Neuromuscular.The following patterns describe the elements of patient/client management provided by physical therapists -- examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge. Pattern D, "Impaired Motor and Sensory Function Associated With Peripheral Nerve Injury," also includes primary prevention/risk factor reduction strategies. This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor function associated with congenital or acquired disorders of the central nervous system in infancy, childhood, and adolescence. Patients/clients may have any one or a combination of the following: * Impaired affect * Impaired arousal and attention * Impaired balance * Impaired cognition * Impaired expressive or receptive communication * Impaired motor function (motor control and motor learning) * Impaired oromotor function * Impaired respiratory function * Impaired sensory integrity * Skeletal deficits INCLUDES patients/clients with: * Anoxia altitude anoxia see under sickness. anemic anoxia that due to decrease in amount of hemoglobin or number of erythrocytes in the blood. anoxic anoxia that due to interference with the oxygen supply. histotoxic anoxia severe histotoxic hypoxia. or hypoxia * Birth trauma * Brain anomalies * Cerebral palsy * Genetic syndromes that affect the central nervous system * Hydrocephalus * Infectious disease that affect the central nervous system (eg, meningitis, encephalitis) * Intracranial neurosurgical procedures * Meningocele * Myelocele * Myelocystoceles * Myelodysplasia * Myelomeningocele * Prematurity * Tethered cord * Traumatic brain injury * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Medical instability * Multisystem trauma * Spinal cord injury secondary to trauma * Tumor ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 036 Meningococcal infection 036.1 Meningococcal encephalitis 052 Chickenpox 052.0 Postvaricella encephalitis 055 Measles 055.0 Postmeasles encephalitis 056 Rubella 056.0 With neurological complications 072 Mumps 072.2 Mumps encephalitis 090 Congenital syphilis 090.4 Juvenile neurosyphilis 320 Bacterial meningitis 320.9 Meningitis due to unspecified bacterium 321 Meningitis due to other organisms 321.8 Meningititis due to other nonbacterial organisms classified elsewhere 322 Meningitis of unspecified cause 322.9 Meningitis, unspecified 323 Encephalitis, myelitis, and encephalomyelitis 323.4 Other encephalitis due to infection classified elsewhere 323.5 Encephalitis following immunization procedures 323.6 Postinfectious encephalitis 323.8 Other causes of encephalitis 323.9 Unspecified cause of encephalitis 331 Other cerebral degenerations 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 333 Other extrapyramidal disease and abnormal movement disorders 333.7 Symptomatic torsion dystonia Athetoid cerebral palsy [Vogt's disease]; double athetosis ath  e·toid , athe·tosic, athe·tot (syndrome) 343 Infantile cerebral palsy 345 Epilepsy 345.1 Generalized convulsive epilepsy 345.2 Petit mal status 345.3 Grand mal status 345.9 Epilepsy, unspecified 348 Other conditions of brain 348.1 Anoxic brain damage 348.3 Encephalopathy, unspecified 741 Spina bifida 742 Other congenital anomalies of nervous system 756 Other congenital musculoskeletal anomalies 756.1 Anomalies of spine 765 Disorders relating to short gestation and unspecified low birthweight 767 Birth trauma 767.0 Subdural and cerebral hemorrhage 767.9 Birth trauma unspecified 768 Intrauterine hypoxia and birth asphyxia fetal asphyxia asphyxia in utero due to hypoxia. asphyxia neonato´rum respiratory failure in the newborn; see also respiratory distress syndrome of newborn, under syndrome. traumatic asphyxia that due to sudden or severe compression of the thorax or upper abdomen, or both. 768.5 Severe birth asphyxia 768.6 Mild or moderate birth asphyxia 768.9 Unspecified birth asphyxia in liveborn infant 771 Infections specific to the perinatal period 771.2 Other congenital infections Congenital toxoplasmosis 780 General symptoms 780.3 Convulsions 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 800 Fracture of vault of skull 801 Fracture of base of skull 803 Other and unqualified skull fractures 804 Multiple fractures involving skull or face with other bones 850 Concussion 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drowning and nonfatal submersion Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (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 Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of performance during established exercise protocols (eg, treadmills, ergometers, 6-minute walk test, 3-minute step test) * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Tests and measures of pulmonary function and ventilatory mechanics Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Measurement of height, weight, length, and girth Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Assessment of level of consciousness * Assessment of level of recall (eg, short-term and long-term memory) * Assessment of orientation to time, person, and place * Screening for gross expressive (eg, verbalization) Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment, work (job/school/play), and leisure activities * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals (eg, educators, rehabilitation counselor, Workers' Compensation claims manager, employer) Cranial Nerve integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Body mechanics: * Measurement of height, weight, length, and girth * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin Joint Integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysts of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity) Neuromotor Development and Sensory integration * Analysis of age- and sex-appropriate development * Analysis of gait and posture * Analysis of involuntary movement * Analysis of reflex movement patterns * Analysis of sensory integration tests * Analysis of voluntary movement * Assessment of behavioral response * Assessment of dexterity, agility, and coordination * Assessment of postural, equilibrium, and righting reactions * Assessment of gross and fine motor skills * Assessment of motor function Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) including Muscle Length) * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex integrity * Assessment of developmentally appropriate reflexes over time * Assessment of normal reflexes (eg, deep tendon reflex) * Assessment of pathological reflexes (eg, Babinski Ba·bin·ski (b  -b nsk ), Joseph François Felix 1857-1932.'s reflex) Self-Care and Home Management (Including ADL and IADL) * ADL and IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals (including educators) Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimation, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) deficits * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of chest wall mobility, expansion, and excursion * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will function with independence in home, school, work, and community environments, within the context of the disability. Depending on motor, perceptual, and cognitive deficits, patient/client will be completely independent or may need varying levels of assistance (eg, family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 6 to 90 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 90 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Cumulative trauma * Deconditioning * Functional loss * Increases in postural deficits * Need for orthotic or adaptive equipment modification * Periods of rapid growth * Surgical intervention * Transition in lifestyle Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the 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 for man include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Need for assistive and adaptive devices is decreased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk of recurrence of condition is reduced. * Risk, of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Perceptual training * Posture awareness training * Strengthening: - active - active assistive - resistive * Stretching * Structured play or leisure activities Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, simulated environment and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Pay) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Performance of and independence in IADL are increased. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Organized functional training programs (simulated instruments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Muscle spasm is reduced. * Pain is decreased. * Quality and quantity of movement between and across body segments is improved. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Joint mobilization * Manual traction * Passive range of motion * Soft tissue mobilization * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Independence in bed mobility, transfers, and gait is maximized. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Physical function and health status are improved. * Joint integrity and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Sense of well-being is improved. * Tolerance to positions and activities is improved. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, 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, compressive garments, corsets, slings, neck collars, serial casting, elastic wraps, oxygen) Electrotherapeutic Modalities Anticipated Goals * Joint integrity and mobility are improved. * Muscle performance is increased. * Neuromuscular function is increased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions * Biofeedback * Neuromuscular electrical stimulation (NMES) Physical Agents and Mechanical Modalities Anticipated Goals * Tolerance to positions and activities is increased. Specific Direct interventions Mechanical modalities: * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability to engage in age-specific, gender-specific, or sex-specific roles in a particu]ar social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers wether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability of caregivers to assist patient/client in functional activities and use of community resources is increased. * Health-related quality of life is improved. * Optimal return to role function (eg. worker, student. spouse. grandparent) is achieved. * Risk of disability associated with congenital or acquired disorders of the central nervous system is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL)-- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man, indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation. leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes hate been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated with Acquired Nonprogressive Disorder of the Central Nervous System in Adulthood This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles. race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor and sensory function associated with acquired nonprogressive disorders of the central nervous system in adulthood. Patients/clients may have any one or a combination of the following: * Impaired affect * Impaired arousal and attention * Impaired balance * Impaired cognition * Impaired expressive or receptive communication * Impaired motor function (motor control and motor learning) * Impaired oromotor control * Impaired respiratory function * Impaired sensory integrity INCLUDES patients/clients with: * Aneurysm * Anoxia or hypoxia * Nonmalignant brain tumor * Cerebrovascular accident (stroke) * Infectious disease that affects the central nervous system * Intracranial neurosurigical procedures * Seizures * Traumatic brain injury * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Immature central nervous system * Malignant brain tumor * Medical instability * Multisystem trauma * Tumor ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 049 Other non-arthropod-borne viral diseases of the central nervous system 049.9 Unspecified non-arthropod-borne viral diseases of the central nervous system Viral encephalitis, not otherwise specified 322 Meningitis of unspecified cause 342 Hemiplegia and hemiparesis 348 Other conditions of brain 348.0 Cerebral cysts 348.1 Anoxic brain damage 431 Intracerebral hemorrhage 433 Occlusion and stenosis of precerebral arteries 434 Occlusion of cerebral arteries 435 Transient cerebral arteries 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 442 Other aneurysm 442.8 Of other specified artery 444 Arterial embolism and thrombosis 444.9 Of unspecified artery 447 Other disorders of arteries and arterioles afferent glomerular arteriole a branch of an interlobular artery that goes to a renal glomerulus. efferent glomerular arteriole one arising from a renal glomerulus, breaking up into capillaries to supply renal tubules. postglomerular arteriole efferent glomerular a. 447.1 Stricture of artery 747 Other congenital anomalies of circulatory system 747.8 Other specified anomalies of circulatory system 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 854 Intracranial injury of other and unspecified nature Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem: stage of recovery (acute, subacute, chronic): phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * 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 Post History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep * patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-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 theraphy) * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition * Assessment of factors that influence motivation * Assessment of level of consciousness * Assessment of level of recall (eg, short-term and long-term memory) * Assessment of orientation to time, person, place, and situation * Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work, (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of environment, work (job/school/play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * IADL scales or indexes * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review reports provided by patient/client, family, significant others, caregivers, or other professionals (eg. rehabilitation counselor, Workers' Compensation claims manager, employer) Cranial Nerve Integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional. behavioral, and vocational status * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities Body Mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion. and balance using electromyography (EMG), videotape, computer-assisted graphics, weight bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance characteristics Integumentary integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin Joint Integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk,, and limb movement * Analysis of myoelectric activity and neurophysiological integrity using electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG]. motor nerve conduction) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of autonomic responses to positional changes * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Assessment of sensorimotor integration * Motor assessment scales * Physical performance scales Muscle Performance (including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Electrophysiologic tests (eg, electromyography [EMG] and nerve conduction velocity [NCV]) Neuromotor Development and Sensory Integration * Analysis of involuntary movement * Analysis of reflex movement patterns * Analysis of voluntary movement * Assessment of behavioral response * Assessment of dexterity, agility, and coordination * Assessment of postural, equilibrium, and righting reactions * Assessment of gross and fine motor skills * Assessment of motor function * Assessment of oromotor function, phonation, and speech production Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain and soreness with joint movement Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Assessment of muscle, joint, or soft tissue characteristics * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) * Electrophysiologic tests (eg, H-reflex) Self-Care and Home-Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment * Analysis of self-care performed in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability, of the condition; preexisting sytemic conditions or diseases; probability of prolonged impairment, functional limitation. or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home and community environments with maximal independence, within the context of the disability. Depending on residual motor, perceptual, and cognitive deficits, patient/client will be completely independent and demonstrate a return to premorbid level of function or may need varyiny levels of assistance (family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 10 to 60 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 10 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Decline in functional independence * Development of complications or secondary impairments * Exacerbation of illness * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be quided by the alleviation of symptoms, and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/client, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client. family significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professions, and interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources. Patient/Client-Related Instruction Anticipated Goals * Ability to perform physical tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Disability associated with acute or chronic illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family significant others and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to Perform Physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Level of supervision required for task performance is decreased, * Motor function (motor control and motor learning) is improved. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary, impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tissue perfusion and oxygenation are enhanced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Aerobic endurance activities, using cycles, treadmills, steppers. Pulleys, weights, hydraulics, elastic resistance bands robotics. and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities training * Gait, locomotion and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Perceptual training * Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights. hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation) * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability, to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Performance of and independence in IADL are increased. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy * household chores, money management, driving a car or using public transportation) * Job coaching * Job simulation * Leisure and play activity training * Organized functional training programs (eg. simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint integrity and mobility are improved. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Performance of and independence in ADL and IADL are increased. * Pain is decreased. * Protection of body parts is increased. * Safety is improved. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, canes, crutches, walkers, wheelchair, power devices, 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. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. Specific Direct interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups-may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability of caregivers to assist patient/client in activities of daily living (ADL) and instrument activities of daily living (IADL) and solve new problems is improved. * Ability to solve problems enhances independence in task performance in varied environments. * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with acquired nonprogressive disorders of the central nervous system is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including ADL -- and work (job/school/play) and leisure activities, including IADL -- are performed safely, efficiently, and at a mammal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System in Adulthood This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations associated with impaired motor and sensory function associated with progressive disorders of the central nervous system in adulthood. Patients/clients may have any one or a combination of the following: * Exacerbation or remission of symptoms with treatment (eg, with radiation, chemotherapy) * Impaired affect * Impaired autonomic function * Impaired cognition * Impaired endurance * Impaired expressive or receptive communication * Impaired motor function * Impaired sensory integrity * Progressive loss of function INCLUDES patients/clients with: * Acquired immunodeficiency syndrome (AIDS) * Alcoholic ataxia * Alzheimer's disease * Amyotrophic lateral sclerosis * Basal ganglia disease * Cerebellar ataxia * Cerebellar disease * Huntington's disease * Idiopathic progressive cortical disease * Intracranial neurosurgical procedures * Malignant brain tumor * Multiple sclerosis * Parkinson's disease * Parkinsonian symptoms * Primary lateral palsy * Progressive muscular atrophy * Seizures * Tumor EXCLUDES patients/clients with: * Amputation * Coma * Medical instability * Multisystem trauma * Poliomyelitis * Progressive nondemyelinating motor neuron diseases ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because die patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 042 Human immunodeficiency virus (HIV) disease 191 Malignant neoplasm of brain 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 331 Other cerebral degenerations 331.0 Alzheimer's disease 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.0 Other degenerative diseases of the basal ganglia 333.3 Tics of organic origin 333.4 Huntington's chorea 333.9 Other and unspecified extrapyramidal disease and abdominal movement disorders 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 334.3 Other cerebellar ataxia 334.8 Other spinocerebellar diseases 335 Anterior horn cell disease 335.2 motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 341 Other demyelinating diseases of central nervous system 341.8 Other demyelinating diseases of central nervous system Central demyelination of corpus callosum 341.9 Demyelinating disease of central nervous system, unspecified 348 Other conditions of brain 348.9 Unspecified condition of brain Through the examination (history, system review, and tests and measures). the physical therapist identifies impairments. functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * 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 Post Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitatizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction, social activity, social support) Social Habits Post and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Screening for gross expressive eg, verbalization) deficits Assistive and Adaptive Devices * Analysis Of effects and benefits including energy conservation and expenditure) while patient/client uses device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, Or other professionals concerning use of or need for device Community and Work Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skins * Analysis of community, work job/school/play), and leisure activities * Analysis of community, work job/school/play), and leisure activities that are performed sing assistive, adaptive, orthotic, protective, supportive, or Prosthetic devices or equipment * Analyses of environment and work job/school/play) tasks * Assessment of functional capacity * Assessment of physiologic responses during community, work job/school/play), and leisure activities * Assessment of safety m community and work (job/school/play) environments * IADL scales or indexes * Questionnaires Completed bY and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care Professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer) Cranial Nerve integrity * Assessment of gag reflex * Assessment Of Muscles innervated by the cranial nerves * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/school/play) Barriers * Analysis of physical space using photography or videotape * Assessment Of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred Postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments Body mechanics: * Determination of dynamic capabilities and limitations during specific work job/school/play) activities * Observation of performance of selected movements or activities videotape analysis of Performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis Of gait, locomotion, and balance on various terrain, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance assessment instruments * Identification and quantification of gait characteristics * Identification and quantification of static and dynamic balance characteristics Motor Function (Motor Learning and Motor Control) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Analysis of stereotypic movements * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Assessment of sensorimotor integration * Motor assessment scales * Physical performance scales Muscle Performance including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of pain and soreness * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCVI) Neuromotor Development and Sensory integration * Analysis of involuntary movements * Analysis of reflex movement patterns * Analysis of voluntary movement * Assessment of gross and fine motor skills * Assessment of oromotor function, phonation, and speech production * Assessment of postural reactions Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Analysis of movement while patient/client uses device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Assessment of muscle, joint, or soft tissue characteristics * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging Reflex integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment * Analysis of self-care performed in unfamiliar environments * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, tight touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the Plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home, community, and work environments, within the context of the disability. Depending on the progression of motor, perceptual, and cognitive deficits, patient/client will need varying levels of assistance family, caregiver, equipment) or supervision to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 6 to 50 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 50 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments * 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 illness is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. * Intensity of care decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational, or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home eference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Postural control is improved. * Preoperative and postoperative complications are reduced. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation, inhibition, and facilitation * Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive. using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotic, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADLs and IADLs) is increased. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg. shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job,/School/Play) Integration/ Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores,heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage * Joint mobilization and manipulation * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Sense of well-being is improved. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls, and other devices) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, 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) Reexamination The physical therapist relies on reexamination,the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- maybe the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person. a physical action, activity or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention,and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Awareness and use of community resources are increased. * Awareness of and response of family and caregivers is increased to modified or add assistive and supportive devices necessary to maintain independence. * Health-related quality of life is improved. * Optimal return to role function (eg, worker, student, spouse grandparent) is achieved. * Risk of disability associated with progressive disorders of the central nervous system is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency. of physical therapist is acceptable to patient/client, family significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family significant others,and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community work (job/school/play), or leisure environment. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Peripheral Nerve Injury This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapist provide the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which has physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice and patient/client age, culture, gender role, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients who have functional limitations due to impaired motor and sensory function associated with peripheral nerve injury. Patients/clients may have one or more of the following: * Mobility deficits * Motor changes * Pain * Reflex changes * Sensory abnormalities INCLUDES patients/clients with: * Compression and entrapment neuropathies (eg. Erb's palsy, acute traumatic or pregnancy-induced carpal tunnel syndrome, cubital tunnel syndrome, radial tunnel syndrome, tarsal tunnel syndrome) * Traumatic and surgical nerve lesions (including macrotrauma and microtrauma) and surgical repairs (including neuropraxia, axonotmesis axonotmesis /ax·on·ot·me·sis/ (ak?son-ot-me´sis) nerve injury characterized by disruption of the axon and myelin sheath but with preservation of the connective tissue fragments, resulting in degeneration of the axon distal to the injury site; regeneration of the axon is spontaneous and of good quality. Cf. neurapraxia and neurotmesis., neurotmesis) EXCLUDES patients/clients with: * Demyelinating disease * Radiculopathies, reflex sympathetic dystrophy syndrome, Bell's palsy, Horner's syndrome ICD-9 Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 350 Trigeminnal nerve disorders 350.1 Trigeminal neuralgia 352 Disorders of other cranial nerves 352.4 Disorders of accessory (11th) nerve 352.5 Disorders of hypogossal (12th) nerve 352.9 Unspecified disorder of cranial nerves 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.6 Phantom limb (syndrome) 354 Mononeuritis of upper limb and mononeuritis multiplex 354.2 Lesion of ulnar nerve 354.3 Lesion of radial nerve 355 Mononeuritis of lower limb and unspecified site 357 Inflammatory and toxic neuropathy 357.1 Polyneuropathy in collagen vascular disease Examination Through the examination (history, systems review, and tests and measures), the physical 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 service of a physical therapist * Current therapeutic interventions * Mechanisms of injury or disease including date of onset and course of events * Onset and pattern of symptoms * Patient/client family, significant other, and caregiver expectations and goals for the therapeutic intervention * Patient/client, family significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation Functional Status and Activity Level * Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Medications * Medications for current condition for which patient/client is seeking the service of a physical therapist * Medications for other conditions Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations. surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-Report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg. memory reasoning ability, anxiety, depression, morale) * Role function (eg, worker, student, spouse, grandparent) * Social function (eg, social interaction. social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking. drug abuse) * Level of physical fitness (self-care, home management, community, work [job/school/play,], and leisure activities) Systems Review The system review man, include: Physiologic and anotomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Tests and Measures Test and measures for this pattern may include: Anthropometric Characteristics * Measurement of height, weight, length, and girth Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation. or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skins * Analysis of community, work (job/school/play), and leisure activities * Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by. patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Analysis of performance of selected tasks or activities * Analysis of preferred postures during performance of tasks and activities * Assessment of dexterity and coordination * Assessment of safety, in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography, (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective. supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Assessment of safety * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance characteristics * Identification of gait characteristics Integumentary Integrity For skin associated with integumentary disruption: * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) Joint Integrity and Mobility * Assessment of joint hypermobility and hypomobility * Assessment of the nature and quality of movement of the joint or body part during performance of specific movement tasks Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of dexterity, coordination, and agility * Assessment of motor control and motor learning * Electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG]. motor nerve conduction) * Motor assessment scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength. power, and endurance * Analysis of muscle strength. power, and endurance using manual muscle testing or dynamometry Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging and videotape * Analysis of the potential to remediate impairment, functional limitation, or disability, through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers. photographic or electronic devices. or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, deep tendon reflex) * Electrophysiologic tests (eg, H-reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of individual performing self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia. position sense) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence tile complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical theraphy. During the prognostic process, the physical therapist develops tile plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency, of visits and duration of the episode of care man. vary, from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition: preexisting systematic conditions or diseases; probability of prolonged impairment, functional limitation. or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Over the course of 4 to 8 months. patient/client win return to premorbid or highest level of function. Expected Range of Number of Visits Per Episode of Care 12 to 56 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patient/clients in this diagnostic group will achieve the goals and outcomes within 12 to 56 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Ability to obtain job reclassification or redesign * Ability to transfer instruction to motor learning * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity, or severity of condition * Comorbidities * Lesion differential diagnosis -- neuropraxis, axonotmesis, or neurotmesis * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Quality of surgical intervention * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of rare, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that die diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings,diagnosis,and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Communication, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific interventions * Case management * Communication (direct or indirect) * Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer) * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Ability to perform tasks is increased. * Awareness and use of community resources are improved. * Behaviors that foster healthy habits, wellness, and prevention are acquired. * Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client,family,significant others,and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Functional independence in activities of daily living (ADL) and instrumental activities of daily living (ADL) is increased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Patient/client knowledge of personal and environmental factors associated with the condition is increased. * Performance levels in employment, recreational or leisure activities are improved. * Physical function and health status are improved. * Progress is enhanced through the participation of patient/client, family, significant others, and caregivers. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety of patient/client, family, significant others, and caregivers is improved. * Self-management of symptoms is improved. * Utilization and cost of health care services are decreased. Specific interventions * Computer-assisted instruction * Demonstration by patient/client or caregivers in the appropriate environment * Periodic reexamination and reassessment of the home program * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct interventions for this pattern ma,%. include. in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased. * Aerobic capacity is increased. * Endurance is increased. * Gait, locomotion, and balance are improved. * Motor function (motor control and motor learning) is improved. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk factors are reduced. * Risk of recurrence of condition is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Strength, power, and endurance are increased. * Weight-bearing status is improved. Specific Direct interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Developmental activities * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Neuromuscular relaxation. inhibition, and facilitation * Posture awareness training * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics. elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. Safety is improved during performance of self-care and home * management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Organized functional training programs Functional Training in Community and Work (Job/School/Play) Reintegration including IADL, Work Hardening, and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Performance of and independence in IADL are increased. Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Risk of recurrence of condition is reduced. * Utilization and cost of health care services are decreased. Specific Direct interventions * Assistive, adaptive, supportive, or protective device training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children. negotiating school environments) * Job coaching * Job simulation * Orthotic device training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased, * Motor function (motor control and motor learning) is improved. * Muscle spasms are reduced. * Pain is decreased. * Risk of secondary impairments is reduced. Ventilation, respiration gas exchange), and circulation are improved. Specific Direct Interventions * Passive range of motion * Soft tissue mobilization or manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Edema, lymphedema, or effusion is reduced. joint stability is increased. * Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Joint integrity, and mobility are improved. * Safety is improved. * Risk of secondary impairments is reduced. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems. environmental controls, and other devices) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, 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, oxyen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphedema, or effusion is reduced. * Joint integrity and mobility are improved, Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Neuromuscular electrical stimulation (NMES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Joint integrity and mobility are improved, * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg. pulsed ultrasound. pulsed electromagnetic fields) * Cryotherapy (eg. cold packs. ice massage) * Deep thermal modalities (eg, ultrasound. phonophoresis) * Hydrotherapy (eg, whirlpool tanks, contrast baths) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs. fluidotherapy) Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also ma,.%, be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups--may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg, worker. student, spouse, grandparent) is achieved. * Risk of disability associated with peripheral nerve injury is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (ADL -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man. indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiologcal, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals. the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client. caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, Primary Prevention/Risk Factor Reduction Strategies Primary prevention is the prevention of disease in a susceptible or a potentially susceptible population through specific strategies such as screening programs or through general health promotion. Progression to pathology -- or from pathology or impairment to disability --is not inevitable. Physical therapist intervention can prevent impairment, functional limitation, or disability, by identifying disablement risk factors (eg, biological characteristics, demographic background, lifestyle factors) and by buffering the disablement process with adaptive or supportive equipment, an exercise program, education, or environmental modifications. Identified Risk Factors for Disability * Abnormal peripheral vascular conditions * Age * Altered sensibility * Anthropometric characteristics (eg, excessive weight, leg-length discrepancny body type) * Attitude * Habitual suboptimal body mechanics (eg, lifting, reaching) * Lifestyle: - fitness level or cardiopulmonary and musculoskeletal deconditioning - muscle tightness or inflexibility (eg, pectoralis major, hamstring, and gastrocnemius-soleus muscles; spinal facets; glenohumeral joint) - physical activity level - physical work demands - psychosocial and socioeconomic stressors - substance abuse (eg, smoking, \alcohol, drugs) * Muscle weakness or imbalance (eg, trunk and hip, quadricep femoris, hamstring, rotator cuff and wrist muscles, finger flexors and extensors) * Design, equipment, or other barriers preventing optimal body, mechanics or posture * Previous history of injury or surgery affecting extremities, spine, posture, or body, mechanics (eg, recurrent lateral ankle sprains, persistent shoulder instability) * Systemic condition predisposing patient/client to contractile or noncontractile deficiency (eg, endocrine disorders, rheumatic diseases) * Underlying spinal dysfunction (eg, postural dysfunction) in home, community or work (job/school/play) environments Primary Preventive interventions * Community program evaluation and development (eg, senior exercise programs, childbirth education or pregnancy exercise programs, youth activity programs) * Consultation (eg, work-site analysis, injury prevention, environmental and ergonomic assessment) * Lifestyle education and modification, including individual or group activities that highlight (1) the relationship between risk factors (eg, substance abuse, physical activity and fitness level, stressors) and peripheral nerve lesions and (2) prevention strategies * Risk factor reduction through individual and group therapeutic exercise and symptom management * Screening programs (eg, athletic preparticipation, preemployment) * Workplace, home, and community ergonomic analysis and modification Impaired Motor Function and Sensory Integrity Associated With Acute or Chronic Polyneuropathies This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age. culture. gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations due to impaired motor and sensory function associated with acute or chronic polyneuropathies. Patients/clients ma,.%, have one or a combination of the following: * Autonomic nervous system dysfunction * Impaired sensory integrity * Impaired motor function (motor control and motor learning) * Skin and bone abnormalities INCLUDES patients/clients with: * Amputation * Axonal polyneuropathies (diabetic. renal, and alcoholic) * Guillain-Barre syndrome * Leprosy EXCLUDES patients/clients with: * Central nervous system lesions * Coma * Compression or traumatic neuropathies * Mixed central nervous system and peripheral lesions * Multisystem trauma * Poliomyelitis ICD-9-CM Codes As of press time. the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes. it is possible for individuals to belong to the group even though the codes man, not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision., Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 030 Leprosy 250 Diabetes mellitus 250.6 Diabetes with neurological manifestations 356 Hereditary and idiopathic peripheral neuropathy 356.4 Idiopathic progressive polyneuropathy 356.9 Unspecified 357 inflammatory and toxic neuropathy 357.2 Polyneuropathy in diabetes 357.4 Polyneuropathy in other diseases classified elsewhere Uremia 357.5 Alcoholic polyneuropathy 357.7 Polyneuropathy due to other toxic agents Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. History Data generated from the history may include: General Demographics * Age * Primary language * Race/ethnicity * Sex Social History * Cultural beliefs and behaviors * Family and caregiver resources * Social interactions. social activities, and support systems Occupation/Employment * Current and prior community and * work (job/school) activities Growth and Development * Hand and foot dominance * Developmental history Living Environment * 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 Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales. angina scales, or visual analog scales * Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test) * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Claudication time tests Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy in determining the effects of other medical or health-related conditions,. during surgical procedures. after drug therapy) * Measurement of body fat composition, using calipers. underwater weighing tanks. or electrical impedance * Measurement of height, weight, length, and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Arousal, Attention, and Cognition * Screening for level of cognition (eg, to determine ability to process commands to measure safety awareness) * Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Computer-assisted analysis of motion, initially without and then with device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of community, work (job/school/play), and leisure activities * Analysis of community work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective. supportive or prosthetic devices or equipment * Analysis of environment work (job/school/play), and leisure activities * Assessment of autonomic responses to positional changes * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * Observation of responses to nonroutine occurrences * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager employer) Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Measurement of physical space * Physical inspection of the environment * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of dexterity and coordination * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Assessment of work (job/school/play) performance through batteries of tests * Computer-assisted motion analysis of patient/client at work * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its irherent tasks or activities, including: - analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Gait, locomotion, and balance assessment instruments * Gait, locomotion, and balance profiles * Identification and quantification of static and dynamic balance charactecristics Integumentary Integrity For skin associated with integumentary disruption: * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin For wound: * Assessment for presence of blistering * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma Joint integrity and Mobility * Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks * Assessment of joint hypermobility and hypomobility * Measurement of soft tissue restrictions Motor Function (Motor Control and Motor Learning) * Analysis of gait, locomotion, and balance * Analysis of head, trunk, and limb movement * Analysis of myoelectric activity and neurophysiological integrity using electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG], motor nerve conduction) * Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping, running, jumping) * Assessment of postural, equilibrium, and righting reactions * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Electrophysiologic tests (eg, electromyography [EMG], nerve conduction velocity [NCV]) Neuromotor Development and Sensory Integration * Assessment of dexterity, agility, and coordination * Assessment of gross and fine motor skills Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Analysis of pain behavior and reaction during specific movements and provocation tests * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of multisegmental movement * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, deep tendon reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg, sharp or dun discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment: potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development: and caregiver consistency or expertise. Prognosis Patient/client will be integrated into age-appropriate home, community, and work environments, within the context of the disability. Expected Range of Number of Visits Per Episode of Care 6 to 24 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 6 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Acute events related to the neuropathy (eg, infected ulcer) * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments (eg, progression of articular changes, muscle weakness, or sensory loss) * Development or progression of wound * Level of patient/client adherence to the intervention program * Mental competence of patient/client *Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Surgical intervention * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and 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. * Energy expenditure is decreased. * Gait, locomotion, and balance are improved. * Motor function (motor control and motor learning) is improved. * Need for assistive and adaptive devices is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Risk of recurrence of injury or condition is decreased. * Risk factors are reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Body mechanics and ergonomics training * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Strengthening - active - active assistive - resistive,using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Intensity of care is decreased. * Performance of and independence in ADL and IADL are increased. * Level of supervision required for task performance is decreased. * Safety when performing self-care and home management tasks and activities is improved. * Tolerance to positions and activities is increased Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device and equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical tasks related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Risk of recurrence of condition is reduced. * Safety is improved during performance of community, work (job/school/play), and leisure tasks and activities * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * Environmental, community, work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Leisure and play activity * Organized functional training programs (eg, back schools, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training * Prosthetic device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Tolerance to positions and activities is increased. * Ventilation, respiration (gas exchange), and circulation are improved. Specific Direct Interventions * Connective tissue massage * Manual traction * Passive range of motion * Soft tissue mobilization and manipulation * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical tasks is increased. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Intensity of care is decreased. * Joint comfort, alignment, and function are improved. * Joint integrity and mobility are improved. * Joint stability is increased. *Level of supervision required for task performance is decreased. * Loading on a body part is decreased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Physical function and health status are improved. * Protection of body parts is increased. * Safety is improved. * Risk of secondary impairments is reduced. * Stresses precipitating or perpetuating injury are minimized. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, 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. * Joint integrity and mobility are improved. * Muscle performance is increased. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Cryotherapy (eg, cold packs, ice massage) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, total contact casting) * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then- are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Health-related quality of life is improved. * Optimal return to role function (eg. worker. student, spouse, grandparent) is achieved. * Risk and cost of hospitalization are reduced. * Risk of disability associated with acute or chronic polyneuropathies is reduced. * Safety of patient/client and caregivers is increased. * Safety, independence, and efficiency of functional mobility (eg. gait, wheelchair, transfers) are maximized. * Self-care and home management activities, including activities of daily living (ADL)--and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment. pathology or impairment that may affect function or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/plan), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Spinal Cord This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation. and socioeconomic status. Patient/Client Diagnostic Group Patients/clients with functional limitations due to impaired motor function and sensation associated with nonprogressive disorders of the spinal cord at an,%- age. Patients/clients may have any one or a combination of the following: * Impaired balance * Impaired endurance * Impaired motor function (motor control and motor learning) * Impaired respiratory function * Impaired sensory integrity INCLUDES patients/clients with: * Benign spinal tumor * Complete and incomplete lesions * Infectious diseases affecting the spinal cord * Spinal compression secondary to osteomyelitis, spondylosis, herniated intervertebral disk. or degenerative joint disease * Spinal cord injury secondary to trauma * Spinal fusion and spinal neurological procedures EXCLUDES patients/clients with: * Amputation * Coma * Guillain-Barre syndrome * Malignant tumor * Meningocele * Medical instability * Multiple sclerosis, amyotrophic lateral sclerosis * Multiple system trauma * Myelocele * Myelomeningocele * Nerve root compression due to lumbar radiculopathy * Orthopedic or spinal instability with unstabilized spine * Progressive spinal cord injury or disease * Tethered cord CD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 192 Malignant neoplasm of other and unspecified parts of nervous system 192.2 Spinal cord Cauda equina 198 Secondary malignant neoplasm of other specified sites 198.3 Brain and spinal cord 225 Benign neoplasm of brain and other parts of nervous system 225.3 Spinal cord Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 239 Neoplasms of unspecified nature 239.7 Endocrine glands and other parts of nervous system 336 Other diseases of spinal cord 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia 344.8 Other specified paralytic syndromes 344.89 Other specified paralytic syndrome Brown-Sequard's syndrome 721 Spondylosis and allied disorders 721.1 Cervical spondylosis with myelopathy 721.4 Thoracic or lumbar spondylosis with myelopathy 721.9 Spondylosis of unspecified site 721.91 With myelopathy 722 Intervertebral disk disorders 722.7 Intervertebral disk disorder with myelopathy 730 Osteomyelitis, periostitis, and other infections involving bone 730.2 Unspecified osteomyelitis 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 806 Fracture of vertebral column with spinal cord injury 839 Other. multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.1 Cervical vertebra, open 839.2 Thoracic and lumbar vertebra, closed 839.3 Thoracic and lumbar vertebra, open 839.4 Other vertebra, closed 839.5 Other vertebra, open 839.6 Other location, closed 839.7 Other location, open 839.8 Multiple and ill-defined, closed 839.9 Multiple and ill-defined, open 952 Spinal cord injury without evidence of spinal bone injury 952.0 Cervical 952.1 Dorsal [thoracic] 952.2 Lumbar Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age: severity of the problem; stage of recovery (subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play)) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2. 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 condition Other Tests and Measures * Laboratory and diagnostic tests * Review of available records * Review of nutrition and hydration Past History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Genitourinary * Integumentary * Musculoskeletal * Neuromuscular * Pregnancy, delivery, and postpartum * Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History * Familial health risks Health Status (Self-report, Family Report, Caregiver Report) * General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue) * Psychological function (eg, memory, reasoning ability, anxiety, depression. morale) * Role function (eg, worker, student, spouse, grandparent) * Social activity (eg. social interaction. social activity, social support) Social Habits (Past and Current) * Behavioral health risks (eg, smoking, drug abuse) * Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities) Systems Review The systems review may include: Physiologic and anatomic status * Cardiopulmonary * Integumentary * Musculoskeletal * Neuromuscular Communication, affect, cognition, language, and learning style Test and Measures Test and measures for this pattern may include: Aerobic Capacity and Endurance * Assessment of autonomic responses to positional changes * Assessment of perceived exertion, dyspnea, or angina during activity using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Assessment of thoracoabdominal movements and breathing patterns with activity * Pulse oximetry Anthropometric Characteristics * Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion * Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy) * Assessment of height. weight. length. and girth * Observation and palpation of trunk, extremity, or body part at rest and during and after activity Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device * Videotape analysis of patient/client using device Community and Work (Job/School/Play) Integration or Reintegration (Including IADL) * Analysis of adaptive skills * Analysis of environment, work (job/school/play), and leisure activities * Assessment of functional capacity * Assessment of physiologic responses during community, work (job/school/play), and leisure activities * Assessment of safety in community and work (job/school/play) environments * IADL scales or indexes * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' * Compensation claims manager, employer) Environmental, Home, and Work (Job/School/Play) Barriers * Analysis of physical space using photography or videotape * Assessment of current and potential barriers * Questionnaires completed by and interviews conducted with patient/client and others as appropriate Ergonomics and Body Mechanics Ergonomics: * Assessment of safety in community and work (job/school/play) environments * Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status * Computer-assisted motion analysis of patient/client at work (job/school/play) * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Ergonomic analysis of the work and its inherent tasks or activities, including: analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress * Functional capacity evaluation, including: - endurance required to perform aerobic endurance activities - joint range of motion (ROM) used to perform task or activity - postures required to perform task or activity - strength required in the work postures necessary to perform task or activity * Videotape analysis of patient/client at work Body mechanics: * Determination of dynamic capabilities and limitations during specific work (job/school/play) activities * Observation of performance of selected movements or activities * Videotape analysis of performance of selected movements or activities Gait, Locomotion, and Balance * Analysis of arthrokinematic, biomechanical, kinematic. and kinetic characteristics of gait, locomotion, and balance, using electromyography (EMG), videotape, computer-assisted graphics, weight-bearing scales, and force plates * Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment * Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water * Analysis of wheelchair management and mobility * Assessment of safety * Gait, locomotion, and balance profiles Integumentary Integrity * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin Joint integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction * Assessment of joint hypermobility and hypomobility Motor Function (Motor Control and Motor Learning) * Analysis of head, trunk, and limb movement * Analysis of posture during sitting, standing, and locomotor activities appropriate for age * Assessment of dexterity, coordination, and agility * Assessment of postural, equilibrium, and righting reactions * Motor assessment scales * Physical performance scales Muscle Performance (Including Strength, Power, and Endurance) * Analysis of functional muscle strength, power, and endurance * Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry * Assessment of muscle tone * Assessment of pelvic-floor musculature * Electrophysiologic tests (eg, electromyography [EMG] and nerve conduction velocity [NCV]) Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of movement while patient/client wears device, using computer-assisted graphic imaging or videotape * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain using questionnaires, graphics, behavioral scales, symptom magnification scales or indexes, or visual analog scales Posture * Analysis of resting posture in any position * Analysis of static and dynamic postures using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis Range of Motion (ROM) (Including Muscle Length) * Analysis of functional ROM * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of pathological reflexes (eg, Babinski's reflex) Self-Care and Home Management (Including ADL and IADL) * ADL or IADL scales or indexes * Analysis of self-care and home management activities * Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, or supportive devices and equipment * Assessment of physiologic responses during self-care and home management activities * Questionnaires completed by and interviews conducted with patient/client and others as appropriate * Review of daily activities logs * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) * Electrophysiologic tests (eg, sensory nerve conduction) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of chest wall mobility, expansion, and excursion * Auscultation auscultation /aus·cul·ta·tion/ (aws?kul-ta´shun) listening for sounds within the body, chiefly to ascertain the condition of the thoracic or abdominal viscera and to detect pregnancy; it may be performed with the unaided ear (direct or immediate a.) or with a stethoscope (mediate a.) . of the heart * Auscultation and mediate percussion of the lungs * Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity, of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity, of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient/client will be integrated or reintegrated into age-appropriate home and community environments with maximal independence, within the context of the disability. Depending on residual motor deficits. patient/client win become completely independent or will need varying levels of assistance (eg, family, caregiver, equipment) to fulfill his or her various roles. Expected Range of Number of Visits Per Episode of Care 4 to 150 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 4 to 150 visits during a single continous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency, or expertise * Chronicity or severity of condition * Comorbidities * Development of complications or secondary impairments * Level of patient/client adherence to the intervention program * Preexisting systemic conditions or diseases * Psychosocial and socioeconomic stressors * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention man be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all 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. * Atelectasis absorption atelectasis , acquired atelectasis obstructive atelectasis; that caused by an obstruction of the airway that prevents intake of air, e.g., secretions, foreign body, tumor, or external pressure. congenital atelectasis that present at birth (primary a.) or immediately thereafter (secondary a.) . is decreased. * Endurance is increased. * Energy expenditure is decreased. * Intensity of care is decreased. * Level of supervision required for task performance is decreased. * Motor function (motor control and motor learning) is improved. * Muscle performance is increased. * Osteogenic effects of exercise are maximized. * Performance of and independence in ADL arid IADL are increased. * Physical function and health status are improved. * Joint integrity and mobility are improved. * Quality and quantity of movement between and across body segments are improved. * Risk factors are reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Stress is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Aerobic endurance activities using treadmills, ergometers, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Aquatic exercises * Balance and coordination training * Breathing exercises and ventilatory muscle training * Conditioning and reconditioning * Gait, locomotion, and balance training * Motor function (motor control and motor learning) training or retraining * Neuromuscular education or reeducation * Posture awareness training * Sensory training or retraining * Strengthening - active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased. * Ability to recognize a recurrence is increased, and intervention is sought in a timely manner. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of condition is reduced. * Safety is improved during performance of self-care and home management tasks and activities. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting) * Assistive and adaptive device or equipment training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children) * Organized functional training programs (eg, simulated environments and tasks) * Orthotic, protective, or supportive device or equipment training Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL and Work Conditioning) Anticipated Goals * Ability to perform physical task related to community and work (job/school/play) integration or reintegration and leisure tasks, movements, or activities is increased. * Costs of work-related injury or disability are reduced. * Safety is improved during performance of community, work (job/school/play) and leisure aft and activities * Risk of recurrence is decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive and adaptive device and equipment training * Environmental, community work (job/school/play), or leisure task adaptation * Ergonomic stressor reduction training * Injury prevention or reduction training * IADL training (eg, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments) * Job coaching * Job simulation * Leisure activity training * Organized functional training programs (eg, simulated environments and tasks) * Orthotic protective, or supportive device or equipment training * Posture awareness training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Motor function (motor control and motor learning) is improved. * Pain is decreased. * Tolerance to positions and activities is increased. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Ability to perform physical task is increased. * Deformities are prevented. * Independence in bed mobility, transfers, and gait is maximized. * Joint stability is increased. * Motor function (motor control and motor learning) is improved. * Optimal joint alignment is achieved. * Physical function and health status are improved. * Safety is improved. * Pressure areas (eg, pressure over bony prominence) are prevented. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Adaptive devices or equipment (eg, raised toilet seats, seating systems environmental controls) * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, splints, braces, casts, shoe inserts, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Airway Clearance Anticipated Goals * Airway clearance is improved. * Cough is improved. * Disability associated with illness or injury is decreased. * Gas exchange is improved. * Independence in self-care for airway clearance techniques is increased. * Need for assistive device (mechanical ventilation) is decreased. * Physical function and health status are improved. * Risk of recurrence of condition is reduced. * Risk of secondary complications is reduced. * Utilization and cost of health care services are decreased. * Ventilation, respiration (gas exchange), and circulation are improved. * Work of breathing is decreased. Specific Direct Interventions * Active cycle of breathing or forced expiratory technique * Assistive cough techniques * Assistive devices for airway clearance (eg, flutter valve) * Autogenic drainage * Breathing strategies (eg, paced breathing, pursed-lip breathing) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Pain is decreased. * Risk of secondary impairments is reduced. Specific Direct Interventions * Biofeedback * Electrical muscle stimulation * Functional electrical stimulation (FES) * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Tolerance to positions and activities is increased. Specific Direct Interventions Mechanical modalities: * Tilt table or standing table Reexamination The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action. activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether then' are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Ability to participate in home, work (job/school/play), or leisure activities is increased. * Health-related quality of life is improved, Opportunities for completion of psychosocial development are optimized. * Optimal return to role function (eg. worker, student, spouse, grandparent) is achieved. * Risk and cost of hospitalization are reduced. * Risk of disability associated with nonprogressive disorders of the spinal cord is reduced. * Safety of patient/client and caregivers is increased. * Safety, independence, and efficiency of functional mobility (eg, gait, wheelchair. transfers) are maximized. * Self-care and home management activities, including activities of daily living (ADI) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed by patient/client and caregivers safely, efficiently, and at a maximal level of independence with or without devices and equipment. * Sexual roles and function are resumed. * Understanding of personal and environmental factors that promote optimal health status is demonstrated. * Understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability, and services provided are acceptable to patient/client, family, significant others. and caregivers. * Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers. * Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers. Secondary Prevention * Risk of functional decline is reduced. * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Patient/client adherence to the intervention program is maximized. * Patient/client and caregivers are aware of the factors that man, indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care. periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers. environment, or task demands. Impaired Arousal, Range of Motion, Sensory Integrity, and Motor Control Associated With Coma, Near Coma, or Vegetative State This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice: and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status. Patient/Client Diagnostic Group Patients with impaired arousal, range of motion (ROM), sensation and motor control associated with coma, near coma, or persistent vegetative state at any age. Patients may have one or a combination of the following: * Autonomic nervous system dysfunction * Impaired sensory integrity * Impaired motor function (motor control and motor learning) * Skin and bone abnormalities INCLUDES patients with: * Anoxia * Cerebrovascular accident (stroke) * Infectious or inflammatory disease * Traumatic brain injury * Tumor EXCLUDES patients with: * Amputation * Medical instability * Multisystem trauma * Pneumonia ICD-9-CM Codes As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them. This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 049 Other non-arthropod-borne viral diseases of the central nervous system 049.9 Unspecified non-arthropod-borne viral diseases of the central nervous system Viral encephalitis, not otherwise specified 322 Meningitis of unspecified cause 342 Hemiplegia and hemiparesis 342.0 Flaccid hemiplegia 348 Other conditions of brain 348.0 Cerebral cysts 348.1 Anoxic brain damage 431 Intracerebral hemorrhage 433 Occlusion and stenosis of precerebral arteries 433.0 Basilar basilar /bas·i·lar/ (bas´i-lar) pertaining to a base or basal part. bas·i·lar (b  s artery 434 Occlusion of cerebral arteries 435 Transient cerebral ischemia 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 442 Other aneurysm 442.8 Of other specified artery 444 Arterial embolism and thrombosis 444.9 Of unspecified artery 447 Other disorders of arteries and arterioles 447.1 Stricture of artery 747 Other congenital anomalies of circulatory system 747.8 Other specified anomalies of circulatory system 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 850 Concussion 850.5 With loss of consciousness of unspecified duration 850.9 Concussion, unspecified 851 Cerebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 853.0 Without mention of open intracranial wound 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drowning and nonfatal submersion Examination 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 Test and Measures Tests and measures for this pattern may include, in alphabetical o Anthropometric Characteristics * Assessment of postures that aggravate or relieve edema, lymphedema, or effusion Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of level of consciousness Assistive and Adaptive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of significant other, family, or caregiver ability to use and care for device * Assessment of alignment and fit of device and inspection of related changes in skin condition * Review of reports provided by family, significant others, caregivers, or other professionals concerning use of or need for device Cranial Nerve Integrity * Assessment of gag reflex * Assessment of response to the following stimuli: - auditory - gustatory - olfactory - vestibular - visual * Assessment of swallowing Environmental, Home, and Work (Job/School/Play) Barriers * Assessment of current and potential barriers * Measurement of physical space using photography or videotape * Physical inspection of the environment * Questionnaires completed b%. and interviews conducted with patient/client and others as appropriate Muscle Performance (Including Strength, Power, and Endurance) * Assessment of muscle tone Neuromotor Development and Sensory integration * Analysis of reflex movement patterns Orthotic, Protective, and Supportive Devices * Analysis of appropriate components of device * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device * Analysis of the potential to remediate impairment, functional limitation, or disability through use of device * Analysis of practicality and ease of use of device * Asessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of family or caregiver ability to put on and remove device and to understand its use and care * Assessment of patient/client use of device * Assessment of safety during use of device * Review of reports provided by family, significant others, caregivers, or other professionals concerning use of or need for device Pain * Assessment of pain and soreness with movement Posture * Observation of resting posture assumed in any position Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging * Assessment of muscle, joint, or soft tissue characteristics Reflex Integrity * Assessment of normal reflexes (eg, stretch reflex) * Assessment of pathological reflexes (eg, Babinski's reflex) Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of gross receptive (eg, vision, hearing) abilities * Assessment of superficial sensations (eg. sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment to determine presence of cyanosis * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest * Auscultation of the heart * Auscultation and mediate percussion of the lungs * Management of airway secretions * Palpation of chest wall (eg. tactile fremitus, pain, diaphragmatic motion) * Palpation of pulses Evaluation, Diagnosis, and Prognosis The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes. specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Patient who continues in coma, near coma, or persistent vegetative state will have minimization of secondary impairments. Expected Range of Number of Visits Per Episode of Care 5 to 20 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients in this diagnostic group will achieve the goals and outcomes within 5 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Comorbidities * Development of complications or secondary impairments * Preexisting systemic conditions or diseases * Support provided by family unit Intervention Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may, be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety, of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3. Coordination, Community, and Documentation Anticipated Goals * Accountability for services is increased. * Available resources are maximally utilized. * Care is coordinated with family significant others, caregivers, and other professionals. * Decision making is enhanced regarding the health of patient/client and use of health care resources by family, significant others, and caregivers. * Other health care interventions (eg, medications) that may affect goals and outcomes are identified. * Family, significant other and caregiver understanding of expectations and goals and outcomes is increased. * Placement needs are determined. Specific Interventions * Case management * Communication (direct or indirect) * Coordination of care with family, significant others, caregivers, other health care professionals, and other interested persons * Discharge planning * Documentation of all elements of patient/client management * Education plans * Patient care conferences * Record reviews * Referrals to other professionals or resources Patient/Client-Related Instruction Anticipated Goals * Awareness and use of community resources by family, significant others and caregivers are improved * Decision making is enhanced regarding health of patient/client and use of health care resources by family significant other and * Disability associated with acute or chronic illness is reduced. * Intensity of care is decreased. * Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased. * Physical function and health status are improved. * Progress is enhanced through the participation of family, significant others and caregivers. * Safety of patient/client, family, significant others, and caregivers is improved. * Risk of secondary impairment is reduced. * Utilization and cost of health care services are decreased. Specific Interventions * Computer-assisted instruction * Demonstration by family or caregivers in the appropriate environment * Use of audiovisual aids for both teaching and home reference * Use of demonstration and modeling for teaching * Verbal instruction * Written or pictorial instruction Direct Interventions Direct interventions for this pattern may include, in order of preferred usage: Therapeutic Exercise (Including Aerobic Conditioning) Anticipated Goals * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Tolerance to positions is increased. Specific Direct Interventions * Nueromuscular relaxation, inhibition, and facilitation * Sensory training or retraining * Stretching Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Risk of secondary impairments is reduced. * Safety is improved during performance of self-care and home management tasks and activities. Specific Direct Interventions * ADL training (eg, bed mobility and transfer training, bathing) for caregiver * Assistive and adaptive device and equipment training for caregiver * Body mechanics training for caregiver * Orthotic, protective or supportive device or equipment training for caregiver Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Joint mobility and integrity are improved. * Risk of secondary impairments is reduced. Specific Direct Interventions * Passive range of motion Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Joint integrity and mobility are improved. * Risk of secondary impairments is reduced. * Safety is improved Specific Direct Interventions * Adaptive devices or equipment (eg, hospital beds. seating systems) * Assistive devices or equipment (eg, wheelchairs) * Orthotic devices or equipment (eg, braces, splints) * Protective devices or equipment (eg, braces, helmets cushions, protective taping) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets,-neck collars, slings, supportive taping, elastic wraps, oxygen) Airway Clearance Techniques Anticipated Goals * Airway clearance is improved. * Risk of secondary complication is reduced. Specific Direct Interventions * Assistive devices for airway. clearance (eg, flutter valve) * Chest percussion, vibration, and shaking * Pulmonary postural drainage and positioning * Suctioning * Techniques to maximize ventilation (eg. maximum inspiratory hold, staircase breathing, manual hyperinflation) Reexamination The physical therapist relies on reexamination. the process of performing selected tests and measures after the initial examination, to evaluate progress and to modified or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention. Outcomes Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment),primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic intervention and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include: Functional Limitation/Disability * Activities of daily living (ADL) are performed safely, efficiently, and at a maximal level of independence by caregivers. * Appropriate placement according to level of function is determined. * Disability associated with coma, near coma, or vegetative state is reduced. * Health-related quality of life is improved. * Potential for return to role function is maintained. * Safety of patient/client and caregivers is increased. * Family significant other, and caregiver understanding of personal and environmental factors that promote optimal health status is demonstrated. * Family significant other, and caregiver understanding of strategies to prevent further functional limitation and disability is demonstrated. Patient/Client Satisfaction * Access, availability and services provided are acceptable to family, significant others, and caregivers. * Administrative management of practice is acceptable to family, significant others, and caregivers. * Clinical proficiency of physical therapist is acceptable to family significant others, and caregivers. * Coordination and conformity of care are acceptable to family, significant others, and caregivers. * Interpersonal skills of physical therapist are acceptable to family significant others, and caregivers. Secondary Prevention * Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include: * Need for additional physical therapist intervention is decreased. * Family significant other, and caregiver adherence to the intervention program is maximized. * Family, significant others, and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: medical status, caregiver status, having environment, pathology or impairment that may affect function, or resources. * Professional recommendations are integrated into home and community environments. * Utilization and cost of health care services are decreased. Criteria for Discharge Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. |
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