Who are physical therapists, and what do they do?

Physical therapists are professionally educated at the college or university level and are required to be licensed in the state or states in which they practice. 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). Graduates from 1926 to 1959 completed physical therapy curricula approved by appropriate accreditation bodies. The CAPTE with limit its scope in 2002 to accredit only those professional programs that award the postbaccalaureate degree.

Physical therapists also may obtain clinical specialist certification 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, in order of most common setting:

* 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, appropriate, and high-quality health care services to both patients and clients. Patients are individuals who are the recipients of physical therapy care and direct intervention. Clients are individuals who are not necessarily sick or injured but who can benefit from a physical therapist's consultation, professional advice, or prevention services. 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 the care and services provided by or under the direction and supervision of a physical therapist (Fig. 1). APTA emphasizes that an examination, evaluation, or intervention -- unless provided by a physical therapist or under the direction and supervision of a physical therapist -- is not physical therapy, nor should it be represented or reimbursed as such.

Figure 1. Model Definition of Physical Therapy for State Practice Acts(a) [BOD 02-97-03-06; Amended BOD 03-95-24-64, BOD 06-94-03-04, BOD 03-93-18-46]

Physical therapy, which is the care and services provided by or under the direction and supervision of a physical therapist includes:

1) Examining (history, systems review, and tests and measures) individuals with impairment, functional limitation, and disability or other health-related conditions in order to determine a diagnosis, prognosis, and intervention; tests and measures may include the following:

* Aerobic capacity and endurance

* Anthropometric characteristics

* Arousal, mentation, and cognition(b)

* Assistive and adaptive devices

* Community and work (job/school/play) integration or reintegration 

* Cranial nerve integrity

* Environmental, home, and work (job/school/play) barriers

* Ergonomics and body mechanics 

* Gait locomotion, and balance

* Integumentary integrity

* Joint integrity and mobility

* Motor function

* Muscle performance

* Neuromotor development and sensory integration 

* Orthotic, protective, and supportive devices

* Pain

* Posture

* Prosthetic requirements

* Range of motion

* Reflex integrity

* Self-care and home management

* Sensory integrity

* Ventilation, respiration, and circulation

2) Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions that may include, but are not limited to:

* Coordination, communication, and documentation

* Patient/client-related instruction

* Therapeutic exercise (including aerobic conditioning)

* Functional training in self-care and home management (including activities of daily living and instrumental activities of daily living)

* Functional training in community and work (job/school/play) integration or reintegration activities (including instrumental activities of daily living, work hardening, and work conditioning)

* Manual therapy techniques (including mobilization and manipulation)

* Prescription application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, and prosthetic devices and equipment

* Airway clearance techniques

* Wound management

* Electrotherapeutic modalities 

* Physical agents and mechanical modalities

3) Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in all age populations

4) Engaging in consultation, education, and research

(a) Direct interventions, which begin with "Therapeutic exercise," are listed in order of preferred usage. (b) This category of tests and measures is referred to as "arousal, attention, and cognition" in the Guide.

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(1,2) on which this Guide is based, impairment is defined as loss or abnormality of physiological, psychological, or anatomical structure or function; functional limitation, as restriction of the ability to perform -- at the level of the whole person -- a physical action, activity, or task in an efficient, typically expected, or competent manner; and disability, as the inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment.

* Interact and practice in collaboration with a variety of professionals, including physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, and audiologists. 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 render.

* Provide prevention and wellness services, including screening and health promotion. Physical therapists are involved in wellness initiatives, including health promotion and education, that stimulate the public to engage in healthy behaviors. They provide preventive care that forestalls or prevents functional decline and the need for more intense care. Through timely and appropriate screening, examination, evaluation, and intervention, they frequently reduce or eliminate the need for costlier forms of care, such as surgery, and also may shorten or even eliminate institutional stays.

* Consult, educate, engage in critical inquiry, and administrate.

* Direct and supervise physical therapy services, including support personnel.

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.(3)

APTA has endorsed the concepts of primary care set forth by the Institute of Medicine's Committee on the Future of Primary Care,(3) including the following:

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

* The "gatekeeper" concept is rejected because of the pejorative connotation that the primary care practitioner's role is to manage costs and, for the most part, keep the "gate" closed.

* 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.

* The role of family and community in the provision of primary care is an important one, and caregivers and care-receivers function in the context of, and are dependent on, a wide range of societal and environmental factors.

As clinicians involved in examination and in the evaluation, diagnosis, prognosis, intervention, and prevention of musculoskeletal and neuromuscular disorders, physical therapists are well positioned to provide those services as members of primary care teams. On a daily basis, physical therapists practicing at acute, chronic, rehabilitative, and preventive stages of care assist patients/clients in the following: restoring health; alleviating pain; and preventing the onset of impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Prevention and wellness activities, including health promotion, are a vital part of physical therapy.

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, and intervene without delay. For patients/clients with low back pain, for example, physical therapists can provide immediate pain reduction and programs for strengthening, flexibility, endurance, postural alignment, instruction in activities of daily living, and work modification. Physical therapist intervention may result not only in more efficient and effective patient care but 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 lost 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, cardiopulmonary, or integumentary disorders. Through community-based agencies, physical therapists coordinate and integrate provision of services to patients/clients with chronic neuromuscular and musculoskeletal disorders.

Physical therapists also provide primary care in industrial or workplace settings, in which they manage the occupational health services provided to employees and 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, cardiopulmonary, or integumentary conditions frequently are treated initially by another health care practitioner and then are referred to physical therapists for secondary care. Physical therapists provide secondary care in a wide range of settings, from hospitals to preschools.

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

Roles in Prevention and Wellness (Including Screening Programs and

Health Promotion)

Physical therapists are involved in prevention and wellness activities, screening, and the promotion of positive health behavior. 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:

* Primary prevention -- Preventing disease 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 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 primary, secondary, or tertiary prevention services; for further examination, intervention, or consultation by a physical therapist; or for referral to another health care practitioner. Candidates for screening generally not patients/clients currently receiving physical therapy services. Screening is based on a problem-focused, systematic collection and analysis of data. Examples of screening activities in which physical therapists engage include:

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

* Identifying children who may need an examination for idiopathic scoliosis 

* Identifying elderly individuals in a community center or nursing home who are at high risk for slipping, tripping, or falling

* Identifying risk factors in the workplace

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

* Conducting prework screening programs

Examples of prevention and wellness activities in which physical therapists engage include:

* Back schools, workplace redesign, strengthening, stretching, endurance exercise programs, and postural training to prevent and treat low back pain, a condition afflicting millions of Americans

* Workplace redesign, strengthening, stretching, endurance exercise, and 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 important in older adults with osteoporosis)

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

* Exercise programs and instruction in activities of daily living (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 cardiopulmonary 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)

The Five Elements of Patient/Client Management

The physical therapist integrates five elements of patient/client management -- examination, evaluation, diagnosis, prognosis, and intervention -- in a manner designed to maximize outcomes (Fig. 2). Examination, evaluation, and establishment of a diagnosis and a prognosis are all part of the process that guides the therapist in determining the most appropriate intervention.

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Examination

Examination is required prior to any intervention and is performed for all patients/clients. The initial examination, which is an investigation, has three components: the patient/client history, relevant Systems reviews, and tests and measures.

History -- The history is an account of past and current health status. It includes identification of complaints, provides the initial source of information about the patient/client, and also suggests the individual's ability to benefit from physical therapy. While taking the history, the physical therapist identifies health-risk factors, health restoration and prevention needs, and coexisting health problems that have implications for intervention. This history commonly is obtained through the gathering of data from the patient/client, family, significant others, caregivers, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer); through consultation with other members of the health care team; and through review of the medical record. Figure 3 lists the types of data that may be generated from the history.

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Systems Review -- The systems review is a brief or limited examination that provides additional information about the general health of the patient/client to help the physical therapist formulate a diagnosis, a prognosis, and a plan of care and select direct interventions. The systems review also assists the physical therapist in identifying possible health problems that require consultation with or referral to another health care provide.

Data generated from a systems review that may affect subsequent examination and intervention include: (1) physiologic and anatomic status (cardiopulmonary, integumentary, musculoskeletal, and neuromuscular) and (2) communication ability, affect, cognition, language, and learning style.

Tests and Measures -- After analyzing all relevant information gathered from the history and systems review, the physical therapist examines the patient/client more closely, selecting tests and measures to elicit additional information. Before, during, and after administering the tests and measures, physical therapists frequently apply their hands to the patient/client to gauge responses, assess physical status, and obtain a more specific understanding of the condition and the diagnostic and therapeutic requirements. Tests and measures commonly performed by physical therapists and the types of data generated are listed in Figure I and 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 make an evaluation, establish a diagnosis and a prognosis, and select direct interventions. The examination therefore may be as brief or as lengthy as necessary. For instance, the physical therapist may conclude from the history and systems review that further examination and management are not required, that the patient/client should be referred to another health care practitioner, or both. Conversely, the physical therapist may decide that a full examination is necessary and then select appropriate tests and measures. Physical therapists frequently perform one or more reexaminations, which are examinations that take place after the initial examination is completed. Because physical therapy is most often an ongoing process delivered over a period of weeks for a single episode of care -- rather than one service delivered during a single visit -- physical therapists rely on reexaminations to modify or redirect intervention and to evaluate progress toward the anticipated goals and desired outcomes. If a reexamination is indicated (eg, because of new clinical indications or failure to respond to intervention), the physical therapist selects and administers additional specific tests and measures. The reexamination has an important quality assurance component, as it allows the physical therapist to focus on the relationship between the elements of patient/client management and the outcomes.

Note: In the course of examining and establishing the diagnosis and the prognosis, the physical therapist may find evidence of physical abuse or domestic violence. In such cases, the physical therapist is bound by ethical principles -- and may be bound by state law or regulation -- to report such findings to the appropriate agencies.

Evaluation

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the examination. Factors that influence the complexity of the examination and the evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's/client's overall physical function and health status. Thus, 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 level of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; potential discharge destinations; and the social supports.

Diagnosis

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the decision reached as a result of the diagnostic process, which includes evaluating the information obtained during the examination; organizing it into clusters, syndromes, or categories; and interpreting it.

The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client. In the event that the diagnostic process does not yield an identifiable cluster, syndrome, or category, intervention may be guided by the alleviation of symptoms and remediation of deficits. Alternatively, the physical therapist may determine that a reexamination is in order and proceed accordingly. 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.

Prognosis

The prognosis includes the predicted optimal level of improvement in function and amount of time needed to reach that level; it also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy.

At this point in patient/client management, the physical therapist establishes plan of care. In designing the plan of care, the physical therapist integrates all of the previous data, incorporates all of the prognostic predictions, and determines the degree to which interventions are likely to achieve anticipated goals and desired outcomes. Goals generally relate to the remediation (to the extent possible) of impairments, whereas outcomes relate to minimization of functional limitation, optimization of health status, prevention of disability, and optimization of patient/client satisfaction. Thus, the plan of care specifies long-term and short-term goals and outcomes, the specific interventions to be used, the duration and frequency of intervention required to reach the goals and outcomes, and criteria for discharge.

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about intervention are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and the desired outcomes. Physical therapist intervention has three components: coordination, communication, and documentation; patient/client-related instruction; and direct interventions Fig. 1).

Coordination, Communication, and Documentation - These services, which are provided for an patients/clients, may include case management; communication (direct or indirect); coordination of care with the patient/client, family, significant others, caregivers, other professionals, and other interested persons; discharge planning; documentation of all elements of patient/client management; education plans; patient care conferences; record reviews; and referrals to other professionals or resources. Through these services, the physical therapist ensures appropriate, coordinated, comprehensive, and cost-effective services between admission and discharge and cost-effective and efficient integration or reintegration to home, community, and work (job/school/play), and leisure environments. Documentation should follow APTA's Guidelines for Physical Therapy Documentation (Appendix 7).

Patient/Client-Related instruction -- These services, which are provided to all patients/clients, may include computer-assisted instruction, demonstration by patient/client or caregivers in the appropriate environment, periodic reexamination and reassessment of the home program, use of audiovisual aids for both teaching and home reference, use of demonstration and modeling for teaching, verbal instruction, and written or pictorial instruction. The physical therapist uses these services to educate the patient/client -- and also the family, significant others, caregivers, or other professionals -- about the current condition, plan of care, and future transition to home, work, or community roles. The physical therapist may include information and training in activities for maintenance of function and primary and secondary prevention. The educational backgrounds, needs, and learning styles of individuals must be taken into account during this process.

Direct interventions -- The physical therapist selects, applies, or modifies direct interventions based on examination and evaluation data, the diagnosis and the prognosis, and the anticipated goals and desired outcomes for a particular patient in a specific patient/client diagnostic group. Based on the results of the 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, in order of preferred usage, the types of direct interventions commonly selected by the physical therapist. Forming the core of most physical therapy plans of care: therapeutic exercise, including aerobic conditioning; functional training in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL); and functional training in community and work (job/school/play) 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: anatomic and physiologic changes related to growth and development; chronicity or severity of the current condition; cognitive status; level of impairment; living environment; multisite or multisystem involvement; overall physical function and health status; potential discharge destinations; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; social supports; and stability of the condition.

Outcomes

At each step of patient/client management, the physical therapist considers the possible outcomes (remediation of functional limitation and disability, optimization of patient/client satisfaction, and primary or secondary prevention).

Beginning with the history, the physical therapist identifies patient/client expectations for therapeutic interventions, perceptions about the clinical situation, and desired outcomes. The physical therapist then considers whether these expectations and outcomes are realistic in the context of the examination and evaluation data. In establishing a diagnosis and a prognosis and selecting direct 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.

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.

Discharge Planning

Discharge -- the process of discontinuing interventions in a single episode of care--occurs based on the physical therapist's analysis of the dynamic interplay between the achievement of anticipated goals and the achievement of desired outcomes. Other indications for discharge include the following:

* The patient/client declines to continue treatment.

* The patient/client is unable to continue to progress toward goals because of medical or psychosocial complications.

* The physical therapist determines that the patient/client will no longer benefit from physical therapy services.

In consultation with appropriate individuals, and in consideration of the goals and outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral. if the physical therapist determines, through examination and evaluation, that intervention is unlikely to be beneficial, the physical therapist discusses those findings and conclusions with the individuals concerned, and there is no further physical therapist intervention. When a patient/client is discharged prior to achievement of desired outcomes, patient/client status and the rationale for discontinuation are documented.

A physical therapy episode of care consists of all patient/client management activities conducted by a physical therapist from initial contact through discharge. A single episode of care should not be confused with multiple episodes of care that may be required by certain individuals in particular patient/client diagnostic groups. For these patients/clients, periodic follow-up is needed over a lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, the environment, or task demands.

Other Professional Roles

Consultation Physical therapist consultants render professional or expert opinion or advice, applying 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, health care practitioner, or health care 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 treatment. 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 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 health care providers, and students

* Planning and conducting education programs for local, state, and federal health 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; and assess new concepts and technologies.

Examples of critical inquiry activities in which physical therapists 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 (Fig. 4); 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.

Delegated responsibilities should be commensurate with the qualifications -- including experience, education, and training -- of the individuals to whom the responsibilities are being assigned. When the physical therapist of record delegates patient care responsibilities to physical therapist assistants or other support personnel, that physical therapist holds responsibility for supervision of the plan of care. Regardless of the setting in which the services are given, the following responsibilities must be held solely by the physical therapist:

* Interpretation of referrals when available

* Initial examination, evaluation, problem identification, diagnosis, and prognosis

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

* Administration of intervention and, as appropriate, determination of (1) tasks that require the expertise and decision-making capacity of the physical therapist and that must be personally rendered by the physical therapist and (2) tasks that may be delegated. Prior to delegating any procedure, the physical therapist should determine that the consequences of the procedure are predictable, the situation is stable, and the basic indicators are not ambiguous and do not require ongoing observation by the physical therapist.

* Delegation of the tasks to be rendered by the physical therapist assistant or other support personnel, including, but not limited to, specific treatments, precautions, special problems, and contraindicated procedures

* Timely review of treatment documentation, reexamination of the patient/client and the anticipated goals and desired outcomes, and revision of the plan of care when indicated

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

References

[1] Physical Disability. Special issue. Phys Ther. 1994;74:375-506.

[2] Verbrugge L, Jette A. The disablement process. Soc Sci Med. 1994;38:1-14,

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

Physical Therapist Assistants

The physical therapist assistant is an educated health care provider who assists the physical therapist in the provision of physical therapy. The physical therapist assistant is a graduate of a physical therapist assistant associate degree program accredited by an agency recognized by the commission on Accreditation in Physical Therapy Education (CAPTE).

The physical therapist of record is the person who is directly responsible for the actions of the physical therapist assistant. The physical therapist assistant may perform physical therapy procedures and related tasks that have been selected and delegated by the supervising physical therapist. Where permitted by law, the physical therapist also may carry out routine operational functions, including supervision of the physical aide and documentation of progress. The ability of the physical therapist assistant to perform the selected and delegated tasks should be assessed on an ongoing basis by the supervising physical therapist. The physical therapist assistant may modify a specific intervention procedure in accordance with changes in patient/client status and within the scope of the establish plan of care.

Physical Therapist Aides

The physical therapy aide is a non-licensed worker who is specifically trained under the direction of a physical therapist. The physical therapy aide performs designated routine tasks related to the operation of a physical therapy service delegated by the physical therapist or in accordance with the law, by a physical therapist assistant.

The physical therapist of record is the person who is directly responsible for the actions of the physical therapy aide. The physical therapy aide providers support that may include patient-related and non-patient-related duties. The physical therapy aide functions only with the continuous on-site supervision of the physical therapist or, where allowable by law or regulation, the physical therapist assistant. Continuous on-site supervision requires the presence of the physical therapist or physical therapist assistant in the immediate area.

Other Support Personnel

When other personnel (eg, exercise physiologists, athletic trainers, massage therapist) work within the supervision of a physical therapy service, they should be employed under their appropriate title. Any involvement in patient/client care activities should be within the limits of their education, in accordance with applicable laws and regulations, and at the discretion of the physical therapist. If such personnel function as an extension of the physical therapist's license, however, their title and all services that they provide must be in accordance with state and federal laws and regulations.