On the Second Edition of the Guide.

We begin the year with something different from the Journal's usual content--the second edition of the Guide to Physical Therapist Practice. This document was developed by APTA to encourage a uniform approach to physical therapist practice and to explain to the world the nature of that practice.

This document has been in development for almost a decade. (See box on page 8 for an outline of the process used to develop the Guide; further description is given in the Guide's Introduction.) As the document itself emphasizes, the Guide is not a set of clinical guidelines, nor is it a set of protocols or a listing of approved tests or interventions. The Guide forms a framework for describing and implementing practice.

The patient/client management model put forth by the Guide appears to be widely used and has provided physical therapists with a common conceptual approach to patient care, and in this way the Guide has proven that it could be an invaluable adjunct to our literature. The second edition contains expanded sections on such topics as diagnosis by physical therapists and the disablement model. As with the first edition, much of what appears in the second edition will be helpful to physical therapists in all areas of practice. And, as with the first edition, for both practical and philosophical reasons, preferred practice patterns are supplied for a limited number of conditions.

If the Guide is to continue playing a salutary role in our profession, physical therapists need to understand what this new edition is--and what it is not. As indicated in the Guide's Introduction, the Guide initially was developed in response to requests from legislative bodies. Given the nature of that impetus, a process was developed and used to generate the Guide. I believe that the process was credible and resulted in an important document that has helped to shape physical therapy as it now exists. The process was not a peer-review process such as that used by scholarly journals, and it did not result in the development of clinical guidelines that are in line with current expectations of evidence-based practice. That was not the Guide's purpose.

Clinical guidelines are the product of intense scrutiny of the literature, and they are developed using methods that are applied by experts with publication records who have knowledge in guideline development. The distinctions between clinical guidelines and the Guide were understood by the Association's leadership and the Guide's developers and are acknowledged in the Guide. The process used to generate both the first and second editions of the Guide resulted in the description of what are called "preferred practice patterns for selected patient/client diagnostic groups." Whether these patterns will give rise over time to clinical guidelines that have a more scholarly foundation or research support is up to the profession and our clinical researchers. But we need to keep in mind that what we now have in the Guide are the opinions of our colleagues on how to manage our patients and clients--and that is very different from evidence for practice.

Both the document and the discussion that led to its creation have benefited the profession, and all those who worked on the Guide editions deserve our appreciation. The Guide, however, is a work in progress, and I hope that the next edition will appear soon--one that will be created not because of political necessity but because of our need to codify a growing body of scientific knowledge. Given APTA's Clinical Research Agenda for Physical Therapy (Phys Ther. 2000;80:499-513), it is clear that we need more data, and we should share pride in a profession that is willing to recognize its limitations and its responsibilities.

The Guide can be viewed as an attempt to develop the best possible document from a body of clinical literature that still contains too many unanswered questions. Too often in the development of the Guide, personal opinions were necessary because of the paucity of data. We should look forward to a third edition that relies less on personal views and more on the evidence that becomes available in the public arena, evidence that deals directly with clinical practice and that has been published in peer-reviewed literature. Again, we see the importance of the Clinical Research Agenda and the necessity of supporting the Foundation for Physical Therapy.

There were six purposes for creating the Guide (page S16). Every reader should consider to what extent those purposes were met and to what extent they could be met. For instance, I believe that the process used to develop the Guide could never achieve the stated goal of "standardizing terminology used in and related to physical therapist practice." I believe that the Guide instead contains an official or semi-official version of how terms should be used. As a peer-reviewed journal, therefore, Physical Therapy will continue to depend on the preponderance of scientific literature for the evolution of terms and definitions.

The Guide was designed to "delineate" tests, interventions, and preferred practice patterns. If we use the traditional definition of delineate, the Guide should accurately convey what the tests, interventions, and preferred practice patterns are. In other words, the Guide should provide lists, which it does--and I believe that is good, because the structure of the Guide does not allow for critical evaluation of tests and interventions.

Nonetheless, value judgments are expressed when it comes to a listing of preferred practice patterns. By listing what is preferred, the developers have made an assertion that the Guide describes what is thought to be best. We should be reminded, however, that preferring something is not the same as having evidence that something is better than something else. Here again we have the basic difference between clinical guidelines and the preferred practice patterns. Guidelines should be developed based on evidence that speaks to the benefits of a form of intervention, whereas the preferred practice patterns are patterns that are considered by the Guide developers to be the most commonly used or the most appropriate.

Because of the extraordinary effort of many people, the Journal this month is publishing something that can greatly enhance practice--when it is properly used. If the Guide is viewed as containing immutable truths, however, we will be using it incorrectly. My hope is that the next edition of the Guide will be based primarily on evidence--and that physical therapists will use that evidence.

Guide to Physical Therapist Practice, Second Edition

In the August 1995 issue of Physical Therapy, the American Physical Therapy Association (APFA) published A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management. Development continued with the addition of Volume II to delineate preferred practice patterns. Volumes I and II were combined to become Parts One and Two of a single document--Guide to Physical Therapist Practice--which was published in the Journal in November 1997. Revisions were made to the Guide based on input from both the general membership and the leadership of APTA and based on changes in APTA House of Delegates policies. These revisions were published in the June 1999 and November 1999 issues of Physical Therapy. Throughout 1999 and 2000, a Board-appointed Project Advisory Group revised Parts One and Two of the Guide to further refine and clarify terminology and definitions used in the Guide. The result--the second edition of the Guide (Parts One and Two)--is being published in this issue of the Journal.

In 1998, APTA began development of Part Three of the Guide to catalog the tests and measures that are used by physical therapists in the examination of patients/clients and in the documentation of patient/client management outcomes. (This part of the Guide, intended as a reference work, will be available on CD-ROM only.) One task force was charged by APTA's Board to examine the available literature pertaining to tests and measures that are used in the assessment of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. Another task force was charged to examine the available literature on tests and measures of health status, health-related quality of life, and patient/client satisfaction. Field reviews were conducted, using APTA's Board, all APTA components (sections and state chapters), a sample of clinical specialists certified by the American Board of Physical Therapy Specialties (ABPTS), and APTA's general membership. Presentations of the work-in-progress were made at APTA Annual Conferences and APTA Combined Sections Meetings throughout 1999 and 2000.

The Part Three task forces also developed a template for documenting the history and systems review components of examination and for documenting intervention, based on the essential data elements of patient/client management described in the Guide. The template (Appendix 6 of the Guide) were reviewed by all APTA components (sections and state chapters), a sample of certified clinical specialists, and APTA's general membership.

Jules M Rothstein, PT, PhD, FAPTA Editor