Preferred Practice Patterns: Neuromuscular.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 Loss of Balance and Falling 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 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. The physical therapist integrates, synthesizes, and interprets the data to determine inclusion in this diagnostic category. 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) * Advanced age * Alteration in senses (auditory, visual, somatosensory) * Dementia * Depression * Dizziness * Fear of falling * History of falls * Medications * Musculoskeletal diseases * Neuromuscular diseases * Prolonged inactivity * Vestibular pathology Impairments, Functional Limitations, or Disabilities * Deconditioning * Difficulty negotiating in community environment * Difficulty negotiating terrains * Disequilibrium * Generalized weakness * Impaired gait pattern * Impaired position sense 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.
331 Other cerebral degenerations
331.0 Alzheimer's disease
332 Parkinson's disease
333 Other extrapyramidal disease and abnormal movement
disorders
334 Spinocerebellar disease
335 Anterior horn cell disease
336 Other diseases of spinal cord
340 Multiple sclerosis
342 Hemiplegia and hemiparesis
345 Epilepsy
359 Muscular dystrophies and other myopathies
386 Vertiginous syndromes and other disorders of
vestibular system
386.0 Meniere's disease
386.1 Other and unspecified peripheral vertigo
386.2 Vertigo of central origin
386.3 Labyrinthitis
780 General symptoms
780.0 Alteration of consciousness
780.2 Syncope and collapse
780.4 Dizziness and giddiness
780.7 Malaise and fatigue
781 Symptoms involving nervous and musculoskeletal systems
781.0 Abnormal involuntary movements
781.2 Abnormality of gait
781.3 Lack of coordination
797 Senility without mention of psychosis
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, drag 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 Test 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) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) 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, observations, reports) * Safety during use of assistive or adaptive devices and equipment (eg, fall scales, reports, interviews, observations) Cranial and Peripheral Nerve Integrity * Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, visual (eg, observations, provocation 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 * 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, 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) * Safety during gait, locomotion, and balance (eg, confidence scales, fall scales, functional assessment profiles, 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, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments) Muscle Performance (Including Strength, Power, and Endurance) * 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) Orthotic, Protective, and Supportive Devices * Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, observations, reports) * 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, fall scales, reports, interviews, observations) 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) Range of Motion (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, flexible rulers, goniometers, inclinometers, ligamentous tests, multisegment flexibility tests, palpation) Reflex Integrity * Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles) * Resistance to passive stretch (eg, tone scales) Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living) * Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) * Safety in self-care and home management activities and environments (eg, fall scales, interviews, observations, reports) 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 gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity, transportation assessments) * Safety in work (job/school/play), community, and leisure activities and environments (eg, fall scales, interviews, observations) 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 Patient/client will reduce the risk of falling through therapeutic exercise, balance training, and lifestyle modification. Expected Range of Number of Visits Per Episode of Care 2 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. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 2 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 Care * 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 with the patient/client, 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 for primary prevention/risk reduction may include: Interventions * Addressing required functions - individualized family service plans (IFSPs) or individualized education plans (IEPs) - informed consent - mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) * Collaboration and coordination with agencies, including: - equipment suppliers - home care agencies - payer groups - schools - transportation agencies * Communication, including: - education plans - documentation * Data collection, analysis and reporting - outcome data - peer review findings - record reviews * Documentation - elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) - outcomes of intervention * Referrals to other professionals or resources Anticipated Goals and Expected Outcomes * Accountability for services is increased. * Individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) are obtained or completed. * Available resources are maximally utilized. * Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies. * Communication occurs through education plans and documentation. * Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews. * 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 client management and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). * Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. * Referrals are made to other professionals or resources whenever necessary and appropriate. * Resources are utilized in a cost-effective way. Patient/Client-Related Instruction Patient/client-related instruction may include: Interventions * Instruction, education, and training of patients/clients and caregivers regarding: - enhancement of performance - health, wellness, and fitness programs - plan for intervention - risk factors for pathology/ pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities 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. * Health status is improved. * 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. * Safety of patient/client, family, significant others, and caregivers 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 - 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 - vestibular 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 - 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. - 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 improved. - 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. - 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 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. - 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 * 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 * Functional training programs - simulated environments and tasks - task adaptation Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Physiological response to increased oxygen demand is improved. * Impact on impairments - Postural control is improved. - 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 - Health status is improved. - 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. - 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 * 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 * Functional training programs - simulated environments and tasks - task adaptation - task training - travel training Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) Physiological response to increased oxygen demand is improved. * Impact on impairments - Postural control is improved. - 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 - Health status is improved. - 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. - 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 * Assistive devices - canes - crutches - long-handled reachers - walkers * Protective devices - braces - helmets * Orthotic devices - braces - shoe inserts 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. - 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. - 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 - 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. - 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 Neuromotor Development 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 neuromotor development 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) * Alteration in senses (auditory, visual) * Birth trauma * Cognitive delay * Developmental coordination disorder * Developmental delay * Dyspraxia * Fetal alcohol syndrome * Genetic syndromes * Prematurity Impairments, Functional Limitations, or Disabilities * Clumsiness during play * Delayed motor skills * Delayed oral motor development * Impaired arousal, attention, and cognition * Impaired locomotion * Impaired sensory integration 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 S326.) 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 * Spinal cord injury Findings That May Require Classification in Additional Patterns * Arthritis * Congenital heart defect 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 (ICI-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.
191 Malignant neoplasm of brain
192 Malignant neoplasm of other and unspecified parts of
nervous system
225 Benign neoplasm of brain and other parts of nervous
system
252 Disorders of parathyroid gland
252.0 Hyperparathyroidism
253 Disorders of the pituitary gland and its hypothalamic
control
253.3 Pituitary dwarfism
262 Other severe, protein-calorie malnutrition
299 Psychoses with origin specific to childhood
299.0 Infantile autism
315 Specific delays in development
315.4 Coordination disorder
315.9 Unspecified delay in development
333 Other extrapyramidal disease and abnormal movement
disorders
333.7 Symptomatic torsion dystonia
345 Epilepsy
345.1 Generalized convulsive epilepsy
345.2 Petit mal status
345.3 Grand mal status
345.9 Epilepsy, unspecified
348 Other conditions of brain
348.1 Anoxic brain damage
348.3 Encephalopathy, unspecified
358 Myoneural disorders
359 Muscular dystrophies and other myopathies
389 Hearing loss
714 Rheumatoid arthritis and other inflammatory polyarthropathies
714.3 Juvenile chronic polyarthritis
728 Disorders of muscle, ligament, and fascia
728.3 Other specific muscle disorders
Arthrogryposis
741 Spina bifida
742 Other congenital anomalies of nervous system
742.3 Congenital hydrocephalus
742.5 Other specified anomalies of spinal cord
745 Bulbus cordis anomalies and anomalies of cardiac septal
closure
745.1 Transposition of great vessels
745.2 Tetralogy of Fallot
745.4 Ventricular septal defect
745.5 Ostium secundum type atrial septal defect
746 Other congenital anomalies of heart
746.0 Anomalies of pulmonary valve
747 Other congenital anomalies of circulatory system
747.1 Coarctation of aorta
748 Congenital anomalies of respiratory system
754 Certain congenital musculoskeletal deformities
754.2 Of spine
754.3 Congenital dislocation of hip
755 Other congenital anomalies of limbs
756 Other congenital musculoskeletal anomalies
756.5 Osteodystrophies
756.51 Osteogenesis imperfecta
758 Chromosomal anomalies
Includes: syndromes associated with anomalies in the
number and form of chromosomes
759 Other and unspecified congenital anomalies
760 Fetus or newborn affected by maternal conditions which
may be unrelated to present pregnancy
760.7 Noxious influences affecting fetus via
placenta or breast milk
762 Fetus or newborn affected by complications of placenta,
cord, and membranes
762.5 Other compression of umbilical cord
763 Fetus or newborn affected by other complications of
labor and delivery
764 Slow fetal growth and fetal malnutrition
765 Disorders relating to short gestation and unspecified low
birth weight
767 Birth trauma
767.0 Subdural and cerebral hemorrhage
767.9 Birth trauma, unspecified
768 Intrauterine hypoxia and birth asphyxia
768.5 Severe birth asphyxia
768.6 Mild or moderate birth asphyxia
768.9 Unspecified birth asphyxia in liveborn infant
770 Other respiratory conditions of fetus and newborn
770.1 Meconium aspiration syndrome
770.7 Chronic respiratory disease arising in the
perinatal period
771 Infections specific to the perinatal period
771.2 Other congenital infections
Congenital toxoplasmosis
779 Other and ill-defined conditions originating in the perinatal
period
780 General symptoms
780.3 Convulsions
753 Symptoms concerning nutrition, metabolism, and development
799 Other ill-defined and unknown causes of morbidity and
mortality
799.0 Asphyxia
800 Fracture of vault of skull
801 Fracture of base of skull
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other
bones
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage,
following injury
853 Other and unspecified intracranial hemorrhage following
injury
854 Intracranial injury of other and unspecified nature
994 Effects of other external causes
994.1 Drowning and nonfatal submersion
995 Certain adverse effects not elsewhere classified
995.5 Child maltreatment syndrome
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, and 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 Test 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) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales,, interviews, questionnaires) 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) Circulation (Arterial, Venous, Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation auscultation /aus·cul·ta·tion/ (aws?kul-ta´shun) listening for sounds within the body, chiefly to ascertain the condition of the thoracic or abdominal viscera and to detect pregnancy; it may be performed with the unaided ear (direct or immediate a.) or with a stethoscope (mediate a.) ., claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) 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 stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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, lifting standards, risk assessment scales) * 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) 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, 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 * Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry ar·throm·e·try (är-thr  m  -tr )n. )Motor Function (Motor Control and Motar 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 motor control tests, finger dexterity tests, manipulative ability tests, observations) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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) Neuromotor Development and Sensory Integration * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) * Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests) 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) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Prosthetic device use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) Range of Motion (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, flexible rulers, goniometers, inclinometers, ligamentous tests, multisegment flexibility tests, palpation) Reflex Integrity * Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) * Electrophysiological integrity (eg, electroneuromyography) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles) * Primitive reflexes and reactions, including developmental (eg, reflex profiles) * 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, 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 analysis, 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, 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 12 months, patient/ client will demonstrate optimal neuromotor development and the highest level of functioning in home, work job/ school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 90 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 90 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Note: These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Periods of rapid growth 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 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 * Neuromotor development training - developmental activities training - motor training - movement pattern training - neuromuscular education or reeducation * Flexibility exercises - muscle lengthening - range of motion - stretching * Gait and locomotion training - developmental activities training - gait training - implement and device training - perceptual training - wheelchair training * Relaxation - breathing strategies - movement strategies - relaxation techniques * 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. * 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. - 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, 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 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, home management, work (job/school/play), community, and leisure 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 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 * Functional training programs - simulated environments and tasks - task adaptation - travel training * IADL training - home maintenance - household chores - shopping - structured play for infants and children - travel training - yard work * 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 * 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. - 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 - 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 - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - 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 mobilization * 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. - Soft tissue swelling, inflammation, or restriction is reduced. - Pain is decreased. * 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. - 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 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 - 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 - crisis - shoe inserts - splints * Prosthetic devices (lower-extremity and upper-extremity) * Protective devices - braces - cushions - helmets - protective taping * Supportive devices - compression garments - corsets - elastic wraps - neck collars - supplemental oxygen 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. - 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 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. * 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are improved. - Work of breathing is decreased. * 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. - 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 secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * 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. Electrotherapeulic Modalities Interventions * Biofeedback * Electrical muscle 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 - 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. - 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 - 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 Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping - total contact casting - vasopneumatic compression devices * Gravity-assisted compression devices - standing frame - 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 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. - 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 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 Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System--Congenital Origin or Acquired in Infancy or Childhood 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 motor function and sensory integrity associated with nonprogressive disorders of the central nervous system (congenital origin or acquired in infancy or childhood)--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) * Anoxia altitude anoxia see under sickness. anemic anoxia that due to decrease in amount of hemoglobin or number of erythrocytes in the blood. anoxic anoxia that due to interference with the oxygen supply. histotoxic anoxia severe histotoxic hypoxia. or hypoxia* Birth trauma * Brain anomalies * Cerebral palsy * Encephalitis * Genetic syndromes affecting central nervous system (CNS) * Hydrocephalus * Infectious disease affecting CNS * Meningocele * Neoplasm * Prematurity * Tethered cord * Traumatic brain injury Impairments, Functional Limitations, or Disabilities * Difficulty negotiating terrains * Difficulty planning movements * Difficulty with manipulation skills * Difficulty with positioning * Frequent falls * Impaired affect * Impaired arousal, attention, and cognition * Impaired expressive or receptive communication * Impaired motor function * Loss of balance during daffy activities * Inability to keep up with peers * Inability to perform work (job/school/play) 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 S345.) 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 * Coma * Spinal cord injury Findings That May Require Classification in Additional Patterns * Congenital Heart Defect * Fracture 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 codespatients/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 (ICD9-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.
036 Meningococcal infection
036.1 Meningococcal encephalitis
052 Chickenpox
052.0 Postvaricella encephalitis
055 Measles
055.0 Postmeasles encephalitis
056 Rubella
056.0 With neurological complications
072 Mumps
072.2 Mumps encephalitis
090 Congenital syphilis
090.4 Juvenile neurosyphilis
225 Benign neoplasm of brain and other parts of nervous system
320 Bacterial meningitis
320.9 Meningitis due to unspecified bacterium
321 Meningitis due to other organisms
321.8 Meningitis due to other nonbacterial
organisms classified elsewhere(*)
322 Meningitis of unspecified cause
322.9 Meningitis, unspecified
323 Encephalitis, myelitis, and encephalomyelitis
323.4 Other encephalitis due to infection classified
elsewhere(*)
323.5 Encephalitis following immunization procedures
323.6 Postinfectious encephalitis(*)
323.8 Other causes of encephalitis
323.9 Unspecified cause of encephalitis
333 Other extrapyramidal disease and abnormal movement
disorders
333.7 Symptomatic torsion dystonia
Athetoid cerebral palsy [Vogt's disease]; double
athetosis (syndrome)
343 Infantile cerebral palsy
345 Epilepsy
345.1 Generalized convulsive epilepsy
345.2 Petit mal status
345.3 Grand mal status
345.9 Epilepsy, unspecified
348 Other conditions of brain
348.1 Anoxic brain damage
348.3 Encephalopathy, unspecified
741 Spina bifida
742 Other congenital anomalies of nervous system
742.3 Congenital hydrocephalus
756 Other congenital musculoskeletal anomalies
756.1 Anomalies of spine
758 Chromosomal anomalies
Includes: syndromes associated with anomalies in the
number and form of chromosomes
759 Other and unspecified congenital anomalies
765 Disorders relating to short gestation and unspecified
low birth weight
767 Birth trauma
767.0 Subdural and cerebral hemorrhage
767.9 Birth trauma, unspecified
768 Intrauterine hypoxia and birth asphyxia
768.5 Severe birth asphyxia
768.6 Mild or moderate birth asphyxia
768.9 Unspecified birth asphyxia in liveborn infant
771 Infections specific to the perinatal period
771.2 Other congenital infections
Congenital toxoplasmosis
780 General symptoms
780.3 Convulsions
799 Other ill-defined and unknown causes of morbidity.
and mortality
799.0 Asphyxia
800 Fracture of vault of skull
801 Fracture of base of skull
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following
injury
853 Other and unspecified intracranial hemorrhage following
injury
854 Intracranial injury of other and unspecified nature
984 Toxic effect of lead and its compounds (including fumes)
985 Toxic effect of other metals
994 Effects of other external causes
994.1 Drowning and nonfatal submersion
* Not a primary diagnosis 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 Test 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 * Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) * Body dimensions (eg, body mass index, girth measurement, length measurement) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) 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) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) 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 stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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) 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 * 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) * Electrophysiological integrity (eg, electroneuromyography) * Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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, technology-assisted analyses, 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) Neuromotor Development and Sensory Integration * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) * Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests) 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) 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) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles) * Primitive reflexes and reactions, including developmental (eg, reflex profiles) * 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) 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 Patient/client will demonstrate optimal motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 90 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 90 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Note: These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Periods of rapid growth Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 Procedural interventions for this pattern may include: Therapeutic Exercise Interventions * Aerobic and endurance conditioning or reconditioning - aquatic programs - gait and locomotor training - increased workload over time - walking and wheelchair propulsion programs * Balance, coordination, and agility 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 - vestibular 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 * Neuromotor development - developmental activities training - motor training - movement pattern training - neuromuscular education or reeducation * 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. - 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, 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 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 - gait and locomotion training - 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 - simulated environments and tasks - task adaptation - travel training * 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. - 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 roles in self-care and home management 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 - 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] 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 - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - 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 axe 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 * 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - 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. - 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 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 - 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 - supplemental oxygen - 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. - 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 daffy living (ADL) and instrumental activities of daffy 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. * 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are improved. - Work of breathing is decreased. * 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. - 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 secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * 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 * Electrical stimulation - functional electrical stimulation (FES) - 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 axe 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. - 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 - 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 Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping - total contact casting - vasopneumatic compression devices * Gravity-assisted compression devices - standing frame - 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 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. - 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 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 Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System--Acquired in Adolescence or Adulthood 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 motor function and sensory integrity associated with nonprogressive disorders of the central nervous system (acquired in adolescence or adulthood)--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) * Aneurysm * Anoxia or hypoxia * Bell palsy * Cerebrovascular accident * Infectious disease that affects the central nervous system * Intracranial neurosurgical procedures * Neoplasm * Seizures * Traumatic brain injury Impairments, Functional Limitations, or Disabilities * Difficulty negotiating terrains * Difficulty planning movements * Difficulty with manipulation skills * Difficulty with positioning * Frequent falls * Impaired affect * Impaired arousal, attention, and cognition * Impaired expressive or receptive communication * Impaired motor function * Loss of balance during daily activities * Inability to keep up with peers * Inability to perform work (job/school/play) activities Note: Some risk factors or consequences of pathology/ pathophysiology--such as traumatic brain injury--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 S363.) 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 * Coma Findings That May Require Classification in Additional Patterns * Fracture * Multisystem trauma 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, 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.
049 Other non-arthropod-borne viral diseases of central nervous
system
049.9 Unspecified non-arthropod-borne viral diseases
of central nervous system
Viral encephalitis, not otherwise specified
225 Benign neoplasm of brain and other parts of nervous system
320 Bacterial meningitis
320.9 Meningitis due to unspecified bacterium
321 Meningitis due to other organisms
321.8 Meningitis due to other nonbacterial
organisms classified elsewhere(*)
322 Meningitis of unspecified cause
322.9 Meningitis, unspecified
323 Encephalitis, myelitis, and encephalomyelitis
323.4 Other encephalitis due to infection classified
elsewhere(*)
323.5 Encephalitis following immunization procedures
323.6 Postinfectious encephalitis(*)
323.8 Other causes of encephalitis
323.9 Unspecified cause of encephalitis
331 Other cerebral degenerations
331.3 Communicating hydrocephalus
331.4 Obstructive hydrocephalus
342 Hemiplegia and hemiparesis
345 Epilepsy
345.1 Generalized convulsive epilepsy
345.2 Petit mal status
345.3 Grand mal status
345.4 Partial epilepsy, with impairment of consciousness
Epilepsy:
partial:
secondarily generalized
345.5 Partial epilepsy, without mention of impairment of
consciousness
Epilepsy:
sensory-induced
345.9 Epilepsy, unspecified
348 Other conditions of brain
348.0 Cerebral cysts
348.1 Anoxic brain damage
348.3 Encephalopathy, unspecified
351 Facial nerve disorders
351.0 Bell's palsy
386 Vertiginous syndromes and other disorders of vestibular system
386.5 Labyrinthine dysfunction
431 Intracerebral hemorrhage
433 Occlusion and stenosis of precerebral arteries
434 Occlusion of cerebral arteries
435 Transient cerebral ischemia
435.1 Vertebral artery syndrome
435.8 Other specified transient cerebral ischemias
436 Acute, but ill-defined, cerebrovascular disease
437 Other and ill-defined cerebrovascular disease
442 Other aneurysm
442.8 Of other specified artery
444 Arterial embolism and thrombosis
444.9 Of unspecified artery
447 Other disorders of arteries and arterioles
447.1 Stricture of artery
780 General symptoms
780.3 Convulsions
781 Symptoms involving nervous and musculoskeletal systems
781.2 Abnormality of gait
Gait:
ataxic
781.3 Lack of coordination
Ataxia, not otherwise specified
799 Other ill-defined and unknown causes of morbidity and
mortality
799.0 Asphyxia
800 Fracture of vault of skull
801 Fracture of base of skull
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following
injury
853 Other and unspecified intracranial hemorrhage following injury
854 Intracranial injury of other and unspecified nature
994 Effects of other external causes
994.0 Drowning and nonfatal submersion
(*) Not a primary diagnosis 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 Test 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) * Edema (eg, girth measurement, palpation, scales, volume measurement) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) 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) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythin, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) 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) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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) 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 * 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) * Electrophysiological integrity (eg, electroneuromyography) * Hand function (eg, fine and gross motor control tests, finger dexterity tests, manipulative ability tests, observations) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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) Neuromotor Development and Sensory Integration * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) * Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests) 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) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) * Primitive reflexes and reactions, including developmental (eg, reflex profiles, screening tests) * 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) 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 testing, 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 12 months, patient/client will demonstrate optimal motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 10 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 10 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Note: These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Periods of rapid growth Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 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 and 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 - vestibular 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 * Neuromotor development training - developmental activities training - motor training - movement pattern training - neuromuscular education or reeducation * 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. - motor 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. - 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 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. Procedural Interventions continued 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 activities of daily living (ADL) and instrumental activities of daily living (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 - simulated environments and tasks - task adaptation - travel training * IADL training - caring for dependents - home maintenance - household chores - shopping - 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. - Symptoms associated with increased oxygen demand are 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 - 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. Procedural Interventions continued Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL] 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 - travel 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 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. - Symptoms associated with increased oxygen demand are 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. Procedural Interventions continued 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity 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. - 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 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 - 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 - supplemental oxygen - 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. - Symptoms associated with increased oxygen demand are 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. - 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 - 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - chest wall manipulation - suctioning ventilatory aids * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis absorption atelectasis , acquired atelectasis obstructive atelectasis; that caused by an obstruction of the airway that prevents intake of air, e.g., secretions, foreign body, tumor, or external pressure. congenital atelectasis that present at birth (primary a.) or immediately thereafter (secondary a.) . is decreased.- Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation axe enhanced. * Impact on impairments - Aerobic capacity is increased. - Airway clearance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Exercise tolerance is improved. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are 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. - 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. 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) - 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, 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 - 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 - pools * Sound agents - phonophoresis - ultrasound * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping * Gravity-assisted compression devices - standing frame - 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. - 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 (ADL) 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 Motor Function, and Sensory Integrity Associated With Progressive Disorders the Central Nervous System This preferred practice pattern describes the generally accepted, d 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 motor function and sensory integrity associated with progressive disorders of the central nervous system--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, 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 * Alcoholic ataxia * Alzheimer disease * Amyotrophic lateral sclerosis * Basal ganglia disease * Cerebellar ataxia * Cerebellar disease * Huntington disease * Idiopathic progressive cortical disease * Intracranial neurosurgical procedures * Multiple sclerosis * Neoplasm * Parkinson disease * Primary lateral palsy * Progressive muscular atrophy * Seizures Impairments, Functional Limitations, or Disabilities * Difficulty coordinating movement * Difficulty with manipulation skills * Difficulty negotiating terrains * Frequent falls * Impaired affect * Impaired arousal, attention, and cognition * Impaired endurance * Impaired motor function * Impaired sensory integrity * Loss of balance during daily activities * Progressive loss of function * Inability to keep up with peers * Inability to negotiate community environment * Inability to perform job/school activities * Lack of safety in home environment Note: Some risk factors or consequences of pathology/ 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 S381.) 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 * Coma Findings That May Require Classification in Additional Patterns * Amyotrophic lateral sclerosis with pneumonia * Parkinson disease with arthritis 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 ICD9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.
042 Human immunodeficiency virus [HIV] disease
191 Malignant neoplasm of brain
192 Malignant neoplasm of other and unspecified parts of nervous
system
237 Neoplasm of uncertain behavior of endocrine glands and
nervous system
237.5 Brain and spinal cord
303 Alcohol dependence syndrome
303.9 Ataxia
331 Other cerebral degenerations
331.0 Alzheimer's disease
331.3 Communicating hydrocephalus
331.4 Obstructive hydrocephalus
332 Parkinson's disease
333 Other extrapyramidal disease and abnormal movement disorders
333.0 Other degenerative diseases of the basal ganglia
333.3 Tics of organic origin
333.4 Huntington's chorea
333.9 Other and unspecified extrapyramidal diseases
and abnormal movement disorders
334 Spinocerebellar disease
334.2 Primary cerebellar degeneration
334.3 Other cerebellar ataxia
334.8 Other spinocerebellar diseases
335 Anterior horn cell disease
335.0 Werdnig-Hoffmann disease
335.1 Spinal muscular atrophy
335.2 Motor neuron disease
336 Other diseases of spinal cord
336.0 Syringomyelia and syringobulbia
340 Multiple sclerosis
341 Other demyelinating diseases of central nervous system
341.8 Other demyelinating diseases of central nervous
system
Central demyelination of corpus callosum
341.9 Demyelinating disease of central nervous system,
unspecified
345 Epilepsy
345.4 Partial epilepsy, with impairment of consciousness
Epilepsy:
partial:
secondarily generalized
345.5 Partial epilepsy, without mention of impairment of
consciousness
Epilepsy:
sensory-induced
348 Other conditions of brain
348.9 Unspecified condition of brain
780 General symptoms
780.3 Convulsions
781 Symptoms involving nervous and musculoskeletal systems
781.2 Abnormality of gait
Gait:
ataxic
781.3 Lack of coordination
Ataxia, not otherwise specified
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 daffy 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 Test 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) * Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry) * Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, exertion scales, observations, oximetry, palpation) Anthropometric Characteristics * Body dimensions (eg, body mass index, girth measurement, length measurement) * Edema (eg, girth measurement, palpation, scales, volume measurement) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) 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) Circulation (Arterial, Venous, and Lymphatic) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) Cranial 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) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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) * 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) Motor Function (Motor Learning and Motor Control) * 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 motor control tests, finger dexterity tests, manipulative ability tests, observations) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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) Neuromotor Development and Sensory Integration * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) * Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests) 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) 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) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) * Primitive reflexes and reactions, including developmental (eg, reflex profiles) * 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) 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 12 months, patient/ client will demonstrate optimal motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 50 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 50 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 on 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 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 Procedural interventions for this pattern may include: Therapeutic Exercise Interventions * Aerobic and 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 - vestibular 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 * Neuromotor development - developmental activities training - motor training - movement pattern training - neuromuscular education or reeducation * 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. - Symptoms associated with increased oxygen demand are decreased. - 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. - 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 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 Serf-Care and Home Management (Including Activates 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 - simulated environments and tasks - task adaptation - travel training * 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 serf-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. - Symptoms associated with increased oxygen demand are 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 - 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 - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - Symptoms associated with increased oxygen demand are 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 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 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 * 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity 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. - 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 secondary impairment 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. - 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 - mechanical ventilators - neck collars - serial casts - slings - supplemental oxygen - 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. - Symptoms associated with increased oxygen demand are 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 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. - 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - chest wall manipulation - suctioning - ventilatory aids * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Exercise tolerance is improved. - Muscle performance (strength, power, and endurance) is increased. Ventilation and respiration/gas exchange are 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. - 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 secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. * Impact on health, wellness, and fitness - Health status is improved. - 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) - 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. - 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. - 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 Physical agents may include: * Cryotherapy - cold packs - ice massage - vapocoolant spray * Hydrotherapy - whirlpool tanks - pools * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping * Gravity-assisted compression devices - standing frame - 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. - 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 impairments is reduced. - Self-management of symptoms 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 Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury 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 peripheral nerve integrity and muscle performance associated with peripheral nerve injury--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) * Neuropathies - Carpal tunnel syndrome - Cubital tunnel syndrome - Erb palsy - Radial tunnel syndrome - Tarsal tunnel syndrome * Peripheral vestibular disorders - Labyrinthitis - Paroxysmal positional vertigo * Surgical nerve lesions * Traumatic nerve lesions Impairments, Functional Limitations, or Disabilities * Difficulty with manipulation skills * Decreased muscle strength * Impaired peripheral nerve integrity * Impaired proprioception * Impaired sensory integrity * Loss of balance during daily activities * Inability to negotiate community environment * Lack of safety in home environment Note: Some risk factors or consequences of pathology/ pathophysiology--such as peripheral vascular disease--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 S399.) 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 Bell palsy * Impairments associated with demyelinating disease * Radiculopathies Findings That May Require Classification in Additional Patterns * Decubitis ulcer * Reflex sympathetic dystrophy syndrome 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.
225 Benign neoplasm of brain and other parts of nervous
system
225.1 Cranial nerves
350 Trigeminal nerve disorders
350.1 Trigeminal neuralgia
352 Disorders of other cranial nerves
352.4 Disorders of accessory [11th] nerve
352.5 Disorders of hypoglossal [12th] nerve
352.9 Unspecified disorder of cranial nerves
353 Nerve root and plexus disorders
353.0 Brachial plexus lesions
353.1 Lumbosacral plexus lesions
353.6 Phantom limb (syndrome)
354 Mononeuritis of upper limb and mononeuritis multiplex
354.0 Carpal tunnel syndrome
354.2 Lesion of ulnar nerve
354.3 Lesion of radial nerve
355 Mononeuritis of lower limb
357 Inflammatory and toxic neuropathy
357.1 Polyneuropathy in collagen vascular disease*
386 Vertiginous syndromes and other disorders of vestibular
system
386.0 Meniere's disease
386.03 Active Meniere's disease, vestibular
386.1 Other and unspecified peripheral vertigo
386.3 Labyrinthitis
767 Birth trauma
767.6 Injury to brachial plexus
Palsy or paralysis:
Erb (Duchenne)
* Not a primary diagnosis 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 Test 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) Anthropametric 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) * Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, girth measurement, palpation, sphygmomanometry, thermography) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, observations, palpation, sphygmomanometry) 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) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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 * 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) * Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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, 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) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) * 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 4 to 8 months, patient/client will demonstrate optimal peripheral nerve integrity and muscle performance and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 56 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 56 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 * Ability 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 on 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 and 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 - vestibular 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 * 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 * Relaxation breathing strategies movement strategies relaxation techniques 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. - 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 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 * Functional training programs - simulated environments and tasks - task adaptation - travel training * 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. - 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 - 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 * Functional training programs - back schools - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - 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 * 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity 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. - 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. - 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 (lower-extremity and upper-extremity) * Protective devices - braces - cushions - helmets - protective taping * Supportive devices - compression garments - corsets - elastic wraps - neck collars - serial casts - slings - supplemental oxygen - 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. - 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. - 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 - 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 - 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 - 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 - 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 * Hydrotherapy - whirlpool tanks - contrast bath * Sound agents - phonophoresis - ultrasound * Thermotherapy - hot packs 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 increased. - 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 Motor Function, and Sensory Integrity Associated With Acute or Chronic Polyneuropathies 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 motor function and sensory integrity associated with acute or chronic polyneuropathies--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) * Amputation * Axonal polyneuropathies - Alcoholic - Diabetic - Renal * Dysfunction of the autonomic nervous system * Guillian-Barre syndrome * Leprosy * Post-polio syndrome Impairments, Functional Limitations, or Disabilities * Decreased endurance * Decreased independence in activities of daffy living * Difficulty with manipulation skills * Impaired motor function * Impaired peripheral nerve integrity * Impaired proprioception * Impaired sensory integrity * Inability to negotiate work environment * Lack of safety in community environment * Loss of balance during daily activities Note: Some risk factors or consequences of pathology/ pathophysiology--such as Guillain-Barre syndrome with aspiration pneumonia--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 S417.) 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 * Coma * Impairments associated with compression or traumatic neuropathies * Impairments associated with multisystem trauma Findings That May Require Classification in Additional Patterns * Decubitis ulcer 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/diems 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.
030 Leprosy
138 Late effects of acute poliomyelitis
250 Diabetes mellitus
250.6 Diabetes with neurological manifestations
337 Disorders of the autonomic nervous system
337.0 Idiopathic peripheral autonomic neuropathy
337.1 Peripheral autonomic neuropathy in disorders
classified elsewhere (*)
337.2 Reflex sympathetic dystrophy
356 Hereditary and idiopathic peripheral neuropathy
356.4 Idiopathic progressive polyneuropathy
356.9 Unspecified
357 Inflammatory and toxic neuropathy
357.0 Acute infective polyneuritis
Guillain-Barre syndrome
357.2 Polyneuropathy in diabetes (*)
357.4 Polyneuropathy in other diseases classified
elsewhere (*)
Uremia
357.5 Alcoholic polyneuropathy
357.7 Polyneuropathy due to other toxic agents
588 Disorders resulting from impaired renal function
588.1 Nephrogenic diabetes insipidus
588.8 Other specified disorders resulting from impaired
renal function
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 Test 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) * Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry) * Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, observations, oximetry, palpation) Anthropametric 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,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) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, electrocardiography, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) 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) * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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) * 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 * 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) * Electrophysiological integrity (eg, electroneuromyography) * 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) 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) * 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, angina 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) Prosthetic Requirements * Prosthetic device use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations) * Residual limb or adjacent segment, including edema, range of motion, skin integrity, and strength (eg, goniometry, muscle tests, observations, palpation, photographic assessments, skin integrity tests, videographic assessments, volume measurement) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) 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) * 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) 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 testing, 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 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 optimal motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 Care * 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 planing 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 on 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 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 in, proved. * 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 Procedural interventions for this pattern may include: Therapeutic Exercise Interventions * Aerobic and 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 - vestibular 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. - Symptoms associated with increased oxygen demand are decreased. - 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. - 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 super-vision 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 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 axe 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 - gait and locomotion training - 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 - simulated environments and tasks - task adaptation - travel training * 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. - Symptoms associated with increased oxygen demand are 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 - 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] 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 - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - Symptoms associated with increased oxygen demand are 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 * 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity 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. - 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 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 - 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 * Prosthetic devices (lower-extremity and upper-extremity) * Protective devices - braces - cushions - helmets - protective taping * Supportive devices - compression garments - corsets - elastic wraps - neck collars - serial casts - slings - supplemental oxygen - 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. - Symptoms associated with increased oxygen demand are decreased. * Impact on impairments - Balance is improved. - Endurance is increased. - Energy expenditure per trait 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. - Prosthetic fit is achieved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - 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 - 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - chest wall manipulation - suctioning - ventilatory aids * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Balance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Exercise tolerance is improved. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are 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. - 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 - 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) 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 - 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. - 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. - 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 * Sound agents - phonophoresis - ultrasound Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - vasopneumatic compression devices * Gravity-assisted compression devices - standing frame - 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. - 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 increased. - 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. - 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 Motor Function, Peripheral Nerve Integrity, and Sensory Integrity Associated Nonprogressive Disorders of the Spinal Cord 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 motor function, peripheral nerve integrity, and sensory integrity associated with nonprogressive disorders of the spinal cord--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) * Benign spinal neoplasm * Complete and incomplete spinal cord lesions * Infectious diseases affecting the spinal cord * Spinal cord compression * Degenerative spinal joint disease * Herniated intervertebral disk * Osteomyelitis * Spondylosis Impairments, Functional Limitations, or Disabilities * Decreased aerobic capacity * Difficulty accessing community * Difficulty with activities of daily living * Difficulty with instrumental activities of daily living * Impaired ventilation * Impaired motor function * Impaired muscle performance * Impaired peripheral nerve integrity * Inability to keep up with peers * Inability to perform work (job/school/play) Note: Some risk factors or consequences of pathology/ pathophysiology--such as abdominal trauma and autonomic dysreflexia--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 S435.) 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 Guillian-Barre syndrome * Meningocele * Nerve root compression due to lumbar radiculopathy * Tethered cord Findings That May Require Classification in Additional Patterns * Decubitis ulcer * Impairments associated with ventilator dependency 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.
225 Benign neoplasm of brain and other parts of nervous
system
225.3 Spinal cord
Cauda equina
237 Neoplasm of uncertain behavior of endocrine glands and
nervous system
237.5 Brain and spinal cord
239 Neoplasms of unspecified nature
239.7 Endocrine glands and other parts of nervous
system
320 Bacterial meningitis
321 Meningitis due to other organisms
336 Other diseases of spinal cord
344 Other paralytic syndromes
344.0 Quadriplegia and quadriparesis
344.1 Paraplegia
344.8 Other specified paralytic syndromes
721 Spondylosis and allied disorders
721.1 Cervical spondylosis with myelopathy
721.4 Thoracic or lumbar spondylosis with myelopathy
721.9 Spondylosis of unspecified site
721.91 With myelopathy
722 Intervertebral disk disorders
722.1 Displacement of thoracic or lumbar intervertebral
disk without myelopathy
722.7 Intervertebral disk disorder with myelopathy
730 Osteomyelitis, periostitis, and other infections involving
bone
730.2 Unspecified osteomyelitis
733 Other disorders of bone and cartilage
733.1 Pathologic fracture
806 Fracture of vertebral column with spinal cord injury
839 Other, multiple, and ill-defined dislocations
839.0 Cervical vertebra, closed
839.1 Cervical vertebra, open
839.2 Thoracic and lumbar vertebra, closed
839.3 Thoracic and lumbar vertebra, open
839.4 Other vertebra, closed
839.5 Other vertebra, open
839.6 Other location, closed
839.7 Other location, open
839.8 Multiple and ill-defined, closed
839.9 Multiple and ill-defined, open
952 Spinal cord injury without evidence of spinal bone injury
952.0 Cervical
952.1 Dorsal [thoracic]
952.2 Lumbar
Examination 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, thee 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) Systems Review 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 Test and measures for this pattern may include those that characterize or quantify: Aerobic Capacity and Endurance * Aerobic capacity during functional activities (eg, activities of daffy living [ADL] scales, indexes, instrumental activities of daffy living [IADL] scales, observations) * Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests) * Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, electrocardiography, exertion scales, observations, palpation, sphygmomanometry) * Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests) Anthropametric 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, 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) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Motivation (eg, adaptive behavior scales) * Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, electrocardiography, palpation, sphygmomanometry, thermography) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry) 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) 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 * 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, frae and gross motor 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, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge 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) Neuromotor Development and Sensory Integration * Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) * Oral motor function, phonation, and speech production (eg, interviews, observations) 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) * Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) * 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) 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 testing, 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 9 months, patient/ client will demonstrate optimal motor function, peripheral nerve integrity, and sensory integrity and the highest level of functioning in home, work (job/school/ play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. 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 4 to 150 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 4 to 150 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. Note: These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: * Cognitive maturation * Periods of rapid growth Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 and 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. - Symptoms associated with increased oxygen demand are decreased. - 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. - 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. - 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 simulated environments and tasks - task adaptation - travel training - 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. - Symptoms associated with increased oxygen demand are 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 - 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] 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 - job coaching - simulated environments and tasks - task adaptation - task training - travel 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 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. - Symptoms associated with increased oxygen demand are 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 * 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 - Balance is improved. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity 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. - 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 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 - 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 - mechanical ventilators - neck collars - serial casts - slings - supplemental oxygen - 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. - Symptoms associated with increased oxygen demand are 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. - 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 - 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. Airway Clearance Techniques Interventions * Breathing strategies - active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques - autogenic drainage - paced breathing - pursed lip breathing - techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - chest wall manipulation - suctioning - ventilatory aids * Positioning - positioning to alter work of breathing - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Nutrient delivery to tissue is increased. - Physiological response to increased oxygen demand is improved. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Exercise tolerance is improved. - Muscle performance (strength, power, and endurance) is increased. - Ventilation and respiration/gas exchange are improved. - Work of breathing is decreased. * 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. - 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. Electrotherapeutic Modalities Interventions * Electrical stimulation - electrical muscle stimulation (EMS) - functional electrical stimulation (FES) - high voltage pulsed current (HVPC) - 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 axe 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 - 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: * Gravity-assisted compression devices - standing frame - tilt table * Compression therapies - compression bandaging - compression garments 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. - Safety is improved. - 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 Arousal, Range of Motion, and Motor Control Associated With Coma, Near Coma, or Vegetative 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 arousal, range of motion, and motor control associated with coma, near coma, or vegetative state--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) * Anoxia * Birth trauma * Cerebral vascular accident * Infectious or inflammatory disease that affects the central nervous system * Neoplasm * Prematurity * Traumatic brain injury Impairments, Functional Limitations, or Disabilities * Impaired arousal * Impaired motor function * Impaired range of motion * Lack of response to stimuli * Impaired sensory integrity Note: Some risk factors or consequences of pathology/ pathophysiology--such as pneumonia--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 S452.) Multiple-Pattern Classification The following examples of examination findings may support 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 classification in both this and another pattern. Findings That May Require Classification in Additional Patterns * Decubitis ulcer * Impairments associated with ventilator dependency 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.
049 Other non-arthropod-borne viral diseases of central nervous
system
049.9 Unspecified non-arthropod-borne viral diseases of
central nervous system
Viral encephalitis, not otherwise specified
191 Malignant neoplasm of brain
225 Benign neoplasm of brain and other parts of nervous
system
322 Meningitis of unspecified cause
342 Hemiplegia and hemiparesis
342.0 Flaccid hemiplegia
348 Other conditions of brain
348.0 Cerebral cysts
348.1 Anoxic brain damage
431 Intracerebral hemorrhage
433 Occlusion and stenosis of precerebral arteries
433.0 Basilar artery
434 Occlusion of cerebral arteries
435 Transient cerebral ischemia
435.1 Vertebral artery syndrome
435.8 Other specified transient cerebral ischemias
436 Acute, but ill-defined, cerebrovascular disease
437 Other and ill-defined cerebrovascular disease
442 Other aneurysm
442.8 Of other specified artery
444 Arterial embolism and thrombosis
444.9 Of unspecified artery
447 Other disorders of arteries and arterioles
447.1 Stricture of artery
747 Other congenital anomalies of circulatory system
747.8 Other specified anomalies of circulatory system
765 Disorders relating to short gestation and unspecified low
birth weight
765.1 Other preterm infants
767 Birth trauma
767.0 Subdural and cerebral hemorrhage
767.9 Birth trauma, unspecified
799 Other ill-defined and unknown causes of morbidity and
mortality
799.0 Asphyxia
850 Concussion
850.5 With loss of consciousness of unspecified duration
850.9 Concussion, unspecified
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage,
following injury
853 Other and unspecified intracranial hemorrhage following
injury
853.0 Without mention of open intracranial wound
854 Intracranial injury of other and unspecified nature
994 Effects of other external causes
994.1 Drowning and nonfatal submersion
Examination 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) Systems Review 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 * Edema (eg, girth measurement, palpation, scales, volume measurement) Arousal, Attention, and Cognition * Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) * Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) * Consciousness, including agitation and coma (eg, scales) Assistive and Adaptive Devices * 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, logs, interviews, observations) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, palpation, sphygmomanometry,) * Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, observations, palpation, sphygmomanometry) Cranial and Peripheral Nerve Integrity * Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation 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) 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) Motor Function (Motor Control and Motor Learning) * Initiation, modification, and control of movement patterns and voluntary postures (eg, observations) Neuromotor Development and Sensory Integration * Oral motor function, phonation and speech production (eg, interviews, observations) Orthotic, Protective, and Supportive Devices * Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, reports) * Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg,ADL scales, pain scales) * Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, interviews, logs, observations, reports) Pain * Pain, soreness, and nociception (eg, provocation tests) Posture * Postural alignment and position (static), including symmetry and deviation from midline (eg, observations) Range of Motion {ROM) {Including Muscle Length) * Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) * Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, multisegment flexibility tests, palpation) Reflex Integrity * Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) * Primitive reflexes and reactions, including developmental (eg, reflex profiles, screening tests) * 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) * Safety in self-care and home management activities and environments (eg, diaries, interviews, logs, observations, reports) 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, observations, palpation) * Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales) 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 months, patient/ client will demonstrate optimal arousal, range of motion, and motor control and the minimization of secondary impairments. 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 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 who are classified into this pattern will achieve the anticipated goals and expected outcomes within 5 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care * 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 - informed consent (guardian 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. * 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 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 patient/client health and the use of health care resources by 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 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) - plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities - transitions across settings Anticipated Goals and Expected Outcomes * Ability to perform physical actions, tasks, or activities is improved. * Awareness and use of community resources by family and caregivers 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 family, significant others, and caregivers. * Disability associated with acute or chronic illnesses is reduced. * Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. * Health status is improved. * Intensity of care is decreased. * Level of supervision required for task performance by family or caregiver is decreased. * 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. * Utilization and cost of health care services are decreased. Procedural Interventions Procedural interventions for this pattern may include Therapeutic Exercise Interventions * Flexibility exercises - muscle lengthening - range of motion - stretching 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. - Pain is decreased. - Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. - Weight-bearing status is improved. * Impact on functional limitations - Level of supervision required for task performance is decreased. - Tolerance of positions and activities is increased. * Risk reduction/prevention - Caregiver management of symptoms is improved. - Preoperative and postoperative complications are reduced. - Risk factors are reduced. - Risk of secondary impairment is reduced. * Impact on health, wellness, and fitness - Health status is improved. - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to caregiver. 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 - dressing - grooming - toileting * Devices and equipment use and training - assistive and adaptive device or equipment training during ADL - orthotic, protective, or supportive device or equipment training during ADL * 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 - Endurance is increased - Sensory awareness is increased. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Ability of caregiver to perform physical actions, tasks, or activities related to home management is improved. - Performance of and independence in ADL by caregiver are increased. - Tolerance of positions and activities is increased. * Risk reduction/prevention - Risk factors are reduced. - Risk of secondary impairments is reduced. - Safety is improved. * Impact on health, wellness, and fitness - Health status is improved. - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to caregiver. Manual Therapy Techniques (Including Mobilization/Manipulation) Interventions * Passive range of motion * Mobilization/manipulation - soft tissue 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 - Integumentary integrity is improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. - Weight-bearing status is improved. * Impact on functional limitations - Ability of caregiver to perform physical actions, tasks, or activities related to home management is improved. - Performance of and independence in activities of daily living (ADL) by caregiver are increased. - Tolerance of positions and activities is increased. * Risk reduction/prevention - Risk factors are reduced. - Risk of secondary impairment is reduced. * Impact on health, wellness, and fitness - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist ate acceptable to caregiver. Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Interventions * Adaptive devices - hospital beds - seating systems * Assistive devices - wheelchairs * Orthotic devices - braces - splints * Protective devices - braces - cushions - helmets - protective taping * Supportive devices - compression garments - corsets - elastic wraps - mechanical ventilators - neck collars - serial casts - slings - supplemental oxygen - 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. - Energy expenditure per unit of work is decreased. - Integumentary integrity is improved. - Joint stability is improved. - Optimal joint alignment is achieved. - Postural control is improved. - Range of motion is improved. - Weight-bearing status is improved. - Work of breathing is decreased. * Impact on functional limitations - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) by caregiver are increased. - Tolerance of positions and activities is increased. * 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. - Stresses precipitating injury are decreased. * Impact on health, wellness, and fitness - Health status is improved. - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to caregiver. Airway Clearance Techniques Interventions * Breathing strategies techniques to maximize ventilation (eg, manual hyperinflation) * Manual/mechanical techniques - assistive devices - chest percussion, vibration, and shaking - suctioning * Positioning - positioning to maximize ventilation and perfusion - pulmonary postural drainage Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Atelectasis is decreased. - Nutrient delivery to tissue is increased. - Symptoms associated with increased oxygen demand are decreased. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Airway clearance is improved. - Cough is improved. - Energy expenditure per unit of work is decreased. - Ventilation and respiration/gas exchange are improved. - Work of breathing is decreased. * Impact on functional limitations - Performance of and independence in activities of daily living (ADL) by - caregiver are increased. - Tolerance of positions and activities is increased. * 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. * Impact on health, wellness, and fitness - Health status is improved. - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Cost of health care services is decreased. - Intensity of care is decreased. - Interpersonal skills of physical therapist are acceptable to caregiver. Physical Agents and Mechanical Modalities Interventions Physical agents may include: * Athermal agents - pulsed electromagnetic fields * Cryotherapy - cold packs - ice massage * Thermotherapy - dry heat - hot packs 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. - Range of motion is improved. - Weight-bearing status is improved. * Impact on functional limitations -Performance of and independence in activities of daily living (ADL) by caregiver are increased. - Tolerance of positions and activities is increased. * Risk reduction/prevention - Complications of soft tissue and circulatory disorders are decreased. - Risk of secondary impairment is reduced. - 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 caregiver. - Administrative management of practice is acceptable to caregiver. - Caregiver's sense of well-being is improved. - Caregiver's stressors are decreased. - Clinical proficiency of physical therapist is acceptable to caregiver. - Coordination of care is acceptable to caregiver. - Interpersonal skills of physical therapist are acceptable to caregiver. 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. |
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