safety

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during the performance of specific movement tasks

* Assessment of joint hypermobility and hypomobility

* Assessment of pain and soreness

* Assessment of response to manual provocation tests

* Assessment of soft tissue swelling, inflammation, or restriction

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Electrophysiologic tests (eg, electromyography [EMG])

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation. or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of activities and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of muscle soreness

* Assessment of pain using questionnaires, graphs, behavioral scales. symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of multisegmental movement

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Self-Care and Home Management (Including ADL and IADL)

* Analysis of self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Over the course of 2 weeks to 4 months, patient/client will demonstrate a return to premorbid or highest level of function.

Expected Range of Number of Visits Per Episode of Care

3 to 21 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 21 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred

usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint and soft tissue swelling, imflammation, or restriction is reduced.

* Level of supervision required for task performance is

* decreased.

* Motor function (motor control and motor learning) is, improved.

* Pain is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Joint integrity and mobility are improved.

* Quality and quantity of movement between and across body segments are improved.

* Risk of recurrence of condition is reduced,

* Risk of secondary impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights,

hydraulics, elastic resistance, robotics, and mechanical or

electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management task and activities.

* Utilization and cost of health care services are decreased.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, and supportive device training Direct interventions continued

Functional Training in Community and Work (Job/School/Play) integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.

* Cost of work-related injury or disability is reduced,

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Assistive and adaptive device or equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* Job coaching

* Job simulation

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement task is increased.

* Motor function (motor control and motor learning) is improved.

* Muscle spasm is reduced.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Quality and quantity of movement between and across body segments are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* Connective tissue massage

* Joint mobilization and manipulation

* Manual traction

* Passive range of motion

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices

and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Deformities are prevented.

* Gait, locomotion, and balance are improved.

* Edema, lymphedema, or effusion is reduced.

* Joint stability is increased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is improved.

* Optimal joint alignment is achieved.

* Physical function and health status are improved.

* Protection of body parts is increased.

* Joint integrity and mobility are improved.

* Safety is improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Stresses precipitating injury are decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, cushions, casts)

* Protective devices or equipment (eg, braces, helmets, protective taping)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars,. serial casts, elastic wraps)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Ventilation, respiration (gas exchange), and circulation are improved.

* Complications are reduced.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Wound and soft tissue healing is enhanced.

Specific Direct interventions

* Biofeedback

* Electrical muscle stimulation

* Iontophoresis

* Neuromuscular electrical stimulation (NMES)

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased.

* Complications resulting from soft tissue and circulatory disorders are decreased.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct interventions Physical agents:

* Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields)

* (Cryotherapy (eg, cold packs, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage)

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)

Mechanical modalities:

* Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting)

* Continuous passive motion (CPM)

* Traction (sustained, intermittent, or positional)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the fife span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with ligament or other connective tissue disorders is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provide are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type)

* Attitude

* Design, equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in home, community, or work (job/school/play) environments.

* Habitual suboptimal body mechanics

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal

deconditioning

- physical activity level

- physical work demands

- psychosocial and socioeconomic stressors

- substance abuse (eg, smoking, alcohol, drugs)

* Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors)

* Muscle weakness or imbalance (eg, trunk and hip muscles)

* Previous history of injury or surgery affecting spine, posture, or body mechanics

* Systemic condition predisposing patient/client to spinal pain with radiculopathy

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors, diet) and sprain and strain and (2) strategies to prevent or reduce these conditions

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, scoliosis, athletic preparticipation, preemployment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Joint Mobility, Motor Function, Muscle Performance, and

Range of Motion Associated Wit Localized inflammation

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/client Diagnostic Group

Patients/clients with functional limitation and impairment secondary to protective tissue response of the synovial joint and the periarticular connective tissue. Patients/clients may or may not have additional contributing factors (eg, workstation and tool design, work rates, physical fitness level, pregnancy, habitual posture) with one or more of the following:

* Edema

* Inflammation of periarticular connective tissue

* Muscle weakness or strain

* Neurovascular changes

* Pain

* Sensory changes

INCLUDES patients/clients with:

* Bursitis

* Capsulitis

* Epicondylitis

* Fasciitis

* Osteoarthritis

* Synovitis

* Tendinitis

EXCLUDES patients with:

* Associated postsurgical procedures

* Deep vein thrombosis (DVT)

* Dislocations

* Fractures

* Hemarthrosis

* Open wounds

* Sepsis

* Systemic disease processes

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

274 Gout 274.0 Gouty arthropathy 350 Trigeminal nerve disorders 350.1 Trigeminal neuralgia 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions

Thoracic outlet syndrome

354 Mononeuritis of upper limb and mononeuritis multiplex 354.0 Carpal tunnel syndrome 354.2 Lesion of ulnar nerve

Cubital tunnel syndrome

355 Mononeuritis of lower limb, unspecified site 355.6 Lesion of plantar nerve

Morton's neuroma

524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 682 Other cellulitis and abscess 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.6 unspecified monoarthritis knee) 716.66 Lower leg 716.9 Arthropathy, unspecified

Inflammation of joint

718 Other derangement of joint 718.8 Other joint derangement, not elsewhere classified

Instability of joint

719 Other and unspecified disorders of joint 719.0 Effusion of joint 719.2 Villonodular synovitis 720 Ankylosing spondylitis and other inflammatory spondylopathies 720.2 Sacroiliitis, not elsewhere classified 722 intervertebral disk disorders 724 Other and unspecified disorders of back 724.0 spinal stenosis, other than cervical 724.2 Lumbago

Low back pain, low back syndrome, lumbalgia

726 Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.10 Disorders of bursae and tendons in shoulder region, unspecified 726.2 Other affections of shoulder region, not elsewhere classified 726.3 Enthesopathy of elbow region 726.31 Medial epicondylitis 726.32 Lateral epicondylitis 726.5 Enthesopathy of hip region

Bursitis of hip

726.6 Enthesopathy of knee, unspecified

Bursitis of knee, not otherwise specified

726.9 Unspecified enthesopathy 726.90 Enthesopathy of unspecified site Tendinitis, not otherwise specified 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 727.04 Radial styloid tenosynovitis

de Quervain's disease

727.6 Rupture of tendon, nontraumatic 727.61 complete rupture of rotator cuff 727.9 Unspecified disorder of synovium, tendon, and bursa 728 Disorders of muscle, ligament, and fascia 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 729.2 Neuralgia, neuritis and radiculitis, unspecified 729.4 Fasciitis, unspecified 732 Osteochondropathies 732.9 Unspecified osteochondropathy 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff capsule) 923 Contusion of upper limb 924 Contusion of lower limb and other unspecified sites

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental History

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current rent clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep

* patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Post and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6- minute walk test, 3-minute step test)

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

Assistive and Adaptive Devices

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of environment and work (job/school/play) tasks

* Assessment of functional capacity

* Review of daffy activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Ergonomics and Body Mechanics

Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of dexterity and coordination

* Assessment of safety in community and work (job/school/play) environments

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Computer-assisted motion analysis of patient/client at work (job/school/play)

* Determination of dynamic capabilities and limitations during specific work job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- assessment of workstation

- computer-assisted motion analysis of patient/client during performance of selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual or potential trauma, cumulative trauma, and repetitive stress

* Functional capacity evaluation, including:

- endurance required to perform aerobic endurance activities

- joint range of motion (ROM) used to performing task or activity

- postures required to perform task or activity

- strength required in the work postures necessary to perform task or activity

* Videotape analysis of patient/client at work Body mechanics:

* Determination of dynamic capabilities and limitations during specific work activities

* Observation of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Assessment of safety

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Integumentary Integrity

For skin associated with integumentary disruption:

* Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors)

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of joint hypermobility and hypomobility

* Assessment of pain and soreness

* Assessment of response to manual provocation tests

* Assessment of soft tissue swelling, inflammation or restriction.

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain and soreness with joint movement

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, video-tape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of multisegmental movement

* Analysis of ROM using a goniometer, tape measure, flexible ruler, inclinometer, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, and soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

Self-care and Home Management including ADL and IADL)

* ADL or IADL scales or indexes

Sensory integrity (Including Proprioception and Kinesthesia)

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure)

* Electrophysiologic tests (eg, sensory nerve conduction)

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

1. Over the course of 8 to 16 weeks, patient/client with demonstrate a return to premorbid or highest level of function.

Expected Range of Number of

Visits Per Epis-ode of Care

6 to 24

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group of achieve the goals and outcomes within 6 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require

New Episode of Care or

That May Modify Frequency of

Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Associated medical interventions (eg, injections, medications, tests)

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Ongoing aggravating risk factors (eg,

* repetititve motion)

* Preexisting systemic conditions or diseases

* Premorbid condition

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of Patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers

* Disability associated with acute or chronic illness is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is de

* Patient/client, family, required,and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved

* Physical function and health status are improved.

* Progress is enhanced through die participation of patient/client, others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Joint and soft tissue swelling, inflammation, or restriction is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Need for assistive, adaptive, orthotic, protective, or supportive devices is decreased.

* Pain is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Joint integrity and mobility are improved.

* Quality and quantity of movement between and across body segments are improved.

* Risk factors are reduced.

* Risk of recurrence of condition is reduced.

* Risk of secondary, impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Conditioning and reconditioning

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening: - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Assistive and adaptive device or equipment training

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device or equipment training

Functional Training in Community and Work Job/School/Play) integration

or Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Intensity of care is decreased.

* Performance of and independence in IADL is increased.

* Level of supervision required for task performance is decreased.

* Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Assistive and adaptive device and equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* Injury prevention or reduction training

* Job coaching

* Job simulation

* Leisure and play activity training

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Joint integrity and mobility are improved.

* Motor function (motor control and motor learning) is improved.

* Muscle spasm is reduced.

* Pain is decreased.

* Quality and quantity of movement between and across body segments are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

* Ventilation, respiration (gas exchange), and circulation are improved.

Specific Direct Interventions

* Connective tissue massage

* Joint mobilization or manipulation

* Manual traction

* Passive range of motion

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices

and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Deformities are prevented.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint stability is increased.

* Level of supervision required for task performance is decreased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is increased.

* Optimal joint alignment is achieved.

* Pain is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Protection of body parts is increased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Sense of well-being is improved.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Stresses precipitating injury are decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Complications are reduced.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

Specific Direct Interventions

* Electrical muscle stimulation

* Functional electrical stimulation (FES)

* Iontophoresis

* Neuromuscular electrical stimulation (NMES)

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased.

* Complications of soft tissue and circulatory disorders are decreased.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Neural compression is decreased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

Physical agents:

* Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields)

* Cryotherapy (eg, cold packs, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Hydrotherapy (eg, whirlpool tanks, contrast baths)

* Superficial thermotherapy (eg, heat, paraffin baths, hot packs, fluidotherapy)

Mechanical modalities:

* Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping, total contact casting)

* Continuous passive motion (CPM)

* Traction (sustained, intermittent, or positional)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with localized inflammation is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type)

* Attitude

* Design, equipment, or other barriers preventing optimal body mechanics or posture in home, community, or work (job/school/play) environments

* Habitual suboptimal posture or body mechanics (eg, scapular retraction, forward-head position, hyperextension of the knees)

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal deconditioning

- physical activity level

- physical work demands

- psychosocial and socioeconomic stressors

- substance abuse (eg, smoking, alcohol, drugs)

* Musculotendinous tightness or inflexibility (eg, Achilles tendon, hamstring muscles, pectoral muscles)

* Musculotendinous weakness or imbalance (eg, quadriceps femoris, hamstring, rhomboid, lower trapezius, pectoral muscles)

* Previous history of injury or surgery affecting posture or body mechanics (eg, shoulder injury resulting in forearm compensation, foot pain resulting in knee or hip compensation)

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg. senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification through individual or group activities that (1) highlight the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and inflammatory conditions and (2) strategies to prevent or reduce these conditions.

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, scoliosis, athletic preparticipation, pre-employment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Joint Mobility, Motor Function, Muscle Performance, Range of

Motion, or Reflex Integrity Secondary to Spinal Disorders

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitations secondary to spinal impairment with or without radiculopathy. Patients/clients may have any one or a combination of the following:

* Altered sensation

* Deep tendon reflex changes

* Muscle weakness

* Positive neural tension tests

* Associated surgical procedures

INCLUDES patients/clients with:

* Cervical, thoracic, or lumbar disk herniation

* Disk disease

* Nerve root compression

* Spinal stenosis

* Stable spondylolisthesis

EXCLUDES patients/clients with:

* Failed surgical procedures

* Fractures or unstable spondylolisthesis

* Neuromuscular disease

* Referred pain with systemic condition

* Sepsis

* Systemic condition (eg, ankylosing spondylitis, Scheurmann's disease, juvenile rheumatoid arthritis, Reiter's disease)

* Traumatic spinal cord injury

* Tumor

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes man not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

353 Nerve root and plexus disorders 715 Osteoarthrosis and allied disorders 716 Other an unspecified arthropathies

716.9 Arthropathy, unspecified Inflammation of joint, not otherwise specified 718 Other derangement of joint

718.3 Recurrent dislocation of joints

718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint

719.2 Villonodular synovitis

719.8 Other specified disorders of joint Calcification of joint 720 Ankylosing spondylitis and other inflammatory spondylopathies 721 Spondylosis and allied disorders

721.1 Cervical spondylosis with myelopathy

721.4 Thoracic or lumbar spondylosis with myelopathy 722 Intervertebral disk disorders

722.7 Intervertebral disk disorder with myelopathy

722.71 Cervical region

722.8 Postlaminectomy syndrome 723 Other disorders of cervical region

723.0 Spinal stenosis other than cervical 724 Other and unspecified disorders of back

724.0 Spinal stenosis, unspecified region

724.00 Spinal stenosis, unspecified region

724.2 Lumbago

Low back pain, low back syndrome, lumbalgia

724.9 Other unspecified back disorders 727 Other disorders of synovium, tendon, and bursa

727.0 Synovitis and tenosynovitis 728 Disorders of muscle, ligament, and fascia

728.2 Muscular wasting and disuse atrophy, not elsewhere classified

728.8 Other disorders of muscle, ligament, and fascia

728.85 Spasm of muscle

728.9 Unspecified disorder of muscle, ligament, and fascia 733 Other disorders of bone and cartilage

733.0 Osteoporosis 738 Other acquired deformity

738.4 Acquired spondylolisthesis 756 Other congenital musculoskeletal anomalies

756.1 Anomalies of spine

756.12 Spondylolisthesis 846 Sprains and strains of sacroiliac region

846.0 Lumbosacral (joint) (ligament) 847 Sprains and strains of other and unspecified parts of back

847.0 Neck 922 Contusion of trunk

922.3 Back

922.31 Back

922.32 Buttock

922.33 Interscapular region

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep

* patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits Post and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

Assistive and Adaptive Devices

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (Job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Ergonomics and Body Mechanics Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of dexterity and coordination

* Assessment of safety in community and work (job/school/play) environments

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Computer-assisted motion analysis of patient/client at work (job/school/play)

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Endurance required to perform aerobic endurance activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of joint range of motion (ROM) used to perform task or activity

- assessment of postures required to perform task or activity

- assessment of strength required in the work postures necessary to perform task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- assessment of workstation

- computer-assisted motion analysis during performance of selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress

* Functional capacity evaluation, including assessment of:

- endurance required to perform aerobic endurance activities

- joint ROM used to perform task or activity

- postures required to perform task or activity

- strength required in the work postures necessary to perform task or activity

* Videotape analysis of patient/client at work

Body mechanics:

* Observation of performance of selected movements or activities

* Videotape analysis of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Gait, locomotion, and balance assessment instruments

* Gait, locomotion, and balance profiles

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of joint hypermobility and hypomobility

* Assessment of pain and soreness

* Assessment of response to manual provocation tests

* Assessment of soft tissue swelling, inflammation, or restriction

* Assessment of sprain

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

* Assessment of pelvic-floor musculature

* Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV])

Neuromotor Development and Sensory integration

* Assessment of dexterity, agility, and coordination

Orthotic, Protective, and Supportive Devices

* Analysis of ability to care for device independently

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain and soreness with joint movement

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of multisegmental movement

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

Self-Care and Home Management including ADL and IADL)

* ADL or IADL scales or indexes

* Analysis of environment

* Analysis of self-care and home management activities

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Sensory integrity (Including Proprioception and Kinesthesia)

* Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense)

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure)

* Electrophysiologic tests (eg, sensory nerve conduction)

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Over the course of 1 to 6 months, patient/client will demonstrate a return to premorbid or highest level of function and integration or reintegration into home, community, work, or leisure activities safely and efficiently.

Expected Range of Number of Visits Per Episode of Care

8 to 24

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 8 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency

of Visits/Duration of Episode

* Ability to obtain job reclassification or redesign, including job or home

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Previous history of spine injury or surgery

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Energy expenditure is decreased.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Postoperative complications are reduced.

* Weight-bearing status is improved.

Specific Direct Interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body mechanics and ergonomics training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Neuromuscular education or reeducation

* Posture awareness training

* Strengthening

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device or equipment training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Functional Training in Community and Work (Job/School/Play) Integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities increased.

* Costs of work-related injury or disability are reduced.

* Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Assistive and adaptive device or equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* Injury prevention or reduction training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* Job coaching

* Job simulation

* Leisure and play activity training

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Motor function (motor control and motor learning) is improved.

* Muscle spasm is reduced.

* Pain is decreased.

* Quality and quantity of movement between and across body segments are improved.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced,

* Tolerance to positions and activities is increased.

* Ventilation, respiration (gas exchange), and circulation are improved.

Specific Direct Interventions

* Connective tissue massage

* Joint mobilization and manipulation

* Manual traction

* Passive range of motion

* Soft tissue mobilization or manipulation

* Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Gait, locomotion and balance are improved. joint stability is increased.

* Loading on a body part is decreased.

* Motor function (motor control and motor learning) is improved.

* Performance of and independence ADL and IADL are increased.

* Pain is decreased.

* Physical function and health status are improved.

* Protection of body parts is increased.

* Joint integrity and mobility are improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Sense of well-being is improved.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Stresses precipitating injury are decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems. environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts. casts)

* Protective devices or equipment (eg, braces. protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased,

* Complications are reduced.

* Edema, lymphedema, or effusion is reduced.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Pain is decreased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Wound and soft tissue healing is enhanced.

Specific Direct Interventions

* Biofeedback

* Electrical muscle stimulation

* Functional electrical stimulation (FES)

* Iontophoresis

* Neuromuscular electrical stimulation (NMES)

* Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Ability to perform movement tasks is increased

* Edema, lymphedema, or effusion is reduced

* Joint integrity and mobility is improved.

* Neural compression is decreased.

* Pain is decreased.

* Risk of secondary impairments is reduced.

* Soft tissue swelling, inflammation, or restriction is reduced.

* Tolerance to positions and activities is increased

Specific Direct Interventions

Physical agents:

* Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields)

* Cryotherapy (eg, cold packs, ice massage)

* Deep thermal modalities (eg, ultrasound, phonophoresis)

* Hydrotherapy (eg, whirlpool tanks, contrast baths, pulsatile lavage)

* Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)

Mechanical modalities:

* Traction (sustained, intermittent, or positional)

Reexamination

The physical therapist relies on reexamination, the process of performing of selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also man be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform. at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability, (inability to engage in age-specific. gender-specific, or sex-specific roles in a particular social context and physical environment), primary, or secondary, prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with spinal disorders is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers,

* Coordination and conformity of care are acceptable to patient/client, family significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology impairment to disability -- is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle, factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability

* Age

* Anthropometric characteristics (eg, excessive weight. leg-length discrepancy, body, type)

* Attitude

* Design, equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in community, home, or work (job/school/play) environments

* Habitual suboptimal body mechanics

* Systemic condition predisposing patient/client to spinal pain with radiculopathy

* Lifestyle:

- fitness level or cardiopulmonary and musculoskeletal deconditioning

- physical activity level

- physical work demands

- psychosocial and socioeconomic stressors

- substance abuse (eg, smoking, alcohol, drugs)

* Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors)

* Muscle weakness or imbalance (eg, trunk and hip muscles)

* Previous history of injury or surgery affecting spine, posture, or body mechanics

Primary Prevention/Risk Factor Reduction Strategies

* Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy, exercise programs, youth activity programs)

* Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment)

* Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and spinal pain and (2) strategies to prevent or reduce pain

* Risk factor reduction through individual and group therapeutic exercise and symptom management

* Screening programs (eg, scoliosis, athletic preparticipation, preemployment)

* Workplace, home, and community ergonomic analysis and modification

Impaired Joint Mobility, Muscle Performance, and Range of Motion

Associated With Fracture

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs: the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitations and impairments secondary to fracture.

INCLUDES patients with:

* Activity-induced hormonal changes

* Certain medications (eg, steroids)

* Known high risk (eg, based on sex, ethnicity, age, lifestyle, menstrual or hormonal changes related to hysterectomy or menopause)

* Nutritional deficiency

* Traumatic injuries

EXCLUDES patients with:

* Bone neoplasms

* Osteogenesis imperfecta

* Paget's disease

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

715 Osteoarthrosis and related disorders 719 Other an unspecified disorders of joint

719.5 Stiffness of joint, not elsewhere classified

719.8 Other specified disorders of joint Calcification ofjoint 722 Intervetebral disk disorders 726 Peripheral enthesopathies and allied syndromes

726.2 Other affections of shoulder region, not elsewhere classified Periarthritis of shoulder scapulohumeral fibrositis 728 Disorders of muscle, ligament. and fascia

728.2 Muscle wasting and disuse atrophy, not elsewhere classified 729 Other disorders of soft tissues

729.9 Other and unspecified disorders of soft tissue Imbalance of posture 732 Osteochondropathies

732.4 Juvenile osteochondrosis of lower extremity, excluding foot tibial tubercle (of Osgood-schlatter) 733 Other disorders of bone and cartilage

733.0 Osteoporosis

733.1 Pathologic fracture

733.8 Malunion and nonunion of fracture

733.82 Nonunion of fracture 736 Other acquired deformities of limbs

736.8 Acquired deformities of other parts of limbs

736.81 Unequal leg length (acquired) 781 Symptoms involving nervous and musculoskeletal systems

781.2 Abnormality of gait Gait: ataxia, paralitic, spastic, staggering 802 Fracture of face bones 805 Fracture of vertebral column without mention of spinal cord injury 808 Fracture of pelvis 810 Fracture of clavicle 811 Fracture of scapula 812 Fracture of humerus 813 Fracture of radius and ulna

813.4 Lower end, closed

813.41 Colles'fracture

813.5 Lower end, open

813.51 Colles'fracture 814 Fracture of carpal bone(s) 815 Fracture of metacarpal bone(s) 816 Fracture of one or more phalanges of hand 820 Fracture of neck of femur 821 Fracture of other unspecified parts of femur 822 Fracture of patella 823 Fracture of tibia and fibula 824 Fracture of ankle 825 Fracture of one or more tarsal or metatarsal bones 826 Fracture of one or more phalanges of foot

Examination

Through the examination (history systems review, and tests and measures), the physical terapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem: stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease. including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family significant other, and caregiver perceptions of patient's/ clients emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management.. community, work [job/school/play], and leisure activities)

Systems Review The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communications, affect, cognition, language, and learning style

Tests and Measures Tests and measures for this pattern may, include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of standard vital signs (eg. blood pressure, heart rate, respiratory. rate) at rest and during and after activity

Anthropometric Characteristics

* Measurement of height, weight, length, and girth

Assistive and Adaptive Devices

* Analysis of alignment and fit of device and inspection of related changes in skin condition

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy, conservation and expenditure) while patient/client uses device

* Analysis of patient/client or caregiver ability to care for device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, and other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of environment, work (job/school,play), and leisure activities

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* IADL scales or indexes

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work Job/School/Play) Barriers

* Assessment of current and potential barriers

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of dexterity and coordination

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Computer-assisted motion analysis of patient/client at work

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- computer-assisted motion analysis of performance of selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress

* Functional capacity evaluation, including:

- endurance required to perform aerobic endurance activities joint range of motion (ROM) used to perform task or activity postures required to perform task or activity strength required in the work postures necessary to perform task or activity

* Videotape analysis of patient/client at work

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematc, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Analysis of wheelchair management and mobility

* Assessment of safety

* Gait, locomotion, and balance assessment instruments

* Gait, locomotion, and balance profiles

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of joint hypermoblility and hypomobility

* Assessment of pain and soreness

* Assessment of soft tissue swelling, inflammation, or restriction

Motor Function (Motor Control and Motor Learning)

* Analysis of gait, locomotion, and balance

* Analysis of head, trunk, and limb movement

* Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping)

* Assessment of autonomic responses to positional changes

* Assessment of dexterity, coordination, and agility

* Physical performance scales

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy, conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and and provocation tests

* Assessment of muscle soreness

* Assessment of pain and soreness with joint movement

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of functional ROM

* Analysis of multisegmental movement

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

Self-Care and Home Management (Including ADL and IADL)

* ADL or IADL scales or indexes

* Analysis of environment

* Analysis of self-care and home management activities

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family significant others, caregivers, or other professionals

Sensory integrity (Including Proprioception and Kinesthesia)

* Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense)

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure)

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity, of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity, of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition: preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement: social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client.

Prognosis

Postfracture, patient/client will minimize rate of bone loss or will increase bone mineral density and will achieve highest level of function.

Expected Range of Number of Visits Per Episode of Care

6 to 18

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility, of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Aerobic capacity is increased.

* Endurance is increased.

* Gait, locomotion, and balance are improved.

* Intensity of care is decreased.

* Joint and soft tissue swelling, inflammation, or restriction is reduced.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Motor function (motor control and motor learning) is improved.

* Need for assistive, adaptive, orthotic, protective, or supportive devices or equipment is decreased.

* Osteogenic effects of exercise are maximized,

* Pain is decreased.

* Performance of and independence ADL and IADL are increased.

* Physical function and health status are improved.

* Postural control is improved.

* Preoperative and postoperative complications are reduced.

* Quality and quantity of movement between and across body segments are improved.

* Risk factors are reduced.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety is improved.

* Self-management of symptoms is improved.

* Sense of well-being is improved.

* Strength, power, and endurance are increased.

* Stress is decreased.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

* Weight-bearing status is improved.

Specific Direct interventions

* Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Balance and coordination training

* Body, mechanics and ergonomics training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Intensity of care is decreased.

* Performance of and independence in ADL and IADL are increased.

* Level of supervision required for task performance is decreased.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing. eating, and toileting)

* Assistive and adaptive device or equipment training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car of using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device or equipment training

Functional Training in Community and Work (Job/School/Play) Integration or Reintegration including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Performance of and independence in IADL are increased.

* Prosthetic devices are used appropriately.

* Risk of recurrence of condition is reduced.

* Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities

* Tolerance to positions and activities is increased,

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Assistive and adaptive device and equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Injury prevention or reduction training

* Job coaching

* Job simulation

* Leisure and play activity training

* Organized functional training programs (eg, back schools, simulated environments and tasks)

* Orthotic, protective, or supportive device or equipment training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved.

Specific Direct interventions * Connective tissue massage * Soft tissue mobilization and manipulation * Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive,

and Prosthetic)

Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint stability is increased. * Edema, lymphedema, or effusion is reduced. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased, * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is increased. * Pain is decreased. * Performance of and independence in ADL and IADL are increased.. * Physical function and health status are improved. * Protection of body parts is increased. joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved.

Specific Direct interventions * Adaptive devices or equipment (eg, raised toilet seats,. seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts) * Prosthetic devices or equipment (eg, artificial limbs) * Protective devices or equipment (eg, braces, protective taping, cushions. helmets) * Supportive devices or equipment (eg, supportive taping, compression garments,. corsets, slings, neck collars, serial casts. elastic wraps, oxygen)

Electrotherapeutic Modalities

Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced.

Specific Direct interventions * Electrical muscle stimulation * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS)

Physical Agents and Mechanical Modalities

Anticipated Goals * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Edema, lymphedema, or effusion is reduced. * Motor function (motor control and motor learning) is improved. * Muscle spasm is decreased. * Pain is decreased. * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased.

Specific Direct Interventions Physical agents: * Cryotherapy (eg, cold packs, ice massage) * Deep thermal modalities (eg, ultrasound, phonophoresis) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination maybe indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which-for some patient/client diagnostic groups-may be the life span, Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected. or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then, are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability * Health-related quality of life is improved. Optimal return to role function (eg, worker, student, spouse. grandparent) is achieved. * Risk of disability associated with fracture is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction * Access, availability and services provided are acceptable to patient/client, family 11/2-. significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family significant others, and caregivers. * Interpersonal skills of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others. and caregivers.

Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that ma,%. indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments * Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). in consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety, and effective adaptation following changes in physical status. caregivers. environment. or task demands.

Primary Prevention/Risk Factor Reduction Strategies

Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology-or from pathology or impairment to disability-is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications.

Identified Risk Factors for Disability * Age * Anthropometric characteristics (eg, excessive weight, leg-length discrepancy, body type) * Attitude * Design. equipment, or other barriers preventing optimal body mechanics or posture underlying spinal dysfunction (eg, postural dysfunction) in home, community, or work job/school/play) environments * Endocrine or hormonal status * Habitual suboptimal body mechanics * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - nutritional status (calcium and vitamin D intake) - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, alcohol, drugs) * Medication history * Muscle tightness or inflexibility (eg, hamstring muscles, hip flexors) * Muscle weakness or imbalance (eg, trunk and hip muscles) * Systematic condition predisposing patient/client to spinal pain with radiculopathy

Primary Prevention/Risk Factor Reduction Strategies * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification through individual or group activities that highlight (1) the relationship between risk factors (eg, smoking, substance abuse, physical activity and fitness level, stressors) and fracture and (2) strategies to prevent or reduce fracture * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, scoliosis, athletic preparticipation, pre-employment) * Workplace. home, and community ergonomic analysis and modification

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of

Motion Associated with Joint Arthroplasty

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with functional limitations secondary to joint arthroplasty with total or partial resurfacing of the joint.

INCLUDES patients/clients with:

* Ankylosing spondylitis

* Bone tumor

* Juvenile rheumatoid arthritis

* Osteoarthritis

* Paget's disease

* Rheumatoid arthritis

* Small joint (eg, interphalangeal) and large joint arthroplasties (eg, hip)

* Steroid-induced avascular necrosis

* Temporomandibular joint (TMJ) syndrome

* Trauma

EXCLUDES patients/clients with:

* Failed surgical procedures

* Unrelated postoperative complications during recovery or rehabilitation (eg, fall with fracture, proximal or distal to prosthesis)

ICD-9-CM Codes

As of press time, the listing below, contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

524 Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 524.60 Temporomandibular joint disorders, unspecified 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 715 Osteoarthrosis and allied disorders 716 Other and unspecified arthropathies 716.8 Other specified arthropathy 717 Internal derangement of knee 717.9 Unspecified internal derangement of knee 718 Other derangement of joint 718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint 719.5 Stiffness of joint. not elsewhere classified 719.7 Difficulty in walking 719.8 Other specified disorders of joint Calcification of joint 729 Other disorders of soft tissue 729.8 Other musculoskeletal symptoms referable to limbs 730 Osteomyelitis, periostitis, and other infections involving bone 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 Osteitis deformans without mention of bone tumor Paget's disease of bone 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 733.8 Malunion and nonunion of fracture 808 Fracture of pelvis 808.0 Acetabulum