Preferred Practice Patterns: Musculoskeletal.

Preferred practice patterns describe the five elements of patient/client management that are provided by physical therapists: examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis (including plan of care), and intervention (with anticipated goals and expected outcomes). Each pattern also addresses reexamination, global outcomes, and criteria for termination of physical therapy services. Examples of ICD-9-CM codes are included.

Primary Prevention/Risk Reduction for Skeletal Demineralization

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patient/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified in this primary prevention/risk reduction pattern as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the need for a prevention/risk reduction program or for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Chronic cardiovascular/pulmonary dysfunction

* Deconditioning

* Hormonal changes

* Hysterectomy

* Medications (eg, anti-epileptic medications, steroids, thyroid hormone)

* Menopause

* Nutritional deficiency

* Paget disease

* Prolonged non-weight-bearing state

Impairments, Functional Limitations, or Disabilities

* Inability to ambulate

* Joint immobilization associated with inactivity

* Prolonged muscle weakness or paralysis

Note:

Prevention and risk reduction are inherent in all practice patterns. Patients/clients included in this pattern are in need of primary prevention/risk reduction only.

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those patients/clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

138 Late effects of acute poliomyelitis
262 Other severe, protein-calorie malnutrition
263 Other and unspecified protein-calorie malnutrition
268 Vitamin D deficiency
269 Other nutritional deficiencies
275 Disorders of mineral metabolism
337 Disorders of the autonomic nervous system
    337.2 Reflex sympathetic dystrophy
344 Other paralytic syndromes
    344.0 Quadriplegia and quadriparesis
    344.1 Paraplegia
    344.3 Monoplegia of lower limb
588 Disorders resulting from impaired renal function
627 Menopausal and postmenopausal disorders
714 Rheumatoid arthritis and other inflammatory
    polyarthropathies
719 Other and unspecified disorders of joint
    719.5 Stiffness of joint, not elsewhere
          classified
    719.7 Difficulty in walking
    719.8 Other specified disorders of joint
          Calcification of joint
    728 Disorders of muscle, ligament, and fascia
    728.2 Muscular wasting and disuse atrophy,
          not elsewhere classified
    728.3 Other specific muscle disorders
          Arthrogryposis
729 Other disorders of soft tissues
    729.9 Other and unspecified disorders of soft tissue
731 Osteitis deformans and osteopathies associated with other
    disorders classified elsewhere
    731.0 Osteitis deformans without mention of
           bone tumor
           Paget's disease of bone
732 Osteochondropathies
    732.0 Juvenile osteochondrosis of spine
733 Other disorders of bone and cartilage
    733.0 Osteoporosis
    733.1 Pathologic fracture
    733.9 Other and unspecified disorders of bone and
          cartilage
    733.90 Osteopenia
737 Curvature of spine
    737.3 Kyphoscoliosis and scoliosis
    737.4 Curvature of spine associated with other
          conditions(*)
756 Other congenital musculoskeletal anomalies
    756.5 Osteodystrophies
    756.51 Osteogenesis imperfecta

524 Dentofacial anomalies, including malocclusion
    524.6 Temporomandibular joint disorders
568 Other disorders of peritoneum
    568.0 Peritoneal adhesions (postoperative) (postinfection)
718 Other derangement of joint
    718.8 Other joint derangement, not elsewhere classified
719 Other and unspecified disorders of joint
    719.5 Stiffness of joint, not elsewhere classified
    719.7 Difficulty in walking
722 Intervertebral disk disorders
    722.4 Degeneration of cervical intervertebral disk
    722.5 Degeneration of thoracic or lumbar
          intervertebral disk
    722.6 Degeneration of intervertebral disk,
          site unspecified
723 Other disorders of cervical region
    723.1 Cervicalgia
    723.5 Torticollis, unspecified
724 Other and unspecified disorders of back
    724.1 Pain in thoracic spine
    724.2 Lumbago
           Low back pain
           Low back syndrome
           Lumbalgia
    724.6 Disorders of sacrum
    724.9 Other unspecified back disorders
           Ankylosis of spine, not otherwise specified
           Compression of spinal nerve root, not else
           where classified
           Spinal disorders, not otherwise specified
725 Polymyalgia rheumatica
728 Disorders of muscle, ligament, and fascia
    728.2 Muscular wasting and disuse atrophy, not
          elsewhere classified
    728.8 Other disorders of muscle, ligament, and fascia
    728.85 Spasm of muscle
729 Other disorders of soft tissues
    729.1 Myalgia and myositis, unspecified
    729.9 Other and unspecified disorders of soft tissue
732 Osteochondropathies
    732.0 Juvenile osteochondrosis of spine
733 Other disorders of bone and cartilage
    733.0 Osteoporosis
736 Other acquired deformities of limbs
    736.3 Acquired deformities of hip
    736.4 Genu valgum or varum
    736.7 Other acquired deformities of ankle and foot
    736.8 Acquired deformities of other parts of limbs
    736.81 Unequal leg length (acquired)
737 Curvature of spine
    737.1 Kyphosis (acquired)
    737.2 Lordosis (acquired)
    737.3 Kyphoscoliosis and scoliosis
738 Other acquired deformity
    738.4 Acquired spondylolisthesis
    738.6 Acquired deformity of pelvis
756 Other congenital musculoskeletal anomalies
    756.1 Anomalies of spine
781 Symptoms involving nervous and musculoskeletal systems
    781.2 Abnormality of gait
    781.9 Other symptoms involving nervous and
          musculoskeletal systems
    781.92 Abnormal posture

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Anthropometric Characteristics

* Body dimensions (eg, body mass index, girth measurement, length measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daily living [IADL] scales, interviews, observations)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Ergonomics and Body Mechanics

Ergonomics

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations; photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

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

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Deep sensations (eg, kinesthesiometry, observations, photty graphic assessments, vibration tests)

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

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a duster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 3 to 6 months, patient/client will demonstrate the ability to maintain an optimal posture and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

6 to 20

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

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, anXd record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education, and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and

- motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary

- exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL]) and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease/disorder/ condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

* Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments

- task simulation and adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- seating systems

* Assistive devices

- canes

- crutches

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- corsets

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Biofeedback

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Osteogenic effects are enhanced.

- Pain is decreased.

* Impact on impairments

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

- Risk reduction/prevention

- Complications of immobility are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Sound agents

- phonophoresis

- ultrasound

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Traction devices

- intermittent

- positional

- sustained

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint tissue swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Fitness is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Interpersonal skills of physical therapist is acceptable to patient/client, family, and significant others.

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Muscle Performance

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified in this pattern for impaired muscle performance as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Acquired immune deficiency syndrome

* Chronic musculoskeletal dysfunction

* Chronic neuromuscular dysfunction

* Diabetes

* Down syndrome

* Pelvic floor dysfunction

* Renal disease

* Vascular insufficiency

Impairments, Functional Limitations, or Disabilities

* Decreased functional work capacity

* Decreased nerve conduction

* Diastasis recti

* Inability to climb stairs

* Inability to perform repetitive work tasks

* Loss of muscle strength, power, endurance

* Stress urinary incontinence

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as myositis with acute exacerbation--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S167.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Fracture

* Impairments associated with amputation

* Impairments associated with primary capsular restriction

* Impairments associated with primary joint arthroplasty

* Impairments associated with primary localized inflammation

* Muscular pain due to cesarean delivery

* Recent bony surgery

Findings That May Require Classification in Additional Patterns

* Post-polio syndrome with bursitis

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes-patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

042 Human immunodeficiency virus [HIV] disease
250 Diabetes mellitus
359 Muscular dystrophies and other myopathies
    359.9 Myopathy, unspecified
443 Other peripheral vascular disease
564 Functional digestive disorders, not elsewhere classified
    564.0 Constipation
569 Other disorders of intestine
    569.4 Other specified disorders of rectum and anus
    569.42 Anal or rectal pain
581 Nephrotic syndrome
582 Chronic glomerulonephritis
583 Nephritis and nephropathy, not specified as acute or chronic
588 Disorders resulting from impaired renal function
618 Genital prolapse
    618.0 Prolapse of vaginal wails without mention of
    uterine prolapse
     Cystocele
     Rectocele
    618.1 Uterine prolapse without mention of vaginal wall
          prolapse
    618.6 Vaginal enterocele, congenital or acquired
    618.8 Other specified genital prolapse
          Incompetence or weakening of pelvic fundus
          Relaxation of vaginal outlet or pelvis
623 Noninflammatory disorders of vagina
    623.4 Old vaginal laceration
624 Noninflammatory disorders of vulva and perineum
    624.4 Old laceration or scarring of vulva
625 Pain and other symptoms associated with female genital
    organs
    625.0 Dyspareunia
    625.1 Vaginismus
    625.6 Stress incontinence, female
714 Rheumatoid arthritis and other inflammatory
    polyarthropathies
    714.0 Rheumatoid arthritis
715 Osteoarthrosis and allied disorders
719 Other and unspecified disorders of joint
    719.7 Difficulty in walking
728 Disorders of muscle, ligament, and fascia
    728.2 Muscular wasting and disuse atrophy,
    not elsewhere classified
    728.8 Other disorders of muscle, ligament, and fascia
    728.85 Spasm of muscle
    728.9 Unspecified disorder of muscle, ligament,
    and fascia
729 Other disorders of soft tissues
    729.1 Myalgia and myositis, unspecified
733 Other disorders of bone and cartilage
    733.0 Osteoporosis
    733.1 Pathologic fracture
739 Nonallopathic lesions, not elsewhere classified
758 Chromosomal anomalies
    758.0 Down's syndrome
780 General symptoms
    780.7 Malaise and fatigue
781 Symptoms involving nervous and musculoskeletal systems
    781.2 Abnormality of gait
    781.3 Lack of coordination
           Ataxia, not otherwise specified
           Muscular incoordination
    781.4 Transient paralysis of limb
    781.9 Other symptoms involving nervous and
          musculoskeletal systems
    781.92 Abnormal posture
799 Other ill-defined and unknown causes of morbidity and
    mortality
    799.3 Debility, unspecified

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Cranial and Peripheral Nerve Integrity

* Electrophysiological integrity (eg, electroneuromyography)

* Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations)

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Electrophysiological integrity (eg, electroneuromyography)

* Hand function (eg, fine and gross control tests, finger dexterity tests, manipulative ability tests, observations)

* Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, gross motor function profiles, movement assessment batteries, observations, physical performance tests, videographic assessments)

Muscle Performance (Including Strength, Power and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

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

* Ability to assume or resume work (job/school/play), community and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Electrophysiological integrity (eg, electroneuromyography)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

* Electrophysiological integrity (eg, electroneuromyography)

Ventilation and Respiration (Gas Exchange)

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a duster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 2 to 6 months, patient/client will demonstrate optimal muscle performance and the highest level of functioning in home, work (job/ school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

6 to 30

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

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education, and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments:

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint integrity and mobility are increased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, horde management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- 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.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self<are and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities are increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegmtion (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

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

* Impact on impairments

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Relaxation is increased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- environmental controls

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Prosthetic devices (lowerextremity and upper-extremity)

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily' living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Biofeedback

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology

- Joint tissue swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- pools

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Compression therapies

- taping

* Gravity-assisted compression devices

- standing frame

- tilt table

* Traction devices

- intermittent

- positional

- sustained

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Neural compression is decreased.

- Osteogenic effects are enhanced.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments:

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IDL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairments is reduced.

Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern-for impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Joint subluxation or dislocation

* Ligamentous sprain

* Musculotendinous strain

* Pregnancy

* Prolonged joint immobilization

* Rheumatoid arthritis

* Scleroderma

* Systemic lupus erythematosus

* Temporomandibular joint syndrome

Impairments, Functional Limitations, or Disabilities

* Decreased range of motion

* Inability to squat due to joint instability

* Muscle guarding or weakness

* Pain

* Postpartum sacroiliac dysfunction

* Swelling or effusion

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as impairments associated with joint hemarthrosis and neuromuscular dysfunction--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis; page S185.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Fracture

* Immobility as a primary result of prolonged bed rest

* Lack of voluntary movement

* Radiculopathy

Findings That May Require Classification in Additional Patterns

* Abrasion or wound

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities-not on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICL-9-CM 2001), Volumes 1 and 3 (Chicago, III: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

337 Disorders of the autonomic nervous system
    337.2 Reflex sympathetic dystrophy
524 Dentofacial anomalies, including malocclusion
    524.6 Temporomandibular joint disorders
625 Pain and other symptoms associated with female genital
    organs
    625.5 Pelvic congestion syndrome
665 Other obstetrical trauma
    665.6 Damage to pelvic joints and ligaments
709 Other disorders of skin and subcutaneous tissue
    709.2 Scar conditions and fibrosis of skin
710 Diffuse diseases of connective tissue
    710.0 Systemic lupus erythematosus
    710.3 Dermatomyositis
    710.4 Polymyositis
714 Rheumatoid arthritis and other inflammatory
    polyarthropathies
    714.0 Rheumatoid arthritis
715 Osteoarthrosis and allied disorders
716 Other and unspecified arthropathies
    716.5 Unspecified polyarthropathy or polyarthritis
    716.9 Arthropathy, unspecified
          Inflammation of joint, not otherwise specified
718 Other derangement of joint
719 Other and unspecified disorders of joint
    719.4 Pain in joint
    719.8 Other specified disorders of joint
          Calcification of joint
724 Other and unspecified disorders of back
    724.6 Disorders of sacrum
    724.9 Other unspecified back disorders
          Ankylosis of spine, not otherwise specified
          Compression of spinal nerve root, not
          elsewhere classified
          Spinal disorder, not otherwise specified
726 Peripheral enthesopathies and allied syndromes
    726.0 Adhesive capsulitis of shoulder
    726.1 Rotator cuff syndrome of shoulder and allied
    disorders
    726.2 Other affections of shoulder region, not elsewhere
    classified
    726.9 Unspecified enthesopathy
727 Other disorders of synovium, tendon, and bursa
    727.0 Synovitis and tenosynovitis
    727.6 Rupture of tendon, nontraumatic
    727.8 Other disorders of synovium, tendon, and bursa
728 Disorders of muscle, ligament, and fascia
    728.4 Laxity of ligament
    728.6 Contracture of palmar fascia
          Dupuytren's contracture
    728.7 Other fibromatoses
    728.8 Other disorders of muscle, ligament, and fascia
729 Other disorders of soft tissues
    729.1 Myalgia and myositis, unspecified
    729.8 Other musculoskeletal symptoms referable to
          limbs
    729.9 Other and unspecified disorders of soft tissue
730 Osteomyelitis, periostitis, and other infections involving
    bone
733 Other disorders of bone and cartilage
830 Dislocation of jaw
831 Dislocation of shoulder
832 Dislocation of elbow
833 Dislocation of wrist
836 Dislocation of knee
837 Dislocation of ankle
838 Dislocation of foot
839 Other, multiple, and ill-defined dislocations
    839.0 Cervical vertebra, closed
    839.8 Multiple and ill-defined, closed
          Arm
          Back
          Hand
          Multiple locations, except fingers or toes alone
          Other ill-defined locations
          Unspecified location
840 Sprains and strains of shoulder and upper arm
    840.4 Rotator cuff (capsule)
841 Sprains and strains of elbow and forearm
842 Sprains and strains of wrist and hand
843 Sprains and strains of hip and thigh
844 Sprains and strains of knee and leg
845 Sprains and strains of ankle and foot
846 Sprains and strains of sacroiliac region
847 Sprains and strains of other and unspecified parts of back
848 Other and ill-defined sprains and strains
    848.1 Jaw
    848.3 Ribs
    848.4 Sternum
    848.5 Pelvis
          Symphysis pubis
905 Late effects of musculoskeletal and connective tissue injuries
    905.6 Late effect of dislocation
    905.7 Late effect of sprain and strain without mention
          of tendon injury

1. pertaining to the vermiform appendix.

2. pertaining to an appendage.

ap·pen·dic·u·lar (

skeletal system) (eg, palpation)

* Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry ar·throm·e·try (är-thr

-tr

)

)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation) Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Combined/cortical sensations (eg, stereognosis, tactile discrimination tests)

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 2 weeks to 6 months, patient/client will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning in home, work (job/ school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

3 to 36

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 3 to 36 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination,

- evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- sensory training or retraining

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments:

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- 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.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management [(Including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)]

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or

- equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition) Pain is decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is increased

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

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Biofeedback

* Electrotherapeutic delivery of medications

- iontophoresis

* Electrical stimulation

- electrical muscle stimulation (EMS)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Serf-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Athermal agents

- pulsed electromagnetic fields

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- whirlpool tanks

- contrast bath

- pools

* Light

- infrared

- laser

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Compression therapies

- taping

- vasopneumatic compression devices

* Mechanical motion devices

- continuous passive motion (CPM)

* Traction devices

- intermittent

- positional

- sustained

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments:

- Integumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living 0ADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulation disorders.

- Risk of secondary impairments is reduced.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the: boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests anti measures) may indicate the presence or risk of pathology/patho-physiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiolagy (Disease, Disorder, or Condition)

* Abnormal response to provocation

* Ankylosing spondylitis

* Bursitis

* Capsulitis

* Epicondylitis

* Fasciitis

* Gout

* Osteoarthritis

* Prenatal and postnatal soft tissue inflammation

* Synovitis

* Tendinitis

Impairments, Functional Limitations, or Disabilities

* Edema

* Inability to perform self-care

* Inflammation of periarticular connective tissue

* Muscle strain

* Muscle weakness

* Pain

* Worker's inability to perform functional activities because of localized joint pain

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as systemic disease processes--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S203.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Deep vein thrombosis

* Fracture

* Impairments associated with dislocation

* Impairments associated with hemarthrosis

* Surgery

Findings That May Require Classification in Additional Patterns

* Open wound

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICL-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

274 Gout
    274.0 Gouty arthropathy
350 Trigeminal nerve disorders
    350.1 Trigeminal neuralgia
353 Nerve root and plexus disorders
    353.0 Brachial plexus lesions
    353.4 Lumbosacral root lesions, not elsewhere classified
354 Mononeuritis of upper limb and mononeuritis multiplex
    354.0 Carpal tunnel syndrome
    354.2 Lesion of ulnar nerve
          Cubital tunnel syndrome
355 Mononeuritis of lower limb
    355.5 Tarsal tunnel syndrome
    355.6 Lesion of plantar nerve
          Morton's metarsalgia, neuralgia, or neuroma
524 Dentofacial anomalies, including malocclusion
    524.6 Temporomandibular joint disorders
682 Other cellulitis and abscess
711 Arthropathy associated with infections
715 Osteoarthrosis and allied disorders
716 Other and unspecified arthropathies
    716.6 Unspecified monoarthritis
    716.9 Arthropathy, unspecified
          Inflammation of joint, not otherwise specified
717 Internal derangement of knee
    717.7 Chondromalacia of patella
718 Other derangement of joint
    718.8 Other joint derangement, not elsewhere classified
          Instability of joint
719 Other and unspecified disorders of joint
    719.0 Effusion of joint
    719.2 Villonodular synovitis
720 Ankylosing spondylitis and other inflammatory
    spondylopathies
    720.2 Sacroiliitis, not elsewhere classified
722 Intervertebral disk disorders
724 Other and unspecified disorders of back
    724.0 Spinal stenosis, other than cervical
    724.2 Lumbago
          Low back pain
          Low back syndrome
          Lumbalgia
726 Peripheral enthesopathies and allied syndromes
    726.0 Adhesive capsulitis of shoulder
    726.1 Rotator cuff syndrome of shoulder and allied
          disorders
    726.10 Disorders of bursae and tendons in
          shoulder region, unspecified
    726.2 Other affections of shoulder region, not
          elsewhere classified
    726.3 Enthesopathy of elbow region
    726.31 Medial epicondylitis
    726.32 Lateral epicondylitis
    726.5 Enthesopathy of hip region
          Bursitis of hip
    726.6 Enthesopathy of knee
    726.60 Enthesopathy of knee, unspecified
    726.9 Unspecified enthesopathy
    726.90 Enthesopathy of unspecified site
727 Other disorders of synovium, tendon, and bursa
    727.0 Synovitis and tenosynovitis
    727.04 Radial styloid tenosynovitis
    727.3 Other bursitis
    727.6 Rupture of tendon, nontraumatic
    727.61 Complete rupture of rotator cuff
    727.9 Unspecified disorder of synovium, tendon, and
          bursa
728 Disorders of muscle, ligament, and fascia
    728.7 Other fibromatoses
    728.7 Plantar fascial fibromatosis
          Plantar fasciitis
    728.9 Unspecified disorder of muscle, ligament,
          and fascia
729 Other disorders of soft tissues
    729.1 Myalgia and myositis, unspecified
    729.2 Neuralgia, neuritis, and radiculitis, unspecified
    729.4 Fasciitis, unspecified
    729.8 Other musculoskeletal symptoms referable to limbs
    729.81 Swelling of limb
732 Osteochondropathies
    732.9 Unspecified osteochondropathy
    840 Sprains and strains of shoulder and upper arm
    840.4 Rotator cuff (capsule)
923 Contusion of upper limb
924 Contusion of lower limb and of other and unspecified sites
927 Crushing injury of upper limb
928 Crushing injury of lower limb

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include: General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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 OADL)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

Anthropametric Characteristics

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, ADL scales, IADL scales, pain scales, play scales)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Cranial and Peripheral Nerve Integrity

* Electrophysiological integrity (eg, electroneuromyography)

* Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations)

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Response to neural provocation (eg, tension tests, vertebral artery compression tests)

* Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

* Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Joint Integrity and Mobility

* Joint play movements, including end feel (all joints of the axial and appendicular skeletal system) (eg, palpation)

* Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

* Electrophysiological integrity (eg, sensory nerve conduction tests)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 2 to 4 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

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 expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions - advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient

- advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning - aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

-Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management: of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant of hers.

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client: satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client. Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work, Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (including Mobilization/Manipulation)

Interventions

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Cools and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, imflammation, or restriction is reduced.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Electrotherapeutic delivery of medications

- iontophoresis

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- high voltage pulsed current (HVPC)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Interpersonal skills of physical therapist art- acceptable to patient/client, family, and significant others.

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Athermal agents

- pulsed electromagnetic fields

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- whirlpool tanks

- contrast bath

- pools

* Light agents

- infrared

- laser

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Compression therapies

- taping

* Mechanical motion devices

- continuous passive motion (CPM)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Degenerative disk disease

* Disk herniation

* History of spinal surgery

* Spinal stenosis

* Spondylolisthesis

Impairments, Functional Limitations, or Disabilities

* Abnormal neural tension

* Altered sensation

* Decreased deep tendon reflex

* Inability to perform lifting tasks

* Inability to perform self-care independently

* Inability to sit for prolonged periods

* Muscle weakness

* Pain with forward bending

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as neoplasm--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis; page S221.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Fracture

* Impairments associated with systemic conditions (eg, ankylosing spondylitis, Scheurermann disease, juvenile rheumatoid arthritis)

* Impairments associated with traumatic spinal cord injury

Findings That May Require Classification in Additional Patterns

* Neuromuscular disease

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

353 Nerve root and plexus disorders
    353.0 Brachial plexus lesions
    353.1 Lumbosacral plexus lesions
    353.2 Cervical root lesions, not elsewhere classified
    353.4 Lumbosacral root lesions, not elsewhere classified
715 Osteoarthrosis and allied disorders
716 Other and unspecified arthropathies
    716.9 Arthropathy, unspecified
          Inflammation of joint, not otherwise specified
718 Other derangement of joint
    718.3 Recurrent dislocation of joint
    718.9 Unspecified derangement of joint
719 Other and unspecified disorders of joint
    719.8 Other specified disorders of joint
          Calcification of joint
720 Ankylosing spondylitis and other inflammatory
    spondylopathies
721 Spondylosis and allied disorders
    721.1 Cervical spondylosis with myelopathy
    721.4 Thoracic or lumbar spondylosis with myelopathy
722 Intervertebral disk disorders
    722.4 Degeneration of cervical intervertebral disk
    722.5 Degeneration of thoracic or lumbar intervertebral
          disk
    722.6 Degeneration of intervertebral disk, site unspecified
    722.7 Intervertebral disk disorder with myelopathy
    722.8 Postlaminectomy syndrome
723 Other disorders of cervical region
    723.0 Spinal stenosis in cervical region
    723.1 Cervicalgia
724 Other and unspecified disorders of back
    724.0 Spinal stenosis, other than cervical
    724.2 Lumbago
          Low back pain
          Low back syndrome
          Lumbalgia
    724.3 Sciatica
    724.9 Other unspecified back disorders
727 Other disorders of synovium, tendon, and bursa
    727.0 Synovitis and tenosynovitis
728 Disorders of muscle, ligament, and fascia
    728.2 Muscular wasting and disuse atrophy,
          not elsewhere classified
    728.8 Other disorders of muscle, ligament, and fascia
    728.85 Spasm of muscle
    728.9 Unspecified disorder of muscle, ligament, and
          fascia
733 Other disorders of bone and cartilage
    733.0 Osteoporosis
738 Other acquired deformity
    738.4 Acquired spondylolisthesis
    738.5 Other acquired deformity of back or spine
756 Other congenital musculoskeletal anomalies
    756.1 Anomalies of spine
    756.11 Spondylolysis, lumbosacral region
    756.12 Spondylolisthesis
846 Sprains and strains of sacroiliac region
    846.0 Lumbosacral (join) (ligament)
847 Sprains and strains of other and unspecified parts of back
922 Contusion of trunk
    922.3 Back

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work {Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers) * Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Cranial and Peripheral Nerve Integrity

* Electrophysiological integrity (eg, electroneuromyography)

* Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations)

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Response to neural provocation (eg, tension tests, vertebral artery compression tests)

* Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ergonomics

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists., job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

* Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Joint Integrity and Mobility

* Joint play movements, including end feel (all joints of the axial and appendicular skeletal system) (eg, palpation)

* Specific body parts (eg, compression and distraction tests)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Hand function (eg, frae and gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Electrophysiological integrity (eg, electroneuromyography)

* Resistance to passive stretch (eg, tone scales)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Combined/cortical sensations (eg, stereognosis, tactile discrimination tests)

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

* Electrophysiological integrity (eg, electroneuromyography)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 1 to 6 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, range of motion, and reflex integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

8 to 24

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 8 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination t3ccurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or

- disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- sensory training or retraining

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased. Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased. -

* Impact on disabilities Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training

- during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (including Mobilization/Manipulation)

Interventions

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Pain is decreased.

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

* Impact on impairments Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living 0ADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Electrotherapeutic delivery of medications

- iontophoresis

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- high voltage pulsed current (HVPC)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

- Soft tissue or wound healing is enhanced.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Athermal agents

- pulsed electromagnetic fields

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- whirlpool tanks

- contrast bath

- pools

* Light agents

- infrared

- laser

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Compression therapies

- taping

* Traction devices

- intermittent

- positional

- sustained

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

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

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired joint mobility, muscle performance, and range of motion associated with fracture--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Bone demineralization

* Fracture

* Hormonal changes

* Medications (eg, anti-epileptic medications, steroids, thyroid hormone)

* Menopause

* Nutritional deficiency

* Prolonged non-weight-bearing state

* Trauma

Impairments, Functional Limitations, or Disabilities

* Inability to access community

* Limited range of motion

* Muscle weakness from immobilization

* Pain with functional movements and activities

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as neoplasm--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S239.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Flail chest

Findings That May Require Classification in Additional Patterns

* Osteogenesis imperfecta

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes-patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

170 Malignant neoplasm of bone and articular cartilage
213 Benign neoplasm of bone and articular cartilage
262 Other severe, protein-calorie malnutrition
263 Other and unspecified protein-calorie malnutrition
268 Vitamin D deficiency
269 Other nutritional deficiencies
275 Disorders of mineral metabolism
627 Menopausal and postmenopausal disorders
715 Osteoarthrosis and allied disorders
719 Other and unspecified disorders of joint
    719.5 Stiffness of joint, not elsewhere classified
    719.8 Other specified disorders of joint
          Calcification of joint
728 Disorders of muscle, ligament, and fascia
    728.1 Muscular calcification and ossification
729 Other disorders of soft tissues
    729.9 Other and unspecified disorders of soft tissue
730 Osteomyelitis, periostitis, and other infections involving
    bone
732 Osteochondropathies
    732.4 Juvenile osteochondrosis of lower extremity,
          excluding foot
733 Other disorders of bone and cartilage
    733.0 Osteoporosis
    733.1 Pathologic fracture
    733.2 Cyst of bone
    733.4 Aseptic necrosis of bone
    733.8 Malunion and nonunion of fracture
    733.9 Other and unspecified disorders of bone and
          cartlage
736 Other acquired deformities of limbs
    736.8 Acquired deformities of other parts of limbs
802 Fracture of face bones
805 Fracture of vertebral column without mention of spinal
    cord injury
    805.6 Sacrum and coccyx, closed
808 Fracture of pelvis
810 Fracture of clavicle
811 Fracture of scapula
812 Fracture of humerus
813 Fracture of radius and ulna
    813.4 Lower end, closed
    813.5 Lower end, open
814 Fracture of carpal bone(s)
815 Fracture of metacarpal bone(s)
816 Fracture of one or more phalanges of hand
819 Multiple fractures involving both upper limbs, and upper
    limbs with ribs(s) and sternum
820 Fracture of neck of femur
821 Fracture of other and unspecified parts of femur
822 Fracture of patella
823 Fracture of tibia and fibula
824 Fracture of ankle
825 Fracture of one or more tarsal and metatarsal bones
826 Fracture of one or more phalanges of foot
827 Other, multiple, and ill-defined fractures of lower limb
828 Multiple fractures involving both lower limbs, lower with
    upper limb, and lower limb(s) with rib(s) and sternum
829 Fracture of unspecified bones

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acme, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits {Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint{s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daily living [IADL] scales, interviews, observations)

* Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Cranial and Peripheral Nerve Integrity

* Electrophysiological integrity (eg, electroneuromyography)

* Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations)

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

* Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Joint Integrity and Mobility

* Joint play movements, including end feel (all joints of the axial and appendicular skeletal system) (eg, palpation)

* Specific body parts (eg, compression and distraction tests, drawer tests, glide tests, shear tests, valgus/varus stress tests)

Motor Function (Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

* Electrophysiological integrity (eg, electroneuromyography)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 3 to 6 months postfracture, patient/client will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

6 to 18

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. /t is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or

- retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance exercises for head, neck, limb, pelvic floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daffy living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is increased.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles are improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy (including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- helmets

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community; and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, horde management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Electrical stimulation

- electrical muscle stimulation (EMS)

- high voltage pulsed current (HVPC)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

- Soft tissue or wound healing is enhanced.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of dally living (Al)L) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Athermal agents

- pulsed electromagnetic fields

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- whirlpool tanks

- contrast bath

- pools

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Gravity-assisted compression devices

- tilt table

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living OADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is in/proved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired joint mobility, motor function, muscle performance, and range of motion associated with joint arthroplasty--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Ankylosing spondylitis

* Arthroplasties

* Avascular a·vascu·lari·ty (-l

necrosis due to steroid use

* Juvenile rheumatoid arthritis

* Neoplasms of the bone

* Osteoarthritis

* Rheumatoid arthritis

* Trauma

Impairments, Functional Limitations, or Disabilities

* Decreased range of motion

* Inability to access transportation

* Inability to dress

* Muscle guarding

* Muscle weakness

* Pain

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as multiple joint replacement, recurrent postoperative dislocation, and secondary postoperative infection--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S257.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Impairments associated with multisite trauma

Findings That May Require Classification in Additional Patterns

* Rheumatoid arthritis with deconditioning

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-945M 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

170 Malignant neoplasm of bone and articular cartilage
171 Malignant neoplasm of connective and other soft tissue
213 Benign neoplasm of bone and articular cartilage
215 Other benign neoplasm of connective and other soft tissue
524 Dentofacial anomalies, including malocclusion
    524.6 Temporomandibular joint disorders
714 Rheumatoid arthritis and other inflammatory
    polyarthropathies
    714.0 Rheumatoid arthritis
    714.3 Juvenile chronic polyarthritis
    714.30 Polyarticular juvenile rheumatoid
          arthritis, chronic or unspecified
715 Osteoarthrosis and allied disorders
716 Other and unspecified arthropathies
    716.8 Other specified arthropathy
717 Internal derangement of knee
    717.9 Unspecified internal derangement of knee
718 Other derangement of joint
    718.9 Unspecified derangement of joint
719 Other and unspecified disorders of joint
    719.5 Stiffness of joint, not elsewhere classified
    719.7 Difficulty in walking
    719.8 Other specified disorders of joint
          Calcification of joint
729 Other disorders of soft tissues
    729.8 Other musculoskeletal symptoms referable to
          limbs
730 Osteomyelitis, periostitis, and other infections involving
    bone
731 Osteitis deformans and osteopathies associated with other
    disorders classified elsewhere
    731.0 Osteitis deformans without mention of bone
    tumor
    Paget's disease of bone
733 Other disorders of bone and cartilage
    733.1 Pathologic fracture
    733.8 Malunion and nonunion of fracture
808 Fracture of pelvis
    808.0 Acetabulum, closed
812 Fracture of humerus
    812.0 Upper end, closed
815 Fracture of metacarpal bone(s)
820 Fracture of neck of femur
    820.8 Unspecified part of neck of femur, closed
    820.9 Unspecified part of neck of femur, open
824 Fracture of ankle
835 Dislocation of hip
836 Dislocation of knee
    836.5 Other dislocation of knee, closed
837 Dislocation of ankle
958 Certain early complications of trauma
    958.3 Posttraumatic wound infection, not elsewhere
    classified

Supplemental Classification of Factors Influencing Health Status
and Contact With Health Services

V43 Organ or tissue replaced by other means
    V43.6 Joint
          V43.61 Shoulder
          V43.64 Hip
          V43.65 Knee
          V43.66 Ankle

          V43.70 Limb

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include: General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

Anthropometric Characteristics

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Cranial and Peripheral Nerve Integrity

* Electrophysiological integrity (eg, electroneuromyography)

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ergonomics:

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Wound

* Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps)

* Signs of infection (eg, cultures, observations, palpation)

* Wound scar tissue characteristics, including banding, pliability, sensation, and texture (eg, observations, scar-rating scales)

Motor Function {Motor Control and Motor Learning)

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

* Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion {ROM) {Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Combined/cortical sensations (eg, stereognosis, tactile discrimination tests)

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 6 months, patient/ client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

12 to 60

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 12 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including: equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

- education plans

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across Settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment 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.

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

- postural control training

- postural stabilization activities

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary

- exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Airway clearance is improved.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily, living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- back schools

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is increased.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per trait of work is decreased.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, Lymphedema or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

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

* Impact on impairments

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- serial casts

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

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

- Pain is decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

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

Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Biofeedback

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- high voltage pulsed current (HVPC)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects are enhanced.

- Pain is decreased.

- Soft tissue or wound healing is enhanced.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

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

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance' is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- whirlpool tanks

- contrast bath

- pools

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths

Mechanical modalities may include:

* Mechanical motion devices

- continuous passive motion (CPM)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

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

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Ankylosis

* Bone graft and lengthening procedures

* Cesarean section

* Connective tissue repair or reconstruction

* Fascial releases

* Fusions

* Internal debridement

* Internal knee derangement

* Intervertebral disk disorder

* Laminectomies

* Muscle, tendon, ligament, capsule repair or reconstruction

* Multisite fractures

* Open reduction internal fixation

* Osteotomies

* Tibial tuberosity procedures

Impairments, Functional Limitations, or Disabilities

* Decreased range of motion

* Decreased strength and endurance due to inactivity

* Impaired joint mobility

* Limited independence in activities of daily living

* Pain

* Swelling

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as failed surgeries--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S276.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Amputation

* Closed head trauma

* Non-union fractures

* Peripheral nerve lesions

* Total joint arthroplasties

Findings That May Require Classification in Additional Patterns

* Neurological sequelae

* Non-healing wound

* Vascular sequelae

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes liked with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

715 Osteoarthrosis and allied disorders
717 Internal derangement of knee
    717.8 Other internal derangement of knee
718 Other derangement of joint
    718.0 Articular cartilage disorder
    718.2 Pathological dislocation
    718.3 Recurrent dislocation of joint
    718.4 Contracture of joint
    718.5 Ankylosis of joint
    718.9 Unspecified derangement of joint
719 Other and unspecified disorders of joint
721 Spondylosis and allied disorders
722 Intervertebral disk disorders
    722.7 Intervertebral disk disorder with myelopathy
723 Other disorders of cervical region
724 Other and unspecified disorders of back
    724.0 Spinal stenosis, other than cervical
    724.3 Sciatica
726 Peripheral enthesopathies and allied syndromes
    726.0 Adhesive capsulitis of shoulder
    726.1 Rotator cuff syndrome of shoulder and allied
          disorders
    726.2 Other affections of shoulder region, not elsewhere
          classified
          Periarthritis of shoulder
          Scapulohumeral fibrositis
    726.9 Unspecified enthesopathy
727 Other disorders of synovium, tendon, and bursa
    727.0 Synovitis and tenosynovitis
    727.1 Bunion
    727.4 Ganglion and cyst of synovium, tendon, and bursa
    727.6 Rupture of tendon, nontraumatic
728 Disorders of muscle, ligament, and fascia
    728.6 Contracture of palmar fascia
          Dupuytren's contracture
731 Osteitis deformans and osteopathies associated with other
    disorders classified elsewhere
    731.0 Osteitis deformans without mention of bone tumor
          Paget's disease of bone

732 Osteochondropathies
    732.4 Juvenile osteochondrosis of lower extremity,
          excluding foot
          Tibial tubercle (of Osgood-Schlatter)
    732.9 Unspecified osteochondropathy
733 Other disorders of bone and cartilage
    733.1 Pathologic fracture
          Spontaneous fracture
    733.8 Malunion and nonunion of fracture
    733.82 Nonunion of fracture
736 Other acquired deformities of limbs
    736.8 Acquired deformities of other parts of limbs
737 Curvature of spine
738 Other acquired deformity
    738.4 Acquired spondylolisthesis
756 Other congenital musculoskeletal anomalies
    756.1 Anomalies of spine
802 Fracture of face bones
805 Fracture of vertebral column without mention of spinal
    cord injury
808 Fracture of pelvis
810 Fracture of clavicle
811 Fracture of scapula
812 Fracture of humerus
813 Fracture of radius and ulna
814 Fracture of carpal bone(s)
815 Fracture of metacarpal bone(s)
816 Fracture of one or more phalanges of hand
820 Fracture of neck of femur
821 Fracture of other and unspecified parts of femur
822 Fracture of patella
823 Fracture of tibia and fibula
824 Fracture of ankle
825 Fracture of one or more tarsal and metatarsal bones
826 Fracture of one or more phalanges of foot
830 Dislocation of jaw
831 Dislocation of shoulder
832 Dislocation of elbow
833 Dislocation of wrist
834 Dislocation of finger
835 Dislocation of hip
836 Dislocation of knee
    836.0 Tear of medial cartilage or meniscus of knee,
    current
    836.1 Tear of lateral cartilage or meniscus of knee,
    current
    836.2 Other tear of cartilage or meniscus of knee,
    current
    836.5 Other dislocation of knee, closed
837 Dislocation of ankle
838 Dislocation of foot
839 Other, multiple, and ill-defined dislocations
    839.0 Cervical vertebra, closed
    839.3 Thoracic and lumbar vertebra, open
    839.8 Multiple and ill-defined, closed
          Arm
          Back
          Hand
          Multiple locations, except for fingers or toes
          alone
840 Sprains and strains of shoulder and upper arm
    840.4 Rotator cuff (capsule)
841 Sprains and strains of elbow and forearm
842 Sprains and strains of wrist and hand
843 Sprains and strains of hip and thigh
844 Sprains and strains of knee and leg
845 Sprains and strains of ankle and foot
846 Sprains and strains of sacroiliac region
847 Sprains and strains of other and unspecified parts of back
848 Other and ill-defined sprains and strains
959 Injury, other and unspecified
    959.2 Shoulder and upper arm
    959.9 Unspecified site