Who Are Physical Therapists, and What Do They Do?

Education and Qualifications

Physical therapists are professionally educated at the0 college or university level and are required to be licensed in the state or states in which they practice. Graduates from 1926 to 1959 completed physical therapy curricula approved by appropriate accreditation bodies. Graduates from 1960 to the present have successfully completed professional physical therapist education programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). As of January 2002, CAPTE accreditation is limited to only those professional education programs that award the postbaccalaureate degree.

Physical therapists also may be certified as clinical specialists through the American Board of Physical Therapy Specialties (ABPTS).

Practice Settings

Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings, including the following:

* Hospitals (eg, critical care, intensive care, acute care, and subacute care settings)

* Outpatient clinics or offices

* Rehabilitation facilities

* Skilled nursing, extended care, or subacute facilities

* Homes

* Education or research centers

* Schools and playgrounds (preschool, primary, and secondary)

* Hospices

* Corporate or industrial health centers

* Industrial, workplace, or other occupational environments

* Athletic facilities (collegiate, amateur, and professional)

* Fitness centers and sports training facilities

Patients and Clients

Physical therapists are committed to providing necessary and high-quality services to both patients and clients. Patients are individuals who are the recipients of physical therapy examination, evaluation, diagnosis, prognosis, and intervention and who have a disease, disorder, condition, impairment, functional limitation, or disability. Clients are individuals who engage the services of a physical therapist and who can benefit from the physical therapist's consultation, interventions, professional advice, prevention services, or services promoting health, wellness, and fitness. Clients also are businesses, school systems, and others to whom physical therapists provide services. The generally accepted elements of patient/client management typically apply to both patients and clients.

Scope of Practice

Physical therapy is defined as the care and services provided by or under the direction and supervision of a physical therapist. Physical therapists are the only professionals who provide physical therapy. Physical therapist assistants--under the direction and supervision of the physical therapist--are the only paraprofessionals who assist in the provision of physical therapy interventions. APTA therefore recommends that federal and state government agencies and other third-party payers require physical therapy to be provided only by a physical therapist or under the direction and supervision of a physical therapist. Examination, evaluation, diagnosis, and prognosis should be represented and reimbursed as physical therapy only when they are performed by a physical therapist. Intervention should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist.

Physical therapists:

* Provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. In the context of the model of disablement[1-4] on which this Guide is based, impairment is defined as loss or abnormality of anatomical, physiological, mental, or psychological structure or function; functional limitation is defined as restriction of the ability to perform, at the level of the whole person, a physical action, task, or activity in an efficient, typically expected, or competent manner; and disability is defined as the inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles that are customary for the individual or expected for the person's status or role in a specific sociocultural context and physical environment.

* Interact and practice in collaboration with a variety of professionals. The collaboration may be with physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, audiologists, and any other personnel involved with the patient/client. Physical therapists acknowledge the need to educate and inform other professionals, government agencies, third-party payers, and other health care consumers about the cost-efficient and clinically effective services that physical therapists provide.

* Address risk. Physical therapists identify risk factors and behaviors that may impede optimal functioning.

* Provide prevention and promote health, wellness, and fitness. Physical therapists provide prevention services that forestall or prevent functional decline and the need for more intense care. Through timely and appropriate screening, examination, evaluation, diagnosis, prognosis, and intervention, physical therapists frequently reduce or eliminate the need for costlier forms of care and also may shorten or even eliminate institutional stays. Physical therapists also are involved in promoting health, wellness, and fitness initiatives, including education and service provision, that stimulate the public to engage in healthy behaviors.

* Consult, educate, engage in critical inquiry, and administrate. Physical therapists provide consultative services to health facilities, colleagues, businesses, and community organizations and agencies. They provide education to patients/clients, students, facility staff, communities, and organizations and agencies. Physical therapists also engage in research activities, particularly those related to substantiating the outcomes of service provision. They provide administrative services in many different types of practice, research, and education settings.

* Direct and supervise the physical therapy service, including support personnel. Physical therapists oversee all aspects of the physical therapy service. They supervise the physical therapist assistant (PTA) when PTAs provide physical therapy interventions as selected by the physical therapist. Physical therapists also supervise any support personnel as they perform designated tasks related to the operation of the physical therapy service.

Roles in Primary Care

Physical therapists have a major role to play in the provision of primary care, which has been defined as

   the provision of integrated, accessible health care services by clinicians
   who are accountable for addressing a large majority of personal health care
   needs, developing a sustained partnership with patients, and practicing
   within the context of family and community.[5]

APTA has endorsed the concepts of primary care set forth by the Institute of Medicine's Committee on the Future of Primary Care,[5] including the following:

* Primary care can encompass myriad needs that go well beyond the capabilities and competencies of individual caregivers and that require the involvement and interaction of varied practitioners.

* Primary care is not limited to the "first contact" or point of entry into the health care system.

* The primary care program is a comprehensive one.

On a daily basis, physical therapists practicing across acute, rehabilitative, and chronic stages of care assist patients/clients in restoring health, alleviating pain, and examining, evaluating, and diagnosing impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Intervention, prevention, and the promotion of health, wellness, and fitness are a vital part of the practice of physical therapists. As clinicians, physical therapists are well positioned to provide services as members of primary care teams.

For acute musculoskeletal and neuromuscular conditions, triage and initial examination are appropriate physical therapist responsibilities. The primary care team may function more efficiently when it includes physical therapists, who can recognize musculoskeletal and neuromuscular disorders, perform examinations and evaluations, establish a diagnosis and prognosis, and intervene without delay. For patients/clients with low back pain, for example, physical therapists can provide immediate pain reduction through programs for pain modification, strengthening, flexibility, endurance, and postural alignment; instruction in activities of daily living (ADL); and work modification. Physical therapy intervention may result not only in more efficient and effective patient care but also in more appropriate utilization of other members of the primary care team. With physical therapists functioning in a primary care role and delivering early intervention for work-related musculoskeletal injuries, time and productivity loss due to injuries may be dramatically reduced.

For certain chronic conditions, physical therapists should be recognized as the principal providers of care within the collaborative primary care team. Physical therapists are well prepared to coordinate care related to loss of physical function as a result of musculoskeletal, neuromuscular, cardiovascular/pulmonary, or integumentary disorders. Through community-based agencies and school systems, physical therapists coordinate and integrate provision of services to patients/clients with chronic disorders.

Physical therapists also provide primary care in industrial or workplace settings, in which they manage the occupational health services provided to employees and help prevent injury by designing or redesigning the work environment. These services focus both on the individual and on the environment to ensure comprehensive and appropriate intervention.

Roles in Secondary and Tertiary Care

Physical therapists play major roles in secondary and tertiary care. Patients with musculoskeletal, neuromuscular, cardiovascular/pulmonary, or integumentary conditions may be treated initially by another practitioner and then referred to physical therapists for secondary care. Physical therapists provide secondary care in a wide range of settings, including acute care and rehabilitation hospitals, outpatient clinics, home health, and school systems.

Tertiary care is provided by physical therapists in highly specialized, complex, and technology-based settings (eg, heart and lung transplant services, burn units) or in response to other health care practitioners' requests for consultation and specialized services (eg, for patients with spinal cord lesions or closed-head trauma).

Roles in Prevention and in the Promotion of Health, Wellness, and Fitness

Physical therapists are involved in prevention; in promoting health, wellness, and fitness; and in performing screening activities. These initiatives decrease costs by helping patients/clients (1) achieve and restore optimal functional capacity; (2) minimize impairments, functional limitations, and disabilities related to congenital and acquired conditions; (3) maintain health (thereby preventing further deterioration or future illness); and (4) create appropriate environmental adaptations to enhance independent function.

There are three types of prevention in which physical therapists are involved:

* Primary prevention. Preventing a target condition in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts.

* Secondary prevention. Decreasing duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention.

* Tertiary prevention. Limiting the degree of disability and promoting rehabilitation and restoration of function in patients with chronic and irreversible diseases.

Physical therapists conduct screenings to determine the need for (1) primary, secondary, or tertiary prevention services; (2) further examination, intervention, or consultation by a physical therapist; or (3) referral to another practitioner. Candidates for screening generally are not patients/clients currently receiving physical therapy services. Screening is based on a problem-focused, systematic collection and analysis of data.

Examples of the prevention screening activities in which physical therapists engage include:

* Identification of lifestyle factors (eg, amount of exercise, stress, weight) that may lead to increased risk for serious health problems

* Identification of children who may need an examination for idiopathic scoliosis

* Identification of elderly individuals in a community center or nursing home who are at high risk for falls

* Identification of risk factors for neuromusculoskeletal injuries in the workplace

* Pre-performance testing of individuals who are active in sports

Examples of prevention activities and health, wellness, and fitness promotion activities in which physical therapists engage include:

* Back schools, workplace redesign, strengthening, stretching, endurance exercise programs, and postural training to prevent and manage low back pain

* Ergonomic redesign; strengthening, stretching, and endurance exercise programs; postural training to prevent job-related disabilities, including trauma and repetitive stress injuries

* Exercise programs, including weight bearing and weight training, to increase bone mass and bone density (especially in older adults with osteoporosis)

* Exercise programs, gait training, and balance and coordination activities to reduce the risk of falls--and the risk of fractures from falls--in older adults

* Exercise programs and instruction in ADL (self-care, communication, and mobility skills required for independence in daily living) and instrumental activities of daily living (IADL) (activities that are important components of maintaining independent living, such as shopping and cooking) to decrease utilization of health care services and enhance function in patients with cardiovascular/pulmonary disorders

* Exercise programs, cardiovascular conditioning, postural training, and instruction in ADL and IADL to prevent disability and dysfunction in women who are pregnant

* Broad-based consumer education and advocacy programs to prevent problems (eg, prevent head injury by promoting the use of helmets, prevent pulmonary disease by encouraging smoking cessation)

* Exercise programs to prevent or reduce the development of sequelae in individuals with life-long conditions

The Five Elements of Patient/Client Management

The physical therapist integrates the five elements of patient/client management--examination, evaluation, diagnosis, prognosis, and intervention--in a manner designed to optimize outcomes (Fig. 1). Appendix 6 contains a template for documenting the five elements of patient/client management.

[Figure 1 ILLUSTRATION OMITTED]

Examination, evaluation, and the establishment of a diagnosis and a prognosis are all part of the process that helps the physical therapist determine the most appropriate intervention(s) to address the outcomes that are desired by the patient/client.

Examination

Examination is required prior to the initial intervention and is performed for all patients/clients. The initial examination is a comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner. The examination has three components: the patient/client history, the systems review, and tests and measures.

History. The history is a systematic gathering of data--from both the past and the present--related to why the patient/client is seeking the services of the physical therapist. The data that are obtained (eg, through interview, through review of the patient/client record, or from other sources) include demographic information, social history, employment and work (job/school/play), growth and development, living environment, general health status, social and health habits (past and current), family history, medical/surgical history, current conditions or chief complaints, functional status and activity level, medications, and other clinical tests. While taking the history, the physical therapist also identifies health restoration and prevention needs and coexisting health problems that may have implications for intervention.

This history typically is obtained through the gathering of data from the patient/client, family, significant others, caregivers, and other interested individuals (eg, rehabilitation counselor, teacher, workers' compensation claims manager, employer); through consultation with other members of the team; and through review of the patient/client record. Figure 2 lists the types of data that may be generated from the history.

[Figure 2 ILLUSTRATION OMITTED]

Data from the history (Fig. 2) provide the initial information that the physical therapist uses to hypothesize about the existence and origin of impairments or functional limitations that are commonly related to medical conditions, sociodemographic factors, or personal characteristics. For example, in the case of a 78-year-old woman who has a medical diagnosis of Parkinson disease and who lives alone, the medical diagnosis would suggest the possibility of the following impairments: loss of motor control, range of-motion deficits, faulty posture, and decreased endurance for functional activities. Epidemiologic research that is available about functional limitations of older women, however, suggests that performance of IADL also may be problematic for that age group. Consequently, in this case, the physical therapist may use the information obtained during the history as well as the epidemiological information to create a "hypothesis" that would require further, in-depth examination during the tests-and-measures portion of the examination.

Systems review. After organizing the available history information, the physical therapist begins the "hands-on" component of the examination. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient. The physical therapist especially notes how each of these last five components affects the ability to initiate, sustain, and modify purposeful movement for performance of an action, task, or activity that is pertinent to function.

The systems review includes the following:

* For the cardiovascular/pulmonary system, the assessment of heart rate, respiratory rate, blood pressure, and edema

* For the integumentary system, the assessment of skin integrity, skin color, and presence of scar formation

* For the musculoskeletal system, the assessment of gross symmetry, gross range of motion, gross strength, height, and weight

* For the neuromuscular system, a general assessment of gross coordinated movement (eg, balance, locomotion, transfers, and transitions)

* For communication ability, affect, cognition, language, and learning style, the assessment of the ability to make needs known; consciousness; orientation (person, place, and time); expected emotional/behavioral responses; and learning preferences (eg, learning barriers, education needs)

The systems review also assists the physical therapist in identifying possible problems that require consultation with or referral to another provider.

Tests and measures. Tests and measures are the means of gathering data about the patient/client. From the comprehensive identification and questioning processes of the history and systems review, the physical therapist determines patient/client needs and generates diagnostic hypotheses that may be further investigated by selecting specific tests and measures. These tests and measures are used to rule in or rule out causes of impairment and functional limitations; to establish a diagnosis, prognosis, and plan of care; and to select interventions.

The tests and measures that are performed as part of an initial examination should be only those that are necessary to (1) confirm or reject a hypothesis about the factors that contribute to making the current level of patient/client function less than optimal and (2) support the physical therapist's clinical judgments about appropriate interventions, anticipated goals, and expected outcomes.

Before, during, and after administering the tests and measures, physical therapists gauge responses, assess physical status, and obtain a more specific understanding of the condition and the diagnostic and therapeutic requirements. There are 24 tests and measures that are commonly performed by physical therapists. These tests and measures, tools used to gather data, and types of data generated are discussed in detail in Chapter 2.

The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination, based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision-making process.

As the examination progresses, the physical therapist may identify additional problems that were not uncovered by the history and systems review and may conclude that other specific tests and measures or portions of other specific tests and measures are required to obtain sufficient data to perform an evaluation, establish a diagnosis and a prognosis, and select interventions. The examination therefore may be as brief or as lengthy as necessary. The physical therapist may decide that a full examination is necessary and then select appropriate tests and measures. Conversely, the physical therapist may conclude from the history and systems review that further examination and intervention are not required, that the patient/client should be referred to another practitioner, or both.

Tests and measures vary in the precision of their measurements; however, useful data may be generated through various means. For instance, data generated from either a gross muscle test of a group of muscles or from a very precise manual muscle test could be used to reject the hypothesis that muscle performance is contributing to a functional deficit. Similarly, even though a functional assessment instrument may quantify a large number of ADL or IADL, it may fail to detect the inability to perform a particular task and activity that is most important to the patient.

The tests and measures that are selected by the physical therapist should yield data that are sufficiently accurate and precise to allow the therapist to make a correct inference about the patient's/client's condition. The selection of specific tests and measures and the depth of the examination vary based on the age of the patient/client; severity of the problem; stage of recovery (acute, subacute, or chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors.

Evaluation

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the examination. They synthesize all of the findings from the history, systems review, and tests and measures to establish the diagnosis, prognosis, and plan of care. Factors that influence the complexity of the evaluation process include the clinical findings, the extent of loss of function, social considerations, and overall physical function and health status. The evaluation reflects the chronicity or severity of the current problem, the possibility of multisite or multisystem involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the severity and complexity of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; potential discharge destinations; and social support.

Diagnosis

Diagnostic labels may be used to describe multiple dimensions of the patient/client, ranging from the most basic cellular level to the highest level of functioning--as a person in society. Although physicians typically use labels that identify disease, disorder, or condition at the level of the cell, tissue, organ, or system, physical therapists use labels that identify 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 assigning of a diagnostic label through the classification of a patient/client within a specific practice pattern is a decision reached as a result of a systematic process. This process includes integrating and evaluating the data that are obtained during the examination (history, systems review, and tests and measures) to describe the patient/client condition in terms that will guide the physical therapist in determining the prognosis, plan of care, and intervention strategies. Thus the diagnostic label indicates the primary dysfunctions toward which the physical therapist directs interventions. The diagnostic process enables the physical therapist to verify the individual needs of each patient/client relative to similar individuals who are classified in the same pattern while also capturing the unique concerns of the patient/client in meeting those needs in a particular sociocultural and physical environment.

If the diagnostic process does not yield an identifiable cluster (eg, of signs or symptoms, impairments, functional limitations, or disabilities), syndrome, or category, the physical therapist may administer interventions for the alleviation of symptoms and remediation of impairments. As in all other cases, the physical therapist is guided by patient/client responses to those interventions and may determine that a reexamination is in order and proceed accordingly.

The objective of the physical therapist's diagnostic process is the identification of discrepancies that exist between the level of function that is desired by the patient/client and the capacity of the patient/client to achieve that level. In carrying out the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other professionals. In addition, as the diagnostic process continues, physical therapists may identify findings that should be shared with other professionals (including referral sources) to ensure optimal care. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist refers the patient/client to an appropriate practitioner.

Making a diagnosis requires the clinician to collect and sort data into categories according to a classification scheme relevant to the clinician who is making the diagnosis. These classification schemes should meet the following criteria:[6]

1. Classification schemes must be consistent with the boundaries placed on the profession by law (which may regulate the application of certain types of diagnostic categories) and by society (which grants approval for managing specific types of problems and conditions).

2. The tests and measures necessary for confirming the diagnosis must be within the legal purview of the health care professional.

3. The label used to categorize a condition should describe the problem in a way that directs the selection of interventions toward those interventions that are within the legal purview of the health care professional who is making the diagnosis.

The preferred practice patterns in Part Two of the Guide describe the management of patients who are grouped by clusters of impairments that commonly occur together, some of which are associated with health conditions that impede optimal function. Each pattern represents a diagnostic classification. The pattern title therefore reflects the diagnosis--or impairment classification--made by the physical therapist. The diagnosis may or may not be associated with a health condition for patients/clients who are classified into that pattern.

The physical therapist uses the classification scheme of the preferred practice patterns to complete a diagnostic process that begins with the collection of data (examination), proceeds through the organization and interpretation of data (evaluation), and culminates in the application of a label (diagnosis).

Prognosis (Including the Plan of Care)

Once the diagnosis has been established, the physical therapist determines the prognosis and develops the plan of care. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level, and also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy.

The plan of care consists of statements that specify the anticipated goals and the expected outcomes, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions that are required to reach the anticipated goals and expected outcomes. The plan of care therefore describes the specific patient/client management and the timing for patient/client management for the episode of physical therapy care.

The plan of care is the culmination of the examination, diagnostic, and prognostic processes. It is established in collaboration with the patient/client and is based on the data gathered from the history, systems review, and tests and measures and on the diagnosis determined by the physical therapist. In designing the plan of care, the physical therapist analyzes and integrates the clinical implications of the severity, complexity, and acuity of the pathology/pathophysiology (disease, disorder, or condition), the impairments, the functional limitations, and the disabilities to establish the prognosis and predictions about the likelihood of achieving the anticipated goals and expected outcomes.

The plan of care identifies anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. (If required, the anticipated goals and expected outcomes may be expressed as short-term and long-term goals.) Anticipated goals and expected outcomes are the intended results of patient/client management and indicate the changes in impairments, functional limitations, and disabilities and the changes in health, wellness, and fitness needs that are expected as the result of implementing the plan of care. The anticipated goals and expected outcomes also address risk reduction, prevention, impact on societal resources, and patient/client satisfaction. The anticipated goals and expected outcomes in the plan should be measurable and time limited.

The plan of care includes the anticipated discharge plans. In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge is the achievement of the anticipated goals and expected outcomes. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Note: In the course of examining the patient/client and establishing the diagnosis and the prognosis, the physical therapist may find evidence of physical abuse or domestic violence. Universal screening for domestic violence is increasingly becoming a statutory requirement.

Intervention

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

* Coordination, communication, and documentation

* Patient/client-related instruction

* Procedural interventions, including

- therapeutic exercise

- functional training in self-care and home management (including ADL and IADL)

- functional training in work (job/school/play), community, and leisure integration and reintegration (including IADL, work hardening, and work conditioning) manual therapy techniques (including mobilization/manipulation)

- prescription, application, and, as appropriate, fabrication of devices and equipment (assistive, adaptive, orthotic, protective, supportive, and prosthetic)

- airway clearance techniques

- integumentary repair and protection techniques

- electrotherapeutic modalities

- physical agents and mechanical modalities

Coordination, communication, and documentation. These administrative and supportive processes are intended to ensure that patients/clients receive appropriate, comprehensive, efficient, and effective quality of 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. Physical therapists are responsible for coordination, communication, and documentation across all settings for all patients/clients.

Administrative and support processes may include addressing required functions, such as advanced care directives, individualized educational plans (IEPs) or 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. Documentation should follow APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

Patient/client-related instruction. The process of informing, educating, or training patients/clients, families, significant others, and caregivers is intended to promote and optimize physical therapy services. Instruction may be related to the current condition; specific impairments, functional limitations, or disabilities; plan of care; need for enhanced performance; transition to a different role or setting; risk factors for developing a problem or dysfunction; or need for health, wellness, or fitness programs. Physical therapists are responsible for patient/client-related instruction across all settings for all patients/clients.

Procedural interventions. The physical therapist selects, applies, or modifies these interventions (listed above) based on examination data, the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient in a specific patient/client practice pattern. Based on patient/client response to interventions, the physical therapist may decide that reexamination is necessary, a decision that may lead to the use of different interventions or, alternatively, the discontinuation of care.

Chapter 3 details the types of procedural interventions commonly selected by the physical therapist. Forming the core of most physical therapy plans of care are: therapeutic exercise, including aerobic conditioning; functional training in self-care and home management activities, including ADL and IADL; and functional training in work (job/school/play), community, and leisure integration or reintegration, including IADL, work hardening, and work conditioning.

Factors that influence the complexity, frequency, and duration of the intervention and the decision-making process may include the following: accessibility and availability of resources; adherence to the intervention program; age; anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; cognitive status; comorbidities, complications, or secondary impairments; concurrent medical, surgical, and therapeutic interventions; decline in functional independence; level of impairment; level of physical function; living environment; multisite or multisystem involvement; nutritional status; overall health status; potential discharge destinations; premorbid conditions; probability of prolonged impairment, functional limitation, or disability; psychosocial and socioeconomic factors; psychomotor abilities; social support; and stability of the condition.

Reexamination

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

Outcomes

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. Beginning with the history, the physical therapist identifies patient/client expectations, perceived need for physical therapy services, personal goals, and desired outcomes. The physical therapist then considers whether these goals and outcomes are realistic in the context of the examination data and the evaluation. In establishing a diagnosis and a prognosis and selecting interventions, the physical therapist asks the question, "What outcome is likely, given the diagnosis?" The physical therapist may use reexamination to determine whether predicted outcomes are reasonable and then modify them as necessary.

As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions on the following domains:

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

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

The physical therapist engages in outcomes data collection and analysis-that is, the systematic review of outcomes of care in relation to selected variables (eg, age, sex, diagnosis, interventions performed)--and develops statistical reports for internal or external use.

Episode of Care, Maintenance, or Prevention

An episode of physical therapy care consists of all physical therapy services that are (1) provided by a physical therapist, (2) provided in an unbroken sequence, and (3) related to the physical therapy interventions for a given condition or problem or related to a request from the patient/client, family, or other provider. A defined number or identified range of number of visits will be established for an episode of care. A visit consists of all physical therapy services provided in a 24-hour period. The episode of care may include transfers between sites within or across settings or reclassification of the patient/client from one preferred practice pattern to another. Reclassification may alter the expected range of number of visits and therefore may shorten or lengthen the episode of care. If reclassification involves a condition, problem, or request that is not related to the initial episode of care, a new episode of care may be initiated.

A single episode of care should not be confused with multiple episodes of care that may be required by certain individuals who are classified in particular patterns. For these patients/clients, periodic follow-up is needed over a lifetime to ensure optimal function and safety following changes in physical status, caregivers, the environment, or task demands.

An episode of physical therapy maintenance is a series of occasional clinical, educational, and administrative services related to maintenance of current function. No defined number or range of number of visits is established for this type of episode.

An episode of physical therapy prevention is a series of occasional clinical, educational, and administrative services related to prevention, to the promotion of health, wellness, and fitness, and to the preservation of optimal function. Prevention services; programs that promote health, wellness, and fitness; and programs for maintenance of function are a vital part of the practice of physical therapy. No defined number or range of number of visits is established for this type of episode.

Criteria for Termination of Physical Therapy Services

Two processes are used for terminating physical therapy services: discharge and discontinuation.

Discharge

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. There may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services as the patient moves between sites or across settings during the episode of care.

Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the anticipated goals and expected outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral.

Discontinuation

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. When termination of physical therapy service occurs prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for discontinuation are documented.

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.

Other Professional Roles of the Physical Therapist Consultation

Consultation is the rendering of professional or expert opinion or advice by a physical therapist. The consulting physical therapist applies highly specialized knowledge and skills to identify problems, recommend solutions, or produce a specified outcome or product in a given amount of time on behalf of a patient/client.

Patient-related consultation is a service provided by a physical therapist at the request of a patient, another practitioner, or an organization either to recommend physical therapy services that are needed or to evaluate the quality of physical therapy services being provided. Such consultation usually does not involve actual intervention.

Client-related consultation is a service provided by a physical therapist at the request of an individual, business, school, government agency, or other organization.

Examples of consultation activities in which physical therapists may engage include:

* Advising a referring practitioner about the indications for intervention

* Advising employers about the requirements of the Americans with Disabilities Act (ADA)

* Conducting a program to determine the suitability of employees for specific job assignments

* Developing programs that evaluate the effectiveness of an intervention plan in reducing work-related injuries

* Educating other health care practitioners (eg, in injury prevention)

* Examining school environments and recommending changes to improve accessibility for students with disabilities

* Instructing employers about job preplacement in accordance with provisions of the ADA

* Participating at the local, state, and federal levels in policymaking for physical therapy services

* Performing environmental assessments to minimize the risk of falls

* Providing peer review and utilization review services

* Responding to a request for a second opinion

* Serving as an expert witness in legal proceedings

* Working with employees, labor unions, and government agencies to develop injury reduction and safety programs

Education

Education is the process of imparting information or skills and instructing by precept, example, and experience so that individuals acquire knowledge, master skills, or develop competence. In addition to instructing patients/clients as an element of intervention, physical therapists may engage in education activities such as the following:

* Planning and conducting academic education, clinical education, and continuing education programs for physical therapists, other providers, and students

* Planning and conducting education programs for local, state, and federal agencies

* Planning and conducting programs for the public to increase awareness of issues in which physical therapists have expertise

Critical Inquiry

Critical inquiry is the process of applying the principles of scientific methods to read and interpret professional literature; participate in, plan, and conduct research; evaluate outcomes data; and assess new concepts and technologies.

Examples of critical inquiry activities in which physical therapists may engage include:

* Analyzing and applying research findings to physical therapy practice and education

* Disseminating the results of research

* Evaluating the efficacy and effectiveness of both new and established interventions and technologies

* Participating in, planning, and conducting clinical, basic, or applied research

Administration

Administration is the skilled process of planning, directing, organizing, and managing human, technical, environmental, and financial resources effectively and efficiently. Administration includes the management, by individual physical therapists, of resources for patient/client management and for organizational operations.

Examples of administration activities in which physical therapists engage include:

* Ensuring fiscally sound reimbursement for services rendered

* Budgeting for physical therapy services

* Managing staff resources, including the acquisition and development of clinical expertise and leadership abilities

* Monitoring quality of care and clinical productivity

* Negotiating and managing contracts

* Supervising physical therapist assistants, physical therapy aides, and other support personnel

The Physical Therapy Service: Direction and Supervision of Personnel

Direction and supervision are essential to the provision of high-quality physical therapy. The degree of direction and supervision necessary for ensuring high-quality physical therapy depends on many factors, including the education, experience, and responsibilities of the parties involved; the organizational structure in which the physical therapy is provided; and applicable state law. In any case, supervision should be readily available to the individual being supervised.

The director of a physical therapy service is a physical therapist who has demonstrated qualifications based on education and experience in the field of physical therapy and who has accepted the inherent responsibilities of the role. The director of a physical therapy service must:

* Establish guidelines and procedures that will delineate the functions and responsibilities of all levels of physical therapy personnel in the service and the supervisory relationships inherent to the functions of the service and the organization

* Ensure that the objectives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization and in accordance with safe physical therapist practice

* Interpret administrative policies

* Act as a liaison between line staff and administration

* Foster the professional growth of the staff

Written practice and performance criteria should be available for all levels of physical therapy personnel in a physical therapy service. Regularly scheduled performance appraisals should be conducted by the supervisor based on applicable standards of practice and performance criteria. Responsibilities should be commensurate with the qualifications--including experience, education, and training--of the individuals to whom the responsibilities are assigned. When the physical therapist of record directs physical therapist assistants to perform specific components of physical therapy interventions, that physical therapist remains responsible for supervision of the plan of care. Regardless of the setting in which the services are given, the following responsibilities must be borne solely by the physical therapist:

* Interpretation of referrals when available

* Initial examination, evaluation, diagnosis, and prognosis

* Development or modification of a plan of care that is based on the initial examination or the reexamination and that includes physical therapy anticipated goals and expected outcomes

* Determination of (1) when the expertise and decision making capability of the physical therapist requires the physical therapist to personally render physical therapy interventions and (2) when it may be appropriate to utilize the physical therapist assistant. A physical therapist determines the most appropriate utilization of the physical therapist assistant that will ensure the delivery of service that is safe, effective, and efficient.

* Provision of physical therapy interventions

* Reexamination of the patient/client in light of the anticipated goals and expected outcomes, and revision of the plan of care when indicated

* Establishment of the discharge plan and documentation of discharge summary/status

* Oversight of all documentation for services rendered to each patient

References

[1] Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965: 100-113.

[2] Nagi S. Disability and Rehabilitation. Columbus, Ohio: Ohio State University Press; 1969.

[3] Nagi S. Disability concepts revisited: implications for prevention. In: Pope A, Tarlov A, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: Institute of Medicine, National Academy Press; 1991.

[4] Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991;71:499-504.

[5] Defining Primary Care:An Interim Report. Washington, DC: Institute of Medicine, National Academy Press; 1995.

[6] Guccione AA. Geriatric Physical Therapy, 2nd ed. St Louis, Mo: Mosby; 2000.