What Types of Interventions Do Physical Therapists Provide?

Introduction

In its broadest sense, 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 methods and techniques to produce changes that are consistent with the examination and reexamination findings, the evaluation, the diagnosis, and the prognosis. Decisions about intervention are contingent on the timely monitoring of patient/client responses to interventions and on the progress made toward anticipated goals and expected outcomes.

Physical therapist intervention consists of three major components (Figure):

* Coordination, communication, and documentation

* Patient/client-related instruction

* Procedural interventions

Coordination, communication, and documentation and patient/client-related instruction are provided as part of intervention for all patients/clients. The use of procedural interventions varies, however, because those interventions are selected, applied, or modified according to examination and reexamination findings and the anticipated goals and expected outcomes for a particular patient/client in a specific diagnostic group.

Physical therapist intervention encourages functional independence, emphasizes patient/client-related instruction, and promotes proactive, wellness-oriented lifestyles. Through appropriate education and instruction, the patient/client is encouraged to develop habits that will maintain or improve function, prevent recurrence of problems, and promote health, wellness, and fitness.

Selection of Procedural Interventions

Physical therapists select interventions based, on the complexity and severity of the clinical problems. In determining the prognosis, the interventions to be used, and the likelihood of an intervention's success, physical therapists also must consider the differences between the highest level of function of which the individual is capable and the highest level of function that is likely to be habitual for that individual. Patients/clients are more likely to achieve the anticipated goals and expected outcomes that are determined with the physical therapist if they perceive a need to function at the highest level of their ability--and if they are motivated to function habitually at that level. Thus understanding the difference between what a person currently does and what that person potentially could do is essential in making a prognosis and identifying realistic, achievable goals and outcomes. Physical therapists ultimately must abide by the decisions of the patient/client regarding actions, tasks, and activities that will be incorporated into a daily routine and regarding what constitutes a meaningful level of function.

The physical therapist's selection of procedural interventions should be based on:

* Examination findings (including those of the history, systems review, and tests and measures), an evaluation, and a diagnosis that supports physical therapy intervention

* A prognosis that is associated with improved or maintained health status through risk reduction; health, wellness, and fitness programs; or the remediation of impairments, functional limitations, or disabilities

* A plan of care designed to improve, enhance, and maximize function through interventions of appropriate intensity, frequency, and duration to achieve anticipated goals and expected outcomes efficiently using available resources

The physical therapist selects, applies, or modifies one or more procedural interventions based on anticipated goals and expected outcomes that have been developed with the patient/client. Anticipated goals and expected outcomes relate to specific impairments, functional limitations, or disabilities; signs or symptoms; risk reduction/prevention; and health, wellness, or fitness needs. The anticipated goals and expected outcomes listed in the plan of care should be measurable and time-specific.

In conjunction with coordination, communication, and documentation and patient/client-related instruction, three categories of procedural interventions form the core of most physical therapy plans of care: therapeutic exercise, functional training in self-care and home management, and functional training in work (job/school/play), community, and leisure integration or reintegration. The other categories of procedural interventions may be used when the examination, evaluation, diagnosis, and prognosis indicate their necessity.

Factors that influence the complexity of both the examination process and the selection of interventions may include chronicity or severity of current condition; level of current impairment and probability of prolonged impairment, functional limitation, or disability; living environment; multisite or multisystem involvement; overall physical function and health status; potential discharge destinations; preexisting systemic conditions or diseases; social supports; and stability of the condition.

Through routine monitoring and reexamination, the physical therapist determines the need for any alteration in an intervention or in the plan of care. The interventions used, including their frequency and duration, are consistent with patient/client needs and physiological and cognitive status, anticipated goals and expected outcomes, and resource constraints. The independent performance of the procedure or technique by the patient/client (or significant other, family, or caregiver) is encouraged following instruction in safe and effective application.

Failing to intervene appropriately to prevent illness or to habilitate or rehabilitate patients/clients with impairments, functional limitations, and disabilities leads to greater costs for both the person and society. The Guide provides administrators and policy makers with the information they need to make decisions about the cost-effectiveness of physical therapist intervention.

Criteria for Termination of Physical Therapy Services

Discharge and discontinuation are the two processes used for terminating physical therapy services.

Discharge is the process of ending physical therapy services that have been provided during a single episode of care when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (that is, when the 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. In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral.

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 anticipated goals and expected 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.

In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discontinuation and provides for appropriate follow-up or referral.

In this chapter, each component of physical therapist intervention--coordination, communication, and documentation; patient/client-related instruction; and procedural interventions--is described, including:

* General definitions. General definitions of each category of intervention are provided.

* Clinical considerations. Clinical considerations for selection of interventions are provided. For procedural interventions, examples are given of the types of examination and diagnostic findings that may indicate that a procedural intervention may be appropriate for a given patient/client. Findings may include pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/prevention needs; and health, wellness, and fitness needs.

* Interventions. Examples of methods, procedures, or techniques that may be used are provided.

* Anticipated goals and expected outcomes. Anticipated goals and expected outcomes are categorized according to a procedural intervention's impact on pathology/ pathophysiology; impairments; functional limitations; disabilities; risk reduction/prevention; health, wellness, and fitness; impact on societal resources; and patient/client satisfaction.

Coordination, Communication, and Documentation

Coordination, communication, and documentation are administrative and supportive processes that are intended to ensure that patients/clients receive appropriate, comprehensive, efficient, effective, and high-quality care from admission through discharge. Coordination is the working together of all parties involved with the patient/client. Communication is the exchange of information. Documentation is any entry into the patient/client record--such as consultation reports, initial examination reports, progress notes, flow sheets, checklists, reexamination reports, or summations of care--that identifies the care or service provided.

Administrative and support processes may include the addressing of such required functions as advance directives, individualized education plans (IEPs), individualized family service plans (IFSPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting); admission and discharge planning; case management; collaboration and coordination with agencies; communication across settings; cost-effective resource utilization; data collection, analysis, and reporting; documentation across settings; interdisciplinary teamwork; and referrals to other professionals or resources.

Physical therapists are responsible for coordination, communication, and documentation across all settings for all patients/clients.

Clinical Considerations

Considerations that may direct the type and specificity of interventions for coordination, communication, and documentation may include:

* Patient/client seeks physical therapy services.

* Patient/client is referred to physical therapy services.

* Patient/client condition indicates need for referral to physical therapy services.

* Patient/client requires referral from the physical therapist to another service or provider.

* Physical therapist obtains informed consent from patient/client in accordance with jurisdictional law.

* Patient/client has signs or symptoms of physical abuse that must be reported in accordance with jurisdictional law.

* Patient/client is admitted to or transferred across patient care settings.

* Physical therapy services are terminated (through discharge or discontinuation).

* Patient/client experiences changes in pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, disabilities, or overall health status.

* Patient/client is managed by interdisciplinary team.

* Physical therapist's plan of care for patient/client requires coordination of resources.

* Patient/client, family, significant other, or caregiver requests physical therapist participation in coordination, communication, and documentation activities.

* Physical therapist is contacted by internal communities or external agencies related to patient/client.

Interventions

Coordination, communication, and documentation may include:

* Addressing required functions

- advance directives

- IFSPs or 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

Anticipated goals and expected outcomes related to interventions for coordination, communication, and documentation may include:

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, IFSPs or 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 other, caregiver, 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 trarisportation 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 is the process of informing, educating, or training patients/clients, families, significant others, and caregivers with the intent to promote and optimize physical therapy services. Instruction may be related to the current condition (eg, specific impairments, functional limitations, or disabilities); the plan of care; the need to enhance performance; transition to a different role or setting; risk factors for developing a problem or dysfunction; or the need for health, wellness, and fitness programs.

Physical therapists are responsible for patient/client-related instruction across all settings for all patients/clients.

Clinical Considerations

Considerations that may direct the type and specificity of interventions for patient/client-related instruction may include:

* Patient/client requires instruction to optimize interventions that are designed to decrease impairments, functional limitations, or disabilities.

* Patient/client requires instruction to reduce risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities.

* Patient/client requires instruction that is appropriate for impaired arousal, attention, and cognition that may have an impact on learning and memory.

* Patient/client requires instruction that is appropriate for sensory impairment (eg, vision, hearing) that may affect learning and skill acquisition.

* Patient/client requires instructional or educational assistive technology (eg, large print cards) or environmental accommodations or modifications (eg, enhanced lighting, signage) that may be required for effective learning and skill acquisition.

* Physical therapist identifies potential learning barriers (eg, beliefs, cultural expectations, and language) that must be addressed prior to and throughout patient/client-related instruction and education.

* Physical therapist identifies patient/client impairments, functional limitations, or disabilities that indicate assistance (eg, caregiver, family member, equipment) is required for effective learning and skill acquisition.

* Physical therapist provides instruction and education to patient/client and patient/client support system regarding the plan of care.

* Physical therapist provides instruction when patient/client has identified personal goals for enhanced performance.

* Physical therapist provides instruction when patient/client is transitioning across care settings or performing in a new role that will require an increased or decreased level of service.

* Physical therapist provides instruction when patient/client will benefit from health, wellness, and fitness programs.

Interventions

Patient/client-related instruction may include:

* 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

Anticipated goals and expected outcomes related to patient/client-related instruction may include:

* 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 increased.

* Utilization and cost of health care services are decreased.

Therapeutic Exercise

Therapeutic exercise is the systematic performance or execution of planned physical movements, postures, or activities intended to enable the patient/client to (1) remediate or prevent impairments, (2) enhance function, (3) reduce risk, (4) optimize overall health, and (5) enhance fitness and well-being. Therapeutic exercise may include aerobic and endurance conditioning and reconditioning; agility training; balance training, both static and dynamic; body mechanics training; breathing exercises; coordination exercises; developmental activities training; gait and locomotion training; motor training; muscle lengthening; movement pattern training; neuromotor development activities training; neuromuscular education or reeducation; perceptual training; postural stabilization and training; range-of-motion exercises and soft tissue stretching; relaxation exercises; and strength, power, and endurance exercises.

Physical therapists select, prescribe, and implement exercise activities when the examination findings, diagnosis, and prognosis indicate the use of therapeutic exercise to enhance bone density; enhance breathing; enhance or maintain physical performance; enhance performance in activities of daily living (Al)L) and instrumental activities of daily living (IADL); improve safety; increase aerobic capacity/endurance; increase muscle strength, power, and endurance; enhance postural control and relaxation; increase sensory awareness; increase tolerance to activity; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; enhance health, wellness, and fitness; reduce complications, pain, restriction, and swelling; or reduce risk and increase safety during activity performance.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary 

- integumentary 

- multiple systems

- musculoskeletal 

- neuromuscular

- pulmonary

* Impairments in the following categories:

- aerobic capacity/endurance (eg, decreased walk distance)

- anthropometric characteristics (eg, increased body mass index)

- arousal, attention, and cognition (eg, decreased motivation to participate in fitness activities)

- circulation (eg, abnormal elevation in heart rate with activity)

- cranial and peripheral nerve integrity (eg, difficulty with swallowing, risk of aspiration, positive neural provocation response)

- ergonomics and body mechanics (eg, inability to squat because of weakness in gluteus maximus and quadriceps femoris muscles)

- gait, locomotion, and balance (eg, inability to perform ankle dorsiflexion)

- integumentary integrity (eg, limited finger flexion as a result of dorsal burn scar)

- joint integrity and mobility (eg, limited range of motion in the shoulder)

- motor function (eg, uncoordinated limb movements)

- muscle performance (eg, weakness of lumbar stabilizers)

- neuromotor development and sensory integration (eg, delayed development)

- posture (eg, forward head, kyphosis)

- range of motion (eg, increased laxity in patellofemoral joint)

- reflex integrity (eg, poor balance in standing)

- sensory integrity (eg, lack of position sense)

- ventilation and respiration/gas exchange (eg, abnormal breathing patterns)

* Functional limitations in the ability to perform actions, tasks, and activities in the following categories:

- self-care (eg, difficulty with dressing, bathing)

- home management (eg, difficulty with raking, shoveling, making bed)

- work (job/school/play) (eg, difficulty with keyboarding, pushing, or pulling, difficulty with play activities)

- community/leisure (eg, inability to negotiate steps and curbs)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to assume parenting role, inability to care for elderly relatives, inability to return to work as a police officer)

- community/leisure (eg, difficulty with jogging or playing golf, inability to attend religious services)

* Risk reduction/prevention in the following areas:

- risk factors (eg, need to decrease body fat composition)

- recurrence of condition (eg, need to increase mobility and postural control for work [job/school/play] actions, tasks, and activities)

- secondary impairments (eg, need to improve strength and balance for fall risk reduction)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to improve golf-swing timing, need to maximize gymnastic performance, need to maximize pelvic-floor muscle function)

- health and wellness (eg, need to improve balance for recreation, need to increase muscle strength to help maintain bone density)

Interventions

Therapeutic exercise may include:

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- movement efficiency and energy conservation training

- 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

- sensory training or retraining

- standardized, programmatic, complementary

- exercise approaches

- task-specific performance training

- vestibular training

* Body mechanics and postural stabilization

- body mechanics training

- postural control training

- postural stabilization activities

- posture awareness training

* 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

Anticipated goals and expected outcomes related to therapeutic exercise may include:

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

- Atelectasis is decreased.

- 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.

- Ventilation and respiration/gas exchange are 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 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

- 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 and Instrumental Activities of Daily Living)

Functional training in self-care and home management is the education and training of patients/clients in activities of daffy living (ADL) and instrumental activities of daffy living (IADL). Functional training in self-care and home management is intended to improve the ability to perform physical actions, tasks, or activities in an efficient, typically expected, or competent manner. Self-care includes ADL such as bed mobility, transfers, dressing, grooming, bathing, eating, and toileting. Home management includes more complex IADL, such as caring for dependents, maintaining a home, performing household chores and yard work, shopping, and structured play (for infants and children). Activities may include accommodation to or modification of environmental and home barriers; ADL and IADL training; guidance and instruction in injury prevention or reduction; functional training programs; training in the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment during self-care and home management activities; task simulation and adaptation; and travel training.

Physical therapists select, prescribe, and implement specific training activities when the examination findings, diagnosis, and prognosis indicate the use of functional training in self-care and home management to enhance health, wellness, and fitness; enhance musculoskeletal, neuromuscular, and cardiovascular/pulmonary capabilities; improve body mechanics; increase assumption or resumption of self-care or home management in a safe and efficient manner; increase postural awareness; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk and increase safety during activity performance.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments that have an impact on function in self-care and home management actions, tasks, and activities in the following categories:

- aerobic capacity/endurance (eg, shortness of breath interferes with raking, shoveling, mopping)

- anthropometric characteristics (eg, swollen arm interferes with grooming)

- arousal, attention and cognition (eg, inability to recall sequence of daily routine interferes with dressing)

- circulation (eg, heart rate increases during hair drying)

- cranial and peripheral nerve integrity (eg, paresthesia interferes with bathing)

- ergonomics and body mechanics (eg, pain increases during vacuuming)

- gait, locomotion, and balance (eg, dizziness interferes with climbing stairs into home)

- integumentary integrity (eg, decreased sensation as a result of second degree burns of hand interferes with personal hygiene)

- joint integrity and mobility (eg, hip and knee pain interferes with taking out trash)

- motor function (eg, loss of finger dexterity interferes with use of utensils)

- muscle performance (eg, decreased lower-extremity strength interferes with bathroom transfers)

- neuromotor development and sensory integration (eg, delayed development interferes with self-care)

- posture (eg, cervical posture interferes with desk work)

- range of motion (eg, decreased shoulder range of motion interferes with reaching behind the back to fasten buttons)

- reflex integrity (eg, primitive reflexes interfere with positioning for feeding)

- sensory integrity (eg, altered proprioception interferes with yard work)

- ventilation and respiration (eg, decreased oxygen saturation interferes with showering)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, inability to bottle feed independently, inability to dress and bathe)

- home management (eg, inability to perform meal preparation tasks)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to assume parenting roles)

- community/leisure (eg, inability to serve as volunteer in hospital coffee shop)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to learn correct biomechanics of lifting for daily activities)

- recurrence of condition (eg, need to use assistive device or equipment to perform tasks that are likely to cause rein jury)

- secondary impairments (eg, need to relearn adaptive skills for self-care and home management)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to increase endurance to complete self-care tasks, need to maximize independence in self-care, need to maximize safety in home management)

- health and wellness (eg, need to improve physical ability to paint landscapes, need to increase ability to travel)

Interventions

Functional training in self-care and home management may include:

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Barrier accommodations or modifications

* Device 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 self<are and home management

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- back schools

- 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

Anticipated goals and expected outcomes related to functional training in self-care and home management may include:

* 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 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 Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living, Work Hardening, and Work Conditioning)

Functional training in work Gob/school/play), community, and leisure integration or reintegration is the education and training of patients/clients in assumption and resumption of roles and functions in the work environment, in the community, and during leisure activities so that (1) the physical actions or activities required for these roles and functions are performed in an efficient, typically expected, or competent manner and (2) the expectations of work (job/school/play), community, and leisure roles are fulfilled.

Work integration or reintegration into roles may include functions such as gaining access to work (job/school/play) environments and workstations, participating in work hardening or work conditioning programs, negotiating school environments, and participating in age-appropriate play activities. Activities may include accommodations to or modifications of environmental and work barriers; functional training programs (eg, work hardening or conditioning programs); guidance and instruction in injury prevention or reduction; job coaching; leisure and play activity training; training in instrumental activities of daily living OADL); task simulation and adaptation; training in the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment during work (job/school/play), community, and leisure activities; and travel training. Community integration or reintegration into roles may include activities such as gaining access to transportation (eg, driving a car, boarding a bus), a neighborhood (eg, negotiating curbs, crossing streets), community businesses and services (eg, banking, shopping), and public facilities (eg, attending theaters, town hall meetings, and places of worship). Leisure integration or reintegration is the process of assuming or resuming roles and functions of avocational and enjoyable pastimes, such as recreational activities (eg, playing a sport) and age-appropriate hobbies (eg, collecting antiques, gardening, or making crafts)

Physical therapists select, prescribe, and implement specific training activities when the examination findings, diagnosis, and prognosis indicate the use of functional training in work (job/school/play), community, and leisure integration or reintegration to enhance health, wellness, and fitness; improve body mechanics; improve safety and efficiency of performance of work (job/school/play), community, and leisure actions, tasks, and activities; increase independence in work and community environments; increase postural awareness; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments that have an impact on function in work Gob/school/play), community, and leisure integration or reintegration actions, tasks, and activities in the following categories:

- aerobic capacity/endurance (eg, shortness of breath interferes with loading delivery van)

- anthropometric characteristics (eg, obesity interferes with accessing transportation)

- arousal, attention, and cognition (eg, inability to recall sequencing in assembly-line processing interferes with job)

- circulation (eg, chest pain interferes with walking during cold weather to catch bus)

- cranial and peripheral nerve integrity (eg, tingling of the feet interferes with pushing cart up ramp)

- ergonomics and body mechanics (eg, pain increases with squatting and reaching to stock shelves)

- gait, locomotion, and balance (eg, unsteady gait interferes with walking in the park)

- integumentary integrity (eg, finger numbness interferes with manipulative skills)

- joint integrity and mobility (eg, elbow hypomobility interferes with driving a bus)

- motor function (eg, ataxic movements interfere with keyboarding)

- muscle performance (eg, decreased trunk strength interferes with participation in school physical education activities)

- neuromotor development and sensory integration (eg, inability to go from sitting position to standing position interferes with office activities)

- posture (eg, leg length discrepancy interferes with standing during food preparation)

- range of motion (eg, decreased shoulder and elbow range of motion interferes with tennis swing)

- reflex integrity (eg, decreased postural reflexes or reactions interfere with walking in a crowd)

- sensory integrity (eg, altered proprioception interferes with stadium stair climbing)

- ventilation and respiration (eg, shortness of breath interferes with postal carrier's mail delivery)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- work (job/school/play) integration or reintegration (eg, inability to perform manual labor)

- community/leisure integration or reintegration (eg, inability to get on and off a train, difficulty with sports activities)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to practice as a surgeon)

- community/leisure (eg, inability to participate in League of Women Voters, inability to participate in local park cleanup, inability to participate as member of community soccer team)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to use correct protective equipment for a given task)

- recurrence of condition (eg, need to learn correct balance of work, rest, and stretching) secondary impairments (eg, need to correctly train for each new task)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to maximize independence or safety in work [job/school/play]), community, and leisure; need to increase endurance to complete work [job/school/play], community, and leisure tasks)

- health and wellness (eg, need to improve breathing efficiency for singing in choir, need to increase strength for community environmental work)

Interventions

Functional training in work (job/school/play), community, and leisure integration or reintegration may include:

* Barrier accommodations or modifications

* Device and equipment use and training

- assistive and adaptive device or equipment training during IADL

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

- prosthetic device or equipment training during IADL

* Functional training programs

- back schools

- job coaching

- simulated environments and tasks

- task adaptation

- task training

- travel training

- work conditioning

- work hardening

* 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 education with use of devices and equipment

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

* Leisure and play activities and training

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to functional training in work (job/school/play), community, and leisure integration or reintegration may include:

* 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)

Manual therapy techniques are skilled hand movements intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or restriction. Procedures and modalities may include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion.

Physical therapists select, prescribe, and implement manual techniques when the examination findings, diagnosis, and prognosis indicate use of manual therapy to decrease edema, pain, spasm, or swelling; enhance health, wellness, and fitness; enhance or maintain physical performance; increase the ability to move; or prevent or remediate impairments, functional limitations, or disabilities to improve physical function.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

- vascular

* Impairments in the following categories:

- anthropometric characteristics (eg, increased limb girth)

- cranial and peripheral nerve integrity (eg, pain on forward bending)

- ergonomics and body mechanics (eg, inability to flex knee)

- gait, locomotion, and balance (eg, inability to flex hip)

- integumentary integrity (eg, decreased skin extensibility)

- joint integrity and mobility (eg, decreased joint play)

- motor function (eg, decreased agility)

- muscle performance (eg, decreased muscle strength)

- posture (eg, forward head)

- range of motion (eg, inability to flex, abduct, and externally rotate hip)

- ventilation and respiration (eg, decreased rib cage mobility)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with brushing teeth, combing hair, sit-to-stand activities)

- home management (eg, difficulty with carrying loads, painting, shoveling)

- work (job/school/play) (eg, difficulty with typing, driving a car)

- community/leisure (eg, inability to ride bicycle)

* Disability--that is, the inability or the restricted ability toperform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (job/school/play) (eg, inability to assume role as family caregiver, inability to resume job as first violinist in orchestra)

- community/leisure (eg, difficulty with varsity swimming, inability to volunteer at neighborhood school)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to perform preventive stretching)

- recurrence of condition (eg, need to learn cycle of dependent position/elevation for edema control)

- secondary impairments (eg, need to continue home traction and massage to maintain mobility)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to increase muscle length to optimize fitness, need to maximize flexibility for ballet)

- health and wellness (eg, need to improve relaxation, need to increase flexibility for yoga)

Interventions

Manual therapy techniques may include:

* Manual lymphatic drainage

* Manual traction

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to manual therapy techniques may include:

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

- Edema, lymphedema, or effusion is decreased.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased

- Pain is decreased.

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

* Impact on impairments

- Airway clearance is improved.

- 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

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

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

* Patient/client satisfaction

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

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

- Coordination of care is acceptable to patient/client.

- 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.

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

Prescription, application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment are processes to select, provide, and train for utilization of therapeutic implements and equipment that are intended to (1) aid patients/clients in performing tasks or movements, (2) support weak or ineffective joints or muscles and serve to enhance performance, (3) replace a missing part of the body, or (4) adapt the environment to facilitate functional performance of activities related to self-care, home management, work, community, and leisure. These devices and equipment may include adaptive, assistive, orthotic, protective, supportive, and prosthetic devices.

Physical therapists prescribe, apply, and, as appropriate, fabricate devices and equipment when the examination findings, diagnosis, and prognosis indicate the use of devices and equipment to decrease edema and swelling; enhance health, wellness, and fitness; enhance performance and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL); enhance or maintain physical performance; increase alignment, mobility, or stability; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; protect body parts; or reduce risk factors and complications.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments in the following categories:

- aerobic capacity/endurance (eg, increased shortness of breath during ambulation with prosthesis)

- anthropometric characteristics (eg, weight gain interferes with orthotic fit)

- arousal, attention, and cognition (eg, decreased attention interferes with safety)

- circulation (eg, decreased peripheral circulation alters venous return)

- cranial and peripheral nerve integrity (eg, loss of sensation)

- ergonomics and body mechanics (eg, back pain)

- gait, locomotion, and balance (eg, footdrop)

- integumentary integrity (eg, pressure ulcer)

- joint integrity and mobility (eg, joint hypermobility)

- motor function (eg, loss of coordination)

- muscle performance (eg, decreased lower-extremity strength)

- neuromotor development and sensory integration (eg, delayed development)

- posture (eg, abnormal foot alignment)

- range of motion (eg, increased hallux adduction)

- reflex integrity (eg, decreased protective reactions)

- sensory integrity (eg, altered proprioception)

- ventilation and respiration/gas exchange (eg, paradoxical breathing)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with entering bathtub)

- home management (eg, difficulty with keyboarding while ordering groceries)

- work (job/school/play) (eg, difficulty with violin playing)

- community/leisure (eg, difficulty with answering hotline telephones without headset, inability to gain access to playground)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to lift child without back support, inability to stand comfortably without orthotics while waitressing)

- community/leisure (eg, difficulty with jogging without pregnancy sling, inability to attend dancing lessons without prosthesis)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to properly monitor skin)

- recurrence of condition (eg, need to use protective seating system)

- secondary impairments (eg, need to continue use of prosthetic device for activity)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to maximize performance with knee brace at the Special Olympics, need to enhance aerobic performance with supplemental oxygen)

- health and wellness (eg, need to enhance endurance for dancing, need to improve use of assistive, adaptive, orthotic, protective, supportive, or prosthetic device during violin practice)

Interventions

Prescription, application, and, as appropriate, fabrication of devices and equipment may include:

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- percussors and vibrators

- 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

- mechanical ventilators

- neck collars

- serial casts

- slings

- supplemental oxygen

- supportive taping

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to prescription, application, and, as appropriate, fabrication of devices and equipment may include:

* 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

- 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 stability is in, proved.

- 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.

- Ventilation and respiration/gas exchange are 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 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

- 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

Airway clearance techniques are a group of therapeutic activities intended to manage or prevent the consequences of impaired mucociliary transport or the inability to protect the airway (eg, impaired cough). Techniques may include breathing strategies for airway clearance, manual/mechanical techniques for airway clearance, positioning, and pulmonary postural drainage.

Physical therapists select, prescribe, and implement airway clearance activities when the examination findings, diagnosis, and prognosis indicate the use of airway clearance techniques to enhance exercise performance; enhance health, wellness, or fitness; enhance or maintain physical performance; improve cough; improve ventilation; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments in the following categories:

- aerobic capacity/endurance (eg, persistent coughing)

- anthropometric characteristics (eg, decreased cough because of obesity)

- arousal, attention, and cognition (eg, inability to understand directions)

- circulation (eg, bilateral pedal edema)

- cranial and peripheral nerve integrity (eg, decreased gag/cough reflex)

- joint integrity and mobility (eg, decreased thoracic mobility) muscle performance (eg, decreased ventilatory muscle strength)

- neuromotor development and sensory integration (eg, coughing on change of position)

- posture (eg, decreased thoracic mobility because of scoliosis)

- ventilation and respiration (eg, increased secretions)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with dressing and bathing because of increased wheezing)

- home management (eg, difficulty with vacuuming because of persistent coughing)

- work (job/school/play) (eg, difficulty with repetitive overhead activities because of shortness of breath)

- community/leisure (eg, inability to negotiate steps because of shortness of breath)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to assume role as caregiver of spouse, inability to return to work at a construction site)

- community/leisure (eg, difficulty with walking to post office, inability to attend a theater performance)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to pursue smoking cessation)

- recurrence of condition (eg, need to continue home airway clearance techniques)

- secondary impairments (eg, need to strengthen muscles of breathing)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to increase diaphragmatic muscle strength, need to maximize breathing capabilities during aerobic class)

- health and wellness (eg, need to increase relaxation for breathing control during speaking, need to optimize oxygen use while providing elder services)

Interventions

Airway clearance techniques may include:

* 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, stair case 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

Anticipated goals and expected outcomes related to airway clearance techniques may include:

* 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

- 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.

Integumentary Repair and Protection Techniques

Integumentary repair and protection techniques involve the application of therapeutic procedures and modalities that are intended to enhance wound perfusion, manage scar, promote an optimal wound environment, remove excess exudate from a wound complex, and eliminate nonviable tissue from a wound bed. Procedures and modalities may include debridement; dressings; orthotic, protective, and supportive devices; physical agents and mechanical and electrotherapeutic modalities; and topical agents.

Physical therapists select, prescribe, and implement procedures and modalities when the examination findings, diaggnosis, and prognosis indicate the use of integumentary repair and protection techniques to enhance tissue perfusion; enhance wound and soft tissue healing; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments in the following categories:

- anthropometric characteristics (eg, increased limb girth)

- circulation (eg, decreased peripheral perfusion) cranial and peripheral nerve integrity (eg, decreased hand sensation as a result of burn)

- gait, locomotion, and balance (eg, decreased balance as a result of foot ulcer pain)

- integumentary integrity (eg, open wound) joint integrity and mobility (eg, limited elbow range of motion because of scar)

- muscle performance (eg, limited strength because of wound pain)

- neuromotor development and sensory integration (eg, knee abrasions because of creeping)

- posture (eg, pressure ulcer because of prolonged sitting)

- range of motion (eg, decreased range of thorax motion as a result of surgical wound)

- reflex integrity (eg, altered withdrawal response)

- sensory integrity (eg, decreased proprioception)

- ventilation and respiration/gas exchange (eg, delayed wound healing because of impaired tissue oxygenation)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with wearing shoes as a result of edematous wound)

- home management (eg, difficulty with dish washing as a result of dermatitis)

- work (job/school/play) (eg, difficulty with lifting and bending because of burn scars, inability to sit in school because of sacral decubitus ulcer)

- community/leisure (eg, inability to go to bank because of residual limb pressure ulcer)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to assume role as parent because of infected wound, inability to return to work as a toll taker because of sensation loss in fingers)

- community/leisure (eg, inability to swim competitively because of skin breakdown, inability to attend school social events because of low serf-esteem associated with facial scarring)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to properly monitor skin)

- recurrence of condition (eg, need to protect skin surfaces)

- secondary impairments (eg, need to maintain scar mobility)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to limit sun exposure during gardening, need to promote foot skin protection during marathon training)

- health and wellness (eg, need to improve nutrition and hydration, need to understand personal and environmental factors that promote optimal health status)

Interventions

Integumentary repair and protection techniques may include:

* Debridement--nonselective

- enzymatic debridement

- wet dressings

- wet-to-dry dressings

- wet-to-moist dressings

* Debridement--selective

- debridement with other agents (eg, autolysis)

- enzymatic debridement

- sharp debridement

* Dressings

- hydrogels

- vacuum-assisted closure

- wound coverings

* Oxygen therapy

- supplemental

- topical

* Topical agents

- cleansers

- creams

- moisturizers 

- ointments 

- sealants

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to integumentary repair and protection techniques may include:

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

- Debridement of nonviable tissue is achieved.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue or wound healing is enhanced.

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

- Tissue perfusion and oxygenation are enhanced.

- Wound size is reduced.

* Impact on impairments

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

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

- Postural control is improved.

- Range of motion is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care, 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.

Electrotherapeutic Modalities

Electrotherapeutic modalities are a broad group of agents that use electricity and are intended to assist functional training; assist muscle force generation and contraction; decrease unwanted muscular activity; increase the rate of healing of open wounds and soft tissue; maintain strength after injury or surgery; modulate or decrease pain; or reduce or eliminate soft tissue swelling, inflammation, or restriction. Modalities may include biofeedback, electrical stimulation (muscle and nerve), and electrotherapeutic delivery of medication.

Physical therapists select, prescribe, and implement these modalities when the examination findings, diagnosis, and prognosis indicate the use of electrotherapeutic modalities to decrease edema and swelling; enhance activity and task performance; enhance health, wellness, or fitness; enhance or maintain physical performance; enhance wound healing; increase joint mobility, muscle performance, and neuromuscular performance; increase tissue perfusion; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; or reduce risk factors and complications.

The use of electrotherapeutic modalities in the absence of other interventions should not be considered physical therapy unless there is documentation that justifies the necessity of their exclusive use.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments in the following categories:

- aerobic capacity/endurance (eg, increased pain with activity)

- anthropometric characteristics (eg, edema)

- circulation (eg, increased limb girth)

- cranial and peripheral nerve integrity (eg, decreased muscle

- activity because of peripheral nerve compression)

- ergonomics and body mechanics (eg, abnormal sequencing of muscle activation)

- gait, locomotion, and balance (eg, incoordination in gait)

- integumentary integrity (eg, open wound)

- joint integrity and mobility (eg, increased joint play)

- motor function (eg, muscle hypertonicity)

- muscle performance (eg, increased muscle spasm)

- neuromotor development and sensory integration (eg, atypical movement patterns)

- posture (eg, static deviation from midline)

- range of motion (eg, increased joint laxity)

- ventilation and respiration/gas exchange (eg, decreased rib cage symmetry)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with rolling, sitting, reaching; inability to dress and bathe)

- home management (eg, difficulty with cleaning, cooking, vacuuming)

- work (job/school/play) tasks (eg, difficulty with manual handling, shoveling)

- community/leisure (eg, difficulty with walking, lifting)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to return to work as court stenographer because of lack of coordination in upper extremities, inability to take care of child because of loss of strength)

- community/leisure (eg, difficulty with card playing because of loss of dexterity, inability to visit friends because of wound)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to learn stress management)

- recurrence of condition (eg, need to continue strengthening program)

- secondary impairments (eg, need to appropriately use transcutaneous electrical nerve stimulation [TENS] for pain management)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to routinely use functional electrical stimulation [FES] to maximize muscle contraction)

- health and wellness (eg, need to increase muscle force to optimize bone density, need to modulate pain during hospital volunteering)

Interventions

Electrotherapeutic modalities may include:

* Biofeedback

* Electrotherapeutic delivery of medications

- iontophoresis 

* Electrical stimulation

- electrical muscle stimulation (EMS)

- electrical stimulation for tissue repair (ESTR)

- functional electrical stimulation (FES)

- high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to electrotherapeutic modalities may include:

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

- Edema, lymphedema, or effusion is decreased.

- 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.

- 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

- Complications of immobility are reduced.

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- 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.

- 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 are a broad group of procedures using various forms of energy that are applied to tissues in a systematic manner and that are intended to increase connective tissue extensibility; increase the healing rate of open wounds and soft tissue; modulate pain; reduce or eliminate soft tissue swelling, inflammation, or restriction associated with musculoskeletal injury or circulatory dysfunction; remodel scar tissue; or treat skin conditions. These agents may include athermal, cryotherapy, hydrotherapy, light, sound, and thermotherapy agents. Mechanical modalities are a group of devices that use forces such as approximation, compression, and distraction and that are intended to improve circulation, increase range of motion, modulate pain, or stabilize an area that requires temporary support. These modalities may include compression therapies, gravity-assisted compression devices, mechanical motion devices, and traction devices.

Physical therapists select, prescribe, and implement use of these agents and modalities when the examination findings, diagnosis, and prognosis indicate the use of physical agents or mechanical modalities to decrease neural compression; decrease pain and swelling; decrease soft tissue and circulatory disorders; enhance airway clearance; enhance movement performance; enhance or maintain physical performance; improve joint mobility; improve tissue perfusion; prevent or remediate impairments, functional limitations, or disabilities to improve physical function; reduce edema; or reduce risk factors and complications.

The use of physical agents or mechanical modalities in the absence of other interventions should not be considered physical therapy unless there is documentation that justifies the necessity of their exclusive use.

Clinical Considerations

Examination findings that may direct the type and specificity of the procedural intervention may include:

* Pathology/pathophysiology (disease, disorder, or condition), history (including risk factors) of medical/surgical conditions, or signs and symptoms (eg, pain, shortness of breath, stress) in the following systems:

- cardiovascular

- endocrine/metabolic

- genitourinary

- integumentary

- multiple systems

- musculoskeletal

- neuromuscular

- pulmonary

* Impairments in the following categories:

- aerobic capacity/endurance (eg, decreased muscle endurance)

- anthropometric characteristics (eg, increased edema)

- circulation (eg, decreased peripheral circulation)

- cranial and peripheral nerve integrity (eg, neural compression)

- ergonomics and body mechanics (eg, segment instability)

- gait, locomotion, and balance (eg, antalgic gait)

- integumentary integrity (eg, skin condition irritated by device)

- joint integrity and mobility (eg, increased joint compression)

- muscle performance (eg, incontinence because of decreased muscle strength)

- neuromotor development and sensory integration (eg, limited tolerance to upright position)

- posture (eg, abnormal postural alignment)

- range of motion (eg, postoperative limitation of motion)

- reflex integrity (eg, decreased deep reflex response)

- sensory integrity (eg, altered proprioception)

- ventilation and respiration (eg, small airway congestion)

* Functional limitations in the ability to perform actions, tasks, or activities in the following categories:

- self-care (eg, difficulty with hair care and ironing, inability to maintain positions)

- work (job/school/play) (eg, difficulty with operating heavy machinery, difficulty with washing windows)

- community/leisure (eg, difficulty with serving in soup kitchen)

* Disability--that is, the inability or the restricted ability to perform actions, tasks, or activities of required roles within the individual's sociocultural context--in the following categories:

- work (eg, inability to return to work as a taxi driver because of neck pain, inability to put child in car seat because of back pain)

- community/leisure (eg, difficulty with jogging with baby stroller because of Achilles tendinitis, inability to go to the movies as a result of incontinence)

* Risk reduction/prevention needs in the following areas:

- risk factors (eg, need to learn how to use proper lower-limb compressive garments)

- recurrence of condition (eg, need to continue daily standing program)

- secondary impairments (eg, need to participate in continuous exercise program)

* Health, wellness, and fitness needs:

- fitness, including physical performance (eg, need to increase muscle length for aquatics, need to maximize pelvic-floor muscle function)

- health and wellness (eg, need to increase circulation during skating, need to modulate pain during shopping)

Interventions

Physical agents may include:

* Athermal agents

- pulsed electromagnetic fields 

* Cryotherapy

- cold packs

- ice massage

- vapocoolant spray

* Hydrotherapy

- contrast bath

- pools

- pulsatile lavage 

- whirlpool tanks

* Light agents

- infrared

- laser

- ultraviolet 

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

- paraffin baths 

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

* Mechanical motion devices

- continuous passive motion (CPM)

* Traction devices

- intermittent 

- positional

- sustained

Anticipated Goals and Expected Outcomes

Anticipated goals and expected outcomes related to physical agents and mechanical modalities may include:

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

- Atelectasis is decreased.

- Debridement of nonviable tissue is achieved.

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Neural compression is decreased.

- 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

- Airway clearance is improved.

- Integumentary integrity is improved.

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

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

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

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

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

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

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

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

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

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

PART TWO: Preferred Practice Patterns

Musculoskeletal

Neuromuscular

Cardiovascular/Pulmonary

Integumentary

How to Use the Preferred Practice Patterns

Part Two contains the preferred practice patterns, which are grouped under flour categories of conditions: Musculoskeletal (Chapter 4), Neuromuscular (Chapter 5), Cardiovascular/Pulmonary (Chapter 6), and Integumentary (Chapter 7). A table of contents preceding each set of patterns lists the pattern titles for that set. Below is an at-a-glance depiction of the contents of each pattern; on the following pages, take a walk through one example of how physical therapists may use Part Two in the management of patients/clients.

Contents of Each Pattern at a Glance

(1) Patient/Client Diagnostic Classification

* Criteria for inclusion (based on examination findings regarding risk factors or consequences of pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

* Criteria for exlusion from pattern or for multiple-pattern classification (based on examination findings)

(2) ICD-9-CM Codes

Codes that may relate to the practice pattern--intended only for information purposes, not for coding purposes

The Five Elements of Patient/Client Management

(3) Examination

Description of the history, systems review, and tests and measures that generate data that help the physical therapist confirm classification of the patients/clients in the pattern

(4) Evaluation, Diagnosis, and Prognosis

(Including Plan of Care)

Description of the evaluation, diagnostic, and prognostic processes, including the expected range of number of visits and factors that may require a new episode of care or that may modify frequency of visits and duration of the episode

(5) Intervention

A listing of the interventions that may be used for patients/clients who are classified in the pattern

(6) Reexamination, Global Outcomes, and Criteria for Termination of Physical Therapy Services

Description of when reexamination is indicated; measurement of global outcomes of physical therapy services in 8 domains; the 2 ways in which physical therapy services are terminated

Examination

First, the patient/client provides a history. Through the history, the physical therapist gathers data--from both the past and the present--related to why the patient/client is seeking physical therapy services. Through the history, the physical therapist learns the chief complaints of the patient/client--in this example, the inability to walk without pain and a sensation of "buckling" in both knees and the inability to participate in recreational sports.

Next, the physical therapist performs a systems review, which is a brief examination of the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. The systems review not only helps focus the examination, it indicates whether the patient/client should be referred for other health care services in addition to physical therapy. In this example, the systems review findings indicate that the patient/client has impairments in the cardiovascular/pulmonary system (high blood pressure at rest), musculoskeletal system (impaired gross range of motion, impaired gross strength, disproportionate weight for height), and neuromuscular system (impaired gait, impaired balance). The systems review suggests there are no current impairments in the integumentary system; however, the history shows the presence of diabetes, which is a risk factor for cardiovascular/pulmonary, neuromuscular, and integumentary conditions. There are no limitations in communication, affect, cognition, language, and learning style.

Based on the history and systems review findings, the physical therapist notes key clinical indications for the use of particular tests and measures during the in-depth portion of the examination. (For examples of clinical indications for the use of tests and measures, refer to Chapter 2.) The key clinical indications in this case example: impaired gait; impaired joint integrity and mobility; impaired muscle performance; and a history of diabetes, hypertension, and morbid obesity. Based on these key clinical indications, the physical therapist decides to examine the following test-and-measure categories in detail: aerobic capacity/endurance, circulation (arterial, venous, and lymphatic), community and work (job/school/play) integration or reintegration (including instrumental activities of daily living [IADL]); environmental, home, and work (job/school/play) barriers; gait, locomotion, and balance; joint integrity and mobility; muscle performance (strength, power, and endurance); pain; range of motion (including muscle length); self-care and home management (including activities of daily living [ADL] and IADL), and ventilation and respiration/gas exchange. Due to the presence of cardiovascular/pulmonary risk factors such as hypertension, the monitoring of vital signs during ambulation will be an important part of the in-depth examination.

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

During the evaluation process, all data from the history, systems review, and tests and measures are synthesized to establish the diagnosis and the prognosis, including the plan of care.

In this example, based on the evaluation of the history, systems review, and tests-and-measures data, the physical therapist determines that the patient/client has the following primary impairments: impaired joint integrity and mobility in the knees; decreased muscle performance; decreased range of motion; and decreased aerobic capacity/endurance with ambulation. The physical therapist hypothesizes that the morbid obesity may be contributing to the knee pain as well as to the decrease in aerobic capacity/endurance.

The physical therapist notes the following functional limitations: difficulty in performing ADL and IADL, inability to run bases during softball league games, and inability to perform heavy household chores. Disability is noted in the following roles: community/leisure (inability to participate on the league softball team), work (job/school/play) (inability to walk to different work sites within the same plant), and home management (inability to perform as homemaker).

Even though patients/clients may be referred to physical therapy services with a medical diagnosis, that does not tell the physical therapist how to manage the patient/client. The medical diagnosis is a diagnostic label that identifies disease at the level of the cell, tissue, organ, or system. In this case, for instance, the medical diagnosis may be osteoarthritis of the knees. The physical therapist's diagnosis, however, is a diagnostic label that identifies the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person. The physical therapist's goal is to restore function, and therefore the physical therapist's examination, evaluation, and interventions focus on impairments, functional limitations, disabilities, risk factor reduction, and prevention.

In this example, the physical therapist determines that decreased muscle performance, decreased range of motion, and pain are the primary contributors to the identified functional limitations. The physical therapist also has noted that the patient/client has decreased aerobic/capacity endurance. The physical therapist therefore focuses on four preferred practice patterns: "Impaired Muscle Performance" (Pattern 4C) "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction" (Pattern 4D) "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4E) and "Impaired Aerobic Capacity/Endurance Associated With Deconditioning" (Pattern 6B).

The physical therapist considers the primary impairments to determine which of the four possible patterns may be the most appropriate classification for the patient/client. The physical therapist scans the inclusions and exclusions for each pattern and the ICD-9-CM codes that are listed in each pattern. If the physical therapist remains uncertain about patient/client classification, the tests-and-measures sections of the individual patterns may suggest additional tests and measures that the physical therapist can perform to confirm placement of the patient/client into a pattern.

In this example, the history and systems review show signs and symptoms of joint effusion but indicate that joint integrity and mobility are not contributing factors. The physical therapist therefore classifies the patient/client in "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4F). The patient/client also has a history of diabetes. If the physical therapist determines that patient/client monitoring for primary prevention of lower-extremity vascular problems and the need to increase aerobic capacity are high priorities, the physical therapist may place the patient/client in an additional pattern: "Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders" (Pattern 6B).

Based on the evaluation, the physical therapist makes the prognosis--that is, determines the predicted optimal level of improvement in function and the amount of time needed to reach that level. The physical therapist refers to the evaluation section of the selected pattern to ascertain whether the therapist's prediction of improvement, frequency of visits, and duration of episode of care are consistent with the expected prognosis and range of number of visits for patients/clients who are classified in that pattern. The physical therapist also notes any factors (eg, age, chronicity or severity of the current condition, adherence to the intervention program) that may modify the frequency of visits or duration of the episode.

In this example, on the basis of such modifying factors as extremely high patient/client motivation, the physical therapist may determine that the patient/client will require fewer visits than are expected to achieve the anticipated goals and expected outcomes for 80% of patients/clients who are classified in the pattern. On the other hand, the presence of morbid obesity may indicate that the patient/client may not be able to improve aerobic capacity/endurance at an expected rate. In addition, if the hypertension and diabetes become uncontrolled, the ability of the patient/client to participate in physical therapy may be affected.

Intervention

As part of the prognostic process, the physical therapist develops a plan of care. This plan delineates the types of interventions (physical therapy procedures and techniques) to be used to produce changes in the condition and in patient/client status, the frequency and duration of those interventions, anticipated goals, expected outcomes, and discharge plans. Anticipated goals and expected outcomes should be measurable and time limited.

Each pattern contains a listing of interventions that are likely to be used for patients/clients who are classified in the pattern. Coordination, communication, and documentation and patient/client-related instruction are interventions that are provided to all patients/clients across all settings. The use of procedural interventions varies for the particular patient/client in the specific pattern. (For examples of clinical considerations for the use of procedural interventions, refer to Chapter 3.) In this example, the physical therapist might select interventions that emphasize therapeutic exercise, functional training in self-care and home management (including ADL and IADL), and functional training in community and work (job/school/play) integration or reintegration (including IADL, work hardening, and work conditioning) in addition to interventions to modulate pain and diminish the effects of joint effusion.

Reexamination, Global Outcomes, and Criteria for Termination of Physical Therapy Services

Reexamination--the process of performing selected tests and measures after the initial examination to determine progress and modify or redirect interventions--may be indicated more than once during a single episode of care. In this example, the physical therapist may decide to perform a reexamination if the patient/client develops a new condition or shows no progress.

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These goals and outcomes are delineated in the shaded boxes that accompany each list of interventions in each 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 (that is, the impact) of the physical therapy services in the following domains: pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/prevention; impact on health, wellness, and fitness; societal resources; and patient/client satisfaction.

The physical therapist uses two processes for terminating physical therapy services: discharge and discontinuation. If the physical therapist determines that the anticipated goals and expected outcomes have been achieved, the patient/client is discharged from physical therapy services. Physical therapy services are discontinued (1) when the patient/client declines to continue intervention, (2) when the patient/client is unable to continue to progress toward the anticipated goals and expected outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended, or (3) when the physical therapist determines that the patient/client will no longer benefit from physical therapy.

A template for documenting all aspects of patient/client management, including termination of physical therapy services, is provided in Appendix 6. Patient/client satisfaction outcomes may be collected using the Patient/Client Satisfaction Questionnaire in Appendix 7.