PART TWO - Preferred Practice Patterns

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PART TWO: ••Ml Preferred Practice '') / / --y MusculoskeletoJ r "- V Neuromuscular Cardiovascular/ Pukiiionary Integumentary

Transcript of PART TWO - Preferred Practice Patterns

Page 1: PART TWO - Preferred Practice Patterns

PART TWO:••Ml

Preferred Practice

'') // --y

MusculoskeletoJr "- V

Neuromuscular

Cardiovascular/Pukiiionary

Integumentary

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How to Use the Preferred Practice Patterns

P art Two contains the preferred practice patterns, which are grouped underfour categories of conditions: Musculoskeletat (Chapter 4), Neuromuscular(Chapter 5), Cardiovascular/Putmonary (Chapter 6), and Integumentary(Chapter 7), A table of contents preceding each set of patterns lists the pattern

titles for that set. Beto«^ is an at-a-gtance depiction of the contents of each pattern; onthe following pages, take a walk through one exampte of how physical therapists mayuse Part Two in the management of patients/clients.

Contents of Each Pattern at a GlancePatient/Client Diagnostic

Classification

• Criteria for irKlusion(based on examination findingsregarding risk factors or conse-quences of patfiology/patho-physiology [disease, disorder, orcondition], impairments, function-al limitations, or disabilities]Criteria for exclusion from patternor for muhiple-pattem classification(based on examination findings]

ICD-9-CM Codes

2Codes that may relate to

the practice pattern—

intended only for information pur-

poses, not for coding purposes

The Five Elements of Patient/Client Management

Examination

3Description of the history,

systems review, and tests

and measures that generate date

that help the physical therapist

confirm classification of the

patients/clients in the pattern

Intervention

5A listing of the interven-

tions that may be used forpatients/clients who are classifiedin the pattern

Evaluation, Diagnosis,

4 and Prognosis

(Including Plan af Care)

Description of the evaluation,diagnostic, and prognosticprocesses, including the expectedrange of number of visits and fac-tors that may require a newepisode of care or that may modifyfrequency of visits and duration ofthe episode

Reexaminatian, Global

A Outcomes, and Criteria

for Termination of

Physical Therapy Services

Description of when reexaminationis indicated; measurement of glob-al outcomes of physical therapyservices in 8 domains; the 2 waysin which physical therapy servicesare terminated

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ExaminationFirst, the patient/client provides a history.Through the history, thephysical therapist gathers data—from both the past and the present—related to w hy the patient/client is seeking physical therapy services.Through the history, the physical therapist learns the chief complaintsof the patient/ctient—in this example, the inability to walk withoutpain and a sensation of "buckling" in both knees and the inability toparticipate in recreational sports.

Next, the physical therapist performs a systems review, w hich is a briefexamination of the anatomical and physiological status of the cardio-vascular/pulmonary, integumentary, musculoskeletal, and neuromuscu-lar systems.The systems review not only helps focus the examination, itindicates whether the patient/client should be referred for otherhealth care services in addition to physical therapy. In this example, thesystems review findings indicate that the patient/client has impair-ments in the cardiovascular/pulmonary system (high blood pressure atrest), musculoskeletal system (impaired gross range of motion,impaired gross strength, disproportionate weight for height), andneuromuscular system (impaired gait, impaired balance).The systemsreview suggests there are no current impairments in the integumen-tary system; however, the history shows the presence of diabetes,w hich is a risk factor for cardiovascular/pulmonary, neuromuscular, andintegumentary conditions.There are no limitations in communication,affect, cognition, language, and learning style.

Based on the history and systems review findings, the physical thera-pist notes key clinical indications for the use of particular tests andmeasures during the in-depth portion of the examination. (For exam-ples of clinical indications for the use of tests and measures, refer toChapter 2,)The key ctinical indications in this case example: impairedgait; impaired joint integrity and mobility; impaired muscle perfor-mance; and a history of diabetes, hypertension, and morbid obesity.Based on these key clinical indications, the physical therapist decidesto examine the following test-and-measure categories in detail: aerobiccapacity/endurance, circulation (arterial, venous, and lymphatic), com-munity and work (job/school/play) integration or reintegration (includ-ing instrumental activities of daily living [IADL]); environmental, home,and w ork (job/school/play) barriers; gait, locomotion, and balance; jointintegrity and mobility; muscle performance (strength, power, andendurance); pain; range of motion (including muscle length); self-careand home management (including activities of daily living [ADL] andtADL), and ventilation and respiration/gas exchange. Due to the pres-ence of cardiovascular/pulmonary risk factors such as hypertension,the monitoring of vital signs during ambulation will be an importantpart of the in-depth examination.

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

Evaluation, Dkignosi*, ond Prognoiu (Including Plan of Carol

nn Om Mi^ ii^Mn h4n

CHAPTER 4

Preferred Practice PatternMusculo kcletai

During the evaluation process, all data from the history, systemsreview, and tests and measures are synthesized to establish the diag-nosis and the prognosis, including the plan of care.

In this example, based on the evaluation of the history, systemsreview, and tests and-measures data, the physical therapist deter-mines that the patient/ctient has the following primary impairments:impaired joint integrity and mobility in the knees; decreased muscleperformance; decreased range of motion; and decreased aerobiccapacity/endurasice with ambulation.The physical therapist hypoth-esizes that the morbid obesity maj- be contributing to the knee painas well as to the decrease in aerobic capacity/endurance,

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

Even though patients/cUents may be referred to physical therapy ser-vices with a medical diagnosis, that does not tell the physical therapisthow to manage the patient/client.The medical diagnosis is a diagnos-tic label that identifies disease at the tevel of the cell, tissue, organ, orsystem. In this case, for instance, the medical diagnosis may beosteoarthritis of ihe knees. The physical therapist s diagnosis, how-ever, is a diagnostic label that identifies the impact of a condition onfunetion at the level ofthe system (especially the movement system)and at the level ofthe whole person. The physical therapist s goal isto restore function, and therefore the physical therapist s examination,evaluation, and interventions focus on impairments, functional limita-tions, disabilitit s, risk factor reduction, and prevention.

In this example, the physical therapist determines that decreasedmuscle performance, decreased range of motion, and pain are theprimary contributors to the identified functional limitations,Thephysical therapist also has noted that the patient/client hasdecreased aerobic/capacity endurance,The physical therapist there-fore focuses on lour preferred practice patterns: "Impaired MusclePerformance" (Pattern 4C) "Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of Motion Associated WithConnective Tissue Dysfunction" (Pattern 4D) "Impaired JointMobility, Motor I'unction, Muscle Performance, and Range of MotionAssociated With Localized Inflammation" (Pattern 4E) and "ImpairedAerobic Capacitv/Endurance Associated With Deconditioning"(Pattern 6B),

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Evaluation continuedImpairedMuscle Performance

Impaired Joinf Mobility, Motor Function,Muscle Performance, and Range of MotionAssocialed Wiih Connective TissueDysfunction

Impaired Joint Mobility, Motor Function,Muscle Performance, and Ronge of MotionAssociated With Localized Inflammation

Impofred Aerobic Capacity/EnduranceAssociated With Deconditioning

The physical therapist considers the primary impair-ments to determine which of the four possible patternsmay be the most appropriate classification for thepatient/client.The physical therapist scans the inclu-sions and exclusions for each pattern and the ICD-9-CMcodes that are listed in each pattern. If the physicaltherapist remains uncertain about patient/client classifi-cation, the tests-and-measures sections of the individualpatterns may suggest additional tests and measures thatthe physical therapist can perform to confirm place-ment of the patient/client into a pattern.

In this example, the history and systems review showsigns and symptoms of joint effusion but indicate thatjoint integrity and mobility are not contributing fac-tors.The physical therapist therefore classifies thepatient/ client in "Impaired Joint Mobility, MotorFunction, Muscle Performance, and Range of MotionAssociated With Localized Inflammation" (Pattern 4F).The patient/client also has a history of diabetes. If thephysical therapist determines that patient/client moni-toring for primary prevention of lower-extremity vas-cular problems and the need to increase aerobiccapacity are high priorities, the physical therapist mayplace the patient/client in an additional pattern:"Primary Prevention/Risk Reduction forCardiovascular/Pulmonary Disorders" (Pattern 6B).

Based on the evaluation, the physical therapist makesthe prognosis—that is, determines the predicted opti-mal level of improvement in function and the amountof time needed to reach that level.The physical thera-pist refers to the evaluation section of the selected pat-tern to ascertain whether the therapist s prediction ofimprovement, frequency of visits, and duration ofepisode of care are consistent with the expected prog-nosis and range of number of visits for patients/clientswho are classified in that pattern.The physical thera-pist also notes any factors (eg, age, chronicity or sever-ity of the current condition, adherence to theintervention program) that may modify the frequencyof visits or duration of the episode.

In this example, on the basis of such modifying factorsas extremely high patient/client motivation, the physi-cal therapist may determine that the patient/client ^villrequire fewer visits than are expected to achieve theanticipated goals and expected outcomes for 80% ofpatients/clients who are classified in the pattern. Onthe other hand, the presence of morbid obesity mayindicate that the patient/client may not be able toimprove aerobic capacity/endurance at an expectedrate. In addition, if the hypertension and diabetesbecome uncontrolled, the ability of the patient/clientto participate in physical therapy may be affected.

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InterventionAs part of the prognostic process, the physical therapist develops a planof care,This plan delineates the types of interventions (physical therapyprocedures and techniques) to be used to produce changes in the condi-tion and in patient/client status, the frequency and duration of those inter-ventions, anticipated goals, expected outcomes, and discharge plans.Anticipated goals and expected outcomes should be measurable andtime limited.

Each pattern contain.' a listing of interventions that are likely to be usedfor patients/clients who are classified in the pattern. Coordination, com-munication, and documentation and patient/ciient-related instructionare interventions that are provided to all patients/clients across all set-tings. The use of procedural interventions varies for the particularpatient/client in the specific pattern. (For examples of clinical considera-tions for the use of procedural interventions, refer to Chapter 3,) In thisexample, the physical therapist might select interventions that emphasizetherapeutic exercise, functional training in self-care and home manage-ment (including ADL ,ind IADL), and functional training in community andwork (job/school/play) integration or reintegration (including IADL, w orkhardening, and work conditioning) in addition to interventions to modu-late piiin and diminish the effects of joint effusion.

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Reexamination, Global Outcomes, and Criteria for Termination ofPhysical Therapy Services

Global Outcomei for Patienb/ClMnti in This Pottem

Crit«rio for lenninotion of Ptiysicaj Hierapy Services

Reexamination—the process of performing selected tests and measuresafter the initial examination to determine progress and modify or redi-rect interventions—may be indicated more than once during a singleepisode of care. In this example, the physical therapist may decide toperform a reexamination if the patient/client develops a ne w conditionor shows no progress.

Throughout the entire episode of care, the physical therapist determinesthe anticipated goals and expected outcomes for each intervention.These goals and outcomes are delineated in the shaded boxes thataccompany each list of interventions in each pattern. As the patient/client reaches the termination of physical therapy services and the endof the episode of care, the physical therapist measures the global out-comes (that is, the impact) of the physical therapy services in the follow-ing domains: pathology/pathophysiology (disease, disorder, orcondition); impairments; functional limitations; disabilities; risk reduc-tion/prevention; impact on health, wellness, and fitness; societalresources; and patient/client satisfaction.

The physical therapist uses two processes for terminating physical ther-apy services: discharge and discontinuation, tf the physical therapistdetermines that the anticipated goals and expected outcomes have beenachieved, the patient/client is discharged from physical therapy services.Physical therapy services are discontinued (1) when the patient/clientdeclines to continue intervention, (2) when the patient/client is unableto continue to progress toward the anticipated goals and expected out-comes because of medical or psychosocial complications or becausefinancial/insurance resources have been expended, or (3) when thephysical therapist determines that the patient/client witl no longer bene-fit from physical therapy,

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

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CHAPTER 4

Preferred Practice Patterns:MusculoskeletalPreferred practice patterns describe the five elements of patient/ciient managementthat are provided by physical therapists: examination (history, systems review, andtests and measures), evaluation, diagnosis, prognosis (including plan of care), andintervention (with anticipated goals and expected outcomes). Each pattern alsoaddresses reexamination, global outcomes, and criteria for termination of physicaltherapy services. Examples of ICD-9-CM codes are included.

Pattern A: Primar>' Prevention/Risk Reduction

for Skeletal Demineralization SI33

PaHern B: Impaired Posture S145

Pattern C: Impaired Muscle Performance S161

Pattern D: Impaired Joint Mobility Motor Function,Muscle Performance, and Range of MotionAssociated With Connective Tissue Dysfunction SI 79

Pattern E: Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Localized Inflammation SI97

Pattern F: Impaired Joint Mobility, Motor Function,Muscle Performance, Range of Motion, andReflex Integrity Associate d With Spinal Disorders S215

Pattern G: impaired Joint Mobility. Muscle Performance, andRange of Motion Associated With Fracture S233

Pattern H: Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Joint Aithroplasty S251

Pattern I: Impaired Joint Mobility Motor Function,Muscle Performance, and Range of MotionAssociated With Bony or Soft Tissue Surgery S269

Pattern J: Impaired Motor Function, Muscle Performance,Range of Motion, Gait, Locomotion, and BalanceAssociated With Amputation S287

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Primary Preventian/Risk Reduction farSkeletal Demineralizatian

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patient/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist,AFfA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a numberof clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession'scode of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socio-economic status,

Patient/Client Diagnostic ClassificationPatients/clients will be classified in this primary prevention/risk reduction pattern as a result of the physical therapist's evaluationof the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate theneed for a prevention/risk reduction program or for health, wellness, or fitness programs. The physical therapist integrates, syn-thesizes, and interprets the data to determine the diagnostic classification.

inclusion

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

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

• Chronic cardiovascular/pulmonary dysfunction• Deconditioning• Hormonal changes• Hysterectomy• Medications (eg, anti-epileptic medications, steroids, thyroid

hormone)• Menopause• Nutritional deficiency• Paget disease• Prolonged non-^veight-bearing state

Impairments, Functional Limitations, or Disabilities

• Inability to ambulate• Joint immobilization associated with inactivity• Prolonged muscle weakness or paralysis

Note:

Prevention and risk reduction are inherent in all practice pat-terns. Patients/clients included in this pattern are in need ofprimary prevention/risk reduction only.

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

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Oi^anization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-S)-CM 2001),Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

138 Late effects ol acute poliornyelitis

262 Other severe, protein-calorie malnutrition

263 Other and unspecified protein-calorie malnutrition

268 Vitamin D deficiency

269 Other nutritional deficiencies

275 Disorders of mineral metabolism

337 Disorders of the autonomic nervous system

337.2 Reflex sympathetic dystrophy

344 Other paralytic syndromes

344.0 Quadriplegia and quadriparesis344.1 Paraplegia

344.3 Monoplegia of lower limb

588 Disorders resulting from impaired renal function

627 Menopausal and postmenopausal disorders

714 Rheumatoid arthritis and other inflammatory

polyarthropathies

719 Other and unspecified disorders of joint719.5 Stiffness of joint, not elsewhere

classified

719.7 Difficulty in walking

719.8 Other specified disorders of jointCalcification of joint

728 Disorders of muscle, ligament, and fescia728.2 Muscular wasting and disuse atrophy,

not elsew^here classified728.3 Other specific muscle disorders

Arthrogryposis

729 Other disorders of soft tissues

729.9 Other and unspecified disorders of soft tissue

731 Osteitis deformans and osteopathies associated with otherdisorders classified elsewhere

731.0 Osteitis deformans wthout mention ofbone tumor

Paget's disease of bone

732 Osteochondropathies

732.0 Juvenile osteochondrosis of spine

733 Other disorders of bone and cartilage

733.0 Osteoporosis

733.1 Pathologic fracture

733.9 Other and unspecified disorders of bone and

cartilage

733.90 Osteopenia

737 Curvature of spine

737.3 Kyphoscoliosis and scoliosis

737.4 Curvature of spine associated with otherconditions*

756 Other congenital musculoskeletal anomalies

756.5 Osteodystrophies

756.51 Osteogenesis imperfecta

• Not a primary diagnosis

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

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

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors, /-or clinicat indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by teat.'; and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

• Age• Sex• Race/ethnicity• Primary language• Education

Social History• C lultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected dischai^^e destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical fiinction (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, communit)', leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past ond Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Mu.sculoskeletal• Neuromuscular• Obstetriciil• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current CondiKon(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patient/client

who rec|uires the services <if a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or cli,sea,se, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions < if patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chit;f com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofcliiily living (IADL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications tor other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •Blood pressureEdemaHeart rateRespiratory rate

IntegtimentaryPresence of scarformation

- Skin colorSkin integrity

MusculoskeletalGross range of motion

- Gross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

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

Aerobic Capacity and Endurance• Aerobic capacity during standardized exercise test protocols

(eg, er^ometry, step tests, time/distance walk/rtm tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)

Arousal, Attention, and Cognition• Motivation (eg, adaptive behavior scales)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

Ergonomics and Body MechanicsErgonomics• Safety in work environments (eg, hazard identification check-

lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg, activitiesof daily Uving [ADL] scales, instrumental activities of daily living[LVDL] scales, observations, photographic assessments, technol-ogy-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities -with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobility skill profiles, observations, video-graphic assessments)

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

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

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Tests and Measures continued

Posture Self-Care and Home A^nagement (Including ADL and IADL)• Postural alignment and position (dynamic), including symmetry • Ability to gain access to home environments (eg, barrier identifi-

and deviation from midline (eg, observations, videogra|>hic cation, observations, physical performance tests)assessments) . Saft ty in self-care and home management activities and environ-

• Postural alignment and position (static), including symmetry and meats (eg, fall scales, interviews, observations)deviation from midline (eg, grid measurement, observations; 1 , 1 / ^ 1 1 / 1 , ^ . • .photographic assessments) Work (Job/Schoo /P ay) Community, and Leisure Integration or

Reintegration (Including IADL)Range of Motion (ROM) (Including Muscle Length) • Ability to gain access to work (job/school/play), community, and• Functional ROM (eg, observations, squat tests, tt>e touch tests) leisure environments (eg, barrier identification, interviews,• Joint active and passive movement (eg, goniometry, inclinome- oliservations, physical capacity tests, transportation assessments)

try, observations, photographic assessments, videographic • Safety in work (job/school/play), community, and leisure activi-assessments) ti< s and environments (eg, diaries, fall scales, interviews, logs,

• Muscle length, soft tissue extensibility, and flexibility (eg, con- observations, videographic assessments)tracture tests, goniometry, inclinometry, ligamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

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

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

The frequency of visits and duration of the episode of care may vary from a short episode -with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Prognosis

Patient/client will reduce the risk of skele-tal demineralization through strength-training and weight-bearing therapeuticexercise programs and through lifestylemodifications.

Expected Ranqe of Number of VisitsPer Episode of Care

3to18This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/ clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 3 to 18 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedelivery.

Factors Thot May ModifyFrequency of Visits

• Accessibility and availability ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, complications, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• Level of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconotnic

factors• Psychomotor abilities• Social support• Stability of the condition

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InterventionIntervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individualsinvolved with the patient/client, using various physical therapy procedures and techniques to produce changes in the condition consis-tent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client responseand the progress made tow ard achieving the anticipated goals and expected oxitcomes,

(>>mmunication, coordination, and documentation and patient/ciient-related instruction are provided for all patients/clients. Proceduralinterventions are selected or modified based on the examination data, the eviiluation, the diagnosis, the prognosis, and the anticipatedgoals and expected outcomes for a particular patient/client For clinical consitlerations in selecting interventions, listings of interven-tions, and listings of anticipated goals and expected outcomes, refer to Chapter i

Coordination, Communication, and Documentation

Coordination, communication, and documentation for primary prevention/risk reduction may include:

Anticipated Goals and Expected OutcomesInterventions• Addressing required functions

individualized family service plans (IFSPs) or individualizededucation plans (IEPs)informed consentmandatory communication and reporting (eg, patient/clientadvocacy and abuse reporting)

• Collaboration and coordination with agencies, including:equipment suppliershome care agenciespayer groupsschoolstransportation agencies

• Communication, including:education plansdocumentation

• Data collection, analysis and reportingoutcome datapeer review tlndingsrecord reviews

• Documentationelements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Referrals to other professionals or resources

Patient/Client-Related Instruction

Accountability for services is increased.Individualized femily service plans (IFSPs) or individualized edu-cation plans (IEPs), infbrmed consent, and mandatory communi-cation arid reporting (eg, patient/client advocacy and abusereportirig) are obtained or completed.Available resources are maximally utilized.Collaboration and coordination occurs with agencies, includingequipment suppliers, home cate agencies, payer groups,schools, and transportation agencies.Communication occurs through education plans anddocumentation.Data are collected, analyzed, and reported, includii^ outcomedata, peer review findings, and record reviews.Decision making is enhanced regarding patient/client healtiniand the use of health care resources by patient/client, fiunlly, sig-nificant others, and caregivers.Documentation occurs throughout patient/client managementand follows APTA s Guidelines for Physical TherapyDocumentation (Appendix 5).Patient/client, femily, significant other, and caregiver understand-ing of anticipated goals and expected outcomes is increased.Referrals are made to other professionals or resources whenev-er necessary and appropriate.Resources are utilized in a cost-effective way.

Patient/ciient-related instruction may include:

Interventions• Instruction, education, and training of

patients/clients and caregiversregarding:

enhancement of performancehealth, wellness, and fitnessprogramsplan for intervention

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

Anticipated Gods and Expected Outcomes• Ability to perform physical actions, tasks, or activities is improved.• Awareness and use of community resources are improved,• Behaviors that foster healthy habits, wellness, and prevention are acquired.• Decision making is enhanced iegatding patient/client health and the use of health

care resources by patient/cUent, femily, significant others, Mid caregivers.• Health status is improved,• Patient/client, family, significant other, and caregiver knowledge and awareness of the

diagnosis, prognosis, interventions, and anticipated goals and expected outcomes areincreased,

• Patient/dient knowledge of personal and environmental fectors associated with thecondition is increased.

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

• Physical function is improved.• Risk of recurrence of condition is reduced,• Safety of patient/client, femily, significant others, and caregivers is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include;

Therapeutic Exercise

Interventions• Aerobic capacity/endurance conditioning or

reconditioningaquatic programsgait and locomotor trainingincreased workload over time

- walking and wheelchair propulsion programs• Balance, coordination, and agility training

developmental activities trainingmotor function (motor control and motorlearning) training or retraining

- neuromuscular education or reeducation- posture awareness training

standardized, programmatic, complementaryexercise approachestask-specific performance training

• Body mechanics and postural stabilization- body mechanics training- posture awareness training

postural control training- postural stabilization activities

• Flexibility exercisesmuscle lengtheningrange of motion

- stretching• Gait and locomotion training

developmental activities traininggait training

- implement and device training- perceptual training

standardized, programmatic, complementaryexercise approaches

• Relaxationbreathing strategiesmovement strategiesrelaxation techniquesstandardized, programmatic, complementaryexercise approaches

• Strength, pow er, and endurance training for head,neck, limb, pelvic-floor, trunk, and ventilatorymuscles- active assistive, active, and resistive exercises

(including concentric, dynamic/isotonic, eccen-tric, isokinetic, isometric, and plyometric)aquatic programs

- standardized, programmatic, complementaryexercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Physiological response to increased oxygen demand is improved.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.

Energy expenditure per unit of work is decreased.Gait, locomotion, and balance are improved.

- Joint integrity and mobility are improved.- Motor function (motor control and motor learning) is improved,- Muscle performance (strength, power, and endurance) is increased,- Postural control is improved.

Quality and quantity of movement between and across body segmentsare improved,

- Range of motion is improved,- Relaxation is increased.- Sensory awareness is increased,- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care,

home management, work (job/school/play), community, and leisure isimproved.

- Level of supervision required for task performance is decreased.Performance of and independence in activities of dally living (ADL) andinstrumental activities of daily living (IADL) with or without devices andequipment are increased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/preventionRisk fectors are reduced.

- Risk of secondary impairment is reduced.- Safety is improved.

• Impact on health, wellness, and fitness- Fitness is improved.

Health status is improved.Physical capacity is increased,

- Physical function is improved.• Impact on societal resources

- Utilization of physical therapy services is optimized.Utilization of physical therapy services results in efficient use of healthcare dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/client,- Cost of health care services is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent,

femily, and significant others.Sense of wrell-being is Improved,

- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Barrier accommodations or modifications• Injury prevention or reduction

injury prevention education during seU-care andhome managementinjury prevention or reduction with use of devicesand equipment

- safety awareness training during self<:are and homemanagement

Antkipotsd Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Physiologicai response to increased oxygen demand is improved.• Impact on ImpsUrments

- Postural control is improved.- Weight-bearii^ status is improved.

• Impact on functional limitations- Ability to peifonn physical actions, tasks, or activities related to self-

care and home mans^ment is improved.- Level of supervision reqtdied for task performanLce is deraeased.- Performance of and independence in ADL and IADL with or without

devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self<are and home manage-

ment rcrfes is improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.

• Impact on health, wellness, and fitness- Fitness is iniproved.- Health utatas is improved.

Hiysical function is improved.• Impact on societal resources

- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in rfflcient use of

health care dollars,• Patient/dient satisfection

- Access, availability, and services provided are acceptaWe topatient/dient.

- Adminiarative management of practice is acceptable to ptatient/dient.- Clinical proficiency of physical therapist is acceptable to

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

- Interpersonal skills of physical therapist are acceptable topatient/client, femily, and significant others.

- Sense of weU-being is improved.- Stressors sire decreased.

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Procedural Interventions continued

Functionol Troining in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activitiesof Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions• Barrier accommodations or modifications• Injury prevention or reduction

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

- injury prevention or reduction with use of devices andequipment

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

Anticipated Goals and Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condi-tion)

Physiological response to increased oxygen demand isimproved.

• Impact on impairments- Postural control is improved,- Weight-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to

work (job/school/play), commimity, and leisure integration orreintegration is improved,

- Level of supervision required for task performance isdecreased,

- Performance of and independence in LADL with or withoutdevices and equipment are increased,

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/preventionRisk fectors are reduced.

- Risk of secondary impairment is reduced.- Safety is improved.

• Impact on health, wellness, and fitnessFitness is improved.Health status is improved.Physical ftmction is improved,

• Impact on societal resources- Costs of work-related injury or disability are reduced.- Utilization of physical therapy services is optimized,- Utilization of physical therapy services results in efficient use of

health care dollars,• Patient/clieot satisfaction

- Access, availability, and services provided are acceptable topatient/client,

- Administrative management of practice is acceptable topatient/client.

- Clinical proficiency of physical therapist is acceptable topatient/client.

- Coordination of care is acceptable to patient/client,- Cost of health care services is decreased.- Interpersonal skills of physical therapist are acceptable to

patient/client, femily, and significant others.Sense of well-being is improved.

- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of pJiysical therapy services and the end of the episode of care,the physical therapist measures the global outcomes ofthe physical therapy services by characterizing or quantifying the impact ofthephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Fvmctional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

In some instances, a particular ;mticipated goal or expected outcome is thorouglily achieved through implementation of a sir^e form ofintervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects ofseveral forms of interventions, leading to enhancement of both health status and health-related quality of life.

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

Discontinuation is the process of ending physical therapy services that havt been provided during a single episode of care w hen (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; < 2 > the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because finam ial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/ciient status and the rationale for termination are documented.

For patients/clients who require multiple epistxles of care, periodic follow-up i** needed over the life span to ensure safety and effective adap-tation following changes in physical status, caregivers, environment, or t;isk demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans tor discharge or discontinuation and provides for appropriate follow-up or referral.

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Impaired Poshjre

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide tor patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist, APTA emphasizes that preferred practice patterns art- the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified in this pattern for impaired posture as a rt suit of the physical therapist's evaluation of the exami-nation data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or riskof pathology/pathophysiology (disease, disorder, or comlition), impairments, functional limitations, or disabilities or the need forhealth, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the examination data to deter-mine the diagnostic classification.

Inclusion

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

Risk Foctors or Consequences of Pathology/Pathophysiology(Disease, Disorder, or Condition)• C'ongenital torticollis• Pain• Pregnancy• Repetitive stress syndrome• Scheuermann disease• Scoliosis, kyphoscoliosis

Impairments, Functional Limitations, or Disabilities

• Impaired joint mobility• Inability to tolerate prolonged sitting• Leg length discrepancy• Muscle imbalance• Muscle weakness

Note:

Some risk factors or consequences of pathology/pathophysiology—such as primary posture impairment asso-ciated with cerebral patsy—may be severe and complex;however, /bey do not necessarily exclude patients/clientsfrom tbis pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visitsand duration of care (See "Evaluation, Diagnosis, andPrognosis,' page SI50,)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client •would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern

• Impairments associated with chronic obstructive pulmon-ary disease with kyphosis

• Impairments associated with spinal stabilization surgery• Radicular signs

Findings Thot May Require Classification inAdditionol Patterns• Impairments associated with scoliosis, with contusion of

the thigh

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

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9tb Revision, Clinical Modification (ICD-9-CM 2001),Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

524 Dentofecial anomalies, including malocclusion

524.6 Temporomandibular joint disorders568 Other disorders of peritoneum

568.0 Peritoneal adhesions (postoperative) (postinfection)718 Other derangement of joint

718.8 Other joint derangement, not elsewhere classified

719 Other and tmspecified disorders of joint

719.5 Stiffness of joint, not elsewhere classified

719.7 Difficulty in walking722 Intervertebral disk disorders

722.4 Degeneration of cervical intervertebral disk

722.5 Degeneration of thoracic or lumbarintervertebral disk

722.6 Degeneration of intervertebral disk,site unspecified

723 Other disorders of cervical region

723.1 Cervicalgia723.5 Torticollis, tinspeclfled

724 Other and tmspecified disorders of back724.1 Pain in thoracic spine

724.2 LumbagoLow back painLow back syndromeLumbalgia

724.6 Disorders of sacrum

724.9 Other unspecified back disordersAnkylosis of spine, not otherwise specifiedCompression of spinal nerve root, not elsewhere classifiedSpinal disorders, not otherwise specified

725 Polymyalgia rheumatica

728 Disorders of muscle, ligament, and fascia

728.2 Muscular w^asting and disuse atrophy, notelsewhere classified

728.8 Other disorders of muscle, ligament, and fascia728.85 Spasm of muscle

729 Other disorders of soft tissues

729.1 Myalgia and myositis, unspecified

729.9 Other and unspecified disorders of soft tissue732 Osteochondropathies

732.0 Juvenile osteochondrosis of spine733 Other disorders of bone and cartilage

733.0 Osteoporosis

736 Other acquired deformities of limbs

736.3 Acquired deformities of hip736.4 Genu valgtim or varum

736.7 Other acquired deformities of ankle and foot736.8 Acquired deformities of other parts of limbs

736.81 Unequal leg length (acquired)

737 Curvature of spine

737.1 Kyphosis (acquired)

737.2 Lordosis (acquired)

737.3 Kyphoscoliosis and scoliosis738 Other acquired deformity

738.4 Acquired spondylolisthesis738.6 Acquired deformity of pelvis

756 Other congenital musculoskeletal anomalies

756.1 Anomalies of spine

781 Symptoms involving nervous and musculoskeletal systems781.2 Abnormality of gait

781.9 Other symptoms involving nervous andmusculoskeletal systems

781.92 Abnormal posture

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

Examination has three components; the patient/client history, the systems review, and tests and measures,The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physi-cal therapist. The systems revieiv is a brief or limited examination of (1) the anatomical and physiological status ofthe cardiovascular/pul-monary, integtimentary, musctiloskeletal, and neuromuscular systems and (2) ttie crommtinication ability, affect, cognition, language, andlearning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination v;u7 ba.sed on patient/ciient age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (earh', intermediate, late, rettirn to activity); home, work (job/school/play), orcommunity sittiation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include;

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Ploy)• Ctirrent and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Uving environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role fiinction (eg, commtinity, leisure,

social, work)• Social ftmction (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medicol/Surgical History• Cardiovascular• Endocrine/metabolic• Ciastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Netiromtisctilar• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patit:nt/client

who requires the services of a physicaltherapist

• Ctirrent therapeutic interventions• Mechanisms of injury or disease. Includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response; to the cur-rent clinical sittiation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior fimctional stattis in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (IADL)

• C-urrent and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications fbr current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical ond Physiological Status

• Cardiovascular/Ptilmonary •Blood pressureEdemaHeart rateRespiratory rate

Integtimentary- Presence of scar

formationSkin colorSkin integrity

Musculoskeletal- Gross range of motion- Gross strength- Gross symmetry- Height- Weight

Neuromuscular- Gross coordinated

movements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

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

Anthropometric Characteristics• Body dimensions (eg, body mass index, girth measurement,

length measurement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg, activities of daOy living [ADL] scales, func-tional scales, instrtimental activities of daily living [IADL] scales,interviews, observations)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, intervie^vs, logs, observations,reports)

Ergonomics and Body MechanicsErgonomics• Functional capacity and performance during work actions,

tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endtirance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in w ork environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,LVDL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

Goit, Locomotion, and Bolance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

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

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Initiation, modification, and control of movement patterns andvoluntary postures (eg, activity indexes)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electronetiromyography)• Muscle strength, po^ver, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• Orthotic, protective, and supportive devices and equipment

use during functional activities (eg,ADL scales, functionalscales, IADL scales, interviews, observations, profiles)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, fall scales, interviews, logs,observations, reports)

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Tests and Measures continued

Pain• Pain, soreness, and nociception (eg, analog scales, discrimina-

tion tests, dyspnea scales, pain drawings and maps, provocationtests, verbal and pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including syntmetry

and deviation from midline (eg, observations, technology assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions; photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional te.sts)

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, int liiiome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, Ugamentous tests, lin-ear measurement, multisegment flexibility tests, palpation)

Self-Care and Home Management (Including ADL and IADL)• Safety in self-care and home management activities and envi-

ronments (eg, diaries, fall scales, intervie^vs, logs, observations,reports, videographic assessments)

Sensory Integrity• D« ep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (including IADL)• Sa(et>' in work (job/school/play), community, and leisure activi-

ties and environments (eg, diaries, fell scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems revie w, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overall health status,

A diagnosis is a label encompassing a cluster of signs and sj'mptoms, syndromes, or categories. It is the restilt of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examination,The diagnostic label indicates the primary dysftinction(s)toward -which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement infunction and the amotmt of time needed to reach that level and may also include a prediction of levels of improvement that may bereached at various intervals during the cotirse of therapy. During the prognostic process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the ctirrent condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Prognosis

Over the course of 3 to 6 months,patient/client will demonstrate the abilityto maintain an optimal posture and thehighest level of functioning in home, w ork(job/school/play), community, and leisureenvironments.

During the episode of care, patient/clientw ill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

6 to 20This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 20 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedelivery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• Accessibility and availability ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, complications, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• Level of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• Stability of the condition

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

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include;

Interventions• Addressing required fimctions

advance directivesindividualized family service plans (IFSPs) or individualizededucation plans GEPs)

- infbrmed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• C ase management• Collaboration and coordination with agencies, including;

equipment suppliershome care agencies

- payer groups- schools

transportation agencies• Communication across settings, including;

case conferencesdocumentationeducation plans

• (;ost-effective resource utilization• Data collection, analysis, and reporting

outcome datapeer review findingsrecord reviews

• Documentation across settings, following APTA's Guidelinesfbr Physical Therapy Documentation (Appendix 5), including;- changes in impairments, functional limitations, and

disabilitieschanges in interventionselements of patient/client management (examination,evalviation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferencespatient care roundspatient/client family meetings

• Referrals to other professionals ov resources

Anticipaited Gods and Expected Outcomes• Accountability for services is inciieased.• Admission data and discharge plannii^ are completed.• Advance directives, individualized family service plans (IFSPs)

or individtralized education plans (IEPs), informed consent, andmandatory ccmuntinication and reporting (eg, patient advocacyand abuse reporting) are obtained or completed.

• Available resources are maximally utilized.• Care is coordinated with patient/client, £amity, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing equipment suppliers, home care ^encies, payer gtoups,schools, and transportation agencies.

• Commtmication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and dooimentation,• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding health, wellness, and

fitness needs.• Deci»on making is enhanced regarding patient/ciient health

and the use of health care resources by patient/client, family,significant others, and cu^givers.

• Documentation occurs throughout patient/client managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/client femily meetings.

• Patient/client, family, significant other, and caregiver under-stan<ling of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources wherj-

ever necessary and appropriate.• Resources are utilized in a cost-effective way.

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Patient/Client-Related Instruction

Patient/client-related instruction may include;

Interventions

• Instruction, education, and training of patients/cUents andcaregivers regarding;- current condition (pathology/pathophysiology

[disease, disorder, or condition], impairments, functionallimitations, or disabilities)enhancement of performancehealth, w^ellness, and fitness programsplan of care

- risk factors for pathology/pathophysiology (disease, dis-order, or condition), impairments, fimctional limitations,or disabilitiestransitions across settingstransitions to new roles

Anticipated Goals and Expected Outcomes• Ability to perform physical actions, tasks, or activities is

improved.• Awareness and use of commtinity resources are improved.• Behaviors that foster healthy habits, wellness, and preven-

tion are acquired.• Decision, making is enhanced regarding patient/ciient

health and the use of health care resources bypatient/client, femity, significant others, and caregivers.

• Disability associated with acute or chronic illnesses isreduced,

• Ftmctional independence in activities of daily living (ADL)and instrumental activities of daily living (LADL) isincreased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for task performance is

decreased.• Patient/client, family, significant other, and caregiver knowl-

edge and awareness of the diagnosis, prognosis, interven-tions, and anticipated goals and expected outcomes areincreased.

• Patient/client knowledge of personal and environmentalfactors associated with the condition is increased.

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

• Physical function is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/client, family, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condition-

ing or reconditioning- aquatic programs- gait and locomotor training

increased workload over timewalking and \vheelchair propulsionprograms

• Balance, c<x)rdination, and agility training- developmental activities training

motor function (motor control andmotor learning) training or retrainingneuromuscular education orreeducationpercepttial trainingposture awareness training

- standardized, programmatic, comple-mentary exercise approachestask-specitic performance training

• Body mechanics and posttiral stabilizationbody mechanics trainingposture awareness trainingpostural control trainingpostural stabilization activities

• Flexibility exercisesmuscle lengtheningrange of motionstretching

• RelaxatioiTbreathing strategiesmovement strategiesrelaxation techniques

- standardized, programmatic, comple-mentary exercise approaches

• Strength, power, and endurance trainingfor head, neck, limb, pelvic-floor, trunk,and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programsstandardized, programmatic, comple-mentary exercise approaches

- task-specific performance training

include:

Anticipat«d Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint sweUing, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.

Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Joint integrity and mobility are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.

Sensory awareness is increased.- We^t-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self<are, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or wiliiout devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Risk factors are reduced.- Risk of recurrence of condition is reduced.

Risk of secondary impairment is reduced.- Safety is improved.- Self-man^ement of symptoms is improved.

• Impact on health, wellnes,s, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/ciient.- Administiative management of practice is acceptaWe to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of phyiacal therapist are acceptaWe to patient/client, fiamily, and

significant others.Sense of well-beii^ is improved.

- Stressors are decreased.

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Procedural Interventions continued

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

Interventions

• ADL trainingbathingbed mobility and transfer trainingdevelopmental activitiesdressing

- eating- grooming

toileting• Devices and equipment use and training

assistive and adaptive device or equipment train-ing during ADL and LADL

- orthotic, protective, or supportive device orequipment training during ADL and LADL

• Functional training programs- back schools

simulated environments and taskstask adaptation

• IADL trainingcaring for dependents

- home maintenancehousehold choresshoppingstructured play for infants and childrenyard work

• Injury prevention or reductioninjury prevention education during self-care andhome managementinjury prevention or reduction with use ofdevices and equipmentsafet>' awareness training during seU-care andhome management

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease/disorder/

condition)- Pain is decreased.

Physiological response to increased oxygen demand is improved.• Impact on impairments

- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is

increased.- Postural control is improved.

Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to

self-care and home management is improved.- Level of supervision required for task performance is

decreased.- Performance of and independence in ADL and IADL with or

without devices and eqviipment are increased.Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care and home man-

agement roles is improved.• Risk reduction/prevention

Risk factors are reduced.Risk of secondary impairments is reduced.

- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.

Health status is improved.Physical capacity is increased.

- Physical function is improved.• Impact on societal resources

- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient tise of

health care dollars.• Patient/client satisfaction

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

- Administrative management of practice is acceptable topatient/client.

- Clinical proficiency of physical therapist is acceptable topatient/client.

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

- Interpersonal skills of physical therapist are acceptable topatient/client, family, and significant others.Sense of well-being is improved.Stressors are decreased.

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Procedural Intervenrions continued

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

Interventions• Devices and equipment use and

trainingassistive and adaptive device orequipment training during IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing IADL

• Functional training programsback schoolsjob coachingsimulated environments

- task simulation and adaptationtask training

• IADL trainingcommunity service training involv-ing instrtimentsschool and play activities trainingincluding tools and instrumentswork training with tools

• Injur>' prevention or reductioninjury prevention education dur-ing work (job/school/play), com-munity; and leisure integration orreintegrationinjury prevention or reductionwith use of devices and equipment

- safety awareness training duringw^ork (job/school/play), communi-t>, and leisure integration orreintegration

• Leisure and play activities and training

Anticipated Gods and Expacted Ovtcomes• Impact on pathology/pathophysiol<^y (disease, disorder, or condititm)

- Pain is decr^sed.Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improval.- Musde performance (strength, power, and endurance) is increased.

Postural control is improved.- Sensory awareness is increased.- Weight-brauring status is improved.

• Impact on functional iiniitati«is- AbiUty to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration is improved.- Level of supervision required for task performance is decreased.

Performance of and independence in IADL with or without devices and equipmentare increased.

- Toletance of positions and activities is increased.• Impact on disabilities

- Ability to assume or resume required work (job/school/play), conimunity, andleisure roles is improved.

• Risk reduction/preventionRisk factors are reduced.

- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is iniproved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Costs of work-related injury or disability are reduced.- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, avMlabiBty, and services provided are acceptable to patient/client.- Administtrative mana^tnent erf pwactice is acceptable to patient/cUent.- Clinkal proficiency of phyMcal therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.

Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

significant others.- Sense of weU-beii^ is improved.- Stressors are decreased.

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Procedural Interventions continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Manual traction• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulation- soft tissue

spinal and peripheral joints• Passive range of motion

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, itnflammation, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Joint int^^rity and mobility are improved.- Muscle performance (strength, i>ower, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.

Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- AbiUty to perform movement tasks is improved.- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), commutiity, and leisure is improved.Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care, home management, work

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.- Self-management of symptotns is improved.

• Impact on health, ivellness, and fitness- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

significant others.Sense of well-being is improved.

- Stressors are decreased.

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,pProcedural Interventions continued

Prescription, Application, and, as

Supportive, and Prosthetic)

Interventions

• Adaptive devicesseating systems

• Assistive devicescanes

- crutches- power devices

static and dynamic splintswalkerswheelchairs

• Orthotic devicesbracescasts

- shoe insertssplints

• Protective devicesbracescushionsprotective taping

• Supportive devicescorsets

- neck collarsserial casts

- slingssupportive taping

Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective,

Antic^xited Gods (sid Expsdad OuMEXMnes• Impact on fmthology/pathopbysiology (disease, disorder, or condition)

- Edema, tpnphedema, or effuskin is reduced.- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased.- Soft tissue swelUng, iaflammation, or restriction is reduced.

• Impact on impakments- Balance is improved,- Endurance is increased.- Energy eaqpenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Joint staWlity is iniproved.- Motor fraction (motor control and motor learning) is improved.- Muscle perftmnance (strength, power, and endurance) is increased.- Optimal joint alignment is achieved.- OjMimal loading on a bod^ part is achieved.- Postural control is improved.- Quality and quantity of nrovement between and across body segments are improved.- Range of motion is improved.- Relaxation is increased.- Weight-bearing status is improved.

• Impact on fimctional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home nmiage-

ment, woik (job/school/play), conununity, and leisure is iniproved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumental

activities of daiiy living (IADL) w th or without devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care, home management, woric

(job/school/play), community, and leisure rotes is improved.• Risk reduction/prevention

- Pressure on body tissues is reduced.- Protection of body parts is increased.- Ri^ factors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impaiiMient is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Hiysical capacity is increased.- Physic^ ftmction is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availabiity, and services provided are acceptable to patient/client.- Administrative mana^ment of practice is acceptable to patient/client.

Clinical proficiency of physical tterapist is acceptable to patient/client.- Coordliation of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of pli^sical therapist are acceptable to patient/client, family, and sig-

nificant others.Sense of well-being is improved.

- Stressors are decreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrical stimulation

- electrical muscle stimulation(EMS)

- functional electrical stimulation(FES)transcutaneous electrical nervestimulation (TENS)

Anticipated Goals and Expected Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Osteogenic effects are enhanced.- Pain is decreased.

• Impact on impairments- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.Quality and quantity of movement between and across body segments areimproved.

- Relaxation is increased.Sensory awareness is increased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and eqtiipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of immobility are redticed.- Risk fectors are reduced.- Risk of recurrence of condition is reduced.

Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resoxirees- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided are acceptable to patient/ciient.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client.- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continuedPhysical Agents and Mechanical Modalities

Interventions

Physical agents may include:• Sound agents

phonophoresisultrasound

• Cryotherapy- cold packs- ice massage

vapocoolant spray• Thermotherapy

dry heathot packsparaffin baths

Mechanical modalities may include:• Traction devices

intermittentpositionalsustained

Goab ond Ejqieded Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint tissue swelling, inflammation, or restriction is reduced.- Neural compression is decreased.- Nutrient delivery to tissue is increased.- Pain is decreased.- Soft tissue swellitig, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairmentsRange of motion is improved.

- Weight-bearing status is improved.• Impact on functional limitations

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

- Performance of and independence in activities of daily livii^ (ADL) and instrumen-tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of soft tissue and cireulatory disorders are decreased.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Physical capacity is increased.- Fitness is improved.- Phy^cal function is improved.

• Impact on societal resotire<;s- Utilization of physical therapy services is optimized.

• Patient/client satisfiiction- Access, availability, and services provided are acceptable to patient/client.- Atkninistiative management of practice is accQ>table to pMient/cBent.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is iicceptable to patient/client.- Interpersonal skills of phy^cal therapist is srcceptable to patient/client, famity, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/cUent 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 thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when apatient is moved from one site to another site within the same setting or across settings during a single episode of care). Although theremay be facUity-specific or payer-specific requirements for doctmientation regarding the conclusion of physical therapy services, dischargeoccurs based on the physical therapist's analysis ofthe achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented.

For patients/cMents who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adap-tation follow ing changes in physical status, caregivers, environment, or task demands. In consultation \vith appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for dischai^e or discontinuation and provides for appropriate f()llow-up or referral.

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ImpairedMuscle Performance

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis tnade by the physical thera-pist. AFFA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, cuJti:re, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified in this pattern for impaired muscle performance as a result of the physical therapist's evaluationof the examination data.The findings from the examination (history, systems leview, and tests and measures) may indicate thepresence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilitiesor the need for health, wellness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to deter-mine the diagnostic classification.

Inclusion

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

Risk Factors or Consequences of Pathology/Pathophysiology(Disease, Disorder, or Condition)• Acquired immune deficiency syndrome• (;hronic musculoskeletal dysfunction• C^hronic neuromuscular dysfunction• Diabetes• Down syndrome• Pelvic floor dysfunction• Renal disease• Va.si ular instifficiency

Impairments, Functional Limitations, or Disabilities• Decreased functional work capacity• Decreased nerve ct)ndtiction• Diastasis recti• Inability to climb stairs• Inability to perform repetitive work tasks• Loss of muscle strength, power, endtirance• Stress urinary incontinence

Note:

Some risk factors or consequences of pathology/pathophysiology—such as myositis with acute exacerbation—may be severe and complex; however, they do not necessarilye.xclude patients/clients from this pattern. Severe and complexrisk factors or consequences may require modification of thefrequency of visits and duration of care. (See "Evaluation,Diagnosis, and Prognosis, page SI67.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity c if the examination findings, the physical therapistmay dt ti^rmine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand anoiher pattern.

Findings That May Require Classification in aDifferent Pattern

• Frai tiire• Imjiairments associated with amputation• Impairments associated with primary capsular restriction• Impairments associated with primary joint arthroplasty• Impairments associated with primary localized inflam-

mation• Muscular pain due to cesarean delivery• Ret ent bony sui^ery

Findings That May Require Classification inAdditional Patterns• Post-j)olio syndrome with bursitis

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

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

042 Human immunodeficiency virus [HIV] disease

250 Diabetes mellitus

359 Muscular dystrophies and other myopathies

359.9 Myopathy, unspecified

443 Other peripheral vascular disease

564 Functional digestive disorders, not elsewhere classified

564.0 Constipation

569 Other disorders of intestine

569.4 Other specified disorders of rectum and anus

569.42 Anal or rectal pain

581 Nephrotic syndrome

582 Chronic glomerulonephritis

583 Nephritis and nephropathy, not specified as acute or chronic

588 Disorders resulting from impaired renal function

618 Genital prolapse

618.0 Prolapse of vaginal walls without mention ofuterine prolapse

CystoceleRectocele

618.1 Uterine prolapse without mention of vaginal wallprolapse

618.6 Vaginal enterocele, congenital or acquired

618.8 Other specified genital prolapse

Incompetence or weakening of pelvic ftmdus

Relaxation of vaginal outlet or pelvis

623 Noninflammatory disorders of vagina

623.4 Old vaginal laceration

624 Noninflammatory disorders of vulva and perineum

624.4 Old laceration or scarring of vulva

625 Pain and other symptoms associated with female genitalorgans

625.0 Dy spareunia625.1 Vaginismus

625.6 Stress incontinence, female714 Rheumatoid arthritis and other inflammatory

polyarthropathies

714.0 Rheumatoid arthritis

715 Osteoarthrosis and allied disorders

719 Other and unspecified disorders of joint

719.7 Difficulty in walking

728 Disorders of muscle, ligament, and fascia

729

733

739758

780

781

799

728.2

728.8

Muscular wasting and disuse atrophy,not elsewhere classified

Other disorders of muscle, ligament, and fascia728.85 Spasm of muscle

728.9 Unspecified disorder of muscle, ligament,and fascia

Other disorders of soft tissues

729.1 Myalgia and myositis, unspecified

Other disorders of bone and cartilage

733.0 Osteoporosis733.1 Pathologic fracture

Nonallopathic lesions, not elsewhere classified

Chromosomal anomalies

758.0 Down's syndrome

General symptoms

780.7 Malaise and fatigue

Symptoms involving nervous and musculoskeletal systems

781.2781.3

781.4781.9

Abnormality of gaitLack of coordination

Ataxia, not otherw^ise specifiedMuscular incoordination

Transient paralysis of Umb

Other symptoms involving nervous andmusculoskeletal systems

781.92 Abnormal posture

Other ill-defined and unkno-wn causes of morbidity andmortalit}'

799.3 Debility, unspecified

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

Examination has three components; the patient/client liistory the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physi-cal therapist.The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) the c ommunication ability, affect, cognition, language, andlearning st>'le of the patient/client. Tests and measures are the means of gathering data about the patient/cUent.

The selection of examination procedures and the depth of the examination ^ aiy based on patient/cUent age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors, i-br clinicat indications in selecting tests and measures and for listings of tests andmeasure.% tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The histor>' may include:

General Demographics• Age• Sex• Race/ethnicity• Primar)' language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobiUty, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromu.scular• Obstetrical• Prior hospitaUzations, surgeries, and

preexisting medical and otlier health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patient/client

who requires the .services of a physicaltherapisr

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic inter\ention

• Patient/i lient, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior ftmctional status in

self-care and home management activi-ties, including activities of daily Uving(ADL) and instrumental activities ofdaily living (IADL)

• Current and prior functional status inwork (job/school/play), conimunity,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, sui^ical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •Blood pressureEdema

- Heart rate- Respiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs know n• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

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

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrtmiental activities of dailyliving [IADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergon\etry, step tests, time/distance walk/run tests, treadmilltests, vheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, IADL scales,interviews, observations)

• Components, alignment, fit, and ability to care for assistive oradaptive devices and equipment (eg, interviews, logs, observa-tions, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment (eg,activity status indexes,ADL scales, aerobic capacity tests, func-tional performance inventories, health assessment question-naires, IADL scales, pain scales, play scales, videographic assess-ments)

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

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration)

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

Environmental, Home, and Work (Job/School/Play) Barriers• Ctirrent and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

Ergonomics and Body MechonicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abili-ty tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, w ork analyses)

• Safet)' in w ork environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific w ork conditions or activities (eg, handling checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, -workstation checklists)

Body mechanics• Body mechanics during seU'-care, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

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Tests and Measures continued

Goit, Locomotion, and Bolance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessment.s)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control lests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobiUty skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry; electroneuromyography, foot-print analyses, gait profiles, mobility' skiU profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, w^eight-bearing scales, wheelchairmobility' tests)

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

Motor Function (Motor Control and Motor Leorning]• Dexterity, coordination, and agiUty (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Flectrophysiological integrity (eg, electroneuromyography)

• Hand function (eg, fine and gross control tests, finger dexteritytests, manipulative ability tests, observations)

• Initiation, modification, and control of movement patterns andvoluntary postures (eg, activity indexes, gross motor functionprofiles, movement assessment batteries, observations, physicalperformance tests, videographic assessments)

Muscle Performance (Including Strength, Pov/er and Endurance)• Electrophysiological integrity (eg, electroneuromyography)

• Muscle strength, power, and endurance (eg, dynamometry, man-ual muscle tests, muscle performance tests, physical capac itytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg, ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• Components, aUgnment, fit, and abiUty to care for orthotic, pro-

tective, and supportive tlevices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentuse during functional activities (eg, ADL scales, functionalscales, IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-tit s with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthasst ssrnent questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevtces and equipment (eg, diaries, faU scales, interviews, logs,observations, reports)

Poin• Pail I, soreness, and nociception (eg, analog scales, discrimina-

tion tests, dyspnea scales, pain drawings and maps, provocationtests, verbal and pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• PosEural alignment and position (dynamic), including symmetry

and deviation from midline (eg, obseir^ations, technology-assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Siiecific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Work [Job/School/Play), Community, and Leisure Integration orReintegration (Including lADl)• Abiiity to asstime or resume work (job/school/play), commtmi-

t) and leisure activities with or without assistive, adaptive,ortliotic, (protective, supportive, or prosthetic devices andequipment (eg, activity profiles, disability indexes, functionalstatus ([uestionnaires, IADL scales, observations, physical capaci-t>' tests)

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

• Saft ty in work (jt)b/school/play), community, and leisure activi-titis and environments (eg, diaries, faU scales, interviews, logs,t)bservations, videographic assessments)

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Tests and Measures continued

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, ligamentous tests, linearmeasurement, multisegment flexibiUty tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

tests)• Electrophysiological integrity (eg, electroneuromyography)

Self-Care and Home Management (Including ADL and IADL)• AbiUty to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and environ-ments (eg, diaries, faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg,electroneuromyography)

Ventilation and Respiration (Gas Exchange)• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluatit)n include the clinical findings, extent of loss of func-tion, chronicity or severity t>f the problem, possibility of multisite or multisystera involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overall health status.

A diagnosis is a label enctjmpassing a cluster of signs and syinpttiins, syndrome.s, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examination.llie diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level and may also include a prediction of levels of imprtwement that may bereached at various intervals during the course oi therapy. Durijig the progntjstic process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, propt).sed frequency and duratitjn of the interventions, anticipated goals, expected out-comes, and discharge plans. Tlie plan of care identifies reiilistic anticipated goals and expected outcomes, taking into consideration theexpectations ofthe patient/ciient and appropriate others.These anticipated gt)als and expected outcomes should be measureable and timeUmited.

The frequency of visits and duration of the episode of care may vary frtjm a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequent y and duration may vary greatly among patients/clients based tjn a varietyof factors that the physical therapist considers tliroughtmt the evaluation procc ss, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise: chronicity or sevt rit> t)f the ctirrent condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Prognosis

Over the course t)f 2 to 6 montlis,patient/cUent will demonstrate optimalmuscle performance and the highest levelt)f ftmctioning in home, work (jt)b/school/play), community, and leisure envi-ronments.

During the episode of care, patient/cUentwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in tliis pattern.

Expected Range of Number of VisitsPer Episode of Care

6 to 30

This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80"/o of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 30 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of t are should be determined bythe physical therapist to maximize effec-tiveness of t are and efficiency of servicedelivery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• Accessibility and availability ofresources

• Adherence tt) the intervention program• Age• Anatomical and physiological chiuiges

related to growth and development• (;aregiver consistency or expertise• Chronicity or severity of the current

condititm• Ctjgnitive stattis• C;omt)rbitities, compUcations, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• Level t>f physical function• Living envirt)nment• Multisite or multisystem involvement• Nutritional status• Overall health status• Pt)tential discharge destinations• Premorbid ctmditit)ns• Prt)babiUty t)f prolonged impairment,

functional limitation, or disabiUty• Psycliolt)gical and st:)cioeconomic

factt)rs• Ps7cht)motor abilities• Social support• Stabilitv of the condition

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

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

• Addressing required functionsadvance directives

- individuaUzed family service plans OFSPs) or individualizededucation plans (IEPs)informed consentmandatory communication and reporting (eg, patientadvocacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including:

equipment suppUers- home care agencies

payer groups.schotjls

- transportation agencies• Communicatit n across settings, including:

case conferences- documentation- education plans

• Cost-effective resource utiUzation• Data collection, analysis, and reporting

outcome datapeer revieiv findingsrecord reviews

• Documentation across settings, following APTA's Guidelinesfor Physical Therapy Documentation (Appendix 5), including:

changes in impairments, functional limitations, anddisabilitieschanges in interventionselements of patient/cUent management (examination,evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention• Interdisciplinary teamwork

case conferencespatient care roundspatient/cUent family meetings

• Referrals to other prtifessionals or resources

Anticipated Goals and Expected Outcomes• Accountability for services is increased.• Atimission data and discharge planning are completed.• Advance directives, individuaUzed family service plans (IFSPs)

or individualized education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximally utilized.• Care is coordinated with patient/client, family, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• CoUaboration and coordination occurs with agencies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are coUected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding health, wellness, and

fitness needs.• Decision making is enhanced regarding patient/cUent health

and the use of health care resources by patient/client, family,significant others, and caregivers.

• Documentation occurs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occtirs through case confer-ences, patient care rounds, and patient/cUent family meetings.

• Patient/client, family, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resovirces when-

ever necessary and appropriate.• Resources are utiUzed in a cost-efiective

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Patient/Client-Related Instruction

Patient/ciient-related instruction may include:

Interventions• Instruction, education, and training of patients/clients and

caregivers regarding:current condition (pathology/pathtjphysiology [disease,disorder, t:)r condition], impairments, functional limitatit>ns,or disabilities)enhancement of perftjrmance

- health, wellness, and fitness programsplan of carerisk factors for patholt)gy/pathophysiology (disease, disor-der, or conditit)n), impairments, functional limitations, ordisabilitiestransitions across settingstransitions tt) new roles

Antkifxitsd Goals and Expected Outcomes• Ability to j)erfonn physical actions, tasks, or activities is

improved.• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired.• Decision making is enhanced regarding patient/cUent health

and the use of health care resourees by patient/cUent, femily,significant others, and caregivers.

• Disability associated with acute or chronic iUnesses isreduced.

• Functional independence in activities of daily Uving (ADL)and instrumental activities of daily Uving (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for task performance is

decreased.• Patient/cUent, family, s^nificant other, and caregiver knowl-

edge and awareness of the diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.

• Patient/cUent knowledge of personal and environmental fac-tors associated with the condition is increased.

• Performance levels in seif-care, home management, work(job/school/play), community, or leisure actions, tasks, or activ-ities are improved.

• Physical function is improved.• Risk tjf recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/cUent, family, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioning- aquatic programs- gait and locomotor training

increased workload over time- •walking and wheelchair propul-

sion programs• Balance, coordination, and agilitj'

trainingdevelopmental activities trainingmotor function (motor control andmotor learning) training orretrainingneuromuscular education orreeducation

- perceptual training- posture awareness training- standardized, programmatic, com-

plementary exercise approachestask-specific performance training

• Body mechanics and postural stabi-lization

body mechanics training- posture awareness training

postural control trainingpostural stabilization activities

• Flexibility exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion training- developmental activities training- gait training- implement and device training

perceptual trainingstandardized, programmatic, com-plementary exercise approaches

- w^heelchair training• Relaxation

breathing strategiesmovement strategiesrelaxation techniquesstandardized, programmatic, com-plementary exercise approaches

• Strength, power, and endurance train-ing for head, neck, Umb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resis-tive exercises (including concen-tric, dynamic/iso tonic, eccentric,isokinetic, isometric, andplyometric)aquatic programsstandardized, programmatic, com-plementary exercise approaches

- task-specific performance training

include:

Anticipated Gools and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxygen demand is improved.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments:- Aerobic capacity is increased.- Balance is improved.

Endurance is increased.Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.- Joint integrity and mobility are increased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are improved.

Range of motion is improved.- Relaxation is iacreased.- Sensory awareness is increased.- Weight45earing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.

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

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/preventionRisk factors are reduced.Risk of recurrence of condition is reduced.Risk of secondary impairments is reduced.

- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitnessFitness is improved.

- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfactionAccess, availability, and services provided are acceptable to patient/client.

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

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

Intensity of care is decreased.Interpersonal skills of physical therapist are acceptable to patient/client, family, andsignificant others.Sense of well-being is improved.Stressors are decreased.

SI 70 /1 78 Guide to Physical Therapist Practice Physical Therapy • Volume 81 • Number 1 • January 2001

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Procedural inlervenrions continued

Functional Training in Sel^Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of DailyUving [IADL]]

Interventions• ADL training

bathing- bed mobility and transfer training

developmental activitiesdressingeatinggroomingtoileting

• Devices and equipment use and trainingassistive and adaptive device or equipmenttraining during ADL and IADLorthotic, protective, or supportive device orequipment trainingduring ADL and IADLprosthetic device or equipment training duringADL and IADL

• Functional training programsback schoolssimulated environments and taskstask adaptation

• IADL training- caring for dependents- home maintenance- household chores

shoppingstructured play for infants and childrenyard w ork

• Injury prevention or reductioninjury prevention education during self-careand home managementinjury prevention or reduction with use ofdevices and equipmentsafety awareness training during seltK:are andhome management

Goals and ExpwtocI OutconwsImpact on pathology/pathophysiology (disease, disorder, or cotKlltion)- Fun Is decreased.- Hiysiologica! response to increased oxygen demand is improved.Impact on impairments- Balance is impvroved.- Endurance is increased.- EnetKS' expenditure per unit of work is decreased.- Motor function (motor control and motor leatnii^ is improved.- Musde performance (strength, power, and endurance) is increased.- Posturjii control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-

care and home managemoit is improved.- Level of supervision required for task performance is decrea^d.- Performance of and independence in AOL and IADL with or without

devices and equipment are increased.- Tolerance of positions and activities are increased.Impact on disabilities- Ability to assume or resume required seif-care and home management

roles is improved.Risk reduction/prevention- Rid£ factors are reduced.- f^sk of secondary impairments is reduced.- Safety is improved.- Self-management of symptcuns is improved.Impact on health, wellness, and fitness- Htness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.Impact on societal resources- Utilization of pliysical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars.Patient/client satisfaction- Access, availability, and services provided are acceptable to

patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of pl^ical thoupist is acceptable to

patient/client.- Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decres^ed.- Interpersonal skills of physical therapist are acceptable to

patient/client, fiunily, and si^iificant others.- Sense of well-being is improved.- Stressors are decreased.

Guide to Physical Therapist Practice 4C Impaired Muscle Performance 179/SI 71

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Procedural Interventions continued

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

Interventions• Devices and equipment use and

trainingassistive and adaptive device orequipment training during IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing IADLprosthetic device or equipmenttraining during IADL

• Functional training programs- back schools- job coaching- simulated environments and tasks- task adaptation

task training• IADL training

- community service training involv-ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

injury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegration

- injury prevention or reductionwith use of devices and equipmentsafety awareness trainingduring work (job/school/play),community, and leisure integra-tion or reintegration

• Leisure and play activities and training

Anticipated Goals and Expected Outcomes• Impact on patholt^/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Enei^ expenditure per unit of work is decreased.

Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awarene^ is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reint^ration is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or restime reqtiired work (job/school/play), community, and leisure

roles is improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.

Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disability are reduced.- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative man^ement of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/dient.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, feunity, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

SI 72 /1 80 Guide to Physical Therapist Practice Physical Therapy • Valume 81 • Number 1 • January 2001

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Procedural Interventions continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

tntervenrions• Manual traction• Massage

- connective tissue massage- therapeutic massage

• Mobilizationsoft tissue

• Passive range of motion

I G o d s CHKI ExfMcMcl OuteOBMiImpact on pathok^/pathophysiology (cUsease, disorder, or condition)

Pain is decreased.$cA timMi s^^tttaig, inftownation, or restriction is reduced.

Impact on impairments- Muscle performance (strength, power, and endurance) is increasol.- Range of motion is improved.- Relaxation is increased.

' Impact on functional limitations- Ability to pedfonn movement tasks is improved.- Ability to perform physical actions, tasks, or actii^ties related to work

(job/school/play), community, and leisure is improved.- Tolerance of positions iuid activities is increased.

' Impact on disabilities- Ability to assume or resume required self<are, home management, work

(job/school/play), community, and leisure roles is impi<oved.' Risk reduction/prevention

- Risk of secondary impairment is reduced.- Self-mana^ment of symptoms is improved.

' Impact on health, weUness, and fitness- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

' Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services result in eflteient use of healtii oire dollars.

• Patient/ciient satisliaction- Access, availabUity, and services provided are acceptatde to patient/client.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is accei«able to patient/client.- Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Inteiperscxial skiUs of phystotl therapist are acceptable to patient/client, £unily, and

significant others.

Stressors are decreased.

Guide to Physical Therapist Prac'ice 4C Impaired Muscle Performance 1 8 1 / S 1 7 3

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Procedural Interventions continuedPrescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orlhotic, Protective,Supportive, and Prosthetic)

Interventions

• Adaptive devicesenvironmental controlsraised toilet seatsseating systems

• Assistive devices- canes- crutches

iong-handled reacherspower devicesstatic and dynamic splintswalkers

- wheelchairs• Orthotic devices

braces- casts

shoe insertssplints

• Prosthetic devices (lower-extremity and upper-extremity)

• Protective devices- braces- cushions

protective taping• Supportive devices

compression garmentscorsetselastic wraps

- neck coUars- serial casts- slings

supportive taping

>^4kipated Goab ond i}q»cted Oulcomes• Impact on padiology/padiophysiolc^y (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Energy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Joint stability is improved.- Muscle performance (strength, power, and endurance) is increased.- Optimal joint alignment is achieved.- Optimal loading on a body part is achieved.- Postural control is improved.

Quality and quantity of movement between and across body segments are improved.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

a^ment, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumental

activities of daily livir^ (tADL) with or without devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on dissdsilities- Ability to assume or resume required self-care, home management, work

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Pressure on body tissues is reduced.- Protection of body parts is increased.

Risk fiictors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-manj ement of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved

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

Utilization of physical therapy services results in efficient use of health care dollars.• Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptabte to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client.

Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, femily, and signif-

icant others.- Sense of well-being is improved.- Stressors are decreased.

SI 74 /1 82 Guide to Physical Therapist Practice Physical Theropy • Voiume 8 1 • Number 1 • January 2001

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Procedural Interventions continued

Eiectrotherapeutic Modalities

Interventions• Biofeedback• Electrical stimulation

- electrical muscle stimulation(EMS)

- functional electrical stimulation(FES)neuromuscular electrical stimula-tion (NMES)

- transcutaneous electrical nervestimulation (TENS)

Gocds ond Expected Outomws

Impact on pathology/pattaophysiotc^- Joint tissue swdMsag, inflammation, or restriction is reduced.- Nutiient delivery to tissue is increased.- Osteogenic effects are enhanced.- Pain is decr^sed.- Soft tissue swetting, inflammation, or restriction is reduced.- Ussue perfti^cm and oxygenation are enhanced.Impact on impairments- Motor functton (motor contrcd and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- QuaUty and quantity of movement between and across body segments are

improved.- Relaxation is increased.- Sensory awareness is increased.Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

man9 |[ement, community, woik (job/ school/ play), and leisure is improved.- Level of supervision reqiured for task performance is decreased.- Performance of and independence in activities of daify living (ADL) and instrumen-

tal activities of daily living CtAJDL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.Impact on disabilities- AbiUty to assume or resume required self-care, home management, work

(job/school/play), commuMty, and leisure roles is improved.Stak reduction/prevention- Complications of immobility are reduced.- Risk &ctors are reduced.- Risk of secondary impaintient is reduced.- Self-Btanagement of symptoms is improved.Impact on iKalth, weUness, and fitness- Fitness is improved.- Phytical capacity is iiK:reased.- Phy^cal function is improved.Impact on societal resources- UtiUzation of physical theiapy services is optimized.- Utilization of physical thempy services results in efficient use of health care dollars.Patient/client satiidaction- Access, avaikbility, and services provided are acceptabte to patient/dient.- Administiative management of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptaMe to patient/dient.- Interpersonal skills of physical therapist are acceptaMe to patient/cUent, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:• Cryotherapy

- cold packsice massagevapocoolant spray

• Hydrotherapypools

• Sound agents- phonophoresis

ultrasound• Thermotherapy

dry heathot packsparaffin baths

Mechanical modalities may include:• Compression therapies

- taping• Gravity-assisted compression devices

standing frame- tilt table

• Traction devices- intermittent

positionalsustained

Anticipoled Gools and Expected Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.

Neural compression is decreased.Osteogenic effects are enhanced.

- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments:- Muscle performance (strength, power, and endurance) is increased.

Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/preventionComplications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairments is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Physical function is improved.

• Impact on societal resourcesUtilization of physical therapy services is optimized.

• Patient/client satisfactionAccess, availability, and services provided are acceptable to patient/dient.

- Administrative management of practice is acceptabte to patient/client.- CHnical proficiency of physical therapist is acceptabte to patient/ctient.

Coordination of care is acceptabte to patient/cUent.tnterpersonat stcitls of physical therapist are acceptable to patient/dient, family, andsignificant others.

- Sense of welt-being is improved.Stressors are decreased.

S I 7 6 / 1 84 Guide to Physical Therapist Practice Physical Therapy • Volume 81 • Number 1 • January 2001

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

Global Outcomes for Patienh/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the iinticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shadeil boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of (itiysicai therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therap) service.s by characterizing or quantifying the impact of thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or conditi(5n)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been prov ided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when apatient is moved from one site to another site within the same setting or across settings during a single episode of care). Although theremay be facility-specific or payer-specific requirements for tiocumentation regarding the conclusion of physical therapy services, dischargeoccurs based on the physical therapists analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that havi; been provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because finamial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adap-tation following changes in physical status, caregivers, environment, or task dcniaiids. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or disconcinuation and provides for appropriate follo^w-up or referral.

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Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Connective TissueDysfunction

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as indiy-idual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

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

Inclusion

The following examples of examination findings may supportthe inclusion of patients/clients in this pattern;

Ri5k Factors or Consequences of Pathology/Paihophysiology(Disease, Disorder, or Condition)• Joint subluxation or dislocation• Ligamentous sprain• Musculotendinous strain• Pregnancy• Prolonged joint immobilization• Rheumatoid arthritis• Scleroderma• Systemic lupus erythematosus• Temporomandibular joint syndrome

Impairmenb, Functional Limitations, or Disabilities• Decreased range of motion• Inabilit)' to squat due to joint instability• Muscle guarding or weakness• Pain• Postpartum sacroiliac dysfunction• Swelling or effusion

Exclusion or Multiple-PaHern Classification

The following examples of examination findings may sup-port s'xclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern• Fracture• Immobility as a primary result of prolonged bed rest• lack of voluntary movement• Radiculopathy

Findings That May Require Classification inAdditional Patterns

• Abrasion or wound

Note:

Some risk factors or consequences of pathology/pathophysiology—such as impairments associated withJoint hemarthrosis and neuromuscutar dysfunction—maybe severe and complex; however, they do not necessarilyexctude patients/ctients from this pattern. Severe and com-plex risk factors or consequences may require modificationof the frequency of visits and duration of care, (See"Evaluation, Diagnosis, and Prognosis," page S185,)

Guide to Physical Therapist Practice 4D Impairments / Connective Tissue Dysfunction 1 8 7 / S 1 7 9

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

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

337 Disorders of the autonomic nervous system

337.2 Reflex sympathetic dystrophy

524 Dentofacial anomalies, including malocclusion

524.6 Temporomandibular joint disorders

625 Pain and other symptoms associated w ith female genital

organs

625.5 Pelvic congestion syndrome

665 Other obstetrical trauma

665.6 Damage to pelvic joints and ligaments

709 Other disorders of skin and subcutaneous tissue

709.2 Scar conditions and fibrosis of skin

710 Diffuse diseases of connective tissue

710.0 Systemic lupus erythematosus

710.3 Dermatomyositis

710.4 Polymyositis714 Rheumatoid arthritis and other inflammatory

polyarthropathies

714.0 Rheumatoid arthritis

715 Osteoarthrosis and allied disorders

716 Other and unspecified arthropathies

716.5 Unspecified polyarthropathy or polyarthritis

716.9 Arthropathy, unspecified

Inflammation of joint, not otherwise specified

718 Other derangement of joint

719 Other and unspecified disorders of joint

719.4 Pain in joint

719.8 Other specified disorders of joint

Calcification of joint

724 Other and unspecified disorders of back

724.6 Disorders of sacrum724.9 Other unspecified back disorders

Ankylosis of spine, not otherwise specifiedCompression of spinal nerve root, notelsewhere classifiedSpinal disorder, not otherwise specified

726 Peripheral enthesopathies and allied syndromes

726.0 Adhesive capsulitis of shoulder

726.1 Rotator cuff syndrome of shoulder and allieddisorders

726.2 Other affections of shoulder region, not elsewhereclassified

726.9 Unspecified enthesopathy

727 Other disorders of synovium, tendon, and bursa

727.0 Synovitis and tenosynovitis

727.6 Rupture of tendon, nontraumatic

727.8 Other disorders of synovium, tendon, and bursa

728 Disorders of muscle, ligament, and fascia

728.4 Laxity of ligament

728.6 Contracture of palmar fascia

Dupuytren's contracture

728.7 Other fibromatoses

728.8 Other disorders of muscle, ligament, and fascia

729 Other disorders of soft tissues

729.1 Myalgia and myositis, unspecified729.8 Other musculoskeletal symptoms referable to

limbs

729.9 Other and unspecified disorders of soft tissue

730 Osteomyelitis, periostitis, and other infections involvingbone

733 Other disorders of bone and cartilage

830 Dislocation of jaw

831 Dislocation of shoulder

832 Dislocation of elbow

833 Dislocation of wrist

836 Dislocation of knee

837 Dislocation of ankle

838 Dislocation of foot

839 Other, multiple, and ill-defined dislocations

839.0 Cervical vertebra, closed

839.8 Multiple and ill-defined, closed

ArmBackHandMultiple locations, except fingers or toes aloneOther ill-defined locationsUnspecified location

SI 8 0 / 1 88 Guide to Physical Therapist Practice Physical Therapy • Volume 81 • Number 1 • January 2001

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ICD-9-CM Codes continued

840 sprains and strains of shoulder and upper arm840.4 Rotator cuff (capsule)

841 Sprains and strains of elbow and forearm842 Sprains and strains of wrist and hand843 Sprains and strains of hip and thigh844 Sprains and strains of knee and leg845 Sprains and strains of ankle and foot846 Sprains and strains of sacroiliac region847 Sprains and strains of other and unspecified parts of back848 Other and ill-defined sprains and strains

848.1 Jaw848.3 Ribs848.4 Sternum848.5 Pelvis

Symphysis pubis905 Late effects of musculoskeletal and connective tissue injuries

905.6 Late effect of dislocation905.7 Late effect of sprain and strain without mention

of tendon injury

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

Examination has three components; the patient/client history, the systems review, and tests and measures. The history is a systematic gath-ering of past and current information (often from the patient/client) related to w hy the patient/client is seeking the services of the physi-cal therapist,The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, andlearning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity sittiation; and other relevant factors,/br clinical indications in selecting tests and measures and for listings of tests andmeasures, toots used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include;

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical fianction (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leistire,

social, work)• Social function (eg, social activity, social

interaction, social support)

SI82 /190 Guide to Physical Therapist Practice

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/cUent to seek

the services of a physical therapist• Concerns or needs of patient/client

•who requires the services of a physicaltherapist

• Ctirrent therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (IADL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include;

Anatomical and Physiological Status

• Cardiovascular/Pulmonar>' •Blood pressureEdema

- Heart rate- Respiratory rate

IntegumentaryPresence of scarformation

- Skin color- Skin integrity

Communication, Affect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Tests and Measures

Tests and measures for this pattern may include those that characterize

Anthropometric Characteristics• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg, activities of daily living [ADL] scales, func-tional scales, instrumental activities of daily living flADL] scales,interviev/s, observations)

• Components, alignment, fit, and ability' to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, LADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

Cranial and Peripheral Nerve Integrity

• Motor distribution of the peripheral nerves (eg, dynamometrj',muscle tests, observations, thoracic outlet tests)

• Response to neural provocation (eg, tension tests, vertebralartery compression tests)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and light touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

Ergonomics and Body MechanicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity tests)

or quantify';

• functional capacity and perfonnance during work actions,iasks, or activities (eg, accelerometr>, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,inierviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentSC lies, standartls for exposure limits)

• .Specific work conditions or activities (eg, handling checklists,lob simulations, lifting models, preemployment screenings, taskanalysis checklists, workstation checklists)

• r<:>ols, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Botly mechimics• Body mechanics during selfKrare, home management, w^ork,

c( immunity, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy -assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Bidance during functional activities with or without the use of

Assistive adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tiA'e, adaptive, orthotic, protective, supportive, or prostheticdt'vices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photogniphic assessments, postural control tests)

• Gait and locomotion during functional activities w ith or w ith-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobility skill profiles, observations, video-graphic assessments)

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Tests and Measures continued

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobility skill profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobility tests)

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

Joint Integrity and Mobility• Joint play movements, including end feel (all joints of the axial

and appendicular skeletal system) (eg, palpation)• Specific body parts (eg, apprehension, compression and distrac-

tion, drawer, glide, impingement, shear, and valgus/varus stresstests; arthrometry)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during fimctional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• Components, alignment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentuse during functional activities (eg,ADL scales, functionalscales, IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes, ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, fall scales, interviews, logs,observations, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimina-

tion tests, dyspnea scales, pain draw ings and maps, provocationtests, verbal and pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, ligamentous tests, lin-ear measurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)• Superficial reflexes and reactions (eg, observations, provocation

tests)

Self-Care and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identi-

fication, observations, physical performance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and envi-ronments (eg, diaries, fall scales, intervie'ws, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)

Ventilation and Respiration/Gas Exchange• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)• Pulmonary signs of ventilatory function, including airway pro-

tection; breath and voice sounds; respiratory rate, rhythm, andpattern; ventilatory flow, forces, and volumes (eg, airway clear-ance tests, observations, palpation, pulmonary function tests,ventilatory muscle force tests)

• Pulmonary' symptoms (eg, dyspnea and perceived exertionindexes and scales)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), communi-

ty, and leisure activities with or without assistive, adaptive,orthotic, protective, supportive, or prosthetic devices andequipment (eg, activity profiles, disability indexes, functionalstatus questionnaires, IADL scales, observations, physical capaci-ty tests)

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

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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

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

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or ,severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Prognosis

Over the course of 2 weeks to 6 months,patient/client will demonstrate optimaljoint mobility, muscle performance, andrange of motion and the highest level offunctioning in home, work (job/school/play), community, and leisureenvironments.

During the episode of care, patient/clientwiU achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

3 to 36

This range represents the lower andupper limits of the number ol physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern wiltachieve the anticipated goah and expect-ed outcomes within 3 to J6 tHsits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiencif of servicedeliverv

Factors That May RequireEpisode of Care or That M o /Modify Frequency of Visits/Duration of Episode

• Accessibility and availability ofresources

• 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• (^omorbitities, 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 prt>longed impairment,

functional limitation, or disability• Psychological and socioeconomic;

factors• Psychomotor abilities• Social support• Stability of the condition

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

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

Coordination, Connmunication, and Documentation

Coordination, communication, and documentation may include;

interventions• Addressing required functions

advance directives- individualized family service plans (IFSPs) or individualized

education plans (IEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including;

equipment suppliershome care agenciespayer groupsschoolstransportation agencies

• Communication across settings, including;- case conferences- documentation

education plans• Cost-effective resource utilization• Data collection, analysis, and reporting

- outcome data- peer review findings- record reviews

• Documentation across settings, following APTA's Guidelinesfor Physical Therapy Documentation (Appendix 5), including;

changes in impairments, functional limitations, anddisabilities

- changes in interventions- elements of patient/client management (examination,

evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferences

- patient care roundspatient/client family meetings

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes• Accountability for services is increased,• Admission data and dischai^e planning are completed,• Advance directives, individualized family service plans (IFSPs)

or individiialized education plans (JEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed,

• Available resources are maximally utilized,• Care is coordinated with patient/client, fanuly, significant oth-

ers, caregivers, and other professionals,• Case is manned throughout the episode of care,• Collaboration and coordination occurs with agencies, includ-

ing equipment suppliers, home care agencies, payer groups,schools, and transportation agencies,

• Commiuiication enhances risk reduction and prevention,• Communication occurs across settings through case confer-

ences, education plans, and documentation,• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record re\iews,• Decision making is enhanced regarding health, wellness, and

fitness needs.• Decision making is enhanced regarding patient/client health

and the use of health care resources by patient/client, family,significant others, and caregivets,

• Documentation occurs throughout patient/client managementand across settings and follows APTA's Guidelines fin- PhysicalTherapy Documentation (Appendix 5),

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/client family meetings,

• Patient/client, fomily, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased,

• Placement needs are determined,• Referrals are made to other professionals or resources when-

ever necessary and appropriate,• Resources arc utilized in a cost-effective way.

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Patient/Clien^Related Instruction

Patient/client-related instruction may include;

Interventions• Instruction, education and training of patients/clients and

caregivers regarding;current condition (pathology/pathophysiology [disease,disorder, or condition], impairments, functional limitations,or disabilities)enhancement of performancehealth, wellness, and fitness programsplan of carerisk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilitiestransitions across settingstransitions to new roles

Goals and Expected Outcomesto perform physical actions, tasks, or activities is

improved.Awareness and use of community resources are improved.Behaviors that foster healthy habits, weltaesst and preventionare acquired.Decision making is enhanced regartlii^ patient/client healthand the use of health care resources by patient/dient, femily,signilieant others, and caregivers.Disability associated widi acute or chronic illnesses isreduced.Functional independence in activities of daily Mving (ADL)and instrumental activities of daily living (IADL) to increased.Health status is improved.Intensity of care is decreased.Level of supervision required for task perfonnance isdecreased.Patient/client, family, significant other, and caregiver knowl-edge and awareness of the (Uagno^, prognosis, interventions,aiid anticipated goals and expected outcomes are increased.Patient/client knowle(%e of personal and environmental fee-tors associated with the concUtktn is increased.Performance levels in self-care, home management, work(job/school/play), community, or leisure actions, tasks, or activ-ities are improved.Physical function is improved.Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safety of patient/cUem, family, s^nificant others, and care-giVers is improved.Self-management of symptoms is imjnoved.Utilization ami cost of he^hh care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include;

Therapeutic Exercise

Interventions• Aerobic capacity/endurance conditioning or

reconditioningaquatic programs

- gait and locomotor training- increased workload over time

walking and wheelchair propulsion programs• Balance, coordination, and agility training

developmental activities trainingmotor function (motor control and motorlearning) training or retraining

- neuromuscular education or reeducation- perceptual training- posture awareness training

standardized, programmatic, complementaryexercise approachessensory training or retrainingtask-specific performance training

• Body mechanics and postural stabilization- body mechanics training- posture awareness training

postural control trainingpostural stabilization activities

• Flexibility exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion training- developmental activities training- gait training

implement and device trainingperceptual trainingstandardized, programmatic, complementaryexercise approaches

- wheelchair training• Relaxation

breathing strategiesmovement strategiesrelaxation techmiquesstandardized, programmatic, complementaryexercise approaches

• Strength, power, and endurance training for head,neck, limb, pelvic-floor, trunk, and ventilatory mus-cles

active assistive, active, and resistive exercises(including concentric, dynamic/isotonic, eccen-tric, isokinetic, isometric, and plyometric)aquatic programs

- standardized, programmatic, complementaryexercise approachestask-specific performance training

Anticipated Goals and Expected Outcomes• Impact on patholc^/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflsunmation, or restriction is reduced.- Nutrient delivery to tissue is increased,

Osteogenic effects of exercise are maximized,- Pain is decreased,- Physiological response to increased oxygen demand is improved.- Soft tissue sweUiiig, inflammation, or restriction is reduced,- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments;- Aerobic capacity is increased,- Balance is improved,- Endurance is increased.

Energy expenditure per unit of work is decreased.Gait, locomotion, and balance are improved.

- Integumentary integrity is improved,- Joint integrity and mobility are improved,- Motor function (motor control and motor learning) is improved,- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.Quality and quantity of movement between and across body s^ments areimproved.Range of motion is improved.Relaxation is increased,

- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to selfcare,

home management, work (job/school/play), community, and leisure isimproved,

- Level of supervision required for task performance is decreased,- Performance of and independence in activities of daily living (ADL) and

instrumental activities of daily living (IADL) with or without devices andequipment are increased,

- Tolerance of positions and activities is increased,• Impact on disabilities

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

• Risk reduction/prevention- Preoperative and postoperative complications are reduced,- Risk factors are reduced.

Risk of recurrence of condition is reduced.Risk of secondary impairments is reduced.

- Safety is improved,- Self-management of symptoms is improved,

• Impact on health, wellness, and fitnessFitness is improved.Health status is improved,

- Physical capacity is increased,- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars.• Patient/cUent satis&ction

- Access, availability, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/client,- Clinical proficiency of physical therapist is acceptable to patient/cUent,- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased.- Intensity of care is decreased,- Interpersonal skills of physical therapist are acceptable to patient/client,

family, and significant others.Sense of well-being is improved,

- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• ADL training

- bathingbed mobility and transfer trainingdevelopmental activitiesdressingeatinggroomingtoileting

• Devices and equipment use and trainingassistive and adaptive device orequipment training during ADL andIADLorthotic, protective, or supportivedevice or equipment training duringADL and IADL

• Functional training programsback schoolssimulated environments and taskstask adaptation

• LADL training- caring for dependents

home maintenancehousehold choresshoppingstructured play for infants and chil-dren

- yard work• Injury prevention or reduction

injury prevention education duringself-care and home managementinjury prevention or reduction withuse of devices and equipmentsafety awareness training during self-care and home management

Anticipated Goals and Exptded Outcomes• Impact on pathology/pathqphysiology (disease, disorder, or condition)

- Pain is decreased,• Impact on impairments

- Balsttice is improved,- Endurance is increased,- Enei^es|)enditureper unit of work is decreased,- Motor functton (motor control and motor learning) is improved,- MiiKle pcstfonnance (stretigth, power, and endurance) is increased.- Postural control is improved,- Sensory awMcness is increased,- Weight-bearing status is improved,- Work of breathir^ is decreased,

• Impact on functional limitations- AbiHty to perform physical actions, tasks, or activities related to self-care and home

management is improved.Level of supervision required for task performance is decreased,

- Performance of and independence in ADL and IADL vnth or without devices andeqiripment are increased,

• Tolerance of positions and activities is increased,• Impact on disabilities

- AbiHty to assimie or resume required self-care and home management roles isimproved,

• Risk reduction/prevention- Risk factors are reduced,- Risk of secondary impairments is reduced,- Safety is improved,- Self-numagement of symptoms is improved,

• Impact Ml health, wellness, and fitness- Fitness is improved,- Health status is improved,- Physical capacity is increased,- Physical Ainction is improved.

• Impact on societal resourt;esUtilization of physical therapy services is optimized.Utilization of {rfrysical thetapy services results in efficient use of health care dollars.

• Patient/dient satis&ction- Access, availability, and services provided are acceptable to patient/client,- Administrative management of practice is acceptable to patient/client.

Clinical profickaicy of physical therapist is acceptable to patient/client.CoonUnation of care is acceptable to patient/client.

- Cost of health care services is decreased,- Intensity of care is decreased,- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

sigiiHcaiit others,- Sense of well-being is improved,- Sttessors are decreased.

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Procedural interventions continued

Functional Training in Work (Job/School/Piay), Community, and leisure Integration or Reintegration (Including Instrumental Activitiesof Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

• Devices and equipment use and training- assistive and adaptive device or equipment

training during IADLorthotic, protective, or supportive device orequipment training during IADL

• Functional training programsback schoolsjob coaching

- simulated environments and tasks- task adaptation

task training• IADL training

community service training involvinginstrumentsschool and play activities training includingtools and instruments

- work training with tools• Injury prevention or reduction

injury prevention education during work(job/school/play), community, and leisureintegration or reintegrationinjury prevention or reduction with use ofdevices and equipment

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

• Leisure and play activities and training

Anticipated Goals and Eiqiected Outcomes• Impact on jMithology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.• Impact on impairments

- Balance is improved.Endurance is increased.Energy exjjenditure per unit of vork is decreased,

- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration isimproved,

- Level of supervision required for task performance is decreased,- Perfonnance of and independence in IADL with or without devices and

equipment are increased,- Tolenince of positions and activities is increased,

• Impact on (Usabilities- Ability to assume or resume required woric (job/school/play), community,

and leisure roles is improved.• Risk reduction/prevention-

- Risk factors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.Self-management of symptoms is improved,

• Impact on health, wellness, and fitnessFitness is improved,

- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disability are reduced.

Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars,• I^tient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client,- Clinical proficiency of physical therapist is acceptable to patient/client,- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased,- Intensity of care is decreased,- Interpersonal skills of physical therapist are acceptable to patient/client,

family, and significant others.Sense of well-being is improved,

- Stressors are decreased.

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Procedural Interventions continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Manual traction• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulation- soft tissue- spinal and peripheral joints

• Passive range of motion

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced,- Neural compression is decreased.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved,- Enei^ expenditure per unit of work is decreased.- Gait, locomotion, and balance is improved,- Joint integrity and mobility are improved,- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.

Quality and quantity of movement between and across body segments are improved,- Range of motion is improved.

Relaxation is increased,- Sensory awareness is increased,- Weight-beadng status is improved,- Woric of breathing is decreased,

• Impact on functional limitations- Ability to perform movement tasks is improved,- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, "woric (job/school/ptey), community, and leisure is improved,- Tolerance of positions and activities is increased,

• Impact on disabilities- Ability to assume or resume required self-care, home management, work

(job/school/play), commtmity, and leisure roles is improved,• Risk reduction/prevention

- Risk factors are reduced.Risk of recurrence of condition is reduced,

- Risk of secondary impairment is reduced,- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Physical capacity is increased,- Physical function is improved,

• Impact on societal resources- Utilization of physical therapy services is optimized,- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided are acceptable to patient/client,- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical theraf^st is acceptable to patient/client,- Coordination of care is acceptable to patient/cUetit.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skiUs of physical therapist are acceptaWe to patient/dient, family, and

significant others.- Sense of well-beii^ is improved,- Stressors are decreased.

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Procedural Interventions continued

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

Interventions

• Adaptive devices- raised toilet seats- seating systems

• Assistive devices- canes

crutcheslong-handled reacherspower devicesstatic and dynamic splints

- walkers- w^heelchairs

• Orthotic devicesbracescastsshoe insertssplints

• Protective devicesbraces

- cushions- protective taping

• Supportive devicescompression garmentscorsets

- elastic wraps- neck collars- serial casts- slings

supportive taping

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced,- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased,- Soft tissue swelling, inflammation, or restriction is reduced,

• Impact on impairmentsBalance is improved.

- Endurance is increased.Energy expendittire per unit of work is decreased.Gait, locomotion, and balance are improved.

- Joint stability is increased- Motor function (motor control and motor leaniing) is improved,- Muscle perfonnance (strength, power, and endurance) is increased.- Optimal joint alignment is achieved.

Optimal loading on a body part is achieved.Postural control is improved.Quality and quantity of movement between and across body segments are improved.Range of motion is improved.

- Relaxation is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.- Level of supervision required for task perfonnance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumental

activities of daily living (IADL) with or without devices and equipment are increased.Tolerance of positions and activities is improved,

• Impact on disabilities- Ability to assume or resume required self-care, home management, work

(job/school/play), community, and leisure roles is improved,• Risk reduction/prevention

- Pressure on body tissues is reduced.- Protection of body parts is increased.- Risk factors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.Self-management of symptoms is improved.Stresses precipitating injury are decreased.

• Impact on health, wellness, and fitness- Health status is improved.- Physical capacity is increased.- Physical function is improved,

• Impact on societal resourees- Utilization of physical therapy services is optimized.

Utilization of physical therapy services results in efficient use of health care dollars,• Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client,- Administrative management of practice is acceptable to patient/client,- Clinical proficiency of physical therapist is acceptable to patient/dient,- Coordination of care is acceptable to patient/dient.

Cost of health care services is decreased.Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to patient/client, family, and sig-nificant others.Sense of well-beir^ is improved.

- Stressors are decreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrotherapeutic delivery of

medications- iontophoresis

• Electrical stimulationelectrical muscle stimulation(EMS)neuromuscular electricalstimulation (NMES)

- transcutaneous electricalnerve stimulation (TENS)

Anticipoted Goals and Expected Outcomes• Impact on pathology/pathophysiology

- Edema, lymphedema, or effusion is reduced,- Joint swelling, intRammation, or restriction is reduced.

Nutrient delivery to tissue is increased,- Osteogenic effects are enhanced,- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairmentsIntegumentary integrity is improved,

- Motor ftmction (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are improved,- Range of motion is improved.- Relaxation is increased,- Sensory awareness is increased,

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, community, work Qob/ school/ play), and leisure is improved.Level erf superviston required for task performance is decreased,

- Performance of and independence in activities of daily living (ADL) and instrumentalactivities of daily living dADL) with or without devices and eqidpment are increased,

- Tolerance of positions and activities is increased,• Impact on disabilities

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

• Risk reduction/prevention- Complications of immobility are reduced,- Risk factors are reduced.- Risk of secondary impairment is reduced,- Self-management of symptoms is improved.

• Impact on health, wellness, and fiitnessPhysical capacity is increased.

- Physical iunction is improved,• Impact on societal resources

- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of healtii care dollars.

• Patient/dient satisfaction- Access, availability, and services provided are acceptaUe to patient/client.- Administrative management of practice is acceptaMe to patient/dient.- Clinic^ proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/client.- Interpersonal skills of physical therapist are acceptable to patient/client, family, aM

s^nificant others.- Sense of well-being is improved.

Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include;• Athermal agents

- pulsed electromagnetic fields• Cryotherapy

cold packsice massagevapocoolant spray

• Hydrotherapywhirlpool tankscontrast bathpools

• Lightinfraredlaser

• Sound agentsphonophoresisultrasound

• Thermotherapydry heathot packsparaffin baths

Mechanical modalities may include;• Compression therapies

- tapingvasopneumatic compression devices

• Mechanical motion devicescontinuous passive motion (CPM)

• Traction devices- intermittent- positional

sustained

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.

Neural compression is decreased,- Nutrient delivery to tissue is increased,- Pain is decreased,- Soft tissue swelling, inflammation, or restriction is reduced,- Tissue perfusion and oxygenation are enhanced,

• Impact on impairments;Integtmientary integrity is improved,

- Muscle performance (strength, power, and endurance) is increased,- Rar^e of motion is improved,- Weight-bearing status is improved,

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care,

home management, work (job/school/play), community, and leisure isimproved.Performance of and independence in activities of daily living (ADL) andinstrumental activities of daily living (LADL) with or without devices andequipment are increased,

- Tolerance of positions and activities is increased,• Impact on disabilities

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

• Risk reduction/preventionComplications of soft tissue and circulation disorders,

- Risk of secondary impairments is reduced,- Self-management of symptoms is improved,- Stresses precipitating injury are decreased,

• Impact on health, wellness, and fitnessPhysical function is improved,

• Impact on societal resourcesUtilization of physical therapy services is optimized.

• Patient/dient satisfaction- Access, availability, and services provided are acceptable to patient/dient.- Administrative manj^ment of practice is acceptable to patient/client.- Clitiical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client.- Interpersonal skills of physical therapist are acceptable to patient/cUent,

family, and significant others.Sense of well-being is improved,

- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy st rvices by characterizing or quantifying the impact of thephysical therapy interventions in the following domains;

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

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

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client wiO no longer benefit from physical therapy When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic fbUow-up is needed over the life span to ensure safety and effective adap-tation following changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for ilischarge or discontinuation and provides for appropriate follow-up or referral.

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

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are i;he boundaries viithin which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified into this pattern—for impaired joint mobility; motor function, muscle performance, and range ofmotion as,sociated with localized inflammation—as a result of the physical therapist's evaluation of the examination data,The find-ings from the examination (history, systems review, and te,sts and measures) may indicate the presence or risk of pathology/patho-physiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fit-ness programs,The physical therapist integrates, synthesizes and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support theinclusion of patients/cUents in this pattern;

Risk Factors or Consequences of Pathology/Pathophysiology(Disease, Disorder, or Condition)• Abnormal response to provocation• Ankylosing spondylitis• Bursitis• Capsulitis• Epicondylitis• Fasciitis• Gout• Osteoarthritis• Prenatal and postnatal soft tissue inflammation• Synovitis• Tendinitis

Impairments, Functional Limitations, or Disabilities

• Edema• Inability' to perform self-care• Inflammation of periarticular connective tissue• Muscle strain• Muscle weakness• Pain• Worker s inability to perform functional activities because of

localized joint pain

Note:

Some risk factors or consequences of pathology/pathophysiology—such as systemic disease processes—may besevere and complex; however, they do not necessarily excludepatients/ clients from this pattern. Severe and complex riskfactors or consequences may require modification of the fre-quency of visits and duration of care. (See "Evaluation,Diagnosis, and Prognosis,'page S203,)

Exclusion or Multipie-Pottern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tion:il patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client v 'ould be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand ,inother pattern.

Findings That May Require Classification in aDifferent Pattern

• Dei:p vein thrombosis• Fracture• Impairments associated with dislocation• Impairments associated w ith hemarthrosis• Surgery

Findings That May Require Classification inAdditional Patterns

• Open wound

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

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001),Volumes 1 and 3 (Chicago, 111; American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

274 Gout

274.0 Gouty arthropathy

350 Trigeminal nerve disorders

350.1 Trigeminal neuralgia

353 Nerve root and plexus disorders

353.0 Brachial plexus lesions

353.4 Lumbosacral root lesions, not elsewhere classified

354 Mononeuritis of upper limb and mononeuritis multiplex

354.0 Carpal tunnel syndrome

354.2 Lesion of ulnar nerve

Cubital tunnel syndrome

355 Mononeuritis of lower limb

355.5 Tarsal tunnel syndrome

355.6 Lesion of plantar nerve

Morton's metarsalgia, neuralgia, or neuroma

524 Dentofacial anomalies, including malocclusion

524.6 Temporomandibular joint disorders

682 Other cellulitis and abscess

711 Arthropathy associated with infections

715 Osteoarthrosis and alUed disorders

716 Other and unspecified arthropathies

716.6 Unspecified monoarthritis

716.9 Arthropathy, unspecified

Inflammation of joint, not otherwise specified

717 Internal derangement of knee

7\7.7 Chondromalacia of patella

718 Other derangement of joint718.8 Other joint derangement, not elsewhere classified

Instability of joint719 Other and unspecified disorders of joint

719.0 Effusion of joint

719.2 Villonodular synovitis720 Ankylosing spondylitis and other inflammatory

spondylopathies720.2 Sacroiliitis, not elsewhere classified

722 Intervertebral disk disorders

724 Other and unspecified disorders of back

724.0 Spinal stenosis, other than cervical

724.2 LumbagoLow back painLow back syndromeLumbalgia

726 Peripheral enthesopathies and allied syndromes726.0 Adhesive capsulitis of shoulder

726.1 Rotator cuff syndrome of shoulder and allieddisorders

726.10 Disorders of bursae and tendons inshoulder region, unspecified

726.2 Other affections of shoulder region, notelsewhere classified

726.3 Enthesopathy of elbow region

726.31 Medial epicondylitis

726.32 Lateral epicondylitis

726.5 Enthesopathy of hip region

Bursitis of hip

726.6 Enthesopathy of knee

726.60 Enthesopathy of knee, unspecified

726.9 Unspecified enthesopathy

726.90 Enthesopathy of unspecified site

727 Other disorders of synovium, tendon, and bursa

727.0 Synovitis and tenosynovitis

727.04 Radial styloid tenosynovitis

727.3 Other bursitis

777.d Rupture of tendon, nontraumatic

727.61 Complete rupture of rotator cuff

727.9 Unspecified disorder of synovium, tendon, and

bursa

728 Disorders of muscle, ligament, and fascia

728.7 Other fibromatoses

728.71 Plantar fascial fibromatosisPlantar fasciitis

728.9 Unspecified disorder of muscle, ligament,and fascia

729 Other disorders of sofi: tissues

729.1 Myalgia and myositis, unspecified

729.2 Neuralgia, neuritis, and radiculitis, unspecified

729.4 Easciitis, unspecified

729.8 Other musculoskeletal symptoms referable to limbs

729.81 Swelling of limb

732 Osteochondropathies

732.9 Unspecified osteochondropathy

840 Sprains and strains of shoulder and upper arm

840.4 Rotator cuff (capsule)

923 Contusion of upper limb

924 Contusion of lower limb and of other and unspecified sites

927 Crushing injury of upper limb

928 Crushing injury of lower limb

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I I

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

Examination has three components; the patient/client history, the systems review, and tests and measures,The history is a systematic gath-ering of past and ctirrent information (often from the patient/client) related to why the patient/client is seeking the services of the physi-cal therapist.The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, andlearning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For ctinicat indications in setecting tests and measures and for listings of tests andmeasures, toots used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include;General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Ploy)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Eamilial health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plain t(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (IADL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems

The systems review may include;

Anatomical and Physiological Status

• Cardiovascular/PulmonaryBlood pressureEdemaHeart rateRespiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

MusculoskeletalGross range of motionGross strengthGross symmetr}'

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Tests and Measures

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

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrumental activities of dailyliving [IADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance ^valk/run tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, IADL scales,interviews, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, intervie^vs, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg,ADL scales, IADL scales, pain scales, play scales)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry', mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Response to neural provocation (eg, tension tests, vertebral

artery compression tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and light touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and light touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

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Tests and Measures continued

Ergonomics and Body Mechanics

Ergonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity' tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safet)' in w ork environments (eg, hazard identification check-lists, job .severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handling checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, w^orkstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Body mechanics• Body mechanics during selfcare, home management, work,

community, or leisure actions, tasks, or activities (eg, ADL scales,IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, pnrtective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during fimctional activities with or with-out the use of assistive, adaptive, orthotic, protective, stipport-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADI. scales, mobility skill profiles, observations, \ ideo-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobility skill profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobility tests)

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

Integumentary Integrity

Associated skin• Aciivities, positioning, and postures that produce or relieve

trauma to the skin (eg, observations, pressure-sensing maps,scales)

• Skin characteristics, including blistering, continuity of skincolor, dermatitis, hair growth, mobility, nail growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Joint Integrity and Mobility• Joint play movements, including end feel (all joints of the axial

and appendicular skeletal system) (eg, palpation)• Specific body parts (eg. apprehension, compression and distrac-

tion, drawer, glide, impingement, shear, and valgus/varus stresstests; arthrometrjO

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytest;s, technology-assisted analyses, timed activity tests)

• Muscle strength, pow er, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, LADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• Cosiiponents, alignment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentlist during functional activities (eg, ADL scales, functionalscales. IADL scales, interviews, observations, profiles)

• Remediation of impairments, fimctional limitations, or disabiU-tie^ with use of orthotic, protective, and supportive devicesand equipment (eg, activity' status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivede\ ices and equipment (eg, diaries, fall scales, interviews, logs,observations, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimina-

tion tests, dyspnea scales, pain drawings and maps, provocationt[-sis, verbal and pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

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Tests and Measures continued

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural aUgnment and position (static), including symmetry anddeviation from midline (eg, grid measurement, observations,photographic assessments)

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

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, ligamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

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

tests)

Self-Care and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

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

Sensory Integrity• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg, sensory nerve conduction

tests)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), community,

and leisure activities w ith or without assistive, adaptive, orthotic,protective, supportive, or prosthetic devices and equipment (eg,activity profiles, disability indexes, functional status question-naires, IADL scales, observations, physical capacity tests)

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

• Safety in w ork (job/school/play), community, and leisure activi-ties and environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnosticprocess, w hich includes integrating and evaluating the data fr(jm the exaniination,The diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The prognosis is the deteimination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level ;ind may also include a prediction of levels of improvement that may bereached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected out-comes, and dischai^e plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others,These anticipated goals and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention, Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity- or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; piobability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Prognosis

Over the course of 2 to 4 months,patient/client will demonstrate optimaljoint mobility, motor function, muscle per-formance, and range of motion and thehighest level of functioning in home, work(job/school/play), communit)', and leisureenvironments.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

6 to 24

This range represents the lowt r andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/ctientswho are classified into this pattern willachieve the anticipated goats and expect-ed outcomes within 6 to 24 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be dett rmined bythe physical therapist to maximize effec-tiveness of care and efficiency <rf servicedelivery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• Accessibility and availability ofresources

• 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• C'omorbitities, complications, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• l^vel of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• Stability of the condition

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

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

- advance directives- individualized family service plans (IFSPs) or individu-

alized education plans (IEPs)informed consentmandatory communication and reporting (eg, patientadvocacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including:

equipment suppliershome care agencies

- payer groupsschools

- transportation agencies• Communication across settings, including:

- case conferencesdocumentationeducation plans

• Cost-effective resource utilization• Data collection, analysis, and reporting

outcome datapeer review^ findingsrecord reviews

• Documentation across settings, following APTA'sGuidelines for Physical Therapy Documentation(Appendix 5), including:- changes in impairments, functional limitations, and

disabilitieschanges in interventionselements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferences

- patient care roundspatient/client family meetings

• Referrals to other professionals or resources

Anridpated Goals and Expected Outcomes• Accountability for services is increased.• Admission data and discharge planning are completed.• Advance directives, individuaMzed family service plans (IFSPs) or

individualized education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advocacyand abuse reporting) are obtained or completed.

• Available resources are maximally utilized.• Care is coordinated with patient/client, fanuly, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, including

equipment suppliers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding health, wellness, and fit-

ness needs.• Decision making is enhanced regarding patient/client health

and the use of health care resources by patient/dient, family,significant others, and caregivers.

• Documentation occurs throi^out patient/client managjementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/cHent family meetings.

• Patient/client, family, significant other, and caregiver understand-ing of anticipated goals and expected outcomes is increased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utilized in a cost-effective way.

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Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions• Instruction, education and training of patients/clients and

caregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional limitations,or disabilities)enhancement of performancehealth, wellness, and fitnessplan of care

- risk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilitiestransitions across settingstransitions to new roles

AiMkipaIwi Godb and Expadad Oulconi(»• Ability to perform frfiysical actions, tasks, or activides is

imp>rovcd.• Awareness and use of cooununity resources are improved.• Behaviors that foster healthy haUts, wellness, and prevention

are acquired.• Decision making is enhanced regatding patient/dient health

and the use of health care resources by patient/dient, fanuly,signifik:ant others, and caregivers.

• Disability associated with acute or chronic illnesses isreduced.

• Functional independence in activities of daily living (ADL)and instrumental activities of daily Hving (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for task perfonnance is

decreased.• Fatient/cUent, fanuly, significant other, and caregiver knowl-

edge and awareness of d}e diagno^, prc^nosis, interventions,and antidpated goals and expected outcomes are increased.

• Patient/client knowledge of personal and envircmmental fac-tors associated with the condition is increased.

• Performance levels in self-care, home management, work()ob/school/play), community, or leisure actions, tasks, or activ-ities are improved.

• Physical functlonis improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/cUent, family, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilizaticm and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioningaquatic programs

- gait and locomotor training- increased workload over time- walking and wheelchair propul-

sion programs• Balance, coordination, and agility

trainingdevelopmental activities training

- motor function (motor control andmotor learning) training or retrain-ingneuromuscular education or reed-ucation

- perceptual training- posture awareness training- standardized, programmatic, com-

plementary exercise approachestask-specific performance training

• Body mechanics and posturalstabilization- body mechanics training

posture aw areness trainingpostural control trainingpostural stabilization activities

• Flexibility exercisesmuscle lengthening

- range of motionstretching

• Gait and locomotion trainingdevelopmental activities traininggait trainingimplement and device training

- perceptual training- standardized, programmatic, com-

plementary exercise approacheswheelchair training

• Relaxation- breathing strategies- movement strategics

relaxation techniquesstandardized, programmatic, com-plementary exercise approaches

• Strength, power, and endurance train-ing for head, neck, limb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programsstandardized, programmatic, com-plementary exercise approachestask-specific performance training

include:

Anticipated Gods and Expected Oi^omes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxygen demand is toproved.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.- Eneigy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Joint integrity and mobility are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.- Quality and quantity of movement between and across body segments are improved.- Range of motion is improved.

Relaxation is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to pierform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumental

activities of daily living (IADL) with or without devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self<are, home management, work

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Safety is improved.

Self-management of symptoms is improved.• Impact on health, wellness, and fitness

Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client.

Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of well-being is improved.

Stressors are decreased.

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Procedural Interventions continued

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

Instrumental Activities of Daily Living [lADL])

Interventions

• ADL training- bathing

bed mobility and transfer training- developmental activities

dressingeatinggrooming

- toileting• Devices and equipment use and

training- assistive and adaptive device or

equipment training during ADLand IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing ADL and IADL

• Functional training programsback schoolssimulated environments and taskstask adaptation

• IADL trainingcaring for dependentshome maintenancehousehold chores

- shopping- structured play for infants and chil-

drenyard work

• Injury prevention or reductioninjury prevention education duringself-care and home managementinjury prevention or reductionw ith use of devices and equipment

- safety awareness training duringself-care and home management

WltK^MrtM GOQIS CMS

• Impact cm pathology/pathoplij^ilolqgy (disease, disoKler,- Pain is decreased.

• Impact on impAinaents- Balance is improved.- Endurance te incre^edi- Ehergy expen«iture per unit of wotlc is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural coatroi is improved.- Sensory awareness is increased.- Weight-beaiti^ status i$ improved.

• Impact on fiuictionai Umitations- AbiUty to perioaa physical actions, tasks, or activities related to self-care and home

maoa^ment is impr(»red.- Level of supervi^on te^iiitd for task performance is decreased.- Performance of and iiutepesidence in ADL ai^ IADL witii or wiAout devtees and

equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- AbiUty to assume or resume required self-care UKI home mamgentertt ides is

improved.• Risk reduction/fwevention

- Risk &ctors are reduced.- Risk of seccmdary impairmerus is reduced.- Safety is taproved.- Setf-man^ement of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health statw is improved.- Physical capacity is increased.- Ph^ ical function is improved.

• Impact on societal resources- Utilization of {rfiysical therapy services is optimized.- UtiMzation of physical tiierapy services results in efficient use of health caie dollars.

• Patient/cUent satis&ction- Access, availablUty, and services provided are acceptable to patient/dient.- Administrative manafqnuent of practice is acceptable to patient/cUent.- Clinical proficiency of physical dierapist is acceptable to patient/cUent.- Coordinsiticm of cai<e is acceptable to patient/cUent.- Cost of beaMi care services is decieased.- Inten^ty of caie is decreased.- Interpersonal skUls of physkal therapist sae acceptatte to patien^cUent, fiimity, and

significant others.- Sense of wdl-being is ioipcoved.- Stressors are decieased.

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Procedural Interventions continued

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

Interventions• Devices and equipment use and

trainingassistive and adaptive device orequipment training during IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing IADL

• Functional training programsback schoolsjob coachingsimulated environments and tasks

- task adaptation- task training

• IADL training- community service training involv-

ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

- injury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegrationinjury prevention or reductionw ith use of devices and equipmentsafety awareness trainingduring work (job/school/play),community, and leisure integra-tion or reintegration

• Leisure and play activities and training

Anticipated Goals and Expected Outcomes

• Impact on pathology/|)athophysiolc^y (disease, disorder, or condition)- Pain is decreased.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of woric is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endiuance) is increased.

Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume required work (job/school/play), community, and

leisure roles is improved.• Risk reduction/prevention

- Risk foctors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.Self-man^ement of symptoms is improved.

• Impact on health, wellness, and fitnessFitness is improved.Health status is improved.

- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disability are reduced.

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

• Patient/client satisfaction- Access, avaHabiUty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/cUent.

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

- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, femUy, and

significant others.Sense of weU-being is improved.

- Stressors are decreased.

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Procedural Intervenrions continuedJ J

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Manual traction• Massage

- connective tissue massage- therapeutic massage

• Mobilization/manipulationsoft tissuespinal and peripheral joints

• Passive range of motion

Goals and Ejcpactad OulemnesImpact on patholc^/pathophysiology (disease, disorder, or condition)- Edona, lymphedema, or elffiision is reduced.- Joint swieUng, inflaomtatiOn, or restriction is reduced.- Neural compression is decreased.- Pain is decreased.- Soft tissue swelUng, inllammittion, or restriction is reduced.Impact on impairments- Balsuice is improved.- Energy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Joint integrity and mobiUty are improved.- Musde performance (streingtiti, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of mjovement between and across body segments ate

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is inctleased.- Weight-bearing status is improved.- Woik of breadiing is decrleased.bnfmct on functional ltaitatipns- Ability to perform movement tasks is improved.- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, woi^ (fob/schooi/play), community, saad leisure is improved.- Toterance of positions and activities is increased.Impact on disabiUties- AbiUty to assume or resume required self-care, home management, work

(job/schooVplay), commyiiity, and leisure roles is improved.Risk reduction/prevention- Risk &ctors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Self-manf^ment of symptoms is improved.Impact on health, weUness, and fitne^- Physical capacity is increased.- Physical function is improved.Impact on societal resources- Utilization of {diysicai therapy services is optimized.- UtiUsition of i^ysical cheirapy services residts in efficient use of health care doUars.Patient/cUent isatisSaction- Access, avaflabUity, atMl services provided are acceptable to patient/dient.- Adnainisoative managiemejnt of jHractlce is acceptaMe to patiem/cUent.- Clinical prCificiency of ph|rsical therapist is acceptable to patient/cUent.• Coordinatton of care is acceptable to patient/dient.- Cost of heaMi care services is decreased.- Intensity of care is decitsased.- Interpersonal skDis of physical therapist are acceptable to patient/cUent, &mUy, and

significant oAers.- Sense of viM-being is improved.- Stre^ors aie decreased.

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

Interventions• Adaptive devices

- raised toilet seats- seating systems

• Assistive devicescanescrutches

- long-handled reachers- power devices- static and dynamic splints- walkers- w^heelchairs

• Orthotic devicesbracescastsshoe inserts

- splints• Protective devices

bracescushionsprotective taping

• Supportive devicescompression garmentscorsets

- elastic wraps- neck coUars- serial casts- slings

supportive taping

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairmentsBalance is improved.Endurance is increased.Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.- Joint stabiUty is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Optimal joint aUgnment is achieved.

Optimal loading on a body part is achieved.Postural control is improved.QuaUty and quantity of movement between and across body segments areimproved.

- Range of motion is improved.Relaxation is increased.

- Weight43earing status is improved.• Impact on functional limitations

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

- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionPressure on body tissues is reduced.Protection of body parts is increased.

- Risk factors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.- Stresses precipitating injtry are decreased.

• Impact on health, wellness, and fitness- Rtness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optimized.- UtUization of physical therapy services results in efficient use of health care doUars.

• Fatient/cUent satisfaction- Access, availability, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of well-being is improved.

Stressors are decreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Electrotherapeutic delivery of

medicationsiontophoresis

• Electrical stimulation- electrical muscle stimulation

(EMS)functional electrical stimulation(FES)high voltage pulsed current(HVPC)

- neuromuscular electrical stimula-tion (NMES)

- transcutaneous electrical nervestimulation (TENS)

Anticipated Goals and Expaded• Impact on pathology/pathophjrSiology (disease, (Usotder, or condition)

- Edema, iymphcdema, or dttai^M is reduced.- Joint swelling, inflaniouttioa, or restriction is reduced.- Nutrient deBiwrf to tissue fe increased.- Osrcc^enic effects are enhanced.- Fain is decreased.- Soft ti^ue swelUi%, inflamniaticxi, or iiestriction is reduced.- Tissue petfusicm and oxygeiisttion are enhanced.

• Impact on impairments- Motor ftmction (motor control and motor learning) is improved.- Muscle performance (stiengltJi, powa; and endurance) is increased.- Prajtural control is improved.- Quality and quantity of movement between and across body s^;ments are

improved.- Range of motion is imjMwved.- Relaxation is tocreased.- SenscHy awareness is itKreased.

• Im^ct on functtonal limitations- Ability to perform physical actions, tasks, or activities related to self-caie, home man-

agement, woric Oob/school/|^by), community, and leisure is improved.- Level of supervision requiteid for task peiformaxtce is decreased.- Performance «rf and indepeiidence in activities of daily living (ADL) and instrumen-

tal activities ctf daily living (IA0L) with or without devices and equipment areincreased.

- Tolerance of positions and i^vities is increased.• Impact on disat^ties

- AMIity to assume or resume required seifcare, home management, woilc(job/school/play), community, aid leisure roles is improved.

• Risk reduction/ptevention- Ccmipikrations of immobility are lechiced.- Ri^ Actors are reduced.- Risk of recurrence of conditton is reduced.- Rtek of secondioy impairment is recteed.- Self-management of symptoms is iniproved.

• Impact on health, wellness, and fitness- Fitne^ is improved.- Phy^al a^>acity is increased.- Physical fimction is improved.

• Impact on societal resources- Utilization of phy^cM ttierapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/dient satisfaction- Access, availabiity, and services provided are acceptable to patient/client.- Administrative management of practice is acceptaMe to pattent/dient.- Clinical proficiency of physical ther^rist is acceptatde to patient/dient.- Coordination of care is acceptable to patient/client.- Interpersonal ddlls of physical ther^st are acceptaMe to patient/cUent, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:• Athermal agents

- pulsed electromagnetic fields• Cryotherapy

- cold packs- ice massage- vapocoolant spray

• Hydrotherapyw^hirlpool tankscontrast bathpools

• light agentsinfraredlaser

• Sound agents- phonophoresis

ultrasound• Thermotherapy

dry heathot packs

- paraffin baths

Mechanical modalities may include:• Compression therapies

- taping• Mechanical motion devices

continuous passive motion (CPM)

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, tymphedema, or effusion is reduced.- Joint sweUing, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Integumentary integrity is improved.- Musde performance (strength, power, and endurance) is increased.- Range of motion is improved.- Weight-bearii^ status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to sdf-care, home

management, work (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of soft tissue and circulatory disorders are decreased.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.- Stresses precipitating injury are decreased.

• Impact on health, wellness, and fitness- Physical function is improved.

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

• Patient/cUent satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/dient.- Interpersonal skills of physical therapist are acceptable to patient/dient, femily, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. ITiese anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

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

Discontinuation is the process of ending physical therapy .services that have Iieen provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (21 the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because fLnant:ial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic fbUow-up i,s needed over the life span to ensure safety and effective adap-tation following changes in physical status, caregivers, envin>nment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for dischai^e or discontinuation and provides for appropriate follow-up or referral.

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Impaired Joint Mobility, Motor Function,Muscle Performance, Ranae of Motion, andReflex Integrity Associated WithSpinal Disorders

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of lac(ors, such as individual patient/cUent needs; the pro-fession s code of ethics and standards of practice; and patient/cUent age, culture, gender roles, nice, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified into this pattern—for impaired joint mobiUty, motor function, muscle performance, range ofmotion, and reflex integrity associated with spinal disorders—as a result of the physical therapist's evaluation of the examinationdata. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk ofpathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need forhealth, weUness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnos-tic classification.

Inclusion

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

Risk Factors or Consequences of Pathology/Pathophysidogy(Disease, Disorder, or Condition)• Degenerative disk disease• Disk herniation• History of spinal surgery• Spinal stenosis• SpondyloUsthesis

Impairments, Functional Limitations, or Disabilities

• Abnormal neural tension• Altered sensation• Decreased deep tendon reflex• Inability to perform Ufting tasks• Inability to perform self-care independently• Inability to sit for prolonged periods• Muscle weakness• Pain with forward bending

Exclusion or Multiple-Pattern ClassificationThe foUowing examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand .mother pattern.

Findings That May Require Cbssificatian in aDifferent Pattern

• Fracture• Impairments associated with systemic conditions (eg,

ankylosing spondyUtis, Scheurermann disease, juvenilerheumatoid arthritis)

• Impairments associated with traumatic spinal cord injury

Findings That May Require Classification inAdditional Patterns• Neuromuscular disea.se

Note:

Some risk factors or consequences of pathology/pathophysiology—such as neoplasm—may be severe and com-plex; however, they do not necessarily exclude patients/clientsfrom this pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visits andduration of care. (See "Evaluation, Diagnosis, and Prognosis,"pageS221.)

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ICD-9-CM CodesThe Usting below contains the ctirrent (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/cUent diagnostic classification is based on impairments, functional limitations, and disabiUties—not on codes—patients/cUents may be classified into the pattern even though the codes Usted with the pattern may not apply to those cUents.

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

353 Nerve root and plexus disorders353.0 Brachial plexus lesions353.1 Lumbosacral plexus lesions353.2 Cervical root lesions, not elsewhere classified353.4 Lumbosacral root lesions, not elsewhere classified

715 Osteoarthrosis and alUed disorders716 Other and unspecified arthropathies

716.9 Arthropathy, unspecifiedInflammation of joint, not otherwise specified

718 Other derangement of joint718.3 Recurrent dislocation of joint718.9 Unspecified derangement of joint

719 Other and unspecified disorders of joint719.8 Other specified disorders of joint

Calcification of joint720 Ankylosing spondylitis and other inflammatory

spondylopathies721 Spondylosis and alUed disorders

721.1 Cervical spondylosis with myelopathy721.4 Thoracic or lumbar spondylosis with myelopathy

722 Intervertebral disk disorders722.4 Degeneration of cervical intervertebral disk722.5 Degeneration of thoracic or lumbar intervertebral

disk722.6 Degeneration of intervertebral disk, site unspecified722.7 Intervertebral disk disorder with myelopathy722.8 Postlaminectomy syndrome

723 Other disorders of cervical region723.0 Spinal stenosis in cervical region723.1 Cervicalgia

724 Other and unspecified disorders of back724.0 Spinal stenosis, other than cervical724.2 Lumbago

Low back painLo'w back syndromeLumbalgia

724.3 Sciatica724.9 Other unspecified back disorders

727 Other disorders of synovium, tendon, and bursa727.0 Synovitis and tenosynovitis

728 Disorders of muscle, Ugament, and fascia728.2 Muscular wasting and disuse atrophy,

not elsewhere classified728.8 Other disorders of muscle, ligament, and fascia

728.85 Spasm of muscle728.9 Unspecified disorder of muscle, Ugament, and

iascia733 Other disorders of bone and cartilage

733.0 Osteoporosis738 Other acquired deformity

738.4 Acqtiired spondylolisthesis738.5 Other acquired deformity of back or spine

756 Other congenital musculoskeletal anomalies756.1 AnomaUes of spine

756.11 Spondylolysis, lumbosacral region756.12 SpondyloUsthesis

846 Sprains and strains of sacroiliac region846.0 Lumbosacml (joint) (Ugament)

847 Sprains and strains of other and unspecified parts of back922 Contusion of trunk

922.3 Back

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ExaminationExamination is a comprehensive screening and specific testing process that lc:ads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overallhealth status, and needs related to restoration of health and to prevention, wt-llness, and fitness.The physical therapist synthesizes theexamination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others,and caregivers may provide information during the examination process.

Examination has three components: the patient/client historj; the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physi-cal therapist.The systems review is a brief or Umited examination of (1) the anatomicat and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) ttie communication ability, affect, cognition, language, andlearning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in .selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by te.sty and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work Uob/School/Play)• Current and prior ^vork

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living envin;)nment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role fimction (eg, community, leisure,

social, work)• Social function (eg, social activit>', social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of pati<'nt/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/dient, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client s emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (L\DL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/I*ulmonaryBlood pressureEdema

- Heart rate- Respiratory rate

IntegumentaryPresence of scarformation

- Skin color- Skin integrity

Musculosketetal- Gross range of motion

Gross strengthGross symmetry

- Height- Weight

NeuromuscutarGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrumental activities of dailyliving [LADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance walk/run tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)

Assistive and Adaptive Devices• Assistive or adaptive devices and eqtiipment use during func-

tional activities (eg,ADL scales, functional scales, LADL scales,intervie'ws, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, reports)

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, LADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, obset^ations,reports)

or quantify:

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Response to neural provocation (eg, tension tests, vertebral

artety compression tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and light touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and light touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Ploy) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)• Physical space and environment (eg, compliance standards,

observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

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Tests and Measures continued

Ergonomics and Body MechanicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand fimction tests, impairment rating scales, manipulative abil-ity tests)

• Eunctional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in w ork environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handling checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, workstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Body mechanics• Body mechanics during self-care, home management, work,

commtmity, or leisure actions, tasks, or activities (eg, ADL scales.LADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, LADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during ftmctional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, LADL scales, mobility skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, tbot-print analyses, gait profiles, mobility' skill profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, ^veight-bearing scales, wheelchairmobility tests)

• Safety during gait, locomotion, and balance (eg, confidencescales, diaries, fall scales, functional as.sessment profiles, logs,reports)

Joint Integrity and Mobility• Joint play movements, including end feel (all joints of the axial

ami appendicular skeletal system) (eg, palpation)

• Specific body parts (eg, compression and distraction tests)

Motar Function (Motar Control and Motar Learning)• Dexterity, coordination, and agiUty (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessmetits)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity' (eg, electroneuromyography)

• Muscle strength, power, and endurance (eg, dynamometry, man-tial muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Mtiscle strength, power, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, LADL scales, obser-\ alions, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• (Components, alignment, fit, and ability to care for orthotic, pro-

tec tive, and supportive devices and eqtiipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• ()rthotic, protective, and supportive devices and eqtiipmentuse during ftinctional activities (eg, ADL scales, functionalscales IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-lies with use of orthotic, protective, and supportive devicesund equipment (eg, activity status indexes,ADL scales, aerobict apacity tests, functional performance inventories, healthassessment questionnaires, LADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, fall scales, interviews, logs,()bser\'ations, reports)

Painin, soreness, and nociception (eg, analog scales, discrimination

tests, pain drawings and tnaps, provocation tests, verbal and pic-torial descriptor tests)

• J^in m specific bodj' parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

ind deviation from midline (eg, observations, technology-assist-eci analyses, videographic assessments)

• Posttiral alignment and position (static), including symmetryiind deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

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Tests and Measures continued

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, Ugamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

tests)• Electrophysiological integrity (eg, electroneuromyography)• Resistance to passive stretch (eg, tone scales)• Superficial reflexes and reactions (eg, observations, provocation

tests)

Self-Core and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability to perform setf-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg, ADL scales, aero-bic capacity tests, LADL scales, interviews, observations, profiles)

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

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg, electroneuromyography)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to asstime or resume work (job/school/play), community,

and leisure activities with or without assistive, adaptive, orthotic,protective, supportive, or prosthetic devices and eqtiipment (eg,activity profiles, disability indexes, fionctional status question-naires, IADL scales, observations, physical capacity tests)

• Ability to gain access to work (job/school/play), commtmity, andleisure environments (eg, barrier identification, interviews, obser-vations, physical capacity tests, transportation assessments)

• Safety in work (job/school/play), commtmity, and leisure activi-ties and environments (eg, diaries. Ml scales, interview's, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered firom the history, systems review, and testsand measures. In the evaltiation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Eactors that influence the complexity of the evahiation include the clinical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of mtJtisite or mtiltisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical ftonction, and overall health status.

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

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Erequency and dtiration may vary greatly among patients/cUents based on a varietyof factors that the physical therapist cotisiders throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations: probability of prolonged impairment, ftmctional limitation, ordisability; and stability of the condition.

Prognosis

Over the course of 1 to 6 months,patient/client wilt demonstrate optimaljoint mobility, motor function, muscle per-formance, range of motion, and reflexintegrity and the highest level of function-ing in home, work (job/school/play), com-munity, and leisure environments.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

8ta24This range represents the lower andupper limit* of the number of physicaltherapist visits reqtiired to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 8 to 24 visits duringa single continuous episode of care.Frequency of visits and dunition of theepisode of care should be detennined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedelivery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Durarion of Episode

• Accessibility and availability ofresotirces

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, complications, or

secondary impairments• Conctirrent medical, surgical, and

therapeutic interventions• Decline in ftmctional independence• Level of impairment• Level of physical function• Living environment• Multisite or mtiltisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• Stability of the condition

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

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

Coordination, Communication, and Documentation

Coordination, commtmication, and documentation may include:

Interventions

• Addressing required functionsadvance directivesindividualized fatnUy service plans (IFSPs) or individualizededucation plans (IEPs)

- informed consent- mandatory communication and reporting (eg, patient advo-

cacy and abuse reporting)• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including:

equipment suppliershome care agenciespayer groups

- schools- transportation agencies

• Communication across settings, including:case conferencesdocumentation

- education plans• Cost-effective resource utilization• Data collection, analysis, and reporting

- outcome data- peer review findings

record reviews• Documentation across settings, following APTA's Guidelines

for Physical Therafjy Documentation (Appendix 5), including:changes in Impairments, functional limitations, anddisabilitieschanges in interventionselements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferences

- patient care rounds- patient/client family meetings

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

• Accountability for services Is increased.• Admission data and discharge plaiuiing are completed.• Advance directives, individtialized family service plans (IFSPs)

or individuaUzed education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximally utilized.• Care is coordinated with patient/client, family, sigtilficant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing eqtiipment suppliers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Commtmication occurs across settings t h ro i ^ case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding health, wellness, and

fitness needs.• Decision making is enhanced regarditig patient/client health

and the tise of health care resources by patient/dient, family,significant others, and caregivers.

• Documentation occurs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confier-ences, patient care rounds, and patient/client family meetings.

• Patient/cUent, jfamily, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resourees are utilized in a cost-effective way.

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Patient/Clien^Related Instruction

Patient/client-related instruction may include:

Intervenrions• Instruction, education and training of patients/clients and

caregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional limitations,or disabilities)enhancement of performance

- health, wellness, and fitness programsplan of care

- risk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilitiestransitions across settingstransitions to ne-w roles

6edb cmd Exp«ct«d CMomies• Abiity to perform physkd Ktions, t a ^ , or activities is

improiwed.• Awraeaess and use of cotnoiiinity resources are improved.• Beilsvli@rs tlmt foster heaMiy habits, wellness, and pievention

aie acquired.• Decisljcm maldng is enbaiiced f^^arding patienVcUent health

and tWe use of health care resources by patient/client, femily,signif ::ani cHlia-s, and cancers .

• Dii^btety associated 'with acute or chronic itinesses isreduced.

• Fuiactionid independence in acti^ittes of dasUy Uvii^ (ADL)and instnimentai activity of ^)lf U^ i (IAZH.) is increased.

• Health status is improved.• Intensity of care is decreased.• Level erf su|Krvtsion required for task performance is

decreased.• Patient/client, family, significant other, and caregiver knowl-

edge and awareness of the diagnosis, prognosis, interventions,and anticipated goals and expected outcomes aie increased.

• Patient/dient knowledge of personal and environmental foe-tors associated with the condition is increased.

• Perfomunce levels in self<are, home management, work(job/school/play), community, or leisure actions, tasks, or activ-ities are improved.

• Kiysical fiinctionis improved.• Bisk of reci»rence of comUtion is reduced.• KMc of secondary impairment is reduced.• Safety; of pxtlent/dient, £uaily, s%nificant others, and care-

is improved.VWhMoa and cost of healda care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Intervenrions• Aerobic capacity/endvirance condi-

tioning or reconditioning- aquatic programs

gait and locomotor trainingincreased workload over time

- walking and wheelchair propul-sion programs

• Balance, coordination, and agilitytraining

developmental activities trainingmotor function (motor control andmotor learning) training or retrain-ingneuromuscular education orreeducation

- perceptual trainingposture awareness trainingstandardized, programmatic, com-plementary exercise approachessensory training or retraining

- task-specific performance training• Body mechanics and postural

stabilization- body mechanics training

posture awareness trainingpostural control trainingpostural stabilization activities

• Flexibility exercisesmuscle lengtheningrange of motion

- stretching• Gait and locomotion training

developmental activities traininggait trainingimplement and device training

- perceptual training- standardized, programmatic, com-

plementary exercise approaches- wheelchair training

• Relaxationbreathing strategiesmovement strategiesrelaxation techniques

- standardized, programmatic, com-plementary exercise approaches

• Strength, power, and endurance train-ing for head, neck, limb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programsstandardized, programmatic, com-plementary exercise approachestask-specific performance training

Anticipated Gods and Expected Outcomes• Impact on pathology/pathc^hysiotogy (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiolc^cal response to increased oxygen demand is improved.- Soft tissue swelling, inflammation, or resttiction is reduced.- Ti^ue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Joint integrity and mobility are improved.- Motor function (motor control and motor learning is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Preoperative and postoperative complications are reduced.- Risk factors are reduced.

Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safety is improved.

- Self-management of symptoms is improved.• Impact on health, wellness, and fitness

- Fitness is improved.- Health status is improved.

Physical capacity is increased.Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/Client.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

significant others.- Sense of well-beiryg is improved.- Stressors are decreased.

S 2 2 4 / 2 3 2 Guide to Physical Therapist Practice Physical Therapy • Volume 81 • Number 1 • January 2001

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Procedural Interventions continued

Functional Training in Self-Gire and Home Management (Including Acriviries of Daily Living [ADL] andInstrumental Acrivities of Daily Living [IADL]|

Intervenrions• ADL training

bathingbed mobility and transfer training

- developmental activitiesdressing

- eatinggroomingtoileting

• Devices and equipment use and trainingassistive and adaptive device or equipmenttraining during ADL and IADL

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

• Functional training programsback schoolssimulated environments and taskstask adaptation

• IADL trainingcaring for dependentshome maintenance

- household choresshoppingstructured play for infants and childrenyard work

• Injury prevention or reduction- injury prevention education during self-care

and home managementinjury prevention or reduction with use ofdevices and equipmentsafety awareness training during self-care andhome management

Anticipated Gods and Expaded Outnames• Impact on pathology/pathophysiok^ (disease, disorder, or condition)

- Rain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is imp>foved.- Endurance is increased.- Energy expt-ndlituie per imit of -wosk is decreased.- Motor function (motor control and motor learning) is improved.- Muscle perfonnance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Wei^t-bearing status is improved.

• Impact on functional limitations- Ability to perfoirm physical actions, tasks, or activities related to self-

care and home management is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in ADL and IADL with or without

devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- AbiUty to assume or resume required self-cai<e and home maimgement

roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Riidc of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wetlness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical Hmction is improved.

• Im{>act on societal resources- Utilization of physical therapy services is optimized.- LTtilization of physk:al therapy services resiilts in efficient use of health

care dollars.• Patient/client satisfaction

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

- Administrative management of practice is ACceptaiAc to patient/client.- Clinical proficiency of frihysicai therapist is acceptaMe to patioit/dient.- Coordination of care is acceptable to patient/dient.- Cost of health care services is (tecreased.- Intensity of care is decreased.- Interpersonitl skills of physical therapist are acceptable to

patient/cUent, fyiruiy, and signi&:ant others.- Sense ofwell-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Funcrional Training in Work (Job/School/Play), Community, and Leisure Integrarion or Reintegration (Including Instrumental Activiriesof Daily Living [IADL], Work Hardening, and Work Conditioning)

Intervenrions• Devices and equipment use and training

assistive and adaptive device orequipment training during IADL

- orthotic, protective, or supportivedevice or equipment trainingduring IADL

• Functional training programsback schools

- job coaching- simulated environments and tasks

task adaptationtask training

• IADL trainingcommunity service training involv-ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

injury prevention educationduring work (job/school/play),community, and leisure integrationor reintegration

- injury prevention or reductionwith use of devices andequipmentsafety aw areness trainingduring work (job/school/play),community, and leisure integrationor reintegration

• Leisure and play activities and training

Anricipated Goals and Exprcted Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Eneigy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to woik

(job/school/play), commutiity, and leisure integration or reintegration is increased.- Level of supervision required for task performance is decreased.

Performance of and independence in IADL with or without devices and equipmentare increased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/preventionRisk factors are reduced.Risk of secondary impairment is reduced.

- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of woric-related injury or disability are reduced.- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/dient satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/dient.

Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physica! therapist are acceptable to patient/dient, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

AAanual Therapy Techniques (Including Mobilization/Manipukition)

Intervenrions• Manual traction• Massage

- coimective tissue massage- therapeutic massage

• Mobilization/manipulation- soft tissue- spinal and peripheral joints

• Passive range of motion

Anikipatedl Gods and Expected Outcomes• Impact on pathoiogy/pathophysiolc^ (disease, disorder; or condition)

- Edema, tymphedenu, or efifiision is reduced.- Joint swelling, inflammation, or restriction is reduced.- Neiual compression is decreased.- Pain is decreiued.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Energy expen<Utute per unit of woik is decreased.- Gait, locomotion, and balance are improved.- Joint integrity and mobility are imjmived.- Muscle perfonnance (strength, power, and endiuance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body sepnents sae

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is imptaved.

• Impact on functional limitations- Ability to perform movement tasks is improved.- Ability to perform physical actions, tasks, or activities related to self-care, home

management, woik (job/schod/play), community, and leisure is improved.- Totenince of positions and activities is increased.

• Impact on disaMlities- AhiUty to assume or resume required self<are, home management, work

(job/school/{day), community, and leisure roles is improved.• Risk reducticHi/prevention

- Risk ^ tors are reduced.- Risk of recurrence of condition is reduced.- Risk of secoodtry impairment is reduced.- Self-mani^ment of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is imfMoved.- niysical capacity is increased.- Physical iunction is Improved.

• Impact on societal resources- Utilization of pliysical therapy services is optimized.- Utilization ot physical ther<i|>y services results in efficient use of health care doUars.

• Patient/cUent satMiction- Access, avaJJability, and services provided are accept^e to patient/dient.- AdnUnlstrative management of practice is acceptiUte to patient/client.- Clinical profik:iency of phy^cal therapist is acceptable to patient/client.- Coordination of care is acceptable to padent/cUent;.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal iddlls of physical therapist are accept^le to patKnt/cUent, &mity, and

significant others.- Sense of welt-bdng is improved.- Stressors are decreased.

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Procedural Interventions conHnuedPrescriprion, Application, and, as Appropriate, Fabricarion of Devices and Equipment (Assisrive, Adaprive, Orthotic, Protecrive,Supportive, and Prostheric)

Interventions• Adaptive devices

- hospital beds- raised toilet seats- seating systems

• Assistive devicescanescrutches

- long-handled reachers- power devices

static and dynamic splintsw alkerswheelchairs

• Orthotic devicesbraces

- castsshoe insertssplints

• Protective devicesbracescushionsprotective taping

• Supportive devicescompression garments

- corsets- elastic wraps- neck coUars

serial castssUngssupportive taping

S228/236 Guide to Physical Therapist Practice

Anlic^ted Gods and ExfwdiKi Oulcames• Impact on patholc^/pathophysiol<W (disease, disorder, or condition)

- Edema, tymphedema, or efliision is reduced.- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased.- Physiological response to increased oxygen demand is improved.

Soft tissue swelling, inflsunmation, or restriction is reduced.• Impact on impairments

- Balance is improved.- Endurance is increased.- Ene^y e^qienditure per unit of woik is decreased.- Gait, locomotion, and balance are improved.- Joint stability is improved.- Musde performance (^lei^^th, power, and endurance) is increased.- Optimal joint alignment is achieved.- Optimal loading on a body part is achieved.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.Range of motion is improved.

- Weight-bearing status is improved.• Impact on functional limitations

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

- Level of supervision reqmred for tadc performance is decreased.Performance of aad indepen<tence in activities of daily living (ADL) and instrumen-tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

- AbiUty to assume or resume required self-care, home man^ement, woric(job/school/play), ajmmunity, and leisure roles is improved.

• Risk reduction/preventionPressure on body tissues is reduced.Protection of bocfy parts is increased.

- Risk fectors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Safety is improved.

Self-management of symptoms is improved.Stresses precipitating injury are decreased.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical tlnsrapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client ^tisbction- Access, availabiMty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to p>atient/dient, £unily, and

significant others.Sense of weU-beii^ is improved.

- Stressors are decreased.

Physical Therapy • Volume 81 • Number 1 • January 2001

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Procedural Interventions continued

Electrotherapeuric Modaliries

Interventions• Electrotherapeutic deUvery of

medicationsiontophoresis

• Electrical stimulationelectrical muscle stimulation(EMS)

- functional electrical stimulation(FES)high voltage pulsed current(HVPC)neuromuscular electrical stimula-tion (NMES)transcutaneous electrical nervestimulation (TENS)

Anlic^pcited Gods and Expactad Onicoines• Impact on patholc^gy/pathophysiology (disease, disorder, or condition)

- Edema, lym|^edema, or effusion is reduced.- Joint swelling, inflainmation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects are enhanced.- Pain is decreased.- Soft tissue or wotind healing is enhanced.- Soft tissue swdling, inflammation, or restriction is reduced.- Tissue perfusion and oxygotation are enhanced.

• Impact on impairments- Integumentary integrity is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.

• Impact on functional Limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task peiformance is decreased.- Perfonnance of uid independence tn activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positicms and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Preoperative and postoperative complications are reduced.- Risk factors are reduced.- Risk of recurrence of condition is reduced.- Risk of seccMidary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is accepuble to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of wdl-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modaliries

IntervenrionsPhysical agents may include:• Athermal agents

pulsed electromagnetic fields• Cryotherapy

cold packsice massagevapocoolant spray

• Hydrotherapywhirlpool tanks

- contrast bath- pools

• light agentsinfraredlaser

• Sound agents- phonophoresis- ultrasound

• Thermotherapy- dry heat

hot packsparaffin baths

Mechanical modalities may include:• Compression therapies

taping• Traction devices

intermittent- positional- sustained

Anticipated Gods and Expected Oukomes• Impact on pathology/pathophysiolc^y (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Neural compression is decreased.- Nutrient deUvery to tissue is increased.- Pain is decreased.

Soft tissue swelUng, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Musde performance (strei^th, power, and endurance) is increased.- Postural control is improved.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daUy Uving (ADL) and instrumen-

tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- CompUcations of soft tissue and circulatory disorders are decreased.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.- Stresses precipitating injury are decreased.

• Impact on health, wellness, and fitness- Fitness is improved.

Physical function is improved.• Impact on societal resourees

- UtiUzation of physical therapy services is optimized.• Patient/cUent satisfiiction

- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of jMactice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of weU-belng is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, w eUness, and fitness• Societal resources• Patient/client satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been providetl during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when apatient is moved from one site to another site within the same setting or across settings during a single episode of care). Although theremay be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, dischargeoccurs hased on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have txen provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress tow^ardoutcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cli< ni: status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adap-tation fbUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

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Impaired Joint Mobility, MusclePerformance^ and Range of MotionAssociated With Fracture

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; the pro-fession s code of ethics and standards of practice; and patient/client age, culturt:, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified into this pattern—for impaired joint mobiUty, muscle performance, and range of motion associat-ed with fracture—as a result of the physical therapist's evaluation of the examination data.The findings lrom the examination (his-tory', systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, orcondition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.The physicaltherapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support theinclusion of patients/cUents in this pattern;

Risk Factors or Consequences of Pathology/Pathophysioiogy(Disease, Disorder, or Condition)• Bone demineralization• Fracture• Hormonal changes• Medications (eg, anti-epileptic medications, steroids, thyroid

hormone)• Menopause• Nutritional deficiency• Prolonged non-weight-bearing state• Trauma

Impairments, Functional Limitations, or Disabilities

• Inabilit>' to access community• Umited range of motion• Muscle weakness from immobilization• Pain with functional movements and activities

Exclusion or Mulriple-PqHern Clossification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay d»,'termine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in oDifferent Pattern

• Flail cliest

Findings That May Require Classification inAdditional Patterns

• Osteogencsis imperfecta

Note:

Some risk factors or consequences of pathology/pathophysiology—such as neoplasm—may be severe and com-plex; however, they do not necessarily exclude patients/ciientsfrom this pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visits andduration of care. (See "Evaluation, Diagnosis, and Prognosis 'page S239.)

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

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

170 Malignant neoplasm of bone and articular cartilage

213 Benign neoplasm of bone and articular cartilage

262 Other severe, protein-calorie malnutrition

263 Other and unspecified protein-calorie maUiutrition

268 Vitamin D deficiency

269 Other nutritional deficiencies

275 Disorders of mineral metabolism

627 Menopausal and postmenopausal disorders

715 Osteoarthrosis and aUied disorders

719 Other and unspecified disorders of joint

719.5 Stiffness of joint, not elsew^here classified

719.8 Other specified disorders of joint

Calcification of joint

728 Disorders of muscle, ligament, and fascia

728.1 Muscular calcification and ossification

729 Other disorders of soft tissues

729.9 Other and unspecified disorders of soft tissue730 Osteomyelitis, periostitis, and other infections involving

bone

732 Osteochondropathies

732.4 Juvenile osteochondrosis of lower extremity,excluding foot

733 Other disorders of bone and cartilage

733.0 Osteoporosis

733.1 Pathologic fracture

733.2 Cyst of bone

733.4 Aseptic necrosis of bone

733.8 Malunion and nonunion of fracture

733.9 Other and unspecified disorders of bone andcartilage

736 Other acquired deformities of limbs

736.8 Acquired deformities of other parts of limbs

802 Fracture of face bones

805 Fracture of vertebral column w ithout mention of spinal

cord injury

805.6 Sacrum and coccyx, closed

808 Fracture of pelvis

810 Fracture of clavicle

811 Fracture of scapula

812 Fracture of humerus

813 Fracture of radius and ulna

813.4 Lower end, closed

813.5 Lower end, open

814 Fracture of carpal bone(s)

815 Fracture of metacarpal bone(s)

816 Fracture of one or more phalanges of hand819 Multiple fractures involving both upper Umbs, and upper

limbs with ribs(s) and sternum

820 Fracture of neck of femur

821 Fracture of other and unspecified parts of femur

822 Fracture of patella

823 Fracture of tibia and fibula

824 Fracture of ankle

825 Fracture of one or more tarsal and metatarsal bones

826 Fracture of one or more phalanges of foot

827 Other, multiple, and iU-defined fractures of low er limb

828 Multiple fractures involving both lower limbs, low er -withupper Umb, and lower Umb(s) with rib(s) and sternum

829 Fracture of unspecified bones

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ExaminationFxamination is a comprehensive screening and specific testing process that lt'ads to a diagnostic classification or, w^hen appropriate, to areferral to another practitioner Examination is required prior to the initial intei-vention and is performed for aU patients/clients.Throughthe examination, the physical therapist may identify impairments, fimctional Umitations, disabilities, changes in physical function or overallhealth stanis, and needs related to restoration of health and to prevention, weUness, and fitness.The physical therapist synthesizes theexamination findings to estabUsh the diagnosis and the prognosis (including the plan of care). The patient/cUent, family, significant others,and caregivers may provide infonnation during the examination process.

Examination has three components; the patient/cUent history, the systems revii-w, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physi-cal therapist.The systems review is a brief or limited examinati<in ot (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) tlte c ommimication abiUty, affiect, cognition, language, andlearning style of the patient/cUent. Tests and measures are the means of gatheiing data about the patient/client.

The selection of examination procedures and the depth of the examination vaiy based on patient/cUent age; severity of the problem; .stageof recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors./-'or clinical indications in selxting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include;

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, a,ssistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobiUty, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, scx:ial activity, social

interaction, social support)

Social/Heahh Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological

• Pulmonary-

Current Condition(s)/Chief Complaint(s)

• Concerns that led patient/client to seekthe servin-s of a physical therapist

• Concerns or needs of patient/clientwho requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and cours<' of events• Onset and pattern of symjitoms• Patient/cUent, family, signilic ant other,

and caregiver expectations and goalsfor the therapeutic intervt ntion

• Patient/client, family, signitic ant other,and caregiver perceptions of patient's/client s emotional response to the cur-rent clinical situation

• Previous occurrence of chit f com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior ftmctional status in

seU-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily Uving (LADL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• MecUcations previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• i^boratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Reviev/

The systems review may include;

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •Blood pressureEdemaHeart rateRespiratory rate

Integumentary- Presence of scar

formationSkin colorSkin integrity

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Meosures

Tests and measures for this pattern may include those that characterize

Aerobic Capacity and Endurance• Aerobic capacity during standardized exercise test protocols

(eg, ergometry, step tests, time/distance walk/run tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg, activities of daily Uving [ADL] scales, func-tional scales, instrumental activities of daily living [IADL] scales,interviews, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, interview's, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabiU-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

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

or quantify;

Cranial ond Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and light touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, and vibration; thoracic oudet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

Ergonomics and Body MechanicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in w ork environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, workstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

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Tests and Measures continued

Body mechanics• Body mechanics dtiring self-care, home management, work,

community, or leisure actions, tasks, or activities (eg, ADL scales,IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, feU scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobility skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dy namometry, electroneuromyography, foot-print analyses, gait profiles, mobility skill profiles, <;ibservations,photographic assessments, technology-assisted assessments,videographic assessments, weight-beadng scales, wheelchairmobiUty tests)

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

Integumentary Integrity

Associated skin• Activities, positioning, and postures that produce or reUeve

trauma to the skin (eg, observations, pressure-sensing maps,scales)

• Assistive, adaptive, orthotic, protective, supportive or prostheticdevices and equipment that may produce or reUeve trauma tothe skin (eg, observations, pressure-sensing maps, risk assess-ment scales)

• Skin characteristics, including bUstering, continuity of skincolor, dermatitis, hair growth, mobiUty, nail growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Joint Integrity and Mobility• Joint play movements, including end feel (all joints of the axial

and appendicular skeletal system) (eg, palpation)• Specific body parts (eg, compression and distraction tests,

drawer tests, glide tests, shear tests, valgus/varus stress tests)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength,power, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• Comptjnents, aUgnment, fit, and abiUty to care for orthotic, pro-

teciive, and supportive devices and equipment (eg, interviews,log , observations, pressure-sensing maps, reports)

• Ortholic, protective, and supportive devices and equipmentuse during functional activities (eg,ADL scales, functionalsc aies, IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional Umitations, or disabUi-tit's with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes, ADL scales, aerobiccapacity tests, functional performance inventories, healthasst ssment questionnaires, LADL scales, pain scales, play scales,videographic assessments)

• Saftty during use of orthotic, protective, and supportivedi'vices and equipment (eg, diaries, feU scales, interviews, logs,observatit)ns, reports)

Pain

• Paiii, soreness, and nociception (eg,analog scales,discriminationtests, pain drawings and maps, provocation tests, verbal and pic-torial descriptor tests)

• Riiii in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed imalyses, videographic assessments)

• Postural aUgnment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)• Functioaal ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinom-

etry, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibiUty, and flexibiUty (eg, con-tracture tests, goniometiy, inclinometry, Ugamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

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Tests and Measures continued

Self-Care and Home Management (Including ADL and IADL) Work (Job/School/Play), Community, and Leisure integration or• Ability to gain access to home environments (eg, barrier identifi- Reintegration (Including IADL)

cation, observations, physical performance tests) • AbiUty to assume or resume work (job/school/play), community,• AbiUty to perform self-care and home management activities and leisure activities with or without assistive, adaptive, orthotic,

with or without assistive, adaptive, orthotic, protective, support- protective, supportive, or prosthetic devices and equipment (eg,ive, or prosthetic devices and equipment (eg,ADL scales, aero- activity profiles, disability indexes, functional status question-bic capacity tests, IADL scales, interviews, observations, profiles) naires, IADL scales, observations, physical capacity tests)

• Safety in self-care and home management activities and environ- * Ability to gain access to work (job/school/play), community, andments (eg, diaries, fall scales, interviews, logs, observations, leisure environments (eg, barrier identification, interviews, obser-reports, videographic assessments) vations, physical capacity tests, transportation assessments)

• Safety in work (job/school/play), community, and leisure activi-bensory Integrity ^^^^ ^^^ environments (eg, diaries, fall scales, interviews, logs,. Deep sensations (eg, kinesthesiometry, observations, photo- observations, videographic assessments)

graphic assessments, vibration tests)

• Electrophysiological integrity (eg,electroneuromyography)

Ventilation and Respiration/Gas Exchange• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)

• Pulmonary signs of ventilatory function, including airw ay pro-tection; breath and voice sounds; respiratory rate, rhythm, andpattern; ventilatory flow, forces, and volumes (eg, airway clear-ance tests, observations, palpation, pulmonary function tests,ventilatory muscle force tests)

• Pulmonary symptoms (eg, dyspnea and perceived exertionindexes and scales)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, phy,sical therapists synthesize the examination data to estabUsh the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of func-tion, chronicity or severity of the problem, possibiUty of multisite or multisystt m involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overall health status

A diagnosis is a label encompassing a cluster of signs and symptoms, syndrome s, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examinati<m.The diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The pmgnosis is the detennination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may bereached at various intervals during the course of therapy. During the prognosti<: process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and dunition of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies reaUstic anticipated goals and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others.Tlit se anticipated g<3;ils and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; Uving environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stabiUty of the condition.

Prognosis

Over the course of 3 to 6 months post-fracture, patient/cUent will demonstrateoptimal joint mobility, muscle perfor-mance, and range of motion and the high-est level of fimctioning in home, work(job/school/play), community, and leisureenvironments.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode or Care

6to 18

This range represents the Xov^cx andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 18 tisits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficieniy of servicedelivery.

Factors That May Require NewEpisode of Care or That MayAAodify Frequency of Visits/Duration of Episode

• AccessibiUty and availabiUty ofresources

• 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• C:omorbitities, complications, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• DecUne in functional independence• Ixvel 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 Umitation, or disability• Psychological and socioeconomic

factors• Psychomotor abiUties• Social support• StabiUty of the condition

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InterventionIntervention is the purposeful interaction of the physical therapist with the patient/client and,w^hen appropriate, w ith other individualsinvolved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistentwith the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response andthe progress made toward achieving the anticipated goals and expected outcomes.

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include;

Interventions• Addressing required functions

- advance directivesindividuaUzed family service plans GFSPs) or individuaUzededucation plans (IEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• CoUaboration and coordination with agencies, including;

equipment suppUershome care agenciespayer groups

- schoolstransportation agencies

• Communication across settings, including;case conferences

- documentationeducation plans

• Cost-effective resource utilization• Data collection, analysis, and reporting

outcome data- peer review findings

record revievvs• Documentation across settings, foUowing APTA's Guidelines

for Physical Therapy Documentation (Appendix 5), including;changes in impairments, functional limitations, anddisabilitieschanges in interventions

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

• Interdisciplinary teamworkcase conferencespatient care roundspatient/client family meetings

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes• AccountabiUty for services is increased.• Admission data and discharge planning are completed.• Advance directives, individualized fiimity service plans (IFSPs)

or individualized education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advocacyand abuse reporting) are obtained or completed.

• Available resources are maximally utiUzed.• Care is coordinated with patient/cUent, fiuiuly, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occiirs with ^encies, including

equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding health, weUness, and fit-

ness needs.• Decision making is enhanced regardir^ patient/client health

and the use of health care resources by patient/cUent, family,significant others, and caregivers.

• Documentation occurs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• InterdiscipUnary collaboration occurs through case confer-ences, patient care rounds, and patient/cUent family meetings.

• Patient/cUent, family, significant other, and caregiver understand-ing of anticipated goals and expected outcomes is increased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utiUzed in a cost-effective way.

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Patient/ClienhRelated Instruction

Patient/cUent-related instruction may include;

Interventions• Instruction, education and training of patients/clients and care-

givers regarding;- current condition (pathology/pathophysiology [disease, dis-

order, or condition], impairments, functional Umitations, ordisabilities)enhancement of performancehealth, wellness, and fitness programsplan of care

- risk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional Umitations, ordisabiUties

- transitions across settingstransitions to new roles

Goat* and Expwted OutcomesAblUtf to perform physical actions, tasks, or activities isiaipforved.Awareness and use of community resourees are improved.Behaviors that foster healthy habits, wellness, and prevention

Decision making is enhanced F^arding patient/dient healthand the use of health care tesources by patient/client, femily,signifilcant others, and caregivers.Disab^ty associated with acute or chronic illnesses isreducied.Functional independence in activities of daily living (ADL) andiiistnunental activities of daily Uving (IADL) is increased.Healtli status is improved.Intensity of care is decreasoJ.Level of supervision required for task performance isdecreased.P^tient/di^nt, family, significant other, and caregiver knowl-edge And awareness of the diagnosis, pn^nosis, interventions,and anticipated ^als and expected outcomes are increased.I^tient/cUent knowledge of personal and envteonmental fec-tors associated with the condition is increased.Perfofmance levels in self-care, home management, woik(Job/school/play), community, or tefexire actions, tasks, or activ-ities aire improved.Physbpal function is improved.Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safcty of patient/dient, femily, significant others, and care-givers is improved.Self-nianagement of symptoms is improved.Utiliziiition and cost of health care services are decreased.

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Procedural Interventions continued

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioning- aquatic programs- gait and locomotor training

increased workload over time- walking and wheelchair propul-

sion programs• Balance, coordination, and agility

trainingdevelopmental activities trainingmotor function (motor controland motor learning) training orretraining

- neuromuscular education orreeducationperceptual trainingposture awareness training

- standardized, programmatic, com-plementary exercise approachestask-specific performance training

• Body mechanics and posturalstabilization

body mechanics trainingposture awareness trainingpostural control training

- postural stabilization activities• Flexibility exercises

muscle lengtheningrange of motionstretching

• Gait and locomotion training- developmental activities training- gait training

implement and device trainingperceptual trainingstandardized, programmatic, com-plementary exercise approaches

- wheelchair training• Relaxation

- breathing strategiesmovement strategiesrelaxation techniques

- standardized, programmatic, com-plementary exercise approaches

• Strength, power, and enduranceexercises for head, neck, Umb, pelvic-floor, trunk, and ventilatory muscles- active assistive, active, and resistive

exercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)

- aquatic programsstandardized, programmatic, com-plementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient deUvery to tissue is increased.

Ostec^enic effects of exercise are maximized,- Pain is decreased.

Physiological response to increased oxygen demand is improved.- Soft tissue swelUng, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.- Energy expendittire per unit of work is decreased.- Gait, locomotion, and balance are improved.

Integumentary integrity is improved.- Joint int^rity and mobility are improved.- Motor function (motor control and motor learning) is improved.

Musde performance (strength, power, and endurance) is increased.- Postural control is improved.

Quality and quantity of movement between and across body segments areimproved.

- Range of motion is improved.Relaxation is increased.

- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

man^ement, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily Uving (ADL) and instrumen-tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Risk fectors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- UtiUzadon of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/cUent.

Clinical proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/dient.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

s^nificant others.Sense of well-being is improved.

- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• ADL training

- bathingbed mobiUty and transfer trainingdevelopmental activitiesdressingeatinggrooming

- toileting• Devices and equipment use and

trainingassistive and adaptive device orequipment training during ADLand IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing ADL and IADLprosthetic device or equipmenttraining during ADL and LADL

• Functional training programsback schoolssimulated environments and tasks

- task adaptation• IADL training

caring for dependentshome maintenance

- household choresshopping

- structured play for infants and chil-dren

- yard work• Injury prevention or reduction

injury prevention education duringself-care and home management

- injury prevention or reductionwith use of devices and equipmentsafety awareness training duringself<;are and home management

l Gods aiMi Expacted Outcomes• Impact on pstthology/pathopUysiology (disease, disorder, or condition)

- Pain is decreased.- niy8iok%icM response to increased oxygen demand is improved.

• bi^pact on impairments- BalaiK% is improved.- Endurance is increased.- Enei]^ expenditure per unit of work is decreased.- Motor functton (motc^* control and motor learning is improved.- Musde p«feirraance (stretigth, power, and endurance) is increased,- Postmri control is improved.- Sensory awsuoie^ is tacreiased.- Wei^-beari|t% ^itus is improved.

• Impact cm functional limitations- AbiBlf to peiftMtn physical actions, tasks, or activities relate to self-care and home

mamsgement is increased.- Level of supervMon required for task performance is decreased.- Beitwmance of and iiKlependence in ADL and IADL witii or without devices and

equi^iBieitt aie tocreased.- Toleiance trf posMons and activities is increased.

• Impact on di^ibfflties- Abilte^ to a ^ i o ^ or resiune required self-care and home mati^emoit roles are

improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-mani^jemcnt of symptoms is improved.

• Impact on heaMi, wtellness, and fitness- Fitness is improved.- Health status is improved.- I%ysical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Padent/diem satisfoction- Access, avaibbility, and services provided are accejHable to patient/dient.- Administrative management of practice is acceptaWe to patient/dient.- Clinical prc^ciency of physical therapist is accept^le to patient/dient.- Coordination of care is acceptable to patient/dient.- Cost erf health care services is decreased.- Intensity of care is decreased.- Interperson^ *ills of physical therapist are acceptable to patient/dient, fiimily, and

significant others.- Sense of well-being is imptx>ved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions

• Devices and equipment use and trainingassistive and adaptive device or equipmenttraining during IADL

- orthotic, protective, or supportive device orequipment training during LADLprosthetic device or equipment trainingduring IADL

• Functional training programs- back schools- job coaching- simulated environments and tasks- task adaptation- task training

• IADL trainingcommunity service training involving instru-ments

- school and play activities training includingtools and instrumentswork training with tools

• Injury prevention or reductioninjury prevention education during work(job/school/play), community, and leisureintegration or reintegrationinjury prevention or reduction with use ofdevices and equipmentsafety awareness training during work(job/school/play), community, and leisureintegration or reintegration

• Leisure and play activities and training

Anticipated Goats and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.

Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration isimproved.

- Level of supervision required for task performance is decreased.- Performance of and independence in LADL with or without devices and

equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- Ability to assume or resume required work (job/school/play), communi-

ty, and leisure roles is improved.• Risk reduction/prevention

- Risk fiactors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disability are reduced.- Utilizjttion of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars.• Patient/dient satis&ction

- Access, availability, and services provided are acceptable topatient/dient.

- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent,

family, and significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Inlervenrions continued

Manual Therapy (Including Mobilization/Manipulation)

Interventions• Massage

- connective tissue massage- therapeutic massage

• MobiUzation/manipulation- soft tissue

• Passive range of motion

Anticipated Goals and Expected Outcomes• Impact on pathoic^/pathophysiol<^y (disease, disorder, or condition)

- Edema, tymf^edema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Fain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint integrity and mobility are improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on fimctional limitations- Ability to petform movement tasks is improved.- Ability to perform physical actions, tasks, or activities related to self<are, home

management, work (job/school/play), commutiity, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care, home management, work

(pb/school/play), community, and leisure roles is improved.• Ri^ reduction/prevention

- Risk iiurtors are reduced.- Risk of secondary impidrment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Htness is improved.- Physical capacity is increased.- PhyNcal function is improved.

• Impact on societal resources- Utilizatioa of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satis&ction- Access, availability, and services provided are acceptaUe to patient/client.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/client.- Coordination of caie is acceptaUe to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/client, femUy, and

significant others.- Sense of weU-being is improved.- Stressors ar<e decreased.

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Procedural Interventions continued

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

Interventions

• Adaptive devices- environmental controls- hospital beds

raised toilet seatsseating systems

• Assistive devicescanes

- crutches- long-handled reachers

pow er devicesstatic and dynamic splintswalkers

- wheelchairs• Orthotic devices

- braces- casts

shoe insertssplints

• Protective devices- braces- cushions

helmetsprotective taping

• Supportive devicescompression garmentscorsetselastic wraps

- neck collars- serial casts- slings

supportive taping

Anticipated Goals and Expected Outcomes• Impact on pathoiogy/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.

Pain is decreased.Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.

Endurance is increased.Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint stability is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Optimal joint alignment is achieved.- Optimal loading on a body part is achieved.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, woik (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activides of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Pressure on body tissues is reduced.- Protection of body parts is increased.- Risk fectors are reduced.- Risk of recurrence of condition is reduced.

Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.- Stresses precipitating injury are decreased.

• Impact on health, weUness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.

Physical function is improved.• Impact on societal resources

- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.

Clinical proficiency of physical therapist is acceptable to patient/cUent.Coordination of care is acceptable to patient/cUent.

- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

significant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Electrolherapeutic Modalities

Interventions• Electrical stimulation

electrical mu.scle stimulation(EMS)

- high voltage pulsed current(HVPC)

- neuromuscular electrical stimula-tion (NMES)transcutaneous electrical nervestimulation (TENS)

Goals ond EiqMdad OwtcomesImpact on patholc^/pathopljiysiology (disease, disorder, or condition)- EdeoM, tymphedema, or eljiiston is reduced.- Joint swelUi^, iiiflammatiqa, or restriction is reduced.- Nutxtent delivery to tissue is increased.- Osteogenic effects are enlaced.- Pain is d«:reased.- Soft tissue or wound healing is enhanced.- Soft tissue swelling, iitfkniniatlon, or restriction is reduced.- Tissue perfusion and oxygenation are entianced.Impact on tanpakmen^- bitepimentary integrity is> improved.- Motor fuBctton (motctr control and motor teaming) is improved.- Muscle perftmnance (^rei|igtti, power, and etidurance) is increased.- Postwal c<Mitrol is impiwvted.- Quality and quantity of miijvement between and across body segments are

improved.- Range of molion is improved.- Rekiiiation is increased.- Sensory awareness is incr :ased.Impact (HI fimctiCMial litnitaticMis- AbiUty to petform physical actions, tasks, or activities rented to self-care, home man-

a^ment, woik Qdb 'schooH/play), community, and leisure is improved.- Level of supervision fequijted for task performance is decreased.- Performance of ^id indepjencknce in activities of ctaUy livii% (ADL) and instrumen-

tal SKCtivities of daily Uvii i (IADL) with or without devices and eqtiipmoit areincreased.

- Totentnce erf posititms and activities is increased.Impact on disatriUties- AMIty to assume or resufljie required self-care, home man^ement, work

(job/schoo]/|>lay), community, and leisure roles is imf^ored.Risk reduction/prevention- CoiinpUcations of immoUUty are reduced.- Preopexative and postoperative complications are reduced.- Risk iKtors are reduced.- Risk of secotidary impairnient is reduced.- Self-management of symptoms is inq>roved.Impact on heaUi, wellness, a^ fitness- Fitness is impfoved.- Physical capacity is iitcresfsed.- Physical ftmction is iai MOvcd.Impact on societal re»>urces- Utilization of physkal theiapy services is optimized.- UtiUzati<Hi ctf pliysical ^xeptpf services results in efficient use of health care dollars.Patient/cUent satisfoction- Access, avaHabiBity, and services provided are acceptable to patient/dient.- Administrative manapemeint of pcsKtice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client- Coordination of care is acjceptaMe to patient/cHeia.- Interpersonal skills of physical therapist are acceptat^ to patient/client, fiimity, and

s^fiiilcant otlwrs.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:• Athermal agents

pulsed electromagnetic fields• Cryotherapy

cold packsice massage

- vapocoolant spray• Hydrotherapy

- whirlpool tankscontrast bath

- pools• Sound agents

- phonophoresis- ultrasound

• Thermotherapydry heat

- hot packs- paraffin baths

Mechanical modalities may include:• Gravity-assisted compression devices

- tilt table

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelUng, inflammation, or restriction is reduced.

Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.

Soft tissue swelUi^, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairmentsIntegumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.Performance of and independence in activities of daily Uvii^ (ADL) and instrumen-tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- CompUcations of soft tissue and circulatory disorders are decreased.- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.

Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.

• Patient/cUent satisfection- Access, availability, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to i>atient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of weU-being is improved.- Stressors Me decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goaLs and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of pliysical 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 thephysical therapy interventions in the follow ing domains:

• Pathology/pathophysiolog)' (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness. and fitness• Societal resources• Patient/client satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge doe^ not occur with a transfer (defined as the time when apatient is moved from one site to another site within the same setting or across settings during a single episode of care). Although theremay be facility-specific or payer-specific requirements fbr documentation regarding the conclusion of physical therapy services, dischargeoccurs hased on the physicat therapists anatysis of the achievement of anttcipated goais and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or bet ause frnanc ial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. Wlien physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic tbllow-up is needed over the life span to ensure safiety and effective adap-tation following changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-,sideration of the outcomes, the physical therapist plans fbr discharge or discontinuation and provides f()r appropriate foUow-up or referral.

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Impaired Joint Mobility, Motor Function,Muscle Performance, and Ranae of MotionAssociated With Joint Arthroplasty

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/cUents who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a •wide variety of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, c ulture. gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/cUents wiU be classified into this pattern—for impaired joint mobility, motor function, muscle performance, and range ofmotion associated with joint arthroplasty—as a result of the physical therapist s evaluation of the examination data.The findingsfrom the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophys-iology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, w^ellness, or fitnessprograms,The physical therapist integrates, synthesizes, and interprets the ttata to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support theinclusion of patients/cUents in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology(Disease, Disorder, or Condition)• Ankylosing spondylitis• Arthroplasties• Avascular necrosis due to steroid use• Juvenile rheumatoid arthritis• Neoplasms of the bone• Osteoarthritis• Rheumatoid arthritis• Trauma

Impairments, Functional Limitations, or Disobilities

• Decreased range of motion• Inability to access transportation• InabiUty to dress• Muscle guarding• Muscle weakness• Pain

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/cUent would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings Thot May Require Classification in aDifferent Pattern• Impairments associated with multisite trauma

Findings That May Require Classification inAdditional Patterns

• Rheumatoid arthritis with deconditioning

Note:

Some risk factors or consequences of pathology/pathophysiology—such as muttipte joint replacement, recur-rent postoperative dislocation, and secondary postoperativeinfection—may be severe and compXes., however, they do notnecessarily exclude patients/clients from this pattern. Severeand complex risk factors or consequences may require modifi-cation of the frequency of visits and duration of care. (See"Evaluation, Diagnosis, and Prognosis," page S297.)

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/client diagnostic classification is based on impairments, fimctional Umitations, and disabUities—not on codes—patients/cUents may be classified into the pattern even though the codes Usted with the pattern may not apply to those cUents.

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

170 Malignant neoplasm of bone and articular cartilage

171 MaUgnant neoplasm of connective and other soft tissue

213 Benign neoplasm of bone and articular cartilage

215 Other benign neoplasm of connective and other soft tissue

524 Dentofacial anomalies, including malocclusion

524.6 Temporomandibular joint disorders

714 Rheumatoid arthritis and other inflammatorypolyarthropathies

714.0 Rheumatoid arthritis

714.3 Juvenile chronic polyarthritis

714.30 Polyarticular juvenUe rheumatoidarthritis, chronic or unspecified

715 Osteoarthrosis and allied disorders

716 Other and unspecified arthropathies

716.8 Other specified arthropathy

717 Internal derangement of knee

717.9 Unspecified internal derangement of knee

718 Other derangement of joint

718.9 Unspecified derangement of joint

719 Other and unspecified disorders of joint

719.5 Stiffness of joint, not elsewhere classified

719.7 Difficulty in walking

719.8 Other specified disorders of jointCalcification of joint

729 Other disorders of soft tissues

729.8 Other musculoskeletal symptoms referable tolimbs

730 Osteomyelitis, periostitis, and other infections involvingbone

731 Osteitis deformans and osteopathies associated with otherdisorders classified elsewhere

731.0 Osteitis deformans without mention of bonetumor

Paget's disease of bone

733 Other disorders of bone and cartilage

733.1 Pathologic fracture

733.8 Malunion and nonunion of fracture

808 Fracture of pelvis

808.0 Acetabulum, closed

812 Fracture of humerus

812.0 Upper end, closed

815 Fracture of metacarpal bone(s)

820 Fracture of neck of femur

820.8 Unspecified part of neck of femur, closed

820.9 Unspecified part of neck of femur, open

824 Fracture of ankle

835 Dislocation of hip

836 Dislocation of knee

836.5 Other dislocation of knee, closed

837 Dislocation of ankle

958 Certain early CompUcations of trauma

958.3 Posttraumatic wound infection, not elsewhereclassified

Supplemental Classification of Factors Influencing Health Statusand Contoct With Health Services

V43 Organ or tissue replaced by other means

V43.6 Joint

V43.61 ShoulderV43.64 HipV43.65 KneeV43.66 AnkleV43.70 limb

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ExaminationExamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Examination is required prior to the initial intervention and is performed fbr aU patients/clients,Throughthe examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overaUhealth status, and needs related to restoration of health and to prevention, welUiess, and fitness.The physical therapist synthesizes theexamination findings to establish the diagnosis and the pn)gnosis (including the plan of care). The patient/cUent, family, significant others,and caregivers may provide information during the examination process.

Examination has three components: the patient/cUent histoiy, the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/cUent is seeking the services of the physi-cal therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary; integumentary, musculoskeletal, and neuromtiscular systems and (2) the communication ability, affect, cognition, language, andlearning style of the patient/client. Tests and measures are ihe means of gathering tlata about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For ctinical indications in selecting tests and measures and for listings of tests andmeasures, toots used to gather data, and the types of data generated by tests and measures, refer ta Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beUefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), commtmity, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Enviranment• Devices and eqtiipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Sel^Report,Family Report, Caregiver Report)• General health perception• Physical ftmction (eg, mobiUty, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning abUity, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Sociol/Health Habits (Past and Current)• Behavioral health risks (t-g, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal liealth risks

Medical/Surgical History• Cardiovasctilar• Endocrine/metabolic• Gastnjintestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/cUent to seek

the services of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfbr the therapeutic intervention

• Patient/client, family, significant other,and carejjiver perceptions oi patient's/client's emotional response to the cur-rent clinical sittiation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Stotus ond Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily Uving(ADL) and instrumental activities ofdaily Uving (LADL)

• Current and prior functional status inw^ork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems revie-w may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •Blood pressureEdemaHeart rateRespiratory rate

Integumentary- Presence of scar

formationSkin colorSkin integrity

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs know^n• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize

Aerobic Copacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrumental activities of dailyUving [IADL] scales, observations)

Anthropometric Choracteristics• Body dimensions (eg, body mass index, girth measurement,

length measurement)

• Edema (eg, girth measurement, palpation, scales, volumemeasurement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, LADL scales,interviews, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties w ith use of assistive or adaptive devices and eqtiipment(eg, activity status indexes, ADL scales, aerobic capacity tests,ftmctional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

or quantify:

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)

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

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checkUsts, interviews, obser-

vations, questionnaires

• Physical space and environment (eg, compUance standards,observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ei^onomics :• Dexterfty and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, maniptilative abil-ity tests)

• Ftmctional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interview's, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-Usts, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handling checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, w^orkstation checklists)

Body mechanics• Body mechanics during self-care, home management, w^ork,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

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Tests and Measures continued

Gait, Locomotion, and Balance• Balance during fimctional activities with or without the tise of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, ADL scales, LADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobility skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobility skill profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobility tests)

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

Integumentary IntegrityAssociated skin• Activities, positioning, and postures that produce or relieve

trauma to the skin (eg, observations, pressure-sensing maps,scales)

• Assistive, adaptive, orthotic, protective, supportive, or prosthet-ic devices and equipment that may produce or reUeve traumato the .skin (eg, observations, risk assessment scales)

• Skin characteristics, including bUstering, continuity of skincolor, dermatitis, hair growth, mobility, nail growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Wotrnd• Activities, positioning, and postures that aggravate the wound

or scar or that produce or reUeve trauma (eg, observations,pressure-sensing maps)

• Signs of infection (eg, cultures, observations, palpation)• Wound scar tissue characteristics, including banding, pliabiUty,

sensation, and texture (eg, observations, scar-rating scales)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

Muscle Performonce (Including Strength, Power, and Endurance)• Bkctrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during ftmctional activi-ties (eg, ADL scales, functional muscle tests, LADL scales, obser-vaiions, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• (ximponents, alignment, fit, and abiUty to care for orthotic, pro-

tet tive, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• C )rthotic, protective, and supportive devices and equipmenttise during functional activities (eg, ADL scales, ftmctional.scales, IADL scales, interviews, observations,profiles)

• Remediation of impairments, functional limitations, or disabiU-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventorfes, healthassessment questionnaires, IADL scales, pain scales, play scales,\ ideographic assessments)

• Salety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, faU scales, interviews, logs,observations, reports)

Pain

• l^in, soreness, and nociception (eg, analog scales, discrimina-tion tests, pain drawings and maps, provocation tests, verbaland pictorial descrfptor tests)

• I'ain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural aUgnment and position (static), including symmetryami deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, obsen'ations, palpation, positional tests)

Ronge of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, ob,sei-vations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibiUty (eg, con-tracture tests, goniometry, inclinometry, Ugamentous tests, lin-ear measurement, multisegment flexibility tests, palpation)

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Tests and Measures continued

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

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

tests)

Self-Care and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrfer identifi-

cation, observations, physical performance tests)• AbiUty to perform self<are and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and environ-ments (eg, diaries, faU scales, interview's, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), community,

and leisure activities with or w ithout assistive, adaptive, orthot-ic, protective, supportive, or prosthetic devices and equipment(eg, activity profiles, disability indexes, functional status ques-tionnaires, IADL scales, observations, physical capacity tests)

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

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, faU scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or mtiltisysteni involvement, preexisting condition(s), potential disch;irgedestination, social considerations, physical fimction, and overaU health status.

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

The fi*;quency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or sevt:rity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; |>robability of prolonged impairment, functional limitation, ordisability; and stabiUty of the condition.

Prognosis

Over the course of 6 months, patient/cUent will demonstrate optimal jointmobility, motor function, muscle perfor-mance, and range of motion and the high-est level of functioning in home, w ork(job/school/play), community, and leisureenvironments.

During the episode of care, patient/cUentwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/cUents who are classified in this pattern.

Expected Range of Number of VisitsPer Episode or Core

12to60

This range represents the lower andupper limits of the number of physicaltherapist vi.sits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/ctientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 12 to 60 visits dur-ing a single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficient:} of servicedelivery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• AccessibiUty and availabiUty ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, CompUcations, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• I.evel of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• OveraU health status• Potential discharge destinations• Premorbid conditions• ProbabiUty of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abiUties• Social support• StabiUty of the condition

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

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

Coordinarion, Communication, and DocumentarionCoordination, commtmication, and documentation may include:

Interventions

• Addressing required functiotis- advance directives- individualized family service plans (IFSPs) or individualized

education plans (IEPs)- informed consent- mandatory communication and reporting (eg, patient advo-

cacy and abuse reporting)• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including:

- equipment supphers- home care agencies- payer groups- schools- transportation agencies

• Commimication across settings, inciudii^:- case conferences- doctimentation

education plans• Cost-effective resource utilization• Data collection, analysis, and reporting

outcome data- peer review fmdii^s- record reviews

• Doctunentation across settings, following APTAs Guidelinesfor Physical Therapy Documentation (Appendix 5), including:- changes in impairments, functional limitations, and

disabilities- changes in interventions- elements of patient/cUent management (examination,

evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamwork- case conferences- patient care rounds- patient/client family meetings

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

• Accountability for services is increased,• Admission data and discharge planning are completed. *• Advance directives, individualized family service plans (IFSPs) »

or individualized education plans (IEPs), informed consent, and:mandatory communication and reporting (eg, patient advoca- ;cy and abuse reporting) are obtained or completed. *

• Available resources are maximally utilized. I• Care is coordinated with patient/client, fitmily, significant oth- »

ers, caregivers, and other professionals. I• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing equipment suppliers, home care agencies, payer groups, 1schools, and transportation agencies. ; i

• Communication enhances risk reduction and prevention. *• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, including outcome

data, peer review fmdings, and record reviews. ''}.• Decision making is enhanced regarding health, wellness, and ^i

fitness needs. ."• Decision making is enhanced regarding patient/client health

and the use of health care resources by patient/client, family,significant others, and caregivers.

• Documentation occurs throughout patient/client managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/client family meetings.'

• Patient/cUent, family, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined." Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utilized in a cost-effective way.

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Patienf/Client-Related Instruction

Patient/client-related instruction may include;

Interventions

• Instruction, education and training of patients/clients andcaregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional limitations,or disabilities)

- enhancement of performance- health, wellness, and fitness programs- plan of care- risk fectors for pathology/pathophysiology (disease, disorder,

or condition), impairments, ftmctional limitations, or disabilities- transitions across settings- transitions to new roles

Anticipated Goals and Expected Outcomes

• Ability to perform physical actions, tasks, or activities isimproved.

• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired.• Decision making is enhanced regarding patient/client health

and the use of health care resources by patient/client, family,significant others, and caregivers.

• Disability associated with acute or chronic illnesses isreduced.

• Etinctional independence in activities of daily living (ADL)and instrumental activities of daily living (IADL) is increased.

" Health status is improved.• Intensity of care is decreased.• Level of supervision required for task perfonnance is

decreased.• Patient/client, family, significant other, and caregiver knowl-

edge and awareness of tbe diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.

• Patient/client knowledge of personal and environmental fec-tors associated with the condition is increased.

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

• Physical function is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/client, family, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions• Aerobic capacity/endtirance condi-

tioning or reconditiotiing- aquatic programs- gait and locomotor training- increased workload over time- walking and wheelchair propul-

sion programs

• Balance, coordination, and agilitytraining- developmental activities training- motor fimction (motor control and

motor learning) training or retrain-ing

- neuromuscular education or reed-ucation

- pereeptual training- posture awareness training- standardized, programmatic, com-

plementary exercise approaches- task-specific perfonnance training

• Body mechanics and postural stabi-lization- body mechanics training- posture awareness training- postural control training- postural stabilization activities

• Flexibility exercises- muscle lengthenir^- range of motion- stretching

• Gait and locomotion training- developmental activities training- gait training- implement and device training- pereeptual training- standardized, programmatic, com-

plementary exercise approaches- wheelchair training

• Relaxation- breathing strategies- movement strategies- relaxation techniques- standardized, programmatic, com-

plementary exercise approaches• Strength, power, and endurance train-

ing for head, neck, limb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resistiveexereises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programs

- standardized, programmatic, com-plementary exereise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes• Impact on pathoiogy/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxj'gen demand is improved.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfiision and oxygenation are enhanced.

• Impact on impairments- Aerohic capacity is increased.- Airway clearance is improved.- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint integrity and mobility' are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are improved.- Range of motion is improved.- Relaxation is increased. -i- Sensory awareness is increased.- Weiglit-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

cement, work (job/school/play), commtmity, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumental

activities of daily living (IADL) with or without devices and equipment are increased.- Tolerance of positions and activities is increased.

• impact on disabilities *- Ability to assume or resume required self-care, home management, work '•

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention [

- Preoperative and postoperative complications are reduced. *- Risk fectore are reduced.- Risk of secondary impairment is reduced-

Safety is improved. ,•- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care

• Patient/cUent satisfaction ' :- Access, availability, and services provided are acceptable to patient/client. ' t rf- Administrative management of practice is acceptable to patient/client. •*- Clinical proficiency of physical therapist is acceptable to patient/client. *' - *f)- Coordination of care is acceptable to patient/dient. "' ^t- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physic^al therapist are acceptable to patient/client, femily, and

significant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Interventions conHnued

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

Interventions• ADL training

- bathing- bed mobility and transfer training- developmental activities

dressing- eating- grooming- toileting

• Devices and equipment use andtraining- assistive and adaptive device or

equipment training during ADLand IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing ADL and L\DL

- prosthetic device or equipmenttraining during ADL and LADL

• Functional training programs- back schools- simulated environments and tasks- task adaptation

• IADL training- caring for dependents- home maintenance- household chores- shopping- structured play for infants and chil-

dren- yard work

• Injury prevention or reduction- injury prevention education during

self<are and home management- injury prevention or reduction

witb use of devices and equipment- safety awareness training during

self-care and home management

Anticipated Goals and Expected Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is Increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to peribrm physical actions, tasks, or activities related to self<are and home

management is increased.- Level of supervision required for task performance is decreased.- Performance of and independence in ADL and IADL with or without devices and

equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self<are and home management roles is '.

improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved,

• Impact on health, wellness, and fitnessFitness is improved.

- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availahility, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client,- Cost of health care services is decreased,- Intensity of care is decreased.

; -1 Interpersonal skills of physical therapist are acceptable to patient/client, femily, andsignificant others.

- Sense of well-being is improved-, -,. Stressors are decreased.

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Procedural Interventions continuedFunctional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activitiesof Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

• Devices and equipment use andtraining

assistive and adaptive device orequipment training during IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing IADLprosthetic device or equipmenttraining during IADL

• Functional training programsback schoolsjob coachingsimulated environments and taskstask adaptationtask training

• IADL training- community service training involv-

ing instrumentsschool and play activities trainingincluding tools and instrumentswork training with tools

• Injury prevention or reductioninjury prevention education dur-ing w ork (job/school/play), com-munity, and leisure integration orreintegrationinjury prevention or reductionwith use of devices and equip-ment

- safety awareness training duringwork (job/school/play), communi-ty, and leisure integration or reinte-gration

• Leisure and play activities and training

Anticipated Gods and Expected Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved- Endurance is increased.- Energy expenditure per unit of woric is decreased.- Motor function (motor control and motor learning) is improved.- Muscle perfonnance (strength, power, and endurance) is increased.

Postural control is improved.Sensory awareness is increased.

- Weight-bearing status is improved.• Impact on functional Uiidtations

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

- Level of supervision required for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Aiaility to assume or resume required work (job/school/play), community, and

leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced,- Risk of secondary impairment is reduced.- Safety is improved- Self-management of sjTnptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disability are reduced.- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/cHent satisfaction- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/dient.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/client, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural ln^erventions continued aManual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulationsoft tissue

• Passive range of motion

Airikipcriwd Gods and Expactod Oulnmws• Impact on pathology/patliaphy^ol<w (disease, disorder, or condition)

- Edema, Lymphedema or effmion is reduced.- Joint swelling, inflaitunation, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Gait, locomotion, and balance are improved.- tote^imentary integrity is improved.- Joint integrity and mobility are improved.- Muscile performance (stren^h, power, and endurance) is increased.- Posturd control is improved.- Qu^ty and quantity of movement between and across body segments are

improved.- Rar^ of mcHion is improved.- Relaxation is increased.- Sensory awareness is increased.- We^ht-bearing status is improved.

• Impact on functioned limitations- Ability to perform movement tasks is improved.- AbiUty to perform physical actions, tasks, or activities related to self<are, home

management, work (job/school/iriay), community, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabilities- AbiUty to assume or rtsume required self-care, home management, work

(job/sdiool/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Htness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical tlierapy services is optimized.- UtiUzation of physical tiierapy services results in efficient use of health care doUars.

• Patient/client satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is accept^le to patient/dient.- Clinical proficiency of physic^ therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/dient.

Cost of health care services is decreased.Intensity of care is decreas&i.

- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, femity, andsignificant others.

- Sense of weU-being is improved.- StresKjrs are decreased.

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Procedural Interventions conHnued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrical stimulation

electrical muscle stimulation(EMS)functional electrical stimulation(FRS)high voltage pulsed current(HVPC)neuromuscular electrical stimula-tion (NMES)transcutaneous electrical nervestimulation (TENS)

Anticipaled Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient deUvery to tissue is increased.- Osteogenic effects are enhanced.- Pain is decreased.- Soft tissue or wound healing is enhanced.- Soft tissue swelUng, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairmentsIntegumentary integrity is improved.

- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.- QuaUty and qitantity of movement between and across body segments are

improved.Range of motion is improved.Relaxation is increased.Sensory awareness is increased.

• Impact on functional Umitations- AbiUty to perform physical' actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Complications of immobiUty are reduced.- fteoperadve and postoperative CompUcations are reduced.- Risk fectors are reduced.- Risk of secondary impainnent is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.

Physical capacity is increased.Physical function is improved.

• Impact on societal resources- UtiUzation of physical dier^y services is optimized.- UtiUzation of physical therapy services results in efSdent use of health care dollars.

• Patient/dient satisfaction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cHent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, femily, and

significant others.Sense of well-being is improved.

- Stressors are decreased.

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Procedural Interventions continuedPhysical Agents and Mechanical Modalities

Interventions

Physical agents may include;• Cryotherapy

- cold packs- ice massage- vapocoolant spray

• Hydrotherapy- whirlpool tanks- contrast bath- pools

• Sound agents- phonophoresis- ultrasound

• Thermotherapy- dry heat- hot packs- paraffin baths

Mechanical modalities may include:• Mechanical motion devices

continuous passive motion (CPM)

Anticipated Gods and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient deUvery to tissue is increased.

Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Integumentary inte^ty is improved.- Musde performance (strength, power, and endurance) is increased.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to self<are, home

management, work (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activities of daily Uvit^ (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionComplications of soft tissue and circulatory disorders are decreased.Risk fectors are reduced.Risk of secondary impairment is reduced.Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Physical capacity is improved.

Physical function is improved.• Impact on societM resourees

- UtiUzation of physical therapy services is optimized.• Patient/cUent satisfection

- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative aaaagptnent of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to padent/cUent.- Coordination of care is acceptable to patient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of well-being is improved.

Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy strvices by characterizing or quantifying the impact of thephysical therapy interventions in the foUowing domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• DLsabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not otrcur with a transfer (defined as the time when apatient is moved from one site to another site ^vithin the same setting or across settings during a single episode of care). Although theremay be faciUty-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, dischargeoccurs based on the physical therapist's analysis of the achievement of anticipated goats and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/cUent, caregiver, or legal guardian decUnes to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial CompUcations or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic follow-up is needed over the Ufe span to ensure safety and effective adap-tation foUowing changes in physical status, caregivers, environment, or task demiuids. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for dist hai^e or discontinuation and provides fbr appropriate foUow-up or referral.

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Impaired Joint Mobility; Motor Function,Muscle Performance, and Range ofMotion Associated With Bony orSoft Tissue Surgery

This preferred practice pattern describes the generally accepted elements of patient/dient management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/dient needs; the pro-fession's code of ethics and standards of practice; and patient/cUent age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients w ill be classified into this pattern—for impaired joint mobiUty, motor function, muscle performance, and range ofmotion associated w ith bony or soft tissue surgery—as a result of the physical therapist's evaluation of the examination data. Thefindings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabiUties or the need for health, wellness, orfitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

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

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

• Ankylosis• Bone graft and lengthening

procedures• Cesarean section• Connective tissue repair or

reconstruction• Fascial releases• Fusions• Internal debridement• Internal knee derangement

Intervertebral disk disorderLaminectomiesMuscle, tendon, Ugament,capsule repair orreconstructionMultisite fracturesOpen reduction internalfixationOsteotomiesTibial tuberosity procedures

Impairments, Functional Limitations, or Disabilities• Decreased range of motion• Decreased strength and endurance due to inactivity• Impaired joint mobility• Limited independence in activities of daily Uving• Pain• Swelling

Note:

Some risk fectors or consequences of pathology/pathophysiology—such as failed surgeries—may be severe andcomplex; however, they do not necessarily excludepatients/clients from this pattern. Severe and complex risk factorsor consequences may require modification of the frequency of vis-its and duration of care. (See 'Evaluation, Diagnosis, and Prognosis,"page S276.)

Exclusion or Multiple-Pattern ClassificationThe following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tion;il patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/cUent would be moreappropriately managed through (1) classification in anentiiely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern• Amputation• Closed head trauma• Non-union fractures• Peripheral nerve lesions• Total joint arthroplasties

Findings That May Require Classification inAdditional Patterns

• Neurological sequelae• Non-healing wound• Vascular sequelae

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/client diagnostic classification is based on impairments, functional Umitations, and disabilities—not on codes—patients/cUents may be classified into the pattern even though the codes Usted with the pattern may not apply to those cUents.

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

715 Osteoarthrosis and aUied disorders

717 Internal derangement of knee

717.8 Other internal derangement of knee

718 Other derangement of joint

718.0 Articular cartilage disorder

718.2 Pathological dislocation

718.3 Recurrent dislocation of joint

718.4 Contracture of joint

718.5 Ankylosis of joint

718.9 Unspecified derangement of joint

719 Other and unspecified disorders of joint

721 Spondylosis and allied disorders

722 Intervertebral disk disorders

722.7 Intervertebral disk disorder with myelopathy

723 Other disorders of cervical region

724 Other and unspecified disorders of back

724.0 Spinal stenosis, other than cervical

724.3 Sciatica

726 Peripheral enthesopathies and aUied syndromes

726.0 Adhesive capsuUtis of shoulder

726.1 Rotator cuff syndrome of shoulder and aUieddisorders

726.2 Other affections of shoulder region, not elsewhereclassified

Periarthritis of shoulderScapulohumeral fibrositis

726.9 Unspecified enthesopathy

727 Other disorders of synovium, tendon, and bursa

727.0 Synovitis and tenosynovitis

727.1 Bunion

727.4 Ganglion and cyst of synovium, tendon, and bursa

727.6 Rupture of tendon, nontraumatic

728 Disorders of muscle, Ugament, and fascia

728.6 Contracture of palmar fesciaDupuytren's contracture

731 Osteitis deformans and osteopathies associated with otherdisorders classified elsewhere731.0 Osteitis deformans without mention of bone tumor

Paget's disease of bone

732 Osteochondropathies

732.4 Juvenile osteochondrosis of lower extremity,excluding foot

Tibial tubercle (of Osgood-Schlatter)

732.9 Unspecified osteochondropathy

733 Other disorders of bone and cartUage

733.1 Pathologic fracture

Spontaneous fracture

733.8 Malunion and nonunion of fracture

733.82 Nonunion of fracture

736 Other acquired deformities of limbs

736.8 Acquired deformities of other parts of limbs

737 Curvature of spine

738 Other acquired deformity'

738.4 Acquired spondylolisthesis

756 Other congenital musculoskeletal anomalies

756.1 Anomalies of spine

802 Fracture of face bones

805 Fracture of vertebral column without mention of spinal

cord injury

808 Fracture of pelvis

810 Fracture of clavicle

811 Fracture of scapula

812 Fracture of humerus

813 Fracture of radius and ulna

814 Fracture of carpal bone(s)

815 Fracture of metacarpal bone(s)

816 Fracture of one or more phalanges of hand

820 Fracture of neck of femur

821 Fracture of other and unspecified parts of femur

822 Fracture of pateUa

823 Fracture of tibia and fibula

824 Fracture of ankle

825 Fracture of one or more tarsal and metatarsal bones

826 Fracture of one or more phalanges of foot

830 Dislocation of jaw

831 Dislocation of shoulder

832 Dislocation of elbow

833 Dislocation of w rist

834 Dislocation of finger

835 Dislocation of hip

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ICD-9-CM Codes continued

836 Dislocation of knee836.0 Tear of medial cartilage or meniscus

current836.1 Tear of lateral cartilage or meniscus of knee,

current836.2 Other tear of cartilage or meniscus of knee,

current836.5 Other dislocation of knee, closed

837 Dislocation of ankle838 Dislocation of foot839 Other, multiple, and iU-defined dislocations

839.0 Cervical vertebra, closed839.3 Thoracic and lumbar vertebra, open839.8 Multiple and ill-defined, closed

ArmBackHandMultiple locations, except for fingers or toesalone

840 Sprains and strains of shoulder and upper arm840.4 Rotator cuff (capsule)

841 Sprains and strains of elbow and forearm842 Sprains and strains of vri.st and hand843 Sprains and strains of hip and thigh844 Sprains and strains of knee and leg845 Sprains and strains of ankle and foot846 Sprains and strains of sacroiUac region847 Sprains and strains of other and unspecified parts of back848 Other and ill-defined sprains and strains959 Injury, other and unspecified

959.2 Shoulder and upper arm959.9 Unspecified site

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

Examination has three components: the patient/client history, the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to -why the patient/client is seeking the services of the physi-cal therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication abiUty, affect, cognition, language, andlearning style of the patient/cUent. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, w ork (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in setecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated hy tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Sociol History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/schooI/pIay), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and community'characteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary'• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/cUent to seek

the services of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, femily, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (LADL)

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

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other cUnical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •- Blood pressure- Edema- Heart rate- Respiratory rate

Integumentary'Presence of scarformationSkin colorSkin integrity

MusculoskeletalGross range of motionGross strengthCiross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transiti<)n.s)

Communication, Affect, Cognition, Language, and Leorning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg. education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those thai characterize

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL| scales, indexes, instrumental activities <»f dailyliving [IADL] scales, observations)

Anthropometric Characteristics• Body dimensions (eg, body mass index, girth measurement,

length measurement)

• Edema (eg, girth measurement, palpation, scales, volume mea-surement)

Assistive and Adoptive Devices• Assistive or adaptive devices and equipment use during iiinc-

tional activities (eg,ADL scales, functional scales, IADL .scales,intervie\vs, observations)

• Components, alignment, fit, and abUity to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, faU scales, interviews, logs, observations,reports)

or qu tntify:

Cranial and Peripheral Nerve Integrity• I'k ctiophysiological integrity (eg, electroneuromyography)

• .Motor distribution of the cranial nerves (eg, dynamometry, mus-i It tests, observations)

• Motor distribution of the peripheral nerves (eg, dynamometry,nmscie tests, observations, thoracic outlet tests)

• Sensory distribution of the cranial nerves (eg, discriminationtests: tactile tests, including coarse and light touch, cold andlit at, pain, pressure, and vibration)

• Sensory tlistribution of the peripheral nerves (eg, discrimina-ti(in tests; tactile tests, including coarse and light touch, cold;ind heat pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• (Airrent and potential barriers (eg, checklists, interview's, obser-

vaiioiis, ijue.stionnaires

• Physical space and environment (eg, compliance standards,1 >bserYatic)ns, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

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Tests ond Measures continued

Ergonomics and Body Mechanics

Ergonomics• Dexterity and coordination durir^ work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checkUsts,job simulations, lifting models, preemployment screenings, taskanalysis checkUsts, workstation checkUsts)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-Usts, vibration assessments)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

Gait, Locomotion, ond Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) w ith or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, di2ziness inventories,dynamic posturography, feU scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobiUty skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adajvtive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobiUty skiU profUes, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobiUty tests)

• Safety during gait, locomotion, and balance (eg, confidencescales, diaries, faU scales, functional assessment profiles, logs,reports)

Integumentary Integrity

Associated skin• Activities, positioning, and postures that produce or reUeve

trauma to the skin (eg, observations, pressure-sensing maps,scales)

• Assistive, adaptive, orthotic, protective, supportive, or prosthet-ic devices and equipment that may produce or relieve traumato the skin (eg, observations, risk assessment scales)

• Skin characteristics, including blistering, continuity of skincolor, dermatitis, hair growth, mobility, nail growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Wound• Activities, positioning, and postures that aggravate the wound

or scar or that produce or relieve trauma (eg, observations,pressure-sensing maps)

• Signs of infection (eg, cultures, observations, palpation)• Wound scar tissue characteristics, including banding, pUabiUty,

sensation, and texture (eg, observations, scar-rating scales)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative abiUty tests, observations)

Muscle Performonce (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual musde tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, pow er, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

Orthotic, Protective, ond Supportive Devices• Components, aUgnment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentuse during functional activities (eg,ADL scales, functionalscales, LADL scales, interviews, observations, profiles)

• Remediation of impairments, functional Umitations, or disabili-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, feU scales, interviews, logs,observations, reports)

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Tests and Measures continued:O

Pain• Pain, soreness, and nociception (eg, analog scales, angina scales,

discrimination tests, dyspnea scales, pain drawings and maps,provocation tests, verbal and pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetry anddeviation from midUne (eg, grid measurement, observations,photographic assessments)

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

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibiUty, and flexibility (eg, con-tracture tests, goniometry, inclinometry, Ugamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

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

tests)

Self-Care and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical jjerformance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, LADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and environ-ments (eg. diaries. faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Elec trophysiological integrity (eg,electroneuromyography)

Work (Job/School/Ploy), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), community,

and leisure activities with or without assistive, adaptive, orthotic,protective, supportive, or prosthetic devices and equipment (eg,activity profiles, disabiUty indexes, functional status question-naires, IADL scales, observations, physical capacity tests)

• Ability to gain access to work (job/school/play), community, andleisure environments (eg, barrier identification, interviews, obser-vations, physical capacity tests, transportation assessments)

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of func-tion, chronicity or severity of the problem, possibUity of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overaU health status.

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

The frequency of visits and dtiration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout tbe evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probabiUty of prolonged impairment, functional Umitation, ordisability; and stabiUty of the condition.

Prognosis

Over the course of 1 to 8 months,patient/cUent wiU demonstrate optimaljoint mobility, motor function, muscle per-formance, and range of motion and thehighest level of functioning in home, work(job/school/play), community, and leisureenvironments.

During the episode of care, patient/cUentwiU achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/cUents who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

6 to 70

This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 70 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedeUvery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• AccessibiUty and availabiUty ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, complications, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• Level of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• ProbabiUty of prolonged impairment,

functional limitation, or disabiUty• Psychological and socioeconomic

factors• Psychomotor abiUties• Social support• StabiUty of the condition

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

Communication, coordination, and documentation and patient/cUent-related instruction are provided for aU patients/cUents across aU set-tings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the progno-sis, and the anticipated goals and expected outcomes for a particular patient/dient. for ctinical considerations in selecting interventions,listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3-

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

- advance directivesindividuaUzed family service plans (IFSPs) or individuaUzededucation plans (IEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, includir^:

- equipment suppliers- home care agencies

payer groupsschools

- transportation agencies• Communication across settings, including:

case conferencesdocumentationeducation plans

• Cost-effective resource UtiUzation• Data coUection, analysis, and reporting

outcome data- peer review findings

record reviews• Documentation across settings, foUowing APTA's Guidelines

for Physical Therapy Documentation (Appendix 5), including:changes in impairments, functional limitations, anddisabilitieschanges in interventionselements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamw^orkcase conferencespatient care rounds

- patient/client family meetings• Referrals to other professionals or resources

Goab cmd Expected Outcomes

• AccountabiUty for services is increased.• AdmissicKi data and dischaige planning are completed.• Advance directives, individualized fainity service plans (IFSPs)

or individualized education plans (IEPs), informed coisent, andmandatory communicaticm aiKl reporting (eg, patient advoca-cy and abuse iieportmg) are obtained or completed.

• AvailaiMe resources are maxiiaalty utUized.• Care is coordii^ted with patient/client, &mily, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of caie.• Collaboration and coordination occurs with agencies, indud-

'm% equipment suppUers, home care agencies, payer groups,schools, and transportation s^ndes.

• Communication enhances risk reduction and prevention.• Communication occurs across settings t h ro i ^ case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, induding outcome

data, peer review finding, and record reviews.• Decision maidng is enhanced regarding health, wellness, and

fitness needs.• Decision maidng is enhanced re^rding patient/cUeitt health

and the use of healtii caie resources by patient/dient, &mUy,s^iifksnt others, and caiegivers.

• DocumentaticKi occurs tfaioughout patient/dient managementand across settii^ and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 3).

• Iaterdiscipltary coilabotation occurs t h r o i ^ case confer-ences, patient care rounds, and patient/dient &mily meetings.

• Patient/dient, faoiUy, significant other, and caiegivar under-standing of anticipated goals mud expected outcomes isincreased.

• Placement needs are det«tnined.• Referrals are made to other professionals (H* resources when-

ever necessary and appropriate.• Kesouices are utilized in a cost-effective way.

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Patient/Client-Related Instruction

Patient/cUent-related instruction may include:

Interventions• Instruction, education and training of patients/cUents and

caregivers regarding:current condition (pathology/pathophysiology [disease,disorder, or condition], impairments, functional Umitations,or disabiUties)

- enhancement of performance- health, wellness, and fitness programs- plan of care- risk factors for pathology/pathophysiology (disease, disor-

der, or condition), impairments, functional limitations, ordisabUities

- transitions across settingstransitions to new roles

Anticipated Gools ond Expected Outcomes• AbiUty to perform physical actions, tasks, or activities is

improved.• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired.• Decision making is enhanced regarding patient/cUent health

and the use of health care resources by patient/cUent, femily,significant others, and caregivers.

• DisabiUty associated with acute or chronic illnesses isreduced.

• Functional independence in activities of daily Uving (ADL)and instrumental activities of daily Uving (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision reqtiired for task performance is

decreased.• I^tient/dient, femily, significant other, and caregiver knowl-

edge and awareness of the diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.

• Patient/dient knowledge of personal and environmentalfectors associated with the condition is increased.

• Performance levels in self<are, home management, work(job/school/play), community, or leisure actions, tasks, oractivities are improved.

• Physical function is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/dient, femily, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• UtiUzation and cost of health care services are decreased.

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Procedural Interventions

Procedviral interventions for this pattern may include:

Theropeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioningaquatic programs

- gait and locomotor training- increased workload over time- waUdng and wheelchair propul-

sion programs• Balance, coordination, and agiUty

trainingdevelopmental activities trainingmotor function (motor control andmotor learning) training or retrain-ing

- neuromuscular education or reed-ucation

- perceptual trainingposture aw areness trainingstandardized, programmatic, com-plementary exercise approachessensory training or retraining

- task-specific performance training• Body mechanics and postural stabi-

lization- body mechanics training

posture aw areness trainingpostural control training

- postural stabilization activities• FlexibUity exercises

- muscle lengtheningrange of motion

- stretching• Gait and locomotion training

developmental activities traininggait trainingimplement and device trainingperceptual training

- standardized, programmatic, com-plementary exerci.se approacheswheelchair training

• Relaxationbreathing strategiesmovement strategies

- relaxation techniquesstandardized, programmatic, com-plementary exercise approaches

• Strength, power, and endurance train-ing for head, neck, limb, pelvic-floor,trunk, and ventilatory muscles

active assistive. active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programs

- standardized, programmatic, com-plementary exercise approachestask-specific performance training

Gods and Exptctad Oirtconwson pailjotogy/pathophfstology (disease, diK>r(kr, or conditkm)

- Joint sweUJflgiinflaiiimation, or restriction is reduced.- Nutrient deUvery to tisme te increased.- Osteo^enlc eifects <tf exercise aie maximized.- Fain is decreased.- Ph^iolo^cal response to Jnciseased oxygen demand is improved.- Soft tissue swellii^, inflammation, or re^riction is reduced.- Tissue perfti^on and oxygenation are enhanced.Impact on impairments- Aeiobk; capacity is increased.- Balance is impmved.- Endurance is increased.- Ene^y expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Int^umecitary integrity Is imj>roved.- Joint int^rity and mobiity are improved.- Motor fuactioQ (motor contiol and motor leanungi) is iinpi'Q'ved.- Muscle peiicirmance (stret^gth, power, and emlurance) is increased.- Postural ccmtrol is improved.- Quality and quantity of movement between aiKl across body si^n«its ate lni{Mx>ved- Rati^ of motion is Impioved.- RelaxaticMi Is increased.- Setisory awarraiess is increased.- We%ht-beafit% status Is improved.Impact on functional Umitaticms- AMty to perform physical actions, ta^cs, or activities related to %lf-care, home

management, woik Oob/sdiool/play), community, and leisure Is improviHi.- Level of si^jervision required for task peiformance is decreased.- Performance of and iadepenctence in activities of ditfly living (ADL) and instrumen-

tal activities of daify Uving (IADL) with or without devices and equipmott areincreased.

- Tolerance <rf positions and activities is increased.Impact cwi dIsaMMties- Abiity to a^ime or resume required self-ciue, hooK mmiagement, weak

Qdb/scMooVpW)' commuaity, and leisure roles is improved.Ri^ reductioa/prcvention- Preoperative and pmtoperative ccwipUcations sue reduced.- Risk i^:tpt8 aie roliKxd.- ^ k of sea>ndary im{>ainnent is reduced.- Safiety is improved.- Seif-aiai»i@ement of symptone is improved.Impact on heatdi, weUness, and fitness- ntiVE^ is improved.- HeaMi status te improved.- PlF^al cs^adty is increased.- nsysk:al fimction is improved.Impact on soctetal resources- Utilization of physical dieiapy services is ofMimized.- Utilization of physical theiapy services results in efficient use (tf health care dcHlars.Patient/cUent sati^iction- Access, availability, and services provided are acceptalile to patient/client.- AdmMs xative management erf practice Is acceptable to patient/client.- CUitfcal {Mofldency of physical therapist is acceptsdtde to patient/dient.- Coordination of care is sx:ceptMe to patient/cUent.- Cost of heahh care services is decreased.- Intensity erf care is decreased.- Intetpersonal skills of phy^cal therapist are accep&ibk to jisttioiVcltent, fiunHy, suid

significant otters.- Sense of weU-being is improved.- Stressors are (tecreased.

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Procedural Interventions continued

Functionol Training in Self-Core ond Home Monagement (Including Activities of Doily Living [ADL] ondInstrumental Activities of Doily Living [IADL])

Interventions• ADL training

- bathing- bed mobiUty and transfer training

developmental activities- dressing- eating

groomingtoileting

• Devices and equipment use andtraining- assistive and adaptive device or

equipment training during ADLand IADL

- orthotic, protective, or supportivedevice or equipment training dur-ing ADL and LADL

- prosthetic device or equipmenttraining during ADL and IADL

• Functional training programsback schoolssimulated environments and tasks

- task adaptation• IADL training

caring for dependentshome maintenancehousehold choresshoppingstructured play for infants andchUdren

- yard work• Injury prevention or reduction

- injury prevention education duringself-care and home managementinjury prevention or reductionwith use of devices and equipmentsafety awareness training duringself-care and home management

Anticipoted Gools ond Expected Outcomes

• Impact on pathology/pathophysiology (disease, disoider, or condition)Pain is decreased.

- Physiological response to increased oxygen demand is improved.• Impact on impairments

- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to self-care and home

management is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in ADL and LADL with or without devices and

equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume required self-care and home management roles is

improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitnessFitness is improved.

- Health status is improved.- Physical capacity is increased.

Physical function is improved.• Impact on societal resources

UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care doUars.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased,- Intensity of care is decreased.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of weU-beii^ is improved.

Stressors are decreased.

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Procedural Interventions continued

Functional Troining in Work (Job/School/Ploy), Community, ond Leisure integrotion or Reintegrotion (Including Instrumentol Activitiesof Doily Living [IADL], Woric Hordening, ond Work Conditioning]

Interventions• Devices and equipment use and

trainingassistive and adaptive device orequipment training during LADLorthotic, protective, or supportivedevice or equipment training dur-ing L\DLprosthetic device or equipmenttraining during IADL

• Functional training programs- back schools- job coaching

simulated environments and tasks- task adaptation

task training• IADL training

community service training involv-ing instruments

- school and play activities trainingincluding tools and instruments•work training with tools

• Injury prevention or reductioninjury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegrationinjury prevention or reductionwith use of devices and equipmentsafety awareness trainingduring work (job/school/play),community, and leisure integrationor reintegration

• Leisure and play activities and training

Anticipoled Gools ond Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.

Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration is improved.Level of supervision required for task perfonnance is decreased.

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

- Tolerance of positions and activities is increased.• Impact on disabiUties

- AbiUty to assimie or resume required work (job/school/play), commtmity, andleisure roles is improved.

• Risk reduction/prevention- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increa,sed.- Physical function is improved.

• Impact on sodetal resourcesCosts of work-related injuiy or disabiUty are reduced.

- Utilization of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care doUars.

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptaWe to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical profidency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.

Intensity of care is dectseased.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of weU-being is improved.

Stressors are (tecreased.

Guide to Physical Therapist Practice 41 Impairments / Bony or Soft Tissue Surgery 2 8 9 / S 2 8 1

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Procedural Interventions conHnued

Manual Therapy Techniques (Including Mabilization/Manipulation)

Interventions• Manual lymphatic drainage• Manual traction• Massage

- connective tissue massagetherapeutic massage

• Mobilization/manipulationsoft tissueperipheral joints

• Passive range of motion

Anficipated Goals and Expected Otffcomes• Impact on pathology/pathophysiology (disease, disordei; or condition)

- Edema, lymphedema, or efiftision is reduced.- Joint swelling, inflammation, or restriction is reduced.

Neural compression is decreased.Soft tissue swellit^, inflatnmation, or restriction is reduced.

- Pain is decreased.• Impact on impairments

- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint integrity and mobiUty are improved.- Muscle perfonnance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform movement tasks is improved.- Ability to perform physical actions, tasks, or activities related to selfcate, home

management, work (job/school/play), community, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care, home management, work

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.

Self-management of symptoms is improved.• Impact on health, wellness, and fitness

- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/client.- Coordination of care is acceptable to patient/client.

Cost of health care services is decreased.Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to patient/client, femily, andsignificant others.

- Sense of well-being is improved.Stressors are decreased.

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Procedural Inferventions continued

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

Interventions• Adaptive devices

- environmental controls- hospital beds

raised toilet seatsseating systems

• Assistive devicescanes

- crutches- long-handled reachers

power devicesstatic and dynamic splintswalkerswheelchairs

• Orthotic devicesbraces

- casts- shoe inserts- splints

• Protective devicesbracescushionsprotective taping

• Supportive devices- compression garments

corsetselastic wrapsneck collarsserial ca.stsslingssupportive taping

Goob and Expscted OuieomesImpact on pathol<^y/pa)lK>physk>Iogy (disease, disorder, CM- condition)- Edema, tym^riiedema, or efifiision is reduced.- Joint swdling, inflaminatioa, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.Im{^ct on impairments- Balance is improved.- Endurance is increased.- Ene^y expenditure per unit of wcwk is decreased.- Gait, locMnotion, and baknce are improved.- Entegumentary int^^ity is improved.- Joint integrtty and mobility are improved.- Joint stability is improved.- Motor function (motor control and motor leaminiO Is iini»oved.- Muscie perfonnance (stret^^th, power, and endiuance) is increased.

a%nment is achieved,loading on a body part is achieved.

- Postural control is impiovied.- QuaUty and quantity of movement between and across body segments ate improved.- Range of motion is improved.- We|^t-bearif% status is improved.Impact on functional UnMtations- Abttty to perform physical actions, tasks, or activities related to self-care, home

mang^ement, woik (job/school/plty), community, and leisure is improved.- Level of supervlaon required for task performance is decreased.- Fetfomrance of and independeiKe in activities of (Mfy M\ix)g (ADL) and in^rumental

%:tMties ctf daily Uvta§ (IAPL) wtth or without devices and equipment aie increased.- Tolerance of portions and activities is increased.Impact on cUsabiUties- Abfiity to assiune or resuine required sdf-care, home management, work

Qob/sdiDol/piay), comminiity, and leisure roles is improved.Risk reduction/prevention- PrraSure on body tissues iis reduced.- Protection of body parts is increased.- Rl* factors are reduced.

of recurrence of coniUtion is reduced,(rf secondary iiiq>ajmient is reduced.

- Self management of symptoms is improved.- Stresses precipitating injury are (tecreased.Impact on heahh, wellness, and fitness- Health status is improved.- Physical c^pactty is increslsed.- Physical ftmction is Improved.Impact on societal resoiuces- Utilfouicm of physical theicapy services is optimized.- Utflisiaition of physical therapy services results in rffident use of health care dollars.Pstttent/dient satlsSKilon- Access, avafiabttty, and services provided are acceptable to patient/client.- Administrsoive mai^gement of practice is acceptable to patient/client.- ClMcal profickncy of pl^ical thenq>ist is acceptaMe to patient/dient.- CocmUnation of cate Is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreaised.- Interpersonal skills of physical then^>ist are accept^le to patient/dient, femily, and

Sense of weU-being is improved.Stressors are decreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrotherapeutic delivery of

medications- iontophoresis

• Electrical stimulation- electrical muscle stimulation

(EMS)- functional electrical stimulation

(FES)high voltage pulsed current(HVPC)neuromuscular electrical stimula-tion (NMES)

- transcutaneous electrical nervestimulation (TENS)

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects are enhanced.- Pain is decreased.

Soft tissue or wound healing is enhanced.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Integumentary integrity is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of immobility are reduced.- Preoperative and postoperative complications are reduced.- Risk factors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availabiUty, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/cUent.

Coordination of care is acceptable to patient/client.- Interpersonal skills of physical therapist are acceptable to patient/client, femily, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Intervenrions continued

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:• Cryotherdpy

- cold packs- ice massage- vapocoolant spray

• Hydrotherapy- w^hirlpool tanks- contrast bath- pools- pulsatile lavage

• Sound agents- phonophoresis- ultrasound

• Thermotherapy- dry heat- hot packs- paraffin baths

Mechanical modalities may include:• Compression therapies

compression bandagingcompression garments

- taping- vasopneumatic compression

devices• Gravity-assisted compression devices

- tilt table• Mechanical motion devices

- continuous passive motion (CPM)

Anticipatod Goob and Expected Outcomes• Impact on pathology/pathophysiology (cUsease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swefling, inflammation, or restriction is reduced.- Nittfknt d^lvery to tissue is increased.- Osteogenic effects are enhanced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissiie perfusion and oxygenation are enhanced.

• Impact on Imp^rments- Integumentary integrity is improved.- Muscle performance (strength, power, and endurance) is increased.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- AbiMty to perform physical actions, tasks, or activities related to self-care, home

mana^ment, woric (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily Uving (ADL) and Instrumen-

tal activities of daily living (LVDL) with or without devices and eqiupment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

- AbiUty to assume or resume required self-care, home management, woric(job/schooiy^lay), community, and leisure roles is improved.

• Risk reduction/prevention- Complications of soft tissue and circulatory disorders are decreased.- Sisk factors are reduced.- Risk of seccMidary impairmeirt is reduced.- Self-management of symptons Is improved.

• Impact on heaith, wellness, and fitness- ntness is improved.- Physical capacity is increased.- Miysical function is improved.

• Impact on societal resources- UtiU2ati<Hi of i^ysical therapy services is optimized.

• Patient/dient satisfection- Access, avsdtobiUty, and services provided are acceptable to patient/cUent.- AcfaninJstiutive nianagement of {vactice is acceptaMe to patient/dient.- Clinical jMoficiency of physical therapist is acceptable to patient/cUent.- CoordinaticMi of care is accefHable to patient/cUent.- Inteipersonal skills of physical therapist are acceptaMe to patient/cUent, femily, and

significant others.- Sense of well-beir^ is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of thephysical therapy interventions in the foUovs'ing domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

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

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care vhen (1) thepatient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial CompUcations or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client wiU no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic foUow-up is needed over the Ufe span to ensure safety and effective adap-tation foUow ing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides fbr appropriate foUow up or refierral.

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Impaired Motor Function, MusclePerformonce, Ronge of Motion, Goit,Locomotion, ond Bolonce Associoted WithAm pu to tion

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundarie.s within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; theprofession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients wiU be classified into this pattern—for impaired motor ftmction, muscle performance, range of motion, gait, locomo-tion, and balance associated with amputation—as a result of the physical therapist's evaluation of the examination data.The findingsfrom the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiol-ogy (disease, disorder, or condition), impairments, functional Umitations, or disabilities or the need for health, wellness, or fitness pro-grams.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

InclusionThe foUowing examples of examination findings may support theinclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology(Disease, Disorder, or Condition)• Amputation• Diabetes• Frostbite• Peripheral vascular disease• Trauma

Impairments, Functional Umitations, or Disabilities

• Decreased community access• Difficulty with manipulation skills• Edema• Joint contracture• Impaired aerobic capacity• Impaired gait pattern• Impaired integument and inadequate shape of residual limb• Impaired performance during activities of daily Uving• Residual limb pain

Exclusion or Multiple-Pattern ClassificationThe following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity' of the examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern

• Amputation with respiratory feUure

Findings That May Require Classification inAdditional Patterns• Openw^ound

Note:

Some risk factors or consequences of pathology/pathophysiology—such as multisystem involvement and trau-matic amputation of multiple parts—msLy be severe and com-plex; however, they do not necessarity exctude patients/clientsfrom this pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visits andduration of care. (See "Evaluation, Diagnosis, and Prognosis,"page

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/cUent diagnostic classification is based on impairments, functional Umitations, and disabUities—not on codes—patients/cUents may be classified into the pattern even though the codes Usted with the pattern may not apply to those cUents.

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

250 Diabetes meUitus

353 Nerve root and plexus disorders

353.6 Phantom limb (syndrome)

440 Atherosclerosis

440.2 Of native arteries of the extremities

442 Other aneurysm

442.3 Of artery of lower extremity

443 Other peripheral vascular disease

459 Other disorders of circulatory system

459.8 Other specified disorders of circulatory system

736 Other acquired deformities of limbs

74 Other congenital anomalies of circulatory system

747.6 Other anomalies of peripheral vascular system

755 Other congenital anomalies of limbs

755.0 Polydactyly

755.1 Syndactyly

755.2 Reduction deformities of upper Umb

755.3 Reduction deformities of lower limb

755.4 Reduction deformities, unspecified Umb

755.5 Other anomalies of upper limb, including shouldergirdle

781 Symptoms involving nervous and musculoskeletal systems

781.2 Abnormality of gait

781.5 Clubbing of fingers

781.9 Other symptoms involving nervous andmusculoskeletal systems

885 Traumatic amputation of thumb (complete) (partial)

886 Traumatic amputation of other finger(s) (complete) (partial)

887 Traumatic amputation of arm and hand (complete) (partial)

895 Traumatic amputation of toe(s) (complete) (partial)

896 Traumatic amputation of foot (complete) (partial)

897 Traumatic amputation of leg(s) (complete) (partial)

905 Late effects of musculoskeletal and connective tissue injuries

905.9 Late effect of traumatic amputation

906 Late effects of injuries to skin and subcutaneous tissues

927 Crushing injurj' of upper limb

928 Crushing injury of lower Umb

929 Crushing injury of multiple and unspecified sites

990 Effects of radiation, unspecified

991 Effects of reduced temperature

991.1 Frostbite of hand

991.2 Erostbite of foot

994 Effects of other external causes

994.0 Effects of Ughtning

997 CompUcations affecting specified body system, notelsewhere classified997.6 Amputation stump compUcation

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ExaminationExamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Examination is required prior to the initial intervention and is performed for aU patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional Umitations, disabiUties, changes in physical function or overallhealth status, and needs related to restoration of health and to prevention, wellness, and fitness.The physical therapist synthesizes theexamination findings to estabUsh the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others,and caregivers may provide information during the examination pn)cess.

Examination has three components: the patient/cUent history, the systems review, and tests and mea.sures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/cUent is seeking the services of the physi-cal therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromu.scular systems and (2) the communication ability, affect, cognition, language, andlearning style of the patient/cUent. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/cUent age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the ty/>es of data generated try tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beUefs and behaviors• Eamily and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), commtmity, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobiUty, sleep

patterns, restricted bed days)• P.sychological function (eg, memory,

reasoning abiUty, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Heahh Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metaboUc• Gastrointestinal• Cienitoiirinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitaUzations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the servic es of a physical therapist• Concerns or needs of patitnt/cUent

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptotns• Patient/client, family, significant other,

and earegiver expectations and goalsfor the therapeutic intervention

• Patient/cl ient, femily, sign ificari t other,and caregiver perceptions of patient's/client's irmotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(.s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior fianctional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily Uving (IADL)

• Current and prior functional status inw ork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary •Blood pressureEdemaHeart rateRespiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

MusculoskeletalGross range of motion

- Gross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrumental activities of dailyUving [IADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance walk/run tests, tread-miU tests, wheelchair tests)

• Cardiovascular signs and symptoms in response to increasedoxygen demand with exercise or activity, including pressuresand flo^v; heart rate, rhythm, and sounds; and superficial vascu-lar responses (eg, electrocardiography, exertion scales, observa-tions, palpation, sphygmomanometry)

• Pulmonary signs and symptoms in response to increased oxy-gen demand with exercise or activity, including breath andvoice sounds; cyanosis; gas exchange; respiratory pattern, rate,and rhythm; ventilatory flow, force, and volume (eg, ausctilta-tion, exertion scales, observations, oximetry, palpation)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Arousal, Attention, and Cognition• Motivation (eg, adaptive behavior scales)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, IADL scales,interviews, observations)

• Components, alignment, fit, and abiUty to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

or quantify:

• Remediation of impairments, functional Umitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

Circulation (Arterial, Venous, and Lymphatic)• Cardiovascular signs, including heart rate, rhythm, and sounds;

pressures and flow; and superficial vascular responses (eg, aus-cultation, claudication scales, palpation, sphygmomanometry,thermography)

• Physiological responses to position change, including autonom-ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg,auscultation, electrocardiography, observations, palpation,sphygmomanometry)

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Sensory distribution of the peripheral nerves (eg, discrimina-

tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)• Physical space and environment (eg, compliance standards,

observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

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Tests and Measures continued

Ergonomics and Body Mechanics

Ergonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, phy.sicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checklists,job simulations, lifting models, preemployment screenings, ta.skanalysis checklists, workstation checklists)

• Ibols, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration as.sessments)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg, ADL scales,IADL scales, observations, photographic asse.ssments, technolo-gy assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,Al>L scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supporiive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, feU scales, motor impairment tests,observations, photographic assessments, postural contn)! tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg, ADL scales, gaitprofiles, IADL scales, mobilit}^ skill profiles, observations, videographic assessments)

• Gait and locomotion with or wthout the use of assistive, adap-tive, orthotic, protective, .supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, niobUity skill profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheek hairmobility' tests)

• Safet>' during gait, locomotion, and balance (eg, confidencescales, diaries, faU scales, functional assessment profiles, logs,reports)

Integumentary Integrity

Associated skin• Activities, positioning, and postures that produce or reUeve trau-

ma to the skin (eg, observations, pressure-sensing maps, scales)• Assistive, adaptive, orthotic, protective, supportive, or prosthet-

ic devices and equipment that may produce or reUeve traumato the skin (eg, observations, pressure-sensing maps, risk assess-ment scales)

• Skin characteristics, including blistering, continuity of skincolor, dermatitis, hair growth, mobiUty, naU growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Wound• Activities, positioning, and postures that aggravate the wound

(jr scar or that produce (;r reUeve trauma (eg, observations,prc ssure-sen,sing maps)

• Signs of infection (eg, cultures, observations, palpation)

• Wound scar tissue characteristics, including banding, pUabiUty,sensation, and texture (eg, observations, scar-rating scales)

Joint Integrity and Mobility• Jl )int play movements, including end feel (all joints of the iixial

ami appendicular skeletal system) (eg, palpation)

• Specific body parts (eg. apprehension, compression and distrac-tion, drawer, gUde, impingement, shear, and valgus/varus stresstests; arthrometry)

Motor Function (Motor Control and Motor Learning)• Dexterit). coordination, and agility (eg, coordination screens,

motoi' impainnent tests, motor proficiency tests, observations,V ideographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative abiUty tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during ftuictional activi-ties (eg, ADL scales, ftmctional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices• < Components, alignment, fit, and ability to care for orthotic, pro-

tct tivc, and svipportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentIIS*.' during functional activities (eg, ADL scales, functionalsc;des, IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabUi-ties \v ith use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, faU scales, interviews, logs,< )bservations, reports)

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Tests and Measures continued

Pain• Pain, soreness, and nociception (eg, analog scales, discrimina-

tion tests, pain draw ings and maps, provocation tests, verbaland pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural aUgnment and position (dynamic), including symmetry

and deviation from midUne (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural aUgnment and position (static), including symmetry anddeviation from midUne (eg, grid measurement, observations, pho-tographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Prosthetic Requirements• Components, alignment, fit, and abiUty to care for the prosthet-

ic device (eg, interviews, logs, observations, pressure-sensingmaps, reports)

• Prosthetic device use during functional activities (eg, ADLscales, functional scales, IADL scales, interviews, observations)

• Remediation of impairments, functional Umitations, or disabili-ties with use of the prosthetic device (eg, activity status index-es,ADL scales, aerobic capacity tests, functional performanceinventories, health assessment questionnaires, IADL scales, painscales, play scales, videographic assessments)

• Residual limb or adjacent segment, including edema, range ofmotion, skin integrity, and strength (eg, goniometry, muscletests, observations, palpation, photographic assessments, skinintegrity tests, videographic assessments, volume measurement)

• Safety during use of the prosthetic device (eg, diaries, fallscales, interviews, logs, observations, reports)

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, incUnome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibiUty, and flexibiUty (eg, con-tracture tests, goniometry, incUnometry, Ugamentous tests, linearmeasurement, multisegment flexibUity tests, palpation)

Self-Care and Home Management (Including ADL and IADL)• AbiUty to gain access to home environments (eg, barrier identi-

fication, observations, physical performance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, pro-files)

• Safety in self-care and home management activities and envi-ronments (eg, diaries, faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• AbiUty to assume or resume work (job/school/play), community,

and leisure activities with or without assistive, adaptive, orthotic,protective, supportive, or prosthetic devices and equipment (eg,activity profiles, disabiUty indexes, functional status question-naires, IADL scales, observations, physical capacity tests)

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

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make cUnical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to estabUsh the diagnosis and prognosis(including the plan of care). Eactors that influence the complexity of the evaluation include the cUnical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overall health status

A diagnosis is a label encompassing a cluster of signs and symptoms, syndrome s, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s)toward w^hich the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may bereached at various intervals during the course of therapy. During the prognosti<: process, the physical therapist develops the plan of cai e.The plan of care identifies specific interventions, proposed frequency and diinition of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies reaUstic anticipated goals and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others.These anticipated goiils and expected outcx)mes should be measureable and timeUmited.

The frequency of visits and duration of the episode of care may vary from a shon episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation pnxess, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise, chronicity or severity of the current condition; Uving environment; multisiteor multisystem involvement; social support; potential discharge destinations: probabiUty of prolonged impairment, functional limitation, ordisabiUty; and stabUity of the condition.

Prognosis

Over the course of 6 months, patient/cUent wiU demonstrate optimal motorfunction; muscle performance; range ofmotion; and gait, locomotion, and balance;and the highest level of functioning inhome, work (job/school/play), community,and leisure environments.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/cUents who are classified in this pattern.

Expected Range of Number of VisitsPer Episode or Care

15 to 45

ITiis range represents the lower andupper limits of the number ot physicaltherapi.st visits required to achieve antici-pated goals :ind expected outcomes It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goah and expect-ed outcomes within 15 to 't 5 visits dur-ing a single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedeUvery.

Factors That May Require NewEpisode of Care or That MayModify Frequency of Visits/Duration of Episode

• Accessibility and avaUability ofresources

• 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• t.ognitive status• Comorbitities, CompUcations, 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• OveraU health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abiUties• Social support• Stability of the condition

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InterventionIntervention is the purposeftil interaction of the physical therapist with the patient/cUent and, when appropriate, with other individualsinvolved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistentwith the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent response andthe progress made toward achieving the anticipated goals and expected outcomes.

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

advance directives- individuaUzed famUy service plans (IFSPs) or individuaUzed

education plans (IEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• CoUaboration and coordination with agencies, including:

- equipment suppUers- home care agencies- payer groups

schoolstransportation agencies

• Communication across settings, including:case conferencesdocumentationeducation plans

• Cost-effective resource UtiUzation• Data coUection, analysis, and reporting

outcome datapeer review findingsrecord reviews

• Documentation across settings, foUowing APTA's Guidelinesfor Physical Therapy Documentation (Appendix 5), including:- changes in impairments, functional Umitations, and

disabiUtieschanges in interventionselements of patient/cUent management (examination, evalu-ation, diagnosis, prognosis, intervention)

- outcomes of intervention• InterdiscipUnary teamwork

case conferencespatient care rounds

- patient/cUent family meetings• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes• AccountabiUty for services is increased.• Admission data and disch»:^e planning are completed.• Advance directives, individuaUzed family service plans (IFSPs)

or individualized education plans (IEPs), informed consent, andmandatory commimication and reportir^ (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximaUy utilized.• Care is coorditiated with patient/cUent, family, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• CoUaboration and coordination occurs with agencies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Commimication occurs across settings through case confer-

ences, education plans, and documentation.• Data are coUected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision makir^ is enhanced regarding health, wellness, and

fitness needs.• Decision making is enhanced regarding patient/cUent health

and the use of health care resources by patient/cUent, family,significant others, and caregivers.

• Documentation occurs throi^out patient/cUent managementand across settings and foUows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/client femily meetings.

• Patient/cUent, family, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utiUzed in a cost-effective way.

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Patient/ClienhRelaled Instruction

Patient/cUent-related instruction may include:

Interventions• Instruction, education and training of patients/cUents and

caregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional limitations,or disabiUties)enhancement of performancellealth, w elUiess, and fitness programsplan of carerisk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabiUtiestransitions across settingstransitions to new roles

AiUkipotsd Gods and Expected Ouieomes• ANIlty to perform physical actions, t a ^ , or activities is

improved.• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired.• Decision masking is enhanced regarding patient/dient health

and the use of health care resources by pattent/cUent, family,significant c^ers, and caregivers.

• Disability associated with acute or chronic illnesses isreduced.

• Functional independence in activities of d^ly Uving (ADL)and in^rumental activities of daily Uvlt^ (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for tadc peiformance is

(tecreased.• Psttient/cUent, fiimity, significant other, and caregiver knowl-

edge and sviaseness of the diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.

• Patient/cUent knowledge of personal and environmental fac-tors associated with the condition is increased.

• Performance levels in self-care, home management, work(job/school/play), community, or leisure actions, ta^cs, or activ-ities are im|»oved.

• Physical function is improved.• Risk of recurrence of condition is rechiced.• Risk of secondary impainnent is reduced.• Safety of patient/cUent, fiunlty, si^iificant others, and care-

givers is improved.• Self-management of symptoms is improved.• UtiUzation and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioningaquatic programsgait and locomotor trainingincreased workload over timewalking and wheelchair propul-sion programs

• Balance, coordination, and agiUtytraining

motor function (motor controland motor learning) training orretrainingneuromuscular education orreeducationperceptual trainingposture awareness training

- standardized, programmatic, com-plementary exercise approachessensory training or retrainingta.sk-specific performance training

• Body mechanics and posturalstabilization

body mechanics training- developmental activities training- posture awareness training- postural control training- postural stabilization activities

• FlexibiUty exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion trainingdevelopmental activities traininggait trainingimplement and device trainingperceptual trainingstandardized, programmatic, com-plementary exercise approachesw^heelchair training

• Relaxationbreathing strategiesmovement strategies

- relaxation techniques- standardized, programmatic, com-

plementary exercise approaches• Strength, power, and endurance train-

ing for head, neck, limb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programsstandardized, programmatic, com-plementary exercise approachestask-specific performance training

include:

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.

Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxygen demand is improved.

Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.

Energy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint integrity and mobiUty are improved.

Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.QuaUty and quantity of movement between and across body segments are improved.

- Range of motion is improved.Relaxation is increased.

- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on ftmctional Umitations- AbUity to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.

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

- Tolerance of positions and activities is increased.• Impact on disabUities

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

• Risk reduction/preventionPreoperative and postoperative CompUcations are reduced.

- Risk factors are reduced.Risk of secondary impairment is reduced.Safety is improved.

- Self-management of symptoms is improved.• Impact on health, weUness, and fitness

- Fitness is improved.Health status is improved.Physical capacity is increased.

- Physical function is improved.• Impact on societal resources

Utilization of physical therapy services is optimized.- UtUization of physical therapy services results in efficient use of health care doUars.

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.

CUnical proficiency of physical therapist is acceptable to patient/cUent.Coordination of care is acceptable to patient/cUent.

- Cost of health care services is decreased.Intensity of care is decreased.Interpersonal skiMs of physical therapist are acceptable to patient/cUent, femily, andsignificant others.

- Sense of weU-being is improved.Stressors are decreased.

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Procedural Interventions continued

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

Interventions• ADI. training

bathing- bed mobiUty and transfer training- developmental activities

dressing- eating

gr(K)mingtoileting

• Devices and equipment use andtraining

assistive and adaptive device orequipment training during ADLand IADL

- orthotic, protective, or supportivedevice or equipment trainingduring ADL and IADLprosthetic device or equipmenttraining during ADL and IADL

• Functional training programsback schoolssimulated environments and taskstask adaptation

• IADL training- caring for dependents- home maintenance

household choresshoppingstructured play for infants andchildreny ard work

• Injury prevention or reduction- injury prevention education

during self-care and homemanagementinjury prevention or reductionwith use of devices andequipmentsafety awareness training duringseLf-care and home management

Anticipated Gods and Eiqiwdied Otrtcomes• Impact on pathology/pathc^hysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on imfmirments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of woric is decreased.- Motor function (motor control and motor learning) is improved.- Musde perfomnance (strength, power, and endurance) is increased.- Postural contrcrt is improved.- Sensory awareness is increased.- Wei^t-bearing status is improved.

• Impact on functional limitatiois- Ability to peifintn physical actions, tasks, or activities related to self-care and home

mani^ment is improved.- Level of sup^'viston required for task performance is decreased.- Fierfofmance of and independence in ADL and IADL with or without devices and

eqxiii»nent are increased.- Toletance of positions and activities is increased.

• Impact on disabflities- AbiUly to assume or resume required self-care and home management roles is

improved.• Risk reduction/prevention

- Risk {actors are r«luced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-muiagement of symptoms is improved.

• Impact cMi health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capicity is increased.- Physical function is impfoved.

• Impact on societal resources- UtiUication of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/cUent satisfoction- Access, availability, and services provided are acceptable to patient/cUent.- Administrative tmna^ama of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity erf care is decreased.- Interpersonal skiUs of physical therapist are acceptable to patient/cUent, femUy, and

Sense of well-being is impsroved.Stressors are decreased.

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Procedural Interventions conHnued

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

Interventions• Devices and equipment use and training

assistive and adaptive device orequipment training during IADLorthotic, protective, or supportivedevice or equipment training dur-ing IADLprosthetic device or equipmenttraining during IADL

• Functional training programs- back schools- job coaching

simulated environments and taskstask adaptationtask training

• IADL trainingcommunity service training involv-ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

- injury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegrationinjury prevention or reductionwith use of devices andequipment

- safety awareness trainingduring work (job/school/play),community, and leisureintegration or reintegration

• Leisure and play activities and training

AnHdfXited &m\$ and Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiol(^cal response to increased oxygen demand is improved.

• Impact on impairments- Balance is impioved.- Endurance is increased.- Eneigy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle perfotmMice (strength, power, and endurance) is increased.- Postural control is improved.

Sensory awareness is increased.- We^t-bearing status is improved.

• Impact on functional Umitations- AbiUty to peiiMm physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume required work (job/school/play), community, and

leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increa^d.- Physical ftmction is impioved.

• Impact on societal resourcesCosts of woik-related injury or disabiUty are reduced.

- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/cUent satisfection- Access, availability, and services provided are acceptable to patient/cUent.- Administrative man^ement of practice is acceptable to patient/dient.- CUnical proficiency of physical therapist is acceptable to patient/cUent.

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

- Intensity of care is decreased.- Inteipersonal skills of physical therapist are acceptable to patient/cUent, femily, and

s^nificant others.- Sense of well-being is impro-wed.- Stressors are decreased.

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Procedural Interventions continued

AAanual Therapy Techniques (Including Mobiiization/AAanipulaHon)

Interventions• Manual lymphatic drainage• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulationsoft tissue

• Passive range of motion

Anlk^xited Gods cmd Expaetod Ouloimes• Impact on pathology/pathophymology (disease, disotxler, or condition)

- Edema, tymphedema, or efifusion is reduced.- Jc»nt sweilir^, inflammation, or restriction is reduced.- Pain is decreased.

Soft tissue swelling, inflammation, or restriction is reduced.• Ini|>act on impairments

- Balance is improved.- Energy expentteure per unit of wotk is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Muscie perforrmmce (stren^h, power, and endurance) is increased.- Postural control is improved.- Quality and quatJtity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform movement tasks is improved.- AbiUty to perform physical actions, tasks, or activities related to self-care, home

maiuigement, wotk (job/school/play), community, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabilities- AbiUty to assume or resume required self-care, home management, work

(job/school/ptoy), community, and leisure roles is improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondjuy impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Hiysical capacity is increased.- Physical furKHon is improved.

• Impact on societal resources- UtiUaation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/dient satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative mat^ement of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.

Intensity of care is decreased.- Interpersonal skills ot physical therapist are acceptaWe to patient/cUent, femily, and

significant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Interventions conHnued

Electrotherapeutic Modalities

Interventions• Electrical stimulation

high voltage pulsed current(HVPC)neuromuscular electricalstUnulation (NMBS)transcutaneous electrical nervestimulation (TENS)

Afilicipcrted GcMik w d Ejqpactod Owtcomu• Impact on pathoiagy/^th(^yBidk)gy (disease, disorder, or conciition)

- Edenna, fympbedema, or efiuskui is reduced.- JFctotswdlli]g,iaflainBation, or restriction is rediKxd.- Nutrieat ddivety to tissue is increased.- Osteogenic effects are enhanced.- Pain is decieased.- Soft tissue or -WOWKI healing is enhanced.- Soft tissue sweffing, inflanunatkm, or nestriction is reduced.- Tissue perfMofi and Qxygenation are enhanced.

• Impact on impainaents- Integumentary integrity is improved.- Motor fiinction (motor control and motor learning) is improved.- Musde peefonxiance (strength, power, and endurance) is increased.- Postunit control is Impioved.- QuaUty and quantity of OKJvement between and across body segments are unproved.- Hange of motion is improved.- Relaxation is increased.- Sensory awaiieness is Increased.

• Impact on ftuictional iiiaitaticMis- Ability to perform physical actions, tadcs, or activities related to self<are, home

managennent, wotk (job/school/ptoy), community, and leisure is improved.- Level erf siqpervisioniequiied for task performance is decreased.- Perforniance of and independence in activities of daily Uving (ADL) and iiistnimen-

tal activities of d ^ Uving (IADL) widi or withoitt devices and equipment areincreased.

- Tdleiance of positicms and activities is increased.• In4>act ixa disabilities

- AbiUty to asaRime or resume tequired self-care, home iaana^ement, wotk(job/sdiool/piay), community, and leisure roles is impioved.

• Risk reduction/prevention- Preopetative and postoperative complications are reduced.- Risk factors are reduced.- Risk of lecunence of condition is reduced.- Risk of secondaa^ impairment is reduced.- Self-management of symptoms is Improved.

• Impact on health, weUness, and fitness- Fitness is improved.- Miysical capacity is increased.- Physical functicm is improved.

• Inq>act on sodetal resources- Utilization of physical therapy services is optimized.- UtiUzadon of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided ate acceptaUe to patient/cUent.- Administrative mans^ment of practice is acceptable to patient/dient.- Clinical profidency of physical therapist is acceptable to patient/client.- Coordkiation of care Ls acceptable to patient/cUent.- Intetpersonai skills of physical therapist are acceptable to patient/cUent, femity, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/cUent 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 .--en'ices by characterizing or quantifying the impact of thephysical therapy interventions in the foUo ving domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional Umitations• DisabUities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfection

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy service.s that have been provided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when apatient is moved from one site to another site within the same setting or across settings during a single episode of care). Although theremay be feciUty-specific or payer-specific requirements for documentation regiirding the conclusion of physical therapy services, dischargeoccurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have l)een provided during a single episode of care when (1) thepatient/cUent, caregiver, or legal guardian declines to continue intervention; (21 the patient/cUent is unable to continue to progress towardoutcomes because of medical or psychosoc-ial complications or because flnanc iaL'insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUeat status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic foUow-up h needed over the Ufc span to ensure safety and effective adap-tation foUowing changes in physical status, caregivers, envin)nment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate foUow-up or referral.

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CHAPTER 5

Preferred PracHce Patterns:NeuromuscularPreferred practice patterns describe the Hve elements of patient/client managementthat are provided by physical therapi.st.s: examination (history, systems review, andtests and measures), evaluation, diagnosis, prognosis (including pian of care), andintervention (with anticipated goals and expected outcomes). Each pattern alsoaddresses reexamination, global outcomes, and criteria for termination of physicaltherapy services. Examples of ICD-9-CM codes are included.

Pattern A: Primary Prevention/Risk Reductionfor Loss of Balance and Falling S307

Pattern B: Impaired Neuromotor Development S319

Pattern C: Impaired Motor Function and Sensory IntegrityAssociated With Nonprogressive Disorders of theCentral Nervous System—Congenital Origin orAcquired in Infancy or Childhood S339

Pattern D: Impaired Motor Function and Sensory IntegrityAssociated With Nonprogressive Disorders of the(Central Nervous System—Acquired inAdolescence or Adulthood S357

Pattern E: Impaired Motor Function and Sensory IntegrityAssociated With Progressive Disorders of theCentral NetT'ous System S375

Pattern F: Impaired Peripheral Nerve Integrity and MusclePerformance Associated With Peripheral Nerve Injury S393

Pattern G: Impaired Motor Function and Sensory IntegrityAssociated With Acute i )r Chronic Polyneuropathies S411

Pattern H: Impaired Motor Function, Peripheral Nerve Integrity,and Sensory Integrity Associated With NonprogressiveDisorders of the Spinal Cord S429

Pattern I: Impaired Arousal, Range of Motion, and Motor ControlAssociated With Coma, Near Coma, or Vegetative State S447

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Primary Prevention/Risk Reduction forLoss of Balance and Falling

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/cUents who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; theprofession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and.socioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified into this primary prevention/risk reduction pattern as a result of the physical therapist's evaluation ofthe examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the need for aprevention/risk reduction program.The physical therapist integrates, synthesizes, and interprets the data to determine inclusion in thisdiagnostic category.

InclusionThe following examples of examination findings may supportthe inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiaiogy(Disease, Disorder, or Condition)• Advanced age• Alteration in senses (auditor}', visual, somatosensory)• Dementia• Depression• Dizziness• Fear of falUng• History of falls• Medications• Musculoskeletal diseases• Neuromuscular diseases• Prolonged inactivity• Vestibular pathology

Impairments, Functional (imitations, or Disabilities• Deconditioning• Difficulty negotiating in community environment• Difficulty negotiating terrains• Disequilibrium• GeneraUzed weakness• Impaired gait pattern• Impaired position sense

Note:

Prevention and risk reduction are inherent in atl practice pat-terns. Patients/ctients inctuded in this pattern are in need ofprimary prevention/risk reduction onty.

Guide to Physical Therapist Practice 5A ^revention/Risk Reduction Loss of Balance and Falling 3 1 5 / S 3 0 7

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/cUent diagnostic classification is based on impairments, functional Umitations, and disabiUties—not on codes—patients/cUents may be classified into the pattern even though the codes Usted with the pattern may not apply to those patients/cUents.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization s International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 200 T),Volumes 1 and 3 (Chicago, IU: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

331 Other cerebral degenerations

331.0 Alzheimer's disease

332 Parkinson's disease

333 Other extrapyramidal disease and abnormal movementdisorders

334 SpinocerebeUar disease

335 Anterior horn ceU disease

336 Other diseases of spinal cord

340 Multiple sclerosis

342 Hemiplegia and hemiparesis

345 EpUepsy

359 Muscular dystrophies and other myopathies386 Vertiginous syndromes and other disorders of

vestibular system386.0 Meniere's disease

386.1 Other and unspecified peripheral vertigo

386.2 Vertigo of central origin

386.3 Labyrinthitis

780 General symptoms

780.0 Alteration of consciousness

780.2 Syncope and coUapse

780.4 Dizziness and giddiness

780.7 Malaise and fatigue

781 Symptoms involving nervous and musculoskeletal systems

781.0 Abnormal involuntary movements

781.2 AbnormaUty of gait

781.3 Lack of coordination

797 Senility without mention of psychosis

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ExaminationExamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner Examination is required prior to the initial intervention and is performed for aU patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional Umitations, disabiUties, changes in physical function or overaUhealth status, and needs related to restoration of health antl to prevention, wellness, and fitness.The physical therapist synthesizes theexamination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/cUent, famUy, significant others,and caregivers may provide information during the examination process.

Examination has three components: the patient/client histtjry, the systems review, and tests and measures. The history is a systematic gath-ering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physi-cal therapist.The systems revietv is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication abiUty, affect, cognition, language, andlearning style of the patient/client. Tests and measures are the means of gathering data about tbe patient/cUent.

The selection of examination procedures and the depth of the examination vary based on patient/cUent age; severity of the problem; stageof recovery (acute, subacute. chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in selecting tests and measures and for tistings of tests andmeasures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beUefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure action.s, ta.sks, or activities

Growth and Development• Developmental histor>'• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected di.scharge de.stinations

General Health Status (Self-Report,Family Report, Caregiver Report)• Generdl health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning abiUty, depression, anxiety)• Role function (eg, community, leisure,

social, w^ork)• Social function (eg, social activity', social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metaboUc• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related condition.s

• Psychological• Pulmonary

Current Condirion(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the serv ices of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• C^urrent therapeutic interventions• Mechanisms of injury or disease, includ-

ing datf of onset and course of events• Onset and pattern of symptoms• Patient/cUent, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervt ntion

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily Uving QADV)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical lests• l.aboratory and diagnostic tests• Review of avaUable records (eg, med-

ical, education, surgical)• Review of other cUnical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Stotus

• Cardiovascular/Pulmonary •Blood pressureEdemaHeart rateRespiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

Musculoskeletal- Gross range of motion- Gross strength- Gross symmetry- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learniag preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

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

Aerobic Capacity ond Endurance• Aerobic capacity during functional activities (eg, activities of

daUy living [ADL] scales, indexes, instrumental activities of dailyUving [IADL] scales, observations)

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

Arousal, Attention, and Cognition• Arousal and attention (eg, adaptabiUty tests, arousal and aware-

ness scales, indexes, profiles, questionnaires)• Cognition, including abUity to process commands (eg, indexes,

interviews, mental state scales, observations, questionnaires, safe-ty checklists)

• Motivation (eg, adaptive behavior scales)• Orientation to time, person, place, and situation (eg, attention

tests, learning profiles, mental state scales)• RecaU, including memory and retention (eg, assessment scales,

intervie'ws, questionnaires)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, LADL scales,interviews, observations)

• Components, aUgnment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, intervie^vs, observa-tions, reports)

• Safety during use of assistive or adaptive devices and equipment(eg, faU scales, reports, interviews, observations)

Cranial and Peripheral Nerve Integrity• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations)• Response to stimuU, including auditory, gustatory, olfactory, pha-

ryngeal, vestibular, visual (eg, observations, provocation tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discriminationtests; tactUe tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration; thoracic outiet tests)

Environmentol, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)

Ergonomics and Body MechanicsErgonomics• Safety in work environments (eg, hazard identification check-

Usts, job severity indexes, Ufting standards, risk assessmentscales, standards for exposure limits)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg, ADL scales,LADL scales, observations, photographic assessments, video-graphic assessments)

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Tests and Measures conHnued

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, LADL scales, observations,videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-ovit the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gait pro-fUes, IADL scales, mobiUty skiU profiles, observations)

• Safety during gait, locomotion, and balance (eg, confidencescales, tall scales, functional assessment profiles, reports)

A4otor Function (Motor Control and AAotor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Initiation, modification, and control of movement patterns andvoluntary postures (eg, movement assessment batteries, neuro-motor tests, observations, physical perfonnance tests, posturalchaUenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests,technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, observa-tions)

OrlhoHc, Protective, and Supportive Devices• Components, aUgnment, fit, and abiUty to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,observations, reports)

• Orthotic, protective, and supportive devices and equipment useduring fimctional activities (eg, ADL scales, functional scales,IADL scales, interviews, observations, profiles)

• Safety during use of orthotic, protective, and supportive devicesand equipment (eg, fell scales, reports, interviews, observations)

Posture• Postural aUgnment and position (dynamic), including symmetry

and deviation from midUne (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural aUgnment and position (static), including symmetry anddeviation from midline (eg, grid measurement, observations,photographic assessments)

Range of Motion (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

trv, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibiUty, and flexibility (eg, con-tracture tests, flexible rulers, goniometers, inclinometers, Uga-mentous tests, multisegment flexibiUty tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex

tests)• Posiund reflexes and reactions, including righting, equUibrium,

and pr<jtective reactions (eg, observations, postural chaUengetests, reflex profiles)

• Resistance to passive stretch (eg, tone scales)

Self-Core and Home Management (Including Activities of DailyLiving and Instrumentol AcHvities of Daily Living)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Safety in self-care and home management activities and environ-

ments (eg, feU scales, interviews, observations, reports)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation test.s)• Det p .sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)

Work fJob/School/Pkiy), Community, and Leisure Integration orReintegration (Including IADL)• AJiiiity to gain access to work (job/school/play), community, and

leisure environments (eg, barrier identification, interviews,observations, physical capacity, transportation assessments)

• Saft ty in w ork (job/school/play), community, and leisure activi-ties and environments (eg, faU scales, interviews, observations)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evatuations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overall health status.

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

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/cUents based on a varietyof factors tbat the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probabiUty of prolonged impairment, functional Umitation, ordisability ; and stabiUty of the condition.

Prognosis

Patient/cUent wiU reduce the risk offalUng through therapeutic exercise, bal-ance training, and Ufestyle modification.

Expected Range of Number of VisitsPer Episode of Care

2to 18

This range represents the low er andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 2 to 18 visits dur-ing a single continuous episode of care.

Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedeUvery.

Factors That May Require Nev/Episode of Care or That May ModifyFrequency of Visits/Duration of Care

• Accessibility and availabiUty ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to grovrth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, CompUcations, 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• ProbabiUty of prolonged impairment,

functional Umitation, or disabiUty• Psychological and socioeconomic

factors• Psychomotor abiUties• Social support• Stability of the condition

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InterventionIntervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individualsinvolved with the patient/client, using various physical therapy procedures and techniques to produce changes in the condition consis-tent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent responseand tbe progress made toward achieving tbe anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/cUent-related instruction are provided for aU patients/cUents across all set-tings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the progno-sis, and the anticipated goals and expected outcomes for a particular patient/cUent. For clinicai considerations in selecting interventions,listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3-

Coordination, Communication, and Documentation

Coordination, communication, and documentation for primary prevention/risk reduction may include:

Interventions

• Addressing required functionsindividuaUzed family service plans (IFSPs) or individuaUzededucation plans (IEPs)intbrmed consentmandatory communication and reporting (eg, patient/cUentadvocacy and abuse reporting)

• Collaboration and coordination with agencies, including:equipment suppliers

- home care agencies- payer groups

schoolstransportation agencies

• C'omniunication, including:education plansdocumentation

• Data coUection, analysis and reportingoutcome datapeer review iindingsrecord revie\vs

• Documentationelements of patient/cHent management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipoted Goals and Expected Outcomes• AccountabiUty for services is increased.• IndividuaUzed family service plans (IFSPs) or individuaUzed

education plans (IEPs), informed consent, and mandatory com-munication and reporting (eg, patient/cUent advocacy andabuse reporting) are obtained or completed.

• Available resources are maximally utiUzed.• Collaboration and coordination occurs with ^encies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Ctimmunication occurs through education plans anddocumentation.

• Data are coUected, analyzed, and reported, kidudii^ outcomedata, peer review findings, and record reviews.

• Ekxision making is enhanced regarding patient/cUent healthand the use of health care resotwces by patient/cUent, femily,sitjnificant others, and caregivers.

• Documentation occurs throughout client management and fol-lows APIA'S Guidelines for Ptrysical Therapy Documentation(Appendix 5).

• Patient/client, femily, significant other, and caregiver under-sttnding of anticipated goals and expected outcomes isincreased.

• Referrals are made to other professionals or resources whenevernecessary and appropriate.

• R«:sources are utiUzed in a cost-effective way.

Pdtient/cUent-related instruction may include:

Interventions• Instruction, education, and training of

patients/cUents and caregiversregarding:

enhancement of performancehealth, weUness, and fitnessprograms

- plan for interventionrisk factors for pathology/patbophysiology (disease, disorder,or condition), impairments, func-tional Umitations, or disabiUties

Anticipated Goals ond Expected Outcomes

• AbiUty to perform physical actions, tasks, or activities is improved.• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention are acquired.• Decision making is enhanced regardir^ patient/cUent health and the use of health

care resources by patient/cUcnt, femily, significant others, and caregivers.• Healtii status fe improved.• Patient/dient, family, significant other, and caregiver kiKmdec^ and awareness of the

diagnosis, prognosis, interventions, and anticipated goals and expected outcomes areincreased.

• Patient/dient knowledge of personal and envin>nmental fectors associated with thecondition is increased.

• Performance levels in seU-care, home management, work (Job/school/play), community,or leisure actions, tasks, or activities are improved.

• Physical function is improved.• Risk of recurrence of condition is reduced.• Safety of patient/cUent, femily, significant others, and caregivers is improved.• UtiUzation and cost of healtii care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic capacity/endurance condi-

tioning or reconditioning- aquatic programs- gait and locomotor training

increased w^orkload over timew aUcing and w^heelchair propul-sion programs

• Balance, coordination, and agiUtytraining

motor function (motor controland motor learning) training orretraining

- neuromuscular education orreeducationperceptual trainingposture awareness trainingstandardized, programmatic, com-plementary exercise approaches

- sensory' training or retraining- task-specific performance training- vestibular training

• Body mechanics and postural stabi-lization

body mechanics trainingposture awareness trainingpostural control training

- postural stabUization activities• FlexibiUty exercises

muscle lengtheningrange of motionstretching

• Gait and locomotion traininggait trainingimplement and device training

- perceptual trainingstandardized, programmatic, com-plementary exercise approacheswheelchair training

• Relaxationbreathing strategies

- movement strategies- relaxation techniques- standardized, programmatic, com-

plementary exercise approaches• Strength, power, and endurance train-

ing for head, neck, Umb, pelvic-floor,trunk, and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isoki-netic, isometric, and plyometric)aquatic programsstandardized, programmatic, com-plementary exercise approachestask-specific performance training

include:

Anticipated Goals and Expected Outcomes• Impact on pathol<^y/pathophysiology (disease,' disorder, or condition)

- Nutrient deUvery to tissue is increased.- Osteogenic effects of exercise are maximized.- Physiological response to increased oxygen demand is improved.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.- Eneigy expenditure per imit of work is decreased.- Gait, locomotion, and balance are improved.- Joint integrity and mobiUty are improved.- Integumentary integrity is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- QuaUty and quantity of movement between and across body segments are

improved.Range of motion is improved.

- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physic^ actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionRisk fectors are reduced.

- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical ftmction is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.- Utili2ation of physicM therapy services results in efficient use of health care doUars.

• Patient/cUent satisfection- Acce^, availabUity, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acce MaUe to patient/cUent.- Cost of health care services is decreased.- Interpersonal skills of jrfipical therapist are acceptable to patient/cUent, femily, and

s^nificant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Injury prevention or reduction

injury prevention education during self-care andhome managementinjury prevention or reduction with use of devicesand equipmentsafety awareness training during self-care andhome management

• Functional training programssimulated environments and taskstask adaptation

Anticip(ri«d Golds and bq»ected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Physiological response to increased oxygen demand is improved.• Im|>act on ini|>airments

- Postural control is improved.- Wei^t-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to

self-care and home management is improved.Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or with-out devices and equipment are increased.

- Tokrance of positions and activities is increased.• Impact on disabUities

- AbUity to assume or resume required self-care and home manage-ment roles is improved.

• Bisk reduction/prevention- Risk fectors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.

Self-management of symptoms is improved.• impact on health, weUness, and fitness

- Health status is improved.- Physical function is improved.

• Impact on societal resources- UtUizatiora of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of

health cate dollars.• Patient/cUent satisfection

- Access, availabiUty, and services provided are acceptable topatient/ctotit.

- Administrative mani^ment of practice is acceptable topatient/cUent.

- CUnical pioflciency of physical therapist is acceptable topatien«/cUent.

- Coordination of care is acceptable to patient/cUent.- Cost of healtti care services is decreased.- Intnpersionstl skills of physical therapist are acceptable to

patient/cUent, femily, and significant others.- Sense of welHxdng is improved.- Stresstirs are decreased.

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Procedural Interventions continued

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

Anticqaoted Goals and E}q>ected Outcomes• Impact on pathology/pathophysiolc^y (disease, disorder, or condition)

- Physiological response to increased oxygen demand is improved.• Impact on impairments

- Postural control is improved.- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to work

(job/schooVplay), commimity, and leisure integration or reintegration is improved.- Level of supervision reqxiired for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume reqviired work (job/school/play), community, and

leisure roles is improved.• Risk reduction/prevention

- Risk fectors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.- Self-management of symptoms is improved.

• Impact on hesdth, weUness, and fitness- Health status is improved.- Physical function is improved.

• Impact on sodetal resources- Costs of woik-related injury or disabiUty are reduced.- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/dient satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Interpersonal skills of phj^ical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of weU-being is improved.- Stressors are decreased.

Interventions• Injury prevention or reduction

- injury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegrationinjury prevention or reductionwith use of devices andequipmentsafety awareness trainingduring work (job/school/play),community, and leisureintegration or reintegration

• Functional training programssimulated environments and taskstask adaptation

- task training- travel training

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Procedural Interventions continued

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

Interventions

• Assistive devices- canes- crutches

long-handled reachers

Protective devicesbraceshelmets

Orthotic devicesbraces

- shoe inserts

Antkipated Gods and Ex|MCtad OutconMs• Impact on pathology/pathc^hyslcdogy (disease, disorder, or condition)

- Pain is decreased.- Physiotoglcal response to tacreascd oxygen demand is improved.

• Impact oh impairments- Balance is irapicoved.- Energy expenditure per uoit of woik is decreased.- Gait, Jocomotioii, and balance are jmpiovcd.- Joint stabiUtjr |$ impioved.- Motor function (motCH- cx«itrol and motor leamiogL) is improved.- Muscle performance (strength, power, and endurance) is increased.- Optimal joint aUgnment is adiieved.- Optimal loadfoig on a body part is adiieved.- Postural contrdl is improved.- (Quality and quantity of movement between and across body segments ate improved.- Weight-bearing status te improved.

• Impact on functional Umitations- AbiUty to perform physical actkins, tasks, or activities related to self-care, home

management, wortc Qob/school/piay), community, and leisure is imprdveid.- Level of supervision required for task performance is (tecreased.- Performance of and independence in activities of daiiy Uving (ADL) and Instrumental

activities of dailjr Uving (JADL) with or without devices and equifHnent are incitased.- Tolerance of po«tions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume required self-care, home management, woifc

(job/school/ptay), conimuiiky, and leisure roles is Improved.

- Pressure on body tissues is reduced.- Protection of body parts is increased.- Risk £tctois are reduced.- Risk of recurrence of ccMidition is reduced.- Risk of secondary impairitiicnt Is reduced.- Safety is im^rioved.- Self-man^fEanait oi syxispuxas is fanproved.- Stresses precj^italng ioiury ate decreased.Impact on heiUh, wellness, and fitness- Health status is imjwoved.- Miysical capacity is kicreased.- niysical function is inq»oved.Impact on societal lesources- Uti&fation of physical dieiapy services is optimized.- UtiUzation of pbysical therapy services results in effiident use of health care doUars.Patient/cUent satis&ction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administn^ive manageaient of practice is accqptable to patient/cUent.- Clinic^ proficiency of physical therapist is acceptat^ to patient/dient.- Coordination of care is acceptsd le to patient/dient.- Cost of health care services is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent, fiimily, and

Sense of well4>eing is improved.Stressors are decreased.

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

Global Outconfies for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/cUent 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 thephysical therapy interventions in the foUowing domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional Umitations• DisabUities• Risk reduction/prevention• Health, weUness, and fitness• Societal resources• Patient/client satisfection

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

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

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial CompUcations or because financial/insurance resources have been expended; or (3) tbe phys-ical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/cUents who require multiple episodes of care, periodic foUow-up is needed over the Ufe span to ensure safety and effective adap-tation foUowing changes in physical status, caregivers, environment, or task demands. In consultation w ith appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontintiation and provides for appropriate foUow-up or referral.

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Impaired NeuromotorDevelopment

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the pro-fession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients •will be classified into this pattern for impaired neuromotor development as a result of the physical therapist'sevaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indi-cate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or dis-abilities or the need for health, wellness, or fitness programs.The physical tht rapist integrates, synthesizes, and interprets the datato determine the diagnostic classification.

Inclusion

The following examples of examination findings may support theinclusion of patients/clients in this pattern;

Risk Factors or Consequences of Pathology/Pothophysiology(Disease, Disorder, or Condition)• Alteration in senses (auditory, visual)• Birth trauma• Cognitive delay• Developmental coordination disorder• Developmental delay• Dyspraxia• Fetal alcohol syndrome• Genetic syndromes• Prematurity'

Impairments, Functional Limitations, or Disabilities• Clumsiness during play• Delayed motor skills• Delayed oral motor development• Impaired arousal, attention, and cognition• Impaired locomotion• Impaired sensory integration

Exclusion or Mulriple-Pattern Classificarion

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern

• Spinal cord injury

Findings That May Require Classification inAdditional Patterns• Arthritis• Congenital heart defect

Note:

Some risk factors or consequences of pathology/pathophysiology—such as neoplasm—may be severe and com-plex; ^O!t'e?'e>; they do not necessarily exclude patients/clientsfrom this pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visits andduration of care. (See "Evaluation, Diagnosis, and Prognosis,'page S326.)

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

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001),Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit reqturements.

191 Malignant neoplasm of brain

192 Malignant neoplasm of other and unspecified parts ofnervous system

225 Benign neoplasm of brain and other parts of nervoussystem

252 Disorders of parathyroid gland

252.0 Hyperparathyroidism

253 Disorders of the pituitary gland and its hypothalamiccontrol

253.3 Pituitary dwarfism

262 Other severe, protein-calorie malnutrition

299 Psychoses with origin specific to childhood

299.0 Infantile autism

315 Specific delays in development

315.4 Coordination disorder

315.9 Unspecified delay in development

333 Other extrapyramidal disease and abnormal movement

disorders

333.7 Symptomatic torsion dystonia

345 Epilepsy

345.1 Generalized con^ijlsive epilepsy

345.2 Petit mal status

345.3 Grand mal status

345.9 Epilepsy, unspecified

348 Other conditions of brain

348.1 Anoxic brain tiamage

348.3 Encephalopathy, unspecified

358 Myoneural disorders

359 Muscular dystrophies and other myopathies

389 Hearing loss

714 Rheumatoid arthritis and other inflammatory poly-

arthropathies

714.3 Juvenile chronic polyarthritis

728 Disorders of muscle, ligament, and fascia728.3 Other specific muscle disorders

Arthrogryposis741 Spina bifida

742 Other congenital anomalies of nervous system

742.3 Congenital hydrocephalus

742.5 Other specified anomalies of spinal cord745 Bulbus cordis anomalies and anomalies of cardiac septal

closure

745.1 Transposition of great vessels

745.2 Tetralog)' of Fallot

745.4 Ventricular septal defect

745.5 Ostium secundum type atrial septal defect

746 Other congenital anomalies of heart

746.0 Anomalies of pulmonary valve

747 Other congenital anomalies of circulatory system

747.1 Coarctation of aorta

748 Congenital anomalies of respiratory system

754 Certain congenital musculoskeletal deformities

754.2 Of spine

754.3 Congenital dislocation of hip

755 Other congenital anomalies of limbs

756 Other congenital musculoskeletal anomalies

756.5 Osteodystrophies

756.51 Osteogenesis imperfecta

758 Chromosomal anomaliesIncludes: syndromes associated with anomalies in thenumber and form of chromosomes

759 Other and unspecified congenital anomalies

760 Fetus or newborn affected by maternal conditions whichmay be unrelated to present pregnancy

760.7 Noxious influences affecting fetus viaplacenta or breast milk

762 Fetus or newborn affected by complications of placenta,cord, and membranes

762.5 Other compression of umbilical cord

763 Fetus or new-born affected hy other complications oflabor and delivery

764 Slow fetal growth and fetal malnutrition

765 Disorders relating to short gestation and unspecified lowbirth weight

767 Birth trauma

767.0 Subdural and cerebral hemorrhage

767.9 Birth trauma, unspecified

768 Intrauterine hypoxia and birth asphyxia

768.5 Severe birth asph^Tcia

768.6 Mild or moderate birth asphyxia

768.9 Unspecified birth asphyxia in livebom infant

770 Other respirator^' conditions of fetus and newborn

770.1 Meconium aspiration syndrome770.7 Chronic respiratory disease arising in the

perinatal period

771 Infections specific to the perinatal period

771.2 Other congenital infections

Congenital toxoplasmosis

779 Other and ill-defined conditions originating in the peri-natal period

780 General symptoms

780.3 Convulsions

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ICD-9-CM Codes continued

783 Symptoms concerning nutrition, metabolism, and devel-opment

799 Other ill-defined and unknown causes of morbidity andmortality799.0 Asphyxia

800 Fracture of vault of skull801 Fracture of base of skull803 < )ther and unqualified skull fractures804 Multiple fractures involving skull or face with other

hones850 (Concussion851 (;erebral laceration and contusion852 Subarachnoid, subdural, and extradural hemorrhage,

following injury853 Other and unspecified intracranial hemorrhage following

injury854 Intracranial injury of other and unspecified nature994 Effects of other external causes

994.1 Drow^ning and nt)nfatal submersion995 ("ertain adverse effects not elsewhere classified

995.5 Child maltreatment syndrome

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

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

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For ctinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated hry tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, and activities

Growth and Development• Developmental history• Hand dominance

Uving Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, conununity, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (IADL)

• Current and prior functional status inwork (job/school/play), conimunity,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

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Systems Review

The systems revieiv may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary- Blood pressure- Edema

Heart rateRespiratory rate

IntegtimentaryPresence of scarformationSkin color

- Skin integrity

Communication, Affiect, Cognition, Language, and Learning Style

• Ability to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

MusculoskeletalGross range of motion

- Gross strength- Gross symmetry- Height- Weight

Neuromuscular- Gross coordinated

movements(eg, balance, locomotion,transfers, transitions)

Tests and Measures

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

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily living [ADL] scales, indexes, instrumental activities of dailyliving [IADL] scales, observations)

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

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)

Arausal, Attention, and Cognition• Arousal and attention (eg, adaptability tests, arousal and

awareness scales, indexes, profiles, questionnaires)• Cognition, including ability to process commands (eg, develop-

mental inventories, indexes, interviews, mental state scales,observations, questionnaires, safety checklists)

• Communication (eg, functional communication profiles, inter-views, inventories, observations, questionnaires)

• Motivation (eg, adaptive behavior scales)• Orientation to time, person, place, and situation (eg, attention

tests, learning profiles, mental state scales)• Recall, including memory and retention (eg, assessment s<.:ales,

interviews, questionnaires)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, IADL scales,intervie'ws, observations)

• Components, alignment, fit, and abiUty to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabilitieswitli use of assistive or adaptive devices and equipment (eg, activ-it) status indexes,ADL scales, aerobic capacity tests, functionalperformance inventories, health assessment questionnaires, IADLscales, pain scales, play scales, videographic assessments)

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

Circulation (Arterial, Venous, Lymphatic)• Cajtliovasctilar signs, including heart rate, rhythm, and sounds;

pressures and flow; and superficial vascular responses (eg, ausctil-tation, claudication scales, electrocardiography, girth measurement,observations, palpation, sphygmomanometry, thermography)

• Cardiovascular symptoms (eg, angina, claudication, dyspnea, andpt r< eived exertion scales)

• Physiological responses to position change, including autonom-ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg, aus-cultation, electrocardiography, observations, palpation, sphygmo-miinometry)

Cranial and Peripheral Nerve Integrity

• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

ck tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Response to stimuli, including auditory, gustatory, olfactory, pha-

ryngeal, vestibular, and visual (eg, observations, provocationtest*-)

• Sensory distribution of the cranial nerves (eg, discriminationtests; tactile tests, including coarse and light touch, cold andheal, pain, pressure, and vibration)

• Sensor)- distribution of the peripheral nerves (eg, discriminationtests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration; thoracic outlet tests)

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Tests and Measures continued

En^fironmental, Home, and Work (Job/School/Ploy) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)• Physical space and environment (eg, compliance standards,

observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

Ergonomics and Body MechanicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abili-ty tests)

• Functional capacity and performance during w ork actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-lists, job severity, lifting standards, risk assessment scales)

• Specific work conditions or activities (eg, handling checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, w^orkstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, video-graphic assessments)

Gait, Locomotion, and Babnce• Balance during ftmctional activities w ith or w ithout the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observations,videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gait pro-files, IADL scales, mobility skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adajvtive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, footprintanalyses, gait profiles, mobility skill profiles, observations, photo-graphic assessments, technology-assisted assessments, videograph-ic assessments, veight-bearing scales, wheelchair mobility tests)

• Safety dtiring gait, locomotion, and balance (eg, confidencescales, diaries, fall scales, functional assessment profiles, logs,reports)

Integumentary IntegrityAssociated skin• Activities, positioning, and postures that produce or relieve trau-

ma to the skin (eg, observations, pressure-sensing maps, scales)• Assistive, adaptive, orthotic, protective, supportive, or prosthetic

devices and equipment that may produce or relieve tratima tothe skin (eg, observations, pressure-sensing maps, risk assess-ment scales)

• Skin characteristics, including blistering, continuity of skincolor, dermatitis, hair growth, mobility, nail growth, tempera-ture, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Joint Integrity and Mobility• Specific body parts (eg, apprehension, compression and distrac-

tion, draw er, glide, impingement, shear, and valgus/varus stresstests; arthrometry)

Motor Funclion (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Electrophysiological integrity (eg, electroneuromyography)• Hand function (eg, fine and gross motor control tests, finger

dexterity tests, manipulative ability tests, observations)• Initiation, modification, and control of movement patterns and

voltintary posttires (eg, activity indexes, developmental scales,gross motor function profiles, motor scales, movement assess-ment batteries, neuromotor tests, observations, physical perfor-mance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endtirance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, pow er, and endurance during functional activi-ties (eg,ADL scales, functional muscle tests, IADL scales, observa-tions, videographic assessments)

• Muscle tension (eg, palpation)

Neuromotor Devebpment and Sensory Integration• Acquisition and evolution of motor skills, including age-appro-

priate development (eg, activity indexes, developmental invento-ries and questionnaires, infent and toddler motor assessments,learning profiles, motor function tests, motor proficiency assess-ments, neuromotor assessments, reflex tests, screens, video-graphic assessments)

• Oral motor function, phonation, and speech production (eg,interviews, observations)

• Sensorimotor integration, including postural, equilibrium, andrighting reactions (eg, behavioral assessment scales, motor andprocessing skill tests, postural challenge tests, observations,reflex tests, sensory profiles, temperament questionnaires, visualperceptual skill tests)

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Tests and Measures conrinued

Orthotic, Protective, and Supportive Devices• Components, alignment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, presstire-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipment useduring functional activities (eg,ADL scales, functional scales,IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-ties with use of orthotic, protective, and supportive devices andequipment (eg, activity status indexes, ADL scales, aerobic capac-ity tests, ftmctional performance inventories, health assessmentquestiormaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of orthotic, protective, and supportive devicesand equipment (eg, diaries, fall scales, interviews, logs, observa-tions, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimination

tests, pain drawings and maps, provocation tests, verbal and pic-torial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

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

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

Prosthetic Requirements• Components, alignment, fit, and ability to care for the prosthetic

device (eg, interview's, logs, observations, presstire-sensing maps,reports)

• Prosthetic device use during functional activities (eg,AI>Lscales, functional scales, IADL scales, interviews, observations)

• Safety during use of the prosthetic device (eg, diaries, fall scales,interviews, logs, observations, reports)

Range of Motion (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, flexible rulers, goniometers, inclinometers,ligamentous tests, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)• Electrophysiological integrity (eg, electroneuromyography)• PosturiU reflexes and reactions, including righting, equilibritim,

and protective reactions (eg, observations, postural challengetests, reflex profiles)

• Primitive reflexes and reactions, including developmental (eg,reflex profiles)

• Resistance to passive stretch (eg, tone scales)• Superficial reflexes and reactions (eg, observations, provocation

tests)

Self-Care and Home Management (Including ADL and lADLJ• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability lo perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive;, ;>r prosthetic devices and equipment (eg, ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Satety in self-care and home management activities and environ-ments (eg, diaries, fall scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, tactile discrimination tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic: assessments, vibration tests)

Ventilation and Respiration/Gas Exchange• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analysis, observations, oximetry)• Ptilmonary signs of ventilatory function, including airway pro-

tection: breath and voice sounds; respiratory rate, rhythm, andpattern: ventilatory flow, forces, and volumes (eg, airway clear-ance tests, observations, palpation, pulmonary function tests,ventilator)' muscle force tests)

• Ptilmonary symptoms (eg, dyspnea and perceived exertionindexes and scales)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), community,

and leisure activities w ith or without assistive, adaptive, ortliot-ic, protective, supportive, or prosthetic devices and equipment(eg, .»ctivit>' profiles, disability indexes, fimctional status ques-tionnaires, IADL scales, observations, physical capacity tests)

• AbiUty to gain access to work (job/school/play), cotnmunit), andleisure environments (eg, barrier identification, interviews,observations, physical capacity, transportation assessments)

• Saleiy in work (job/school/play), commtmity, and leisure activi-ties ;ind environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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Prognosis

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

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

The frequenc>' of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisabiUty; and stability of the condition.

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

• Accessibility and availability ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, compUcations, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• DecUne 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• ProbabiUty of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• StabiUty of the condition

Over the course of 12 months, patient/client will demonstrate optimal neuromo-tor development and the highest level offtmctioning in home, work (job/school/play), community, and leisureenvironments, within the context of theimpairments, functional limitations, anddisabilities.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

6 to 90

This range represents the lower andupper limits ot the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 90 visits duringa single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined bythe physical therapist to maximize effec-tiveness of care and efficiency of servicedelivery.

Note:

These patients/clients may require multi-ple episodes of care over the Ufetime toensure safety and effective adaptation fol-lo^ving changes in physical status, care-givers, environment, or task demands.Factors that may lead to these additionalepisodes of care include:

• Cognitive maturation• Periods of rapid growth

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Interventioni T

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

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

Coordination, Communication, and Documentation

Coordination, communication, and doctimentation may include:

Interventions

• Addressing required functionsadvance directivesindividualized family service plans (IFSPs) or individualizededucation plans (IEPs)informed consent

- mandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, including:

eqtiipment suppliershome care agenciespayer groupsschools

- transportation agencies• Communication across settings, including:

case conferencesdocumentationeducation plans

• Cost-effective resource utilization• Data collection, analysis, and reporting

- outcome data- peer review findings

record reviews• Documentation across settings, following APTA's Guidelines

for Physical Therapy Documentation (Appendix 5), including:changes in impairments, functionat limitations, anddisabilitieschanges in interventions

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

• Interdisciplinary teamworkcase conferences

- patient care rounds- patient/client family meetings

• Referrals to other professionals or resources

Antidpatsd Goals and Expected Oufeiomes• Accountability for services is increase.• Admission data and dischai^e planning are completed.• Advance directives, individualized fiunity service plans (IFSPs)

or Individi^Uzed education plans (IEPs), informed consent, andmand^ory communication and reportii^ (eg, patient advocacyand abuse reporting) are obtained or completed.

• Available resources are maximally utilized,• Care is coordinated with patient/client, femity, significant oth-

ers, caiegivers, and other professionals.• Case is mana^d throughout the episode of care.• Collaboration and coordination occurs with ^encies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation ^oicies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are collected, anafyzed, and reported, including outcome

data, peer review flodit^, and record reviews,• Decision making is enhanced regaining health, weltness, and

fitness needs.• Decision making is enhanced regarding patient/cUent health

and the use of health care resources by patient/client, &mily,significant others, and caregivers.

• Documentation occurs throughout patient/client managementand across setting and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboratian occurs thro t^ case conferences,patient care rounds, and patient/client family meetings.

• Patient/client, family, significant other, and car^ver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined,• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utilized in a cost-effective way.

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Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

• Instruction, education and training of patients/clients andcaregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional limitations,or disabilities)enhancement of performancehealth, w ellness, and fitness programsplan of care

- risk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilities

- transitions across settingstransitions to new roles

Anticipated Goals and Expected Outcomes

• Ability to perform physical actions, tasks, or activities isimproved.

• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired.• Decision making is enhanced regarding patient/client health

and the use of health care resourees by patient/client, family,significant others, and caregivers.

• Disability associated with acute or chronic illnesses isreduced.

• Functional independence in activities of daily living (ADL)and instrumental activities of daily living (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for task performance is

decreased.• Patient/client, femily, significant other, and caregiver knowl-

edge and awareness of the diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.

• Patient/client knowledge of personal and environmental fac-tors associated with the condition is increased.

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

• Physical function is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/cUent, family, significant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions• Aerobic capacity/endurance conditioning or

reconditioningaquatic programsgait and locomotor trainingincreased workload over timewalking and w^heelchair propulsion programs

• Balance, coordination, and agility training- developmental activities training

motor function (motor control and motor learn-ing) training or retrainingneuromuscular education or reeducationperceptual trainingposture awareness trainingstandardized, programmatic, complementary exer-cise approachessensory training or retrainingtask-specific performance training

• Body mechanics and postural stabilizationbody mechanics training

- posture awareness training- po.stural control training

postural stabilization activities• Neuromotor development training

developmental activities trainingmotor training

- movement pattern trainingneuromuscular education or reeducation

• Flexibility exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion training- developmental activities training- gait training

implement and device trainingperceptual trainingwheelchair training

• Relaxationbreathing strategiesmovement strategiesrelaxation techniques

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

active assistive, active, and resistive exercises(including concentric, dynamic/isotonic, eccen-tric, isokinetic, isometric, and ptyometric)

- aquatic programsstandardized, programmatic, complementary exer-cise approachestask-specific performance training

Anlic^Kited Gocris end Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Nutrient delivery to tissue is increased,- Osteo^nic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact CMI itnpairments:- Aerobic capacity is increased.- Balance is improved.- Endurance is increased.- Energy expeiKliture per unit of work is decreased.- Gait, locomotion, and balance are improved.- Joint integrity and mobility are improved.- Motor function (motor control and motor leantiog) is improved,- Muscte performance (strength, power, and endurance) Is increased.- Postural ccmttol is improved.- Quality and quantity of movement between and across body seg-

ments are improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearir^ status is improved.- Wotk of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to

self-care, home man^ement, work (job/school^b^), conununity,and leisure is improved.

- Level of supervision reqtiired for task performance is decreased.- Performance of and independence in ADL and IADL with or with-

out devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care, home management,

wotk (job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-nianagement of symptoms is improved.

• Impact on health, weUness, and fitness- Fitness is improved.- Heaith status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient tise of

health care dollars.• Patient/cMent satisfaction

- Access, avaUabillty, and services provided are acceptable topatient/dient.

- Administrative management of practice is acceptable topatient/cUent.

- Clinical proficiency of physical therapist is acceptable topatient/cUent.

- Cootdination of care is acceptaWe to patient/dient.- Cost of health care services is decreased.

Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to

patient/client, family, and significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continuedFunctional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] andInstrumental Activities of Daily Uving [IADL])

Interventions• ADL training

- bathingbed mobility and transfer trainingdevelopmental activitiesdressing

- eatinggroomingtoileting

• Ftmctional training programssimulated environments and taskstask adaptation

- travel training• IADL training

- home maintenancehousehold choresshoppingstructured play for infants and childrentravel training

- yard w ork• Devices and equipment use and training

- assistive and adaptive device or equip-ment training during ADL and IADLorthotic, protective, or supportivedevice or equipment training duringADL and IADL

- prosthetic device or equipment train-ing during ADL and LADL

• Injury prevention or reduction- injury prevention education during self-

care and home managementinjury prevention or reduction w ith useof devices and equipmentsafety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes• Impact on patholqgy/pathophysiology (disease, disorder, or condition)

- Pain is decreased.Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of woik is decreased

Motor function (motor control and motor learning) is improved.Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care and

home management is improved.- Level of suf>ervision required for task performance is decreased.- Performance of and independence in ADL and IADL with or without devices

and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self-care and home man^ement roles is

improved,• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Health status is improved.

Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Utilization of physical therapy services is optitnized.- Utilization of physical therapy services results in efficient use of health care

dollars.• Patient/dient satisfection

- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/cUent.- Clinical proficiency of physical therapist is acceptable to patient/cHent.- Cootdination of care is acceptable to patient/dient,- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family,

and significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Devices and equipment use and

trainingassistive and adaptive device orequipment training during LADLorthotic, protective, or supportivedevice or equipment training dur-ing IADLprosthetic device or equipmenttraining during LADL

• Functional training programsjob coaching

- simulated environments and taskstask adaptationtask trainingtravel training

• IADL trainingcommunity service training involv-ing instruments

- school and play activities trainingincluding tools and instrumentsw ork training with tools

• Injury prevention or reductioninjury prevention educationduring work (job/school/play),community, and leisureintegration or reintegrationinjury prevention or reductionwith use of devices and equipmentsafety awareness trainingduring work (job/school/play),community, and leisureintegration or reintegration

• Leisure and play activities training

Anticipated Gods and Exprcted OirtcamM• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Phy^ological response to increased oxygen demand is improved.

• Impact on impaUrmentsBalance is improved.Endurance is increased.Energy ex{>enditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postiffal control is improved,- Sensory awareness is increased.- Weight-bearir^ stattis is improved.- Work of breathing is decreased.

• Impact on functional Umitations- Ability to perform physical actions, tasks, or activities related to work

(job/school/play), community, and leisure integration or reintegration is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in IADL witii or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to asstune or resimie required work (job/school/play), community, and

leisure roles is improved.• Risk reduction/prevention

- Risk fcctors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.Self-management of symptoms is improved.

• Impact on health, wellnei^, and fitness- Fitness is improved.- Health status is improved,- Physteal capacity is increased.- Physical function is improved.

• Impact on societal resourees- Costs of work-related injury or debility are reduced.- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satis&ction- Access, availability, and services provided are acceptable to patient/dient- Admtaistrative mana^^ment of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/cMent.- Coordination of care is acceptable to patient/dient,- Cost of health care services is decreased,- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Manual traction• Massage

- connective tissue massage- therapeutic massage

• Mobilization/manipulationSoft tissue mobilization

• Passive range of motion

Antkipated Gods am) Expected Outcomes• Impact on pathology/piathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced,- Joint swelling, inflammation, or restriction is reduced.

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

• Impact on impairments- Balance is improved.- Energy expenditure per unit of work is decreased.

Gait, locomotion, and balance are improved.- Joint mtegrity and mobility are improved.- Musde performance (strength, power, and endtirance) is increased.- Postiual control is improved.- Quality and quantity of movement between and across body segments are improved.

Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Work of breathing is decreased.

• Impact on functional Umitations- Ability to perform movement tasks is improved.- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required self<are, home management, woik

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitnessPhysical capacity is increased.

- Physical fimction is improved.• Impact on societal resourees

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

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Adaptive devices

environmental controlshospital bedsraised toilet seatsseating systems

• Assistive devicescanes

- crutcheslong-handled reacherspower devicesstatic and dynamic splintswalkerswheelchairs

• Orthotic devicesbracescastsshoe insertssplints

• Prosthetic devices (lower-extremityand upper-extremity)

• Protective devicesbracescushionshelmetsprotective taping

• Supportive devicescompression garmentscorsetselastic wrapsneck collarssupplemental oxygen

Afrikipcrind Gt>ds and &qpwltod OMcomw• Impact on pathcrft^y/patitofihj^lology (disease, disorder, or condition)

- Edema, lymphedema, or effMon Is reduced.- JoAat sfiKlUng, ioffaunfiiation, or restriction is reduced.

to incieased oxygen demand is improved.- Soft tissue sweHifl inflammation, or restxk:tion is reduced.Impact on impairments- Balance is improved.- Endur^ice is iiKaneased,• Energy expenditure pet unit of woik is decreased,- G^t, locoanotion, and balutce are iinproived.- Integumentary integrity is Improvted.- Joint s MUty is teprtjved,- Motor fuiKtion (nKHor control aod motor learning) is iiq>roved.- Muscle perfonnance (strength, power, and endue^ice) is increased.- Optimal joint aU^omoit is adilevied.- Optimal losuling on a body part is achieved.- Postural control is improved,- Quality and quantity of movement between and across body segments are improved.- Range ctf motion is improved.- Weight-bearing status is improved.Impact on functional Umitatiotis- Ability to perform physical auctions, t a ^ , or activities related to self-care, home man-

agement, woric (jc^/schooVpliay), community, and leisure is improved.- Level of supervision requited for task per&Mmance is decreased.- Perfonnance of and indepencbncx in activities of dally iivii^ (ADL) and instrumental

activities of daily Uving (lADL) with or without devices aad equipment are increased.- Tolerance of portions and activities is improved.Impact on disabilities- Ability to assume or restune reqiMred self<are, home management, woik

(job/school/pla0, commutkity, and leisure roles is improved.Risk reductiOTi/preventton- Pi?essure on body tissues is reduced.- Proteaton of body parts is increased.- Risk fectors are reduced.- Risk of secondary impairment Is reduced.- Safety is improved.- Self-management of symptoms Is improved.Impact on h^ th , wellness, and fitness- Health status is improved,- Pheysical capacity is increased,- Physical ftmction Is improved.Impact on societal resouices- Utilization of physical tt^rapy services is optimized.- Utilization of physical therapy services residts in efficient use of health care dollars.Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative man^emcnt of practice is acceptjd)le to patient/dient.- Clinical proficiency of physical dKntpi^ is acceptaUe to patient/dient.- Coordination of care is acceptable to patient/cUent

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent, femlly, and sig-

nificant others.- Sense of well-beii^ is improved.

Stressors are decreased.

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Procedural Interventions continuedEledrotherapeutic Modalities

Interventions

• Biofeedback• Electrical muscle stimulation

- electrical muscle stimulation(EMS)

- neuromuscular electrical stimula-tion (NMES)transcutaneous electrical nervestimulation (TENS)

d Exp«c|»dImpact on pathology/pathophysiology- Etfema, lymplHXteoo, or cBMsion is reduced.- Joint swcUtog, lolkmmatkKi) or restriction is reduced.- Nutrient delivay to tistiue is increased,- Osteo^nic elects are enhatK:ed.- P ^ te decreased.- Soft ti^ue swellta^, infktnnii^on, or re^riction is reduced,- Tissue perfusion and oxygemtion are enhaiKed.Impact on impairments- Motor ftmction (motor control and motor learning) is improved.- Musde performance (streni^, power, and endurance) is increasol.- Postural control Is improved,- Quality and quantity of movement between and across body s^ments are improved.- Range of motton is improved.- Sensory awareness is Lncreak:d.Impact on fiuictiiCMial limitations- AMity to peifiMii phy^al actions, tasks, or activities related to self-care, home man-

agement, community, wod( <job/ scho(H/ play), and letoure is improved,- Level of supervision required for task perfonnance is decreased.- Perfonnance of and independence in activities of dally living (ADL) and instrumental

iKtivities of daily living (lADL) with CH* without devices and equipment areincreased.

- Ibleiimce of positions aiid activities is increased.Impact on disaUUties- AbiUty to assume or resume required self-care, home management, wock

(job/school/play), community, and leisure roles is improved.Risk reduction/prevention- CompUcations ctf immobility are reduced.- Risk fiictors are reduced.- Risk of secondary impairment is reduced.- Self-managemoit of symptoms is improved.Impact on health, wellness, and fitness- I%ysical function is im{»<oved.Im{Kict on societal resouiice$- Utilization of physical therapy services is optimized,- Utilization of i^sical thirapy services results in rffident use of health care dollars.Patient/dient satMiction- Access, availabfllty, and services provided sax acceptaUe to patient/cUent.- Acbninlstrative mai^geiaoit e€ piactice is acceptable to paiient/cUent.- CUnical proficiency of physical therapl^ is acceptable to patient/dient.- Coordination of care is acceptable to patien /'cUent,- Interpersonal skills of phy^cal therapist are acceptaUe to patient/cUent, femily, and

^gniflcant others.- Sense of well-being is improiwed.- Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

InterventionsMechanical modaUties may include:• Compression therapies

compression bandagingcompression garments

- taping- total contact casting- vasopneumatic compression

devices• Gravity-assisted compression devices

standing frame- tilt table

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Edema, lymphedema, or effusion is reduced.- Joint swelUng, inflammation, or restriction is reduced,- Nutrient deUvery to tissue is increased.- Osteogenic effects are enhanced..

Pain is decreased.- Soft tissue sweUing, inflammation, or restriction is reduced.

Ussue perfusion and oxygenation are enhanced.• Impact on impairments:

- Integumentary integrity is improved.- Musde performance (strength, power, and endurance) is increased.- Range of motion is improved,- Weight-bearing status is improved.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), commtmity, and leisure is improved.Performance of and independence in activities of daily Uvir^ (ADL) and instrumen-tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

- AbiUty to assume or resume required self-care, home management, woik(job/school/play), commtmity, and leisure roles is improved.

• Risk reduction/prevention- CompUcations of soft tissue and cireulatory disorders are decreased.- Risk of secondary impairments is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitnessPhysical lunction is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.

Clinical profidency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Interjjersonal skills of physical therapist are acceptable to patient/cUent, femily, and

significant others.- Sense of weU-beir^ is improved.- Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the- iinticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/dient satisfection

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

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

Discontinuation is the process of ending physical therapy services that havt heen provided during a single episode of care when (1) thepatient/cUent, caregiver, or legal guardian declines to continue intervention: (2j the patient/dient is unable to continue to progress towardoutcomes because of medical or psychosocial complications or becau.se flnani iaL'insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminatedprior 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 tbll<:)w-up i.'- needed over the Ufe span to ensure safety and effective adap-tation following changes in physical status, caregivers. environment, «r task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

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Impaired Motor Function and SensoryIntegrity Associated With NonprogressiveDisorders of the Central Nervous System—Conaenital Origin or Acquired in Infancy orChildhood

This preferred practice pattern describes the generally ace epted elements of patient/client management that physical therapistsprovide for patients/clients •who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries w ithin which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide varietj' of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients will be classified into this pattern—for impaired motor function and sensory integrity associated with nonprogres-sive disorders of the central nervous system (congenital origin or acquired in infancy or childhood)—as a result of the physicaltherapist's evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures)may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limita-tions, or disabilities or the need for health, wellness, or fitness programs.Tlie physical therapist integrates, synthesizes, and inter-prets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may supportthe inclusion of patients/clients in this pattern;

Risk Factors or Consequences of Pothology/Pathophysiology(Diseose, Disorder, or Condition)

Anoxia or hypoxiaBirth traumaBrain anomaliesCerebral palsyEncephalitisCienetic syndromes affect-ing central nervous sys-tem (CNS)

HydrocephalusInfectious disease affectingCNSMeningoceleNeoplasmPrematurityTethered cordTraumatic brain injury

Impairments, Functional Limitotions, or Disabilities

Impaired expressive orreceptive communicationImpaired motor functionLoss of balance duringdaily activitiesInability to keep up withpeersInability to perform work(job/school/play) activities

Difficulty negotiating ter-rainsDifficulty planning move-mentsDifficulty with manipula-tion skillsDifficulty w ith positioningFrequent fallsImpaired affectImpaired arousal, attention,and cognition

Nofe:Some risk factors or consequences of pathology/pathophysiology—such as neoplasm—may be severe andcomplex; however, they do not necessarily excludepatients/clients from this pattern. Severe and complex riskfactors or consequences may require modification of the fre-quency of visits and duration of care. (See "Evaluation,Diagnosis, and Prognosis," page S345.)

Guide to Physical Therapist Practice

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern

• Amputation• Coma• Spinal cord injury

Findings That May Require Classification inAdditional Patterns• Congenital Heart Defect• Fracture

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

This listing is intended for general infonnation only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001),Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

036

052

055

056

072

090

225320

321

322

323

333

343345

348

Meningococcal infection

036.1 Meningococcal encephalitis

Chickenpox

052.0 Postvaricella encephalitis

Measles

055.0 Postmeasles encephalitis

Rubella

056.0 With neurological complications

Mumps

072.2 Mtimps encephalitis

Congenital syphilis

090.4 Juvenile neurosyphilis

Benign neoplasm of brain and other parts of nervous system

Bacterial meningitis

320.9 Meningitis due to unspecified bacterium

Meningitis due to other organisms

321.8 Meningitis due to other nonbacterialorganisms classified elsewhere*

Metungitis of unspecified cause

322.9 Meningitis, unspecified

Encephalitis, myelitis, and encephalomyelitis

323.4 Other encephalitis due to infection classifiedelsewhere*

323.5 Encephalitis following immunization procedures

323.6 Postinfectious encephalitis*

323.8 Other causes of encephalitis

323.9 Unspecified cause of encephalitis

Other extrapyramidal disease and abnormal movementdisorders

333.7 Symptomatic torsion dystoniaAthetoid cerebral palsy [Vogt's disease]; doubleathetosis (syndrome)

Infantile cerebral palsy

Epilepsy

345.1 Generalized convulsive epilepsy

345.2 Petit mal status

345.3 Grand mal status

345.9 Epilepsy, unspecified

Other conditions of brain

348.1 Anoxic brain damage

348.3 Encephalopathy, unspecified

741 Spina bifida

742 Other congenital anomalies of nervous system

742.3 Congenital hydrocephalus

756 Other congenital musculoskeletal anomalies

756.1 Anomalies of spine

758 Chromosomal anomaliesIncludes; syndromes associated with anomalies in thenumber and form of chromosomes

759 Other and unspecified congenital anomalies

765 Disorders relating to short gestation and unspecifiedlow birth weight

767 Birth trauma

767.0 Subdural and cerebral hemorrhage

767.9 Birth trauma, unspecified

768 Intrauterine hypoxia and birth asphyxia

768.5 Severe birth asphyxia

768.6 Mild or moderate birth asphyxia

768.9 Unspecified birth asphyxia in liveborn infant

771 Infections specific to the perinatal period

771.2 Other congenital infections

Congenital toxoplasmosis

780 General symptoms

780.3 Convulsions799 Other ill-defined and unknowfn causes of morbidity,

and mortality'

799.0 Asphyxia

800 Fracture of vault of skull

801 Fracture of base of skull

803 Other and unqualified skull fractures

804 Multiple fractures involving sktxO or foce with other bones

850 Concussion

851 Cerebral laceration and contusion

852 Subarachnoid, subdural, and extradural hemorrhage, follow-ing injury

853 Other and unspecified intracranial hemorrhage followinginjury

854 Intracranial injtiry of other and unspecified nature

984 Toxic effect of lead and its compounds (including fumes)

985 Toxic effect of other metals

994 Effects of other external causes

994.1 Drowning and nonfatal submersion

* Not a primary diagnosis

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

Examination has three components; the patient/client history, the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/ctient is seeking the services of the physi-cal therapist.The systems revieiv is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monary, integtimentary, musculoskeletal, and netiromuscular systems and (2) the communication abiUty, affect, cognition, language, andlearning style of the patient/client. Tests and measures arc tlie means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabilitation (earh', intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. Ior clinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated tjy testi and measures, refer to Chapter 2.

Patient/Client History

The history may include:General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beliefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), cotnmunity, andleisure actions, tasks, or activities

Growth and Development• Developmental histor>'• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological function (eg, memorj,

reasoning abiiity, depression, anxiety)• Role function (eg, cotnmunity, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Guide to Physical Therapist Practice

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• Familial health risks

Medical/Surgical History• Cardiovascular• Endcjcrine/metabolic• Gastrointestinal• Genitourinary'• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Piilmonasy

Current Condition(s)/Chief Complaintjs)• Concerns that led patient/client to seek

the ser\ices of a physical therapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing dale of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significant other,

and caregiver expectations and goalsfor the tlierapeutic intervention

• Patient/client, family, signiiicant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

')(', impairments

Functional Status and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily Uving(ADL) and instrumental activities ofdaily living (LADL)

• C urrent and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, sui^ical)• Review of other clinical findings (eg,

nutrition and hydration)

/ Nonprogressive CNS Disorders—Child 349/S341

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/PulmonaryBlood pressureEdemaHeart rateRespiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

MusculoskeletalGross range of motion

- Gross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, ond learning Style

• Ability to make needs know n• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

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

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily Uving [ADL] scales, indexes, instrumental activities of dailyliving [LADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance walk/run tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth meastirement,

length measurement)

Arousal, Attention, and Cognition• Arousal and attention (eg, adaptability tests, arousal and

awareness scales, indexes, profiles, questionnaires)• Cognition, including ability to process commands (eg, develop-

mental inventories, indexes, interviews, mental state scales,observations, questionnaires, safety checklists)

• Communication (eg, functional communication profiles, inter-views, inventories, observations, questionnaires)

• Motivation (eg, adaptive behavior scales)• Orientation to time, person, place, and situation (eg, attention

tests, learning profiles, mental state scales)• Recall, including memory and retention (eg, assessment scales,

interview's, questionnaires)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, LADL scales,interviews, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and eqtiipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional limitations, or disabili-ties wfith use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,ftmctional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

Circulation (Arterial, Venous, and Lymphatic)• Cardiovascular signs, including heart rate, rhythm, and

sounds; pressures and flow; and superficial vascularresponses (eg, auscultation, claudication scales, electro-cardiography, girth measurement, observations, palpation,sphygmomanometry, thermography)

• Cardiovascular symptoms (eg, angina, claudication, dyspnea,and perceived exertion scales)

• Physiological responses to position change, including autonom-ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg,auscultation, electrocardiography, observations, palpation,sphygmomanometry)

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Tests and Measures continued

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Response to stimuli, incltiding auditory, gustatory, olfactory, pha-

r>'ngeal, vestibular, and visual (eg, observations, provocationtests)

• Sensory distribution of the cranial nerves (eg, discriminationtests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and light touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checkUsts, interviews, obser-

vations, questionnaires)• Physical space and environment (eg, compliance standards,

observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ei onom ics• Dexterity' and coordination during ^vork (job/school/play)

(eg, hand function tests, impairment rating scales, manipula-tive ability tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-Usts, job severity indexes, Ufting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checkUsts,job simulations, lifting models, preemployment screenings, taskanalysis checkUsts, workstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysischecklists, vibration assessments)

Body mechanics• Body mechanics during seUk:are, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-g)'-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fiill scales, motor impairment tests,observations, photographic assessments, postural control tests)

• (iait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ivt, or prosthetic devices or equipment (eg,ADL scales, gaitj:irofiles, IADL scales, mobility skill profiles, observations, video-graphic assessments)

• < iait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices or(quipment (eg, dynamometry, electroneuromyography, foot-prmt analyses, gait profiles, mobility skiU profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobility tests)

• Safety during gait, locomotion, and balance (eg, confidencesciiles, diaries, faU scales, functional assessment profiles, logs,leport.s)

Integumentary Integrity

Associated skin• Activities, positioning, and postures that produce or reUeve

trauma to the skin (eg, observations, pressure-sensing maps,sciles)

• Assistive, adaptive, orthotic, protective, supportive, or pros-ihetic devices and equipment that may produce or reUeveiniuma to the skin (eg, observations, pressure-sensing maps,risk assessment scales)

• Vkin characteristics, including blistering, continuity of skincolor, dermatitis, hair growth, mobility, nail growth, temper-ature, texture, and turgor (eg, observations, palpation, pho-tographic assessments, thermography)

Joint Integrity and Mobility• Specific body parts (eg, apprehension, compression and distrac-

1 i( in, drawer, glide, impingement, shear, and valgus/varus stressrests; arthrometry)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agiUty (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Electrophysiological integrity (eg, electroneuromyography)• Hand ftmction (eg, fine and gross motor control tests, finger

dexterity tests, maniptilative ability tests, observations)• initiation, modification, and control of movement patterns and

voluntary postures (eg, activity indexes, developmental scales,gross motor fimction profiles, motor scales, movement assess-ment batteries, neuromotor tests, observations, physical perfor-mance tests, postural chaUenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)• Muscle strength, power, and endurance (eg, dynamometry, man-

ual muscle tests, muscle performance tests, technology-assistedanal) ses, physical capacity tests, technology-assisted analyses,timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg, ADL scales, functional muscle tests, IADL scales, obser-vations, videographic assessments)

• Muscle tension (eg, palpation)

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Tests and Measures continued

Neuromotor Development and Sensory Integration

• Acquisition and evolution of motor skiUs, including age-appro-priate development (eg, activity indexes, developmentalinventories and questionnaires, itifant and toddler motorassessments, learning profiles, motor function tests, motorproficiency assessments, neuromotor assessments, reflextests, screens, videographic assessments)

• Oral motor function, phonation, and speech production (eg,interviews, observations)

• Sensorimotor integration, including posttiral, equilibritim, andrighting reactions (eg, behavioral assessment scales, motor andprocessing skill tests, postural challenge tests, observations,reflex tests, sensory profiles, temperament questionnaires, visu-al perceptual skill tests)

Orthotic, Protective, and Supportive Devices• Components, aUgnment, fit, and abiUty to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentuse during ftmctional activities (eg,ADL scales, fimctionalscales, IADL scales, interviews, observations, profiles)

• Remediation of impairments, fimctional limitations, or disabili-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety dtiring use of orthotic, protective, and supportivedevices and equipment (eg, diaries, faU scales, interview's, logs,observations, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimina-

tion tests, pain drawings and maps, provocation tests, verbaland pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, incUnome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibiUty (eg, con-tracture tests, goniometry, inclinometry, Ugamentous tests, Unearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)• Electrophysiological integrity (eg, electroneuromyography)• Postural reflexes and reactions, including righting, equilibrium,

and protective reactions (eg, observations, postural challengetests, reflex profiles)

• Primitive reflexes and reactions, including developmental (eg,reflex profiles)

• Resistance to passive stretch (eg, tone scales)• Superficial reflexes and reactions (eg, observations, provocation

tests)

Self-Care and Home Management (Including ADL ond IADL)• AbiUty to gain access to home environments (eg, barrier identi-

fication, observations, physical performance tests)• AbiUty to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and envi-ronments (eg, diaries, faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg,electroneuromyography)

Ventilation and Respiration/Gas Exchange• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)• Pulmonary signs of ventilatory function, including airway pro-

tection; breath and voice sounds; respiratory rate, rhythm, andpattern; ventilatory flow, forces, and volumes (eg, airway clear-ance tests, observations, palpation, pulmonary function tests,ventilatory mtiscle force tests)

• Pulmonary symptoms (eg, dyspnea and perceived exertionindexes and scales)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• AbiUty to assume or resume work (job/school/play), communi-

ty, and leistire activities w ith or w ithout assistive, adaptive,orthotic, protective, supportive, or prosthetic devices andequipment (eg, activity profiles, disabiUty indexes, functionalstatus questionnaires, L\DL scales, observations, physical capaci-ty tests)

• AbiUty to gain access to work (job/school/play), community,and leisure environments (eg, barrier identification, interviews,observations, physical capacity tests, transportation assess-ments)

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, faU scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make cUnical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to estabUsh the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of func-tion, chronicity or severity of the problem, possibiUty of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and oveniU health stattis

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data fnim the examination.'I'he diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The pn>gnosis is the determination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level ;md may also include a prediction of levels of improvement that may bereached at various intervals during the course of therapy. During the prognostit process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies realistic anticipated goats and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others.llicse anticipated goals and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expenisc chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

Factors That May Require NewEpisode of Care or That May Modify

Prognosis Per Episode of Care Frequency of Visits/Duration of Care

Patient/cUent wiU demonstrate optimalmotor function and sensory integrity andthe highest level of functioning in home,work (job/school/play), community, andleisure environments, within the contextof the impairments, ftmctional limita-tions, and disabilities.

During the episode of care, patient/clientwill achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/cUents who are classified in this pattern.

Expected Range of Number of VisitsPer Episode of Care

6to90

This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected oiitt omes. It isanticipated that 80% of patients/clientsivho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 90 i'i.<iits duringa single continuous episodi' of cure.Frequency ol' visits and duration of theepisode of care should be dttermined bythe physical therapist to maximi/e effec-tiveness of care and efficiency of servicedelivery.

Note:

These patients/clients may require multi-ple episodes of care over the lifetime toensure safety and effective adaptation fol-lowing changes in physical status, care-givers, environment, or task demands.Factors that may lead to these additionalepisodes ot care include:

Accessibility and availability ofresourcesAdherence to the intervention programAgeAnatomical and physiological changesrelated to growth and developmentCaregiver consistency or expertiseChronicity or severity of the currentconditionC Cognitive statusComorbitities, compUcations, orsecondary impairmentsCxmcurrent medical, surgical, andtherapeutic interventionsDecline in functional independenceLevel of impairmentLevel of physical functionUving environmentMultisite or mtiltisystem involvementNutritional statusOveraU health statusPotential discharge destinationsPremorbid conditionsProbability' of prolonged impairment,functional Umitation, or disabilityPsychological and socioeconomicfactorsPsychomotor abilitiesSocial supportStability of the condition

Cognitive maturationPeriods of rapid growth

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

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include;

Interventions• Addressing required functions

- advance directivesindividuaUzed family service plans (IFSPs) or individuaUzededucation plans (IEPs)informed consent

- mandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination w ith agencies, including;

equipment suppUershome care agenciespayer groupsschools

- transportation agencies• Communication across settings, including;

- case conferencesdocumentationeducation plans

• Cost-effective resource utiUzation• Data coUection, analysis, and reporting

- outcome data- peer review findings

record reviews• Documentation across settings, foUow ing APTA's Guidelines

for Physical Therapy Documentation (Appendix 5), including;changes in impairments, functional limitations, anddisabilities

- changes in interventionselements of patient/cUent management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamwork- case conferences

patient care roundspatient/cUent family meetings

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes• AccountabiUty tot services is increased.• Admission data and discharge planning are completed.• Advance directives, indi'vidiiallzed family service plans (IFSPs)

or individuaUzed education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximally utiUzed.• Care is coordinated with patient/client, family, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Commtmication occurs across settings through case confer-

ences, education plans, and documentation.• Data are collected, analyzed, and reported, indudii^ outcome

data, peer review findings, and record reviews.• Decision making Is enhanced regarding health, wellness, and

fitness needs.• Decision making is enhanced regarding patient/cUent health

and the use of health care resotirces by patient/cUent, fianiily,significant others, and caregivers.

• Documentation occurs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/cUent family meetings.

• Patient/cUent, femily, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources ^

ever necessary and appropriate.• Resources are utiUzed in a cost-effective way.

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Patient/ClienhRelated Instruction

Patient/cUent-related instruction may include;

Interventions

• Instruction, education and training of patients/cUents and care-givers regarding:

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

- enhancement of performancehealth, weUness, and fitness programsplan of carerisk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilities

- transitions across settingstransitions to new roles

Aniicipaled Goak and Expeded Oulcomes• Ability to perfonn physical actions, tasks, or activities is

improved.• Awareness and use of conimunity resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are acquired,• Decision making is enhanced regarding patient/client health

and the use of health care resources by patient/cUent, family,significant others, and caregivers.

• DisabiUty associated with acute or chronic illnesses isreduced.

• Functional independence in acdvities of daily Uving (ADL)and instrumental activities of daily Uviii (IADL) is increased,

• Health status is improved.• Intensity of care is decreased.• Lirvel of supervision required for task performance is

decreased.• Patient/cUent, family, significant other, and caregiver knowl-

edge and awareness of the di^nosis, prognosis, interventions,and iknticipated goals and expected outcomes are increased.

• Patient/cUent knowlec^ of personal and environmental fac-tors associated with the condition is increased.

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

• Physical function is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/cUent, fiamily, significant others, and care-

givers is improved.• Self-man^ement of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may

Therapeutic Exercise

Interventions• Aerobic and endurance conditioning or

reconditioning- aquatic programs- gait and locomotor training

increased workload over timewalking and wheelchair propulsionprograms

• Balance, coordination, and agiUty training- motor function (motor control and

motor learning) training or retrainingneuromuscular education or reeduca-tionperceptual trainingposture awareness trainingstandardized, programmatic, comple-mentary exercise approaches

- sensory training or retrainingtask-specific performance training

- vestibular training• Body mechanics and postural stabilization

body mechanics trainingposture awareness trainingpostural control trainingpostural stabilization activities

• FlexibiUty exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion trainingdevelopmental activities traininggait trainingimplement and device trainingperceptual training

- standardized, programmatic, comple-mentary exercise approaches

- wheelchair training• Neuromotor development

developmental activities trainingmotor trainingmovement pattern trainingneuromuscular education orreeducation

• Relaxationbreathing strategiesmovement strategies

- relaxation techniquesstandardized, programmatic, comple-mentary exercise approaches

• Strength, power, and endurance trainingfor head, neck, Umb, pelvic-floor, trunk,and ventilatory muscles

active assistive, active, and resistiveexercises (including concentric,dynamic/isotonic, eccentric, isokinetic,isometric, and plyometric)aquatic programsstandardized, programmatic, comple-mentary exercise approachestask-specific performance training

S348/356 Guide to Physical Therapist Practice

include:

Anticipated Goab and Expected Outcomes• Impact on patholc^y/pathophysiology (disease, disorder, or condition)

- Joint swelUng, inflammation, or restriction is reduced.Nutrient deUvery to tissue is increased.Osteogenic effects of exereise are maximized.

- Pain is decreased.Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are etihanced.

• Impact on impairments;- Aerobic capacity is increased.

Balance is improved.Endurance is increased.Enei^ expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.- Joint integrity and mobiUty are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.Quality and quantity of movement between and across body segments are improved.Range of motion is improved.

- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), commtmity, and leisure is improved.Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily Uving (ADL) and instrumentalactivities of daily Uving (LADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionRisk factors are reduced.Risk of secondary impairments is reduced.Safety is improved.Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.

Physical capacity is increased.Physical function is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.- Utilization of physical therapy services restilts in efficient tise of health care dollars.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/cUent.

Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.

Intensity of care is decreased.- Interpersonal sldlls of physical therapist are acceptable to patient/cUent, family, and

s^nificant others.Sense of well-being is improved.

- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• ADL training

- bathingbed mobiUty and transfer trainingdevelopmental activitiesdressingeatinggroominggait and locomotion trainingtoileting

• Devices and equipment use and trainingassistive and adaptive device or ec(uipment train-ing during ADL and IADLorthotic, protective, or supportive device or equip-ment training during ADL and IADL

• Fvmctional training programssimulated environments and tasks

- task adaptation- travel training

• LVDL training- caring for dependents

home maintenancehousehold choresshopping

- structured play for infants and children- yard work

• Injury prevention or reduction- injury prevention education during self-care and

home managementinjury' prevention or reduction with use of devicesand equipmentsafety awareness training during self-care andhome management

Antic iotod Gotii tmi Ei^ected Outconnes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- P^n ^ decreased.- Phfsiokiglica! response to increased oxygen demand is improved.

• Impact (HI impairments- Btdance is improved.- Endimuice is increased.- Enat^ cacpctKUture per unit of work is decreased.• Motor lunctiCMi (motor control and motor leanut^) is improved,- MiKck pe^rmance (strength, power, and endurance) is increased.- Postural ctatttiol is improved.- ScMocy anNueoess is increased.- Weight< beiiring: status is improved.- Woik rf bieathing is decreased.

• Impact cm functional limitations- AbUity to |ierform physical actions, tasks, or activities related to self-

care iind home n»iiagement is improved,- Level of supervision reqviired for ta^ performance is decreased.- Peifomtance of and independence in ADL and IADL with or with-

out devices ^)d equipment arc incre^ed.- Tolerance of positions and activities is Increased,

• Impact on di$idbiUties- Ability to Msume or resume roles in self-care and home manage-

ment is iniprowd.• Rtek reduction/prevention

- Risk factors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Health status is improved.- Hiysical capacity is increased.- Hiysical function is improved,

• Impact on societal resourees- Utilization of physical therapy services is optimized,- UtiUzation of physical therapy services results in efficient use of

health care dollars.• Patient/dient satisfection

- Access, availabiUty, and services provided are acceptable topatient/dient

management of practice is acceptable to

CUoical pinoflciency erf physical therapist is acceptable to

CooKttnatlon of care is acceptable to patient/cUent.Cost of iK^alth care services is decreased.In^nstey erf care is decreased.Inn»|)ersOBal skflls of physical therapist are acceptable topatient/dient, &ailiy, and significant others.Sense of "vkecttbeing Is improved.Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Devices and equipment use and

training- assistive and adaptive device or

equipment training during IADL- orthotic, protective, or supportive

device or equipment training dur-ing IADLprosthetic device or equipmenttraining during IADL

• Functional training programsjob coachingsimulated environments and tasks

- task adaptationtask training

- travel training• LADL training

community service training involv-ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

- injury prevention education dur-ing work (job/school/play), com-munity, and leisure integration orreintegrationinjury prevention or reductionwith use of devices and equip-mentsafety aw areness training duringwork (job/school/play), communi-ty, and leisure integration or reinte-gration

• Leisure and play activities training

Anticipated Goals and Expected Outcomes

• Impact on pathology/piathophysiology (disease, disorder, or condition)- Pain is decreased.

Physiological response to increased oxygen demand is improved.• Impact on impairments

- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.

Postural control is improved.Sensory awareness is increased.

- We^ht-bearing status is improved.- Work of breathing is decreased.

• Impact on functional Utnitations- Ability to perform physical actions, tasks, or activities rdated to work

(job/school/play), community, and leisure inte^:ation or reintegration is improved.Level of supervision reqtiired for task performance is decreased.I^rformance of and independence in IADL with or without devices and equipmentare increased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

- AbiUty to assume or resume required work (job/school/play), community, and leisureroles is improved.

• Risk reduction/prevention- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

Impact on health, wellness, and fitness- Fitness is improved.

Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of wotk-related injury or disabiUty are reduced.- UtiUzation of physical therapy services is optimized,- UtiUzation of physical therapy services results in efficient use of health care doUars.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical profidency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patienVcUent, femily, and

s^nificant others.Sense of weU-being is improved.

- Stressors are decreased.

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Procedural Interventions continuedManual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Manual traction• Massage

connective tissue massagetherapeutic massage

• MobiUzation/manipulationsoft tissue

• Passive range of motion

Anticipated Goab and {xpedMi Outcomes• Impact on pathotogy/pathoph)^ol<^y (disease, disorder, or concUtion)

- Edema, lymphecteima, or eft^ion is reduced.- Joint sweUng, biJtanunation, or restriction is reduced.- Fain is decreased.- Soft tissue swidUng, infbunmation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Enei^ expenditure per unit erf work is decreased.- Gidt, locomotitm, and balance are improved.- Integumentary inte|0ty is improved,- Joint integrity and mobiUtjr are improved.- Musde performance (strei^th, powei; and endurance) is increased,- Postucal control is improved.- Quality and quantity of movement between and across body segments are

improved.- Rai^e of ttnotion is improved,- Relaxation is increased.- Sensory awareness is increased.- We^t-beauing status is in^sroved.- Work of breaching is decreased.

• Impact on functional Imitations- Ability to perform movement tasks is improved.- AMity to perfonn physiad actions, tasks, or activities related to self-care,

home manaj^ment, woik (jdb/school/fday), community, and leisure isimproved.

- Tolerance of positions and activities is increased.• Impact cMi disaMities

- AMity to assume or resume required self-care, home n:raiiagement, wottk(fob/school/pky)i cc»nmunity, and teisure roles is improved.

• Risk reduction/prevention- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Self-majnuigement of s;%ptEHns is improved.

• Impact on health, wellness, and fitness- Phy^cal capacity is iacreased.- Phy^cal function is improved.

• Impact on sodetal resources- UtiMztttion of phyi^cal therapy services is optimized.- Utilization of phyisicM theiapy services results in efficient use of health

carectotlars.• Patient'dtent satisfection

- Access, avi^at^lity, and services provided sax: acceptable to patient/cUent.- Adndnistradve management of practice is acceptable to patient/cHent.- CUnical profidency <rf phj)i cal tiierafrist is acceptable to patient/dient.- Coordination of caic te jKxeptaWe to patient/dient.- Cost of healA care services is decreased.- bitensity erf aae ik decreaaed.- bueipersonal sidlls of pli;r: cal therapist are acceptable to patient/cUent,

femily, iuid si nUScffOtt othens.- Sense of weHbelrtg is inqiroved.- Stressors are decrbased.

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Procedural Interventions continued

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

Interventions

• Adaptive devicesenvironmental controlshospital bedsraised toilet seatsseating systems

• Assistive devicescanescrutcheslong-handled reacherspower devices

- static and dynamic sphnts- walkers- wheelchairs

• Orthotic devicesbracescastsshoe insertssplints

• Protective devicesbracescushionshelmetsprotective taping

• Supportive devices- compression garments- corsets

elastic wrapsneck collarsserial castsslingssupplemental oxygensupportive taping

Aniicipcrted Goals and Expeded Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)Edema, tymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.- Pain is decreased.

Physiological response to increased oxygen demand is improved.Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Endurance is increased.- Enei^ expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint stability is improved.

Motor fimction (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Optimal joint alignment is achieved.- Optimal loading on a body part is achieved.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Weight-beadng status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, wotk (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.Perfonnance of and independence in activities of daily livii^ (ADL) and instrumen-tal activities of daily livii^ (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is improved.• Impact on disabilities

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

• Risk reduction/prevention- Pressure on body tissues is reduced.- Protection of body parts is increased.

Risk factors are reduced.Risk of secondary impairment is reduced.Safety is improved.

- Self-management of symptoms is improved.• Impact on health, wellness, and fitness

- Health stattis is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourcesUtilization of physical therapy services is optimized.Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfaction- Access, availability, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to patient/client.- Clinical proficiency of physical therapist is acceptable to patient/cUent.

Coordination of care is acceptable to patient/client.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

s^nificant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

Airway Clearance Techniques

Interventions• Breathing strategies

active cycle of breathing or forcedexpiratory' techniques

- assisted cough/huff techniquesautogenic drainagepaced breathingpursed lip breathingtechniques to maximize ventilation(eg, maximum inspiratory hold, stair-case breathing, manual hyperinfla-tion)

• Positioningpositioning to alter work ofbreathing

- positioning to maximize ventilationand perfusionpulmonary postural drainage

AnAkipotad Goals and Expscted Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)Nutrient delivery to tissue is increased.

- Physiological response to increased oxygen demand is improved.- Symptoms associated with increased oxygen dtanmd are decreased.- Ussue perfusion and oxygenation are enh^iced.

• Impact on impaixments- Airway clearance is improved.- C o i ^ is improved.- finduran^e is increased.- Energy expenditure per unit of work is decreased.- Muscte perfonnance (strength, power, and endtnance) is increased.- Ventilation and respiration/gas exchange ate improved.- AJSbtk of breathing is decreased.

• Impact on ftmctional limitations- Abiity to perform physical actions, tasks, or activities related to setf-care, home man-

agement, community, work (job/ school/ play), and leisure is improved.- Performance of and independence in activities of daily living (ADL) and instrumental

activittes of daily living (LVDL) with or without devices and equipment are increased.- Tolerance of portions and activities is increased.

• ImfKict on disabilities- Ability to assume or resume required sdf-care, home man^ement, wotk

(|ob/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Ri^ Actors are reduced.- Ri^ of secondary impainnent is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Health status is improved.- Physical capacity is increased.- Wiysical function is improved.

• Impact on societal resources- Utilization erf physical therapy services is optimized.- Utilization of phyisical therapy services results in efficient use of health care doUars.

• Patient/ctent satisfaction- Access, availaWlity, and services provided are acceptable to patient/client.- Administrative management of practice is acceptaUe to patient/client.- Clinical jMoflciency of physical therapist is acceptable to patient/client.- Coordination of cate is acceptat^e to patient/dient.- Cost of health care services is decreased.- IntenMty of care is decreaised.- Intetpersonal ^dtts of physical therapist are acceptable to padent/cltent, family, aM

s^iiflcant others.- Sense of wdl-being is improved.- Stressors are ckcreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrical stimulation

- functional electrical stimulation (FES)- neuromuscular electrical stimulation (NMES)- transcutaneous electrical nerve stimulation

(TENS)

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disea^, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.

Nutrient delivery to tissue is increased.Osteogenic effects are enhanced..Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.- Quality and quantity of movement between and across bocty seg-

ments are improved.Range of motion is improved.Sensory awareness is increased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-

care, home management, community, woik (job/ school/ play), andleisure is improved.

- Level of supiendsion required for task performance is decreased.- Performance of and independence in activities of daily living (ADL)

and instrumental activities of daily living (IADL) with or withoutdevices and eqxiipment are increased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of immobility are reduced.

Risk factors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, weltness, and fitness- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of

health care dollars.• Patient/client satisfection

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

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

Interpersonal skills of physical therapist are acceptable topatient/client, family, and significant others.

- Sense ofwell-being is improved.Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Mechanical modalities may include:• Compression therapies

compression bandagingcompression garments

- tapingtotal contact castingvasopneumatic compressiondevices

• Gravity-assisted compression devicesstanding frame

- tilt table

Anticipate Goals and Expected Oirtcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects are enhanced..- Pain is decreased.- Soft tissue swellir^, inftamination, or restriction is reduced.- Tissue perfusion and oxygienation are enhanced.

• Impact on impairments:- Integumentary integrity is improved.- Muscle performance (strength, power, and eiKlunince) is increased.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, woik (job/school/play), community, ld leisure is in^roved.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment satincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Complications of soft tissue and circulatory disorders are decreased.- Risk of secondary impairments is reduced.- SelPman^ement of symptoms is inqjroved.

• Impact on health, wellness, arid fitnessPhysical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optlimiz«l.

• Patient/client satisfection- Access, availaWlity, and services provUb^d are accep^Ue to patient/dient.- Administrative mans^ement of practice is accepmbife to patient/dient.- Clinical proficiency of physical tterafrfst is acceptabk to piUient/cUent.- Coordination of care is acceptable to i»tient/cUeitt.- Interpersonal ^dlls of physical therapist aie accQ>table to pattent/dient, tanily, and

significant others.Sense of well-being is improved.

- Stressors are decreased.

Guide to Physical Therapist Practice ';C Impoirments / Nonprogressive CNS Disorders-Child 363/S355

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in eachpreferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care,the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of thephysical therapy interventions in the following domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/client satisfaction

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

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

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care vi'hen (1) thepatient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminatedprior 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 foUow-up is needed over the life span to ensure safety and effective adap-tation foUow ing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate fbUow-up or referral.

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Impaired Motor Function and SensoryIntegrity Associated With NonprogressiveDisorders of the Central Nervous System—Acquired in Adolescence or Adulthood

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns art' the boundaries n ithin which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety ol factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age, ciiliiire, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients wiU be classified into this pattern—for impaired motor function and sensory integrity associated with nonprogres-sive disorders of the central nervous system (acquired in adolescence or adulthood)—as a result of the physical therapist's evalua-tion of the examination data.The finding.s from the examination (history, systems review, and tests and measures) may indicate thepresence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilitiesor the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to deter-mine the diagnostic classification.

Inclusion

The foUowing examples of examination findings may support theinclusion of patients/clients in this pattern:

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

• Aneurysm• Anoxia or hypoxia• Bell palsy• Cerebrovascvilar accident• Infectious disease that

Intracranial neurosurgicalproceduresNeoplasmSeizuresTraumatic brain injury-

affects the central nervoussystem

Impairments, Functional Limitations, or Disabilities

Difficulty negotiating ter-rainsDifficulty planning move-mentsDifficulty w ith manipula-tion skillsDifficulty with positioningFrequent fallsImpaired affectImpaired arousal, attention,and cognition

Impaired expressive orreceptive communicationImpaired motor functionLoss of balance during dailyactivitiesInability to keep up withpeersInability' to perform work(job/school/play) activities

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity ofthe examination findings, the physical therapistmay determine that the patient/client would be moreappropriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Classification in aDifferent Pattern

• Amputation• (

Findings That May Require Classification inAdditional Patterns

• Fraetiire• Multisystem trauma

Note:Some risk factors or consequences of pathology/pathophysiology—such as traumatic brain injury—may besevere and complex; however, they do not necessarily exctudepatients/clients from this pattern. Severe and complex risk fac-tors or consequences may require modification of the frequen-cy of visits and duration of care. (See "Evaluation, Diagnosis, andPrognosis,' page S363 )

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

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICT)-9-CM 2001).Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

049

225320

321

322

323

331

342

345

348

351

Other non-arthropod-borne viral diseases of central nervoussystem

049.9 Unspecified non-arthropod-bome viral diseasesof central nervous system

Viral encephalitis, not otherwise specified

Benign neoplasm of brain and other parts of nervous system

Bacterial meningitis

320.9 Meningitis due to unspecified bacterium

Meningitis due to other organisms

321.8 Meningitis due to other nonbacterialorganisms classified else^vhere*

Meningitis of unspecified cause

322.9 Meningitis, unspecified

Encephalitis, myelitis, and encephalomyelitis

323.4 Other encephalitis due to infection classifiedelsewhere*

323.5 Encephalitis following immumzation procedures

323.6 Postinfectious encephalitis*

323.8 Other causes of encephalitis

323.9 Unspecified cause of encephalitis

Other cerebral degenerations

331.3 Communicating hydrocephalus

331.4 Obstructive hydrocephalus

Hemiplegia and hemiparesis

Epilepsy

345.1 Generalized convulsive epilepsy

345.2 Petit mal status

345.3 Grand mal status

345.4 Partial epilepsy, with impairment of consciousness

Epilepsy:partial:

secondarily generalized

345.5 Partial epilepsy, without mention of impairment ofconsciousness

Epilepsy:sensory-induced

345.9 Epilepsy, unspecified

Other conditions of brain

348.0 Cerebral cysts

348.1 Anoxic brain damage

348.3 Encephalopathy, unspecified

Facial nerve disorders

351.0 BeUs palsy

386 Vertiginous syndromes and other disorders of vestibular system

386.5 Labyrinthine dysfunction

431 Intracerebral hemorrhage

433 Occlusion and stenosis of precerebral arteries

434 Occlusion of cerebral arteries

435 Transient cerebral ischemia

435.1 Vertebral artery syndrome

435.8 Other specified transient cerebral ischemias

436 Acute, but ill-defined, cerebrovascular disease

437 Other and ill-defined cerebrovascular disease

442 Other aneurysm

442.8 Of other specified artery

444 Arterial embolism and thrombosis

444.9 Of unspecified artery

447 Other disorders of arteries and arterioles

447.1 Stricture of artery

780 General symptoms

780.3 Convulsions

781 Symptoms involving nervous and musculoskeletal systems

781.2 Abnormality of gaitGait:

ataxic781.3 Lack of coordination

Ataxia, not otherwise specified

799 Other ill-defined and unknown causes of morbidity andmortality

799.0 Asphyxia

800 Fracture of vault of skuU

801 Fracture of base of skull

803 Other and unqualified skull fractures

804 Multiple fractures involving skull or face with other bones

850 Concussion

851 Cerebral laceration and contusion

852 Subarachnoid, subdural, and extradural hemorrhage, follow-ing injury

853 Other and unspecified intracranial hemorrhage following injury

854 Intracranial injury of other and unspecified nature

994 Effects of other external causes

994.1 Drowning and nonfatal submersion

* Not a primary diagnosis

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ExaminationExamination is a comprehensive screening and specific testmg process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Examination is required prior to the imtial intervention and is performed for all patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overallhealth status, and needs related to restoration of health and to prevention, wellness, and fitness.The physical therapist synthesizes theexamination findings to estabUsh the diagnosis and the prognosis (including the plan of care). The patient/cUent, family, significant others,and caregivers may provide information durmg the examination process.

Examination has three components: the patient/cUent history', the systems review, and tests and measures. The history is a systematic gath-ering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physi-cal therapist.The systetns review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pul-monar f, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, andlearning style of tbe patient/client. Tests and measures are the means of gathering data alx)ut the patient/cUent.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The histor>' may include:

General Demographics• Age• Sex• Race/etlmicity• Primary language• Education

Social History• Culttiral beUefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), communitj', andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobiUty, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning abiUty, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg, smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal liealth risks

Medical/Surgical History• Cardiovascular• Endocrine/metabolic• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitaUzations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonar\'

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of patient/cUent

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or disease, includ-

ing date of onset and cours<.' of events• Onset and pattern of symptoms• Patient/client,family,significant other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, signiiicant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous occurrence of chltf com-plaint(s)

• Prior therapeutic interventions

Functional Status and Activity Level• Current and prior ftmctional status in

self-care and home management activi-ties, including activities of daily living(ADL) and instrumental activities ofdaily living (LADL)

• Current and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findmgs (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatomical and Physiological Status

• Cardiovascular/Pulmonary *- Blood pressure

EdemaHeart rateRespiratory rate

IntegumentaryPresence of scarformation

- Skin color- Skin integrity

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

NeuromuscularGross coordinatedmovements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Test and measures for this pattern may include those that characterize

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily Uving [ADL] scales, indexes, instrumental activities of dailyUving [LADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance walk/run tests, tread-mill tests, wheelchair tests)

Anthropometric Characteristics• Body composition (eg, body mass index, impedance

measurement, skinfold thickness measurement)• Body dimensions (eg, body mass index, girth measurement,

length measurement)• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Arousal, Attention, and Cognition• Arousal and attention (eg, adaptability tests, arousal and

aw areness scales, indexes, profiles, questionnaires)• Cognition, including abiUty to process commands (eg, develop-

mental inventories, indexes, interviews, mental state scales,observations, questionnaires, safety checkUsts)

• Communication (eg, functional communication profiles, inter-views, inventories, observations, questionnaires)

• Motivation (eg, adaptive behavior scales)• Orientation to time, person, place, and situation (eg, attention

tests, learning profiles, mental state scales)• Recall, including memory and retention (eg, assessment scales,

interview's, questionnaires)Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, IADL scales,interviews, observations)

• Components, aUgnment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

S360/368 Guide to Physical Therapist Practice

or quantify:

• Remediation of impairments, functional limitations, or disabili-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

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

Circulation (Arterial, Venous, and Lymphatic)• Cardiovascular signs, including heart rate, rhythm, and sounds;

pressures and flow; and superficial vascular responses (eg, auscul-tation, claudication scales, electrocardiography, girth measure-ment, observations, palpation, sphygmomanometry, thermography)

• Cardiovascular symptoms (eg, angina, claudication, dyspnea,and perceived exertion scales)

• Physiological responses to position change, including autonom-ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg,auscultation, electrocardiography, observations, palpation,sphygmomanometry)

Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

muscle tests, observations, thoracic outlet tests)• Response to neural provocation (eg, tension tests, vertebral

artery compression tests)• Response to stimuU, including auditory, gustatory, olfactory, pha-

ryngeal, vestibular, and visual (eg, observations, provocation tests)• Sensory distribution of the cranial nerves (eg, discrimination

tests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

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Tests and Measures cantinued

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checklists, interviews, obser-

vations, questionnaires)• Physical space and environment (eg, compliance standards,

observations, photographic assessments, questionnaires, struc-tural specifications, videographic assessments)

Ergonomics and Body MechanicsErgonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairment rating scales, manipulative abil-ity tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dj'namometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observ ations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-Usts. job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, workstation checklists)

• Tools, devices, equipment, and w^orkstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Body mechanics• Body mechanics during self-care, home management, work,

community, or leisure actions, tasks, or activities (eg, ADL scales,lAl L scales, observations, photographic assessments, technolo-gy-;issisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or -without the use of

assistive. adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturogi-aphy, fall scales, motor impainnent testsobservations, photographic assessments, postural control tests)

• Gait ami locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg, ADL scales, gaitprofiles, IADL scales, mobilit>' skill profiles, obset^ations. video-grapbic assessments)

• Gait and kx:omotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometr>\ electroneuromyography, foot-print analyses, gait profiles, mobiUty skill profiles, observations,photographic assessments, technology-assisted assessments,videogniphic assessments, w^eight-bearing scales, wheelchairmobilit)' tests)

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

Integumentary Integrity

Associated skin• Activities, positioning, and postures that produce or reUeve trau-

ma to the skin (eg, observations, pressure-sensing maps, scales)• Assistive, adaptive, orthotic, protective, supportive, or pros-

thetic devices and equipment that may produce or reUevetrauma to the skin (eg, observations, pressure-sensing maps,risk assessment scales)

• Skin characteristics, including blistering, continuity of skincolor, dermatitis, hair giowth, mobility, nail growth, temper-atui'e, texture, and turgor (eg, observations, palpation, pho-tograpbic assessments, thermography)

Joint Integrity and Mobility• SjKCific body parts (eg, apprehension, compression and distrac-

tion, drawer, glide, impingement, shear, and valgus/varus stresstests; arthrometry)

Motor Function (Motor Control and Motor Learning)• Dexterity, coordination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,vids'ographic assessments)

• Elet:trciphysiol()gical integrity (eg, electroneuromyography)• H.ind (unction (eg, fine and gross motor control tests, finger

dt-xterity tests, manipulative ability tests, observations)• Initiation, modification, and control of movement patterns and

voluntary postures (eg, activity indexes, developmental scales,gi OSS motor function profiles, motor scales, movement assess-ment batteries, neuromotor tests, obseir^ations, physical perfor-mance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Elet trophysiological integrity (eg, electroneuromyography)• Mu.Ncle strength, power, and endurance (eg, dynamometry, man-

ual musck; tests, muscle performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Musck strength, power, and endurance during functional activi-ti(-s (eg,ADL scales, functional muscle tests, IADL scales, obser-v;ition,s, videographic assessments)

• Muscle tension (eg, palpation)

Neuromotor Development and Sensory Integration• Acquisition and evolution of motor skiUs, including age-appro-

priate development (eg, activity indexes, developmental inven-tories and questionnaires, learning profiles, motor ftmctiontests, motor proficiency assessments, neuromotor assessments,rerti.'x tests, screens, videographic assessments)

• Oral motor function, phonatitjn, and speech production (eg,interviews, observations)

• Sensorimotor integration, including postural, equiUbrium, andrighting reactions (eg, behavioral assessment scales, motor andprocessing skiU tests, postural challenge tests, observations,reflex tests, sensory profiles, temperament questionnaires, \ isu-al perceptual skill tests)

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Tests and Measures continued

Orthotic, Protective, and Supportive Devices• Components, alignment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, mterviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipmentuse during functional activities (eg,ADL scales, functionalscales, IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance inventories, healthassessment questionnaires, LADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportivedevices and equipment (eg, diaries, faU scales, interviews, logs,observations, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discritruna-

tion tests, pain drawings and maps, provocation tests, verbaland pictorial descriptor tests)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural aUgnment and position (dynamic), including symmetry

and deviation from midUne (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural aUgnment and position (static), including symmetryand deviation from midline (eg, grid measurement, observa-tions, photographic assessments)

• Specific body parts (eg, angle assessments, forward-bendingtest, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, gomometry, inclinom-

etry, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibiUty (eg, con-tracture tests, gomometry, inclinometry, Ugamentous tests, linearmeasurement, multisegment flexibiUty tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observafions, reflex tests)• Electrophysiological Integrity (eg, electroneuromyography)• Postural reflexes and reactions, including righting, equiUbrium,

and protective reactions (eg, observations, postural challengetests, reflex profiles, videographic assessments)

• Primitive reflexes and reactions, including developmental (eg,reflex profiles, screening tests)

• Resistance to passive stretch (eg, tone scales)• Superficial reflexes and reactions (eg, observations, provocation

tests)

Self-Care and Home-Management (Including ADL and IADL)• AbiUty to gain access to home environments (eg, barrier identi-

fication, observations, physical performance tests)• AbiUty to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aertvbic capacity tests, IADL scales, interviews, observations, profiles)

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

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg,electroneuromyography)

Ventilation and Respiration/Gas Exchange• Pulmonary- signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)• Pulmonary signs of ventilatory function, including airw ay pro-

tection; breath and voice sounds; respiratory rate, rhythm, andpattern; ventilatory flow, forces, and volumes (eg, airway clear-ance testing, observations, palpation, pulmonary function tests,ventilatory muscle force tests)

• Pulmonary' symptoms (eg, dyspnea and perceived exertionindexes and scales)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), communi-

ty, and leisure activities w ith or without assistive, adaptive,orthotic, protective, supportive, or prosthetic devices andequipment (eg, activity profiles, disabiUty indexes, functionalstatus questionnaires, LADL scales, observations, physical capaci-ty tests)

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

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, faU scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to estabUsh the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of funotion, chronicit)' or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, phy sical function, and ovcniU health status

A diagnosis is a label encompassing a cluster of signs and symptoms, syndn^mes, or categories. It is the result of the systematic diagnosticpr(x;ess, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s)toward which the therapist will direct interventions. The prognosis is the determination ofthe predicted optimal level of improvement infunction and the amount of time needed to reach that level and may also inckule a. prediction of levels of improvement that may bereached at various intervals dtiring the course of therapy. During the prognostic process, the physical tlierapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected out-comes, and dischai^e plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration theexpectations of the patient/client and appropriate others.These anticipated goals and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/cUents based on a varietyt)f factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes relate^d togrowth and development; caregiver consistency or expertise; chronicity or sc verity of the ctirrent condition; living environment; multisiteor multisystem involvement; social support; potential discharge destinations; probiibility of prolonged impairment, functional Umitation, ordisability; and stabiUty of the condition.

Factors That May Require NewExpected Range of Number of Visits Episode of Care or That May Modify

Prognosis Per Episode or Care Frequency of Visits/Duration of Care

Over the course of 12 months, patient/client will demonstrate optimal motorfunction and sensory integrity and thehighest level of functioning in home, work(job/school/play), community, and leisureenvironments, within the context of theimpairments, functional limitations, anddisabilities.

During the episode of care, patient/cUentwiU achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes fbr patients/clients who are classified in this pattern.

10to60

This range represents the lower andupper Umits ofthe number of physicaltherapist visits required to ac hieve antici-pated goals and expected outcomes, ft isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 10 to 60 "isits dur-ing a single continuous episode of care.Frequency of visits and duration nf theepisode of cave should be determined bythe physical therapist to maximize effec-tiveness of ciire and efficient y of servicedelivery.

Note:

1 hese patients/clients may require multi-ple episodes of care over the Ufetinie toensure .safety and effective adaptation fol-lowing changes in physical si at us, care-givers, environment, or task demandsFactors that may lead to these idditionalepisodes of c.ire include:

• Cognitive maturation• Periods of rapid growth

Accessibility and availabiUty ofresourcesAdherence to the intervention programAgeAnatomical and physiological changesrelated to growth and developmentCaregiver consistency or expertiseChronicity or severity of the currentconditionCognitive statusComorbitities, complications, orsecondary impairments(A>ncurrent medical, surgical, andtherapeutic interventionsDecUne in functional independenceLevel of impairmentLevel of physical functionLiving environmentMultisite or multisystem involvementNutritional statusOverall health statusPotential discharge destinationsPremorbid conditionsProbabiUty of prolonged impairment,functional limitation, or disabiUtyPsychological and socioeconomicfactorsPsychomotor abiUtiesSocial supportStability of the condition

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

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

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

advance directivesindividualized family service plans (IFSPs) or individualizededucation plans (IEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• CoUaboration and coordination with agencies, including:

equipment suppUershome care agenciespayer groups

- schools- transportation agencies

• Communication across settings, including:case conferencesdocumentationeducation plans

• Cost-effective resource UtiUzation• Data coUection, analysis, and reporting

outcome datapeer review findingsrecord reviews

• Documentation across settings, following APTA's Guidelinesfor Physical Therapy Documentation (Appendix 5), including:

changes in impairments, functional Umitations, anddisabiUtieschanges in interventionselements of patient/cUent management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferencespatient care rounds

- patient/cUent family meetings• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

• AccountabiUty for services is increased.• Admission data and dischai;ge planning are completed.• Advance directives, individuaUzed family service plans (IFSPs)

or individualized education plans (IEPs), informed consent, andmandatory commimication and reporting (eg, patient advoca-cy and abuse reportii^) are obtained or completed.

• Available resources are maximaUy utiUzed.• Care is coordinated with patient/cUent, femily, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are coUected, analyzed, and reported, including outcome

data, peer review fmdings, and record reviews.• Decision making is enhanced regarding health, wellness, and

fitness needs.• Decision maidng is enhanced regarding patient/cUent health

and the use of health care resources by patient/client, family,significant others, and caregivers.

• Documentation occurs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occurs through case confer-ences, patient care rounds, and patient/client family meetings.

• Patient/client, family, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utiUzed in a cost-effective way.

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Patient/ClienhRelated Instruction

Patient/client-related instruction may include:

Interventions• Instruction, education and training of patients/cUents and

caregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional Umitations,or disabiUties)enhancement of performancehealth, w^eUness, and fitness programsplan of care

- risk factors fbr pathology/pathophysiology (disease, disor-der, or condition), impairments, functional limitations, ordisabilitiestransitions across settingstransitions to new roles

Antkipoiwi Gkxiis and Expactad Outcomes• Ability to potform physical actions, ta^cs, or activities is

improved.• Awareness and use of community resources are improved.• Behaviors that foster healthy haUts, wellness, and prevention

are acquired.• Decision making is enhanced regarding patient/dient health

and the use of health care resources by patient/client, femily,significant others, and caregivers.

• DisabiUty associated with acute or chronic illnesses isreduced.

• Functional independence in activities of daily living (ADL)and instrumental activities of daily living (IADL) is increased.

• Health status is improved.• Intensity of care is decreased.• Level of supervision required for task performance is

decreased.• Patient/client, femily, significant other, and cai^ver knowl-

edge and awareness of the diagnosis, prognosis, interventions,and anticipated goals and e3q>ected outcomes are increased.

• Patient/client knowledge of personal and envbonmental foe-tors associated with the condition is increased.

• Perfonnance levels in selfcare, home management, work(job/school/play), community, or leisure actions, tasks, or activ-ities are improved.

• Physical functio is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/client, £uniiy, gnificant others, and care-

givers is improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions continued

Procedural mterventions for this pattern may include:

Therapeutic Exercise

Interventions• Aerobic and endurance conditioning or

reconditioningaquatic programs

- gait and locomotor trainingincreased w^orkload over timewalldng and wheelchair propulsion pro-grams

• Balance, coordination, and agiUty trainingdevelopmental activities training

- motor function (motor control and motorlearning) training or retrainingneuromuscular education or reeducation

- perceptual trainingposture awareness training

- standardized, programmatic, complemen-tary exercise approaches

- sensory training or retrainingtask-specific performance training

- vestibular training• Body mechanics and postural stabOization

body mechanics trainingposture aw areness trainingpostural control trainingpostural stabilization activities

• FlexibiUty exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion training- developmental activities training- gait training- implement and device training

perceptual trainingstandardized, programmatic, complemen-tary exercise approaches

- w^heelchair training• Neuromotor development training

- developmental activities trainingmotor trainingmovement pattern trainingneuromuscular education or reeducation

• Relaxationbreathing strategies

- movement strategiesrelaxation techniquesstandardized, programmatic, complemen-tary exercise approaches

• Strength, power, and endurance training forhead, neck, Umb, pelvic-floor, trunk, and venti-latory muscles

active assistive, active, and resistive exer-cises (including concentric, dynamic/iso-tonic, eccentric, isokinetic, isometric, andplyometric)aquatic programsstandardized, programmatic, complemen-tary exercise approachestask-specific performance training

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient deUvery to tissue is increased.- Osteogemc effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oxygen demand is improved.

Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.

Balance is improved.Endurance is increased.

- Enei^ expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.

Integumentary integrity is improved.- Joint integrity and mobility are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Postural control is improved.QuaUty and quantity of movement between and across body segments areimproved.

- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily Uving (ADL) and instru-mental activities of daily Uving (IADL) with or without devices and equipmentare increased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionPreoperative and postoperative CompUcations are reduced.Risk factors are reduced.

- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.

Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Fitness is improved.

Health status is improved.Physical capacity is increased.Physical function is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.

Utilization of physical therapy services results in efficient use of health care dollars.• Padent/cUent satisfection

- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.

Coordination of care is acceptable to patient/cUent.Cost of health care services is decreased.Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to patient/client, family,and significant others.Sense of weU-being is improved.

- Stressors are decreased.

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Procedural Interventions continued

Functional Training in Self-Care and Home Management (Including Activities of Daily Uving (ADL) andInstrumental Activities of Daily LJving(IADLj

Interventions• AI>L training

bathingbed mobiUty and transfer training

- developmental activitiesdressingeatinggroomingtoileting

• Devices and equipment use and training- assistive and adaptive device or equipment

training during activities of daily living(ADL) and instrumental activities of daily liv-ing (L\DL)

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

- prosthetic device or equipment training dur-ing ADL and LVDL

• Functional training programssimulated environments and taskstask adaptationtravel training

• IADL trainingcaring for dependentshome maintenancehousehold choresshoppingyard w^ork

• Injury prevention or reductioninjury prevention education during self-careand home managementinjury prevention or reduction with use ofdevices and equipmentsafety awareness training during self-careand home management

Anticipated Goois and EjqMcted Outcmnes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.- Symptoms associated with increased o:!cygen demand are decreased.

• Impact on impairmentsBalance is improved.

- Endurance is increased.- Energy expenditure per unit of woric is decreased.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care

and home management is imjMoved.- Level of supervision required for task perfonnance is decreased.- Perfonnance of and independence in ADL and IADL with or without

devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- AbiUty to assume or resume required self-care and home management

roles is improvetl.• Risk reduction/prevention

Risk fectors are reduced.- Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Health status is improved.

Physical capacity is increased.Physical function is improved.

• Impact on societal resourees- UtiUzation of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars.• Patient/cUent satisfaction

- Access, availabiUty, and services provided are acceptable to patient/client.- Administrative management of practice is acceptable to {mtient/dient.- Clinical proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to pattent/cUent.- Ccwt of health care services is decreased.- Intensity of care is decreased.- Interj^rsonal skills of physical therajMst are acceptable to patient/dient,

femily, and significant others.Sense of well-being is improved.

- Stressors are decreased.

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Procedural Interventions continued

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration

(Including instrumental Activities of Daily Living [IADL] and Work Conditioning)

Interventions• Devices and equipment use and training

assistive and adaptive device or equipmenttraining during LADL

- orthotic, protective, or supportive device orequipment training during LADL

• Functional training programs- back schools- job coaching

simulated environments and taskstask adaptationtask trainingtravel training

• LVDL trainingcommunity service training involving instru-ments

- school and play activities traimng includingtools and instruments

- work training with tools• Injury prevention or reduction

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

- injury prevention or reduction with use ofdevices and equipmentsafety awareness training during work(job/school/play), community, and leisure inte-gration or reintegration

• Leisure and play activities training

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

Pain is decreased.- Physiological response to increased oxygen demand is improved.

Symptoms associated with increased oxygen demand are decreased.• Impact on impairments

- Balance is improved.- Endurance is increased.

Eneigy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endvirance) is increased.- Postural control is improved.- Sensory awareness is increased.- We^Jit-bearmg status is improved.

Work of breathing is decreased.• Impact on functional limitations

- AbiUty to perform physical actions, tasks, or activities related to work(job/school/play), community, and leisure integration or reintegration isimproved.Level of supervision required for task performance is decreased.Performance of and independence m IADL with or without devices andequipment are mcreased.

- Tolerance of {wsitions and activities is mcreased.• Impact on disabiUties

- AbiUty to assume or resume required work Qob/school/play), community,and leisure roles is improved.

• Risk reduction/preventionRisk factors are reduced.Risk of secondary impairment is reduced.

- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitnessFitness is improved.Health status is improved.Physical capacity is increased.Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disabiUty are reduced.

Utilization of physical therapy services is optimized.UtiUzation of physical therapy services results in efficient use of healthcare dollars.

• Patient/cUent satisfaction- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.

Clinical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.

Cost of health care services is decreased.Intensity of care is decreased.

- Interpersonal skiUs of physical therapist are acceptable to patient/cUent,family, and significant others.Sense of weU-being is improved.Stressors are decreased.

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Procedural Interventions continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulationsoft tissue

• Passive range of motion

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.

Pain is decreased.Soft tissue swelUng, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Energy expenditure per uttit of work is decreased.- Gait, locomotion, and balance are improved.

Integumentary integrity is improved.Musde performance (strength, power, and endurance) is increased.Postural control is improved.

- Quality and quantity of movement between and across body segments areimproved.

- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional Umitations- Ability to perform movement tasks is improved.- AbiUty to perform physical actions, tasks, or activities related to self-care, home

management, work (job/scthool/play), community, and leisure is improved.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assume or resume required self-care, home management, work

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

Risk fectors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, weUness, arid fitnessPhysical capacity is increa.sed.Physical function is improved.

• Impact on societal resources- UtiUzation of physical thetapy services is optimized.- Utilization of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/dient.- CUnical profldency of physical therapist is acceptable to patient/cHent.

Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, femily, and

significant others.Sense of well-being is impioved.Streraors are decreased.

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Procedural Interventions continued

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

Interventions• Adaptive devices

- environmental controlshospital bedsraised toilet seatsseatmg systems

• Assistive devices- canes- crutches- long-handled reachers

power devicesstatic and dynamic spUntswalkerswheelchairs

• Orthotic devices- braces

castsshoe insertssplints

• Protective devicesbracescushions

- helmets- protective taping

• Supportive devicescompression garmentscorsetselastic w raps

- neck collarsserial castsslingssupplemental oxygensupportive taping

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelUng, inflammation, or restriction is reduced.

Pam is decreased.- Physiological response to increased oxygen demand is improved.

Soft tissue swelling, inflammation, or restriction is reduced.Symptoms associated with increased oxygen demand are decreased.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.

Gait, locomotion, and balance are improved.Integumentary integrity is improved.

- Joint StabiUty is improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.

Optimal joint aUgnment is achieved.Optimal loading on a body part is achieved.

- Postural control is improved.- QuaUty and quantity of movement between and across body segments are improved.- Range of motion is improved.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), commimity, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and mdependence in activities of daily Uving (ADL) and instrumental

activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Pressure on body tissues is reduced.- Protection of body parts is increased.

Risk fectors are reduced.- Risk of secondary impairment is reduced.

Safety is improved.- Self-management of symptoms is improved.- Stresses precipitating injury are decreased.

• Impact on health, wellness, and fitnessHealth status is improved.Physical capacity is increased.

- Physical function is improved.• Impact on societal resources

- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care doUars.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/dient.

Clinical proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/cUent.

Cost of health care services is decreased.- Lntensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent, family, and

significant others.- Sense of weU-being is improved.

Stressors are decreased.

S 3 7 0 / 3 7 8 Guide to Physical Therapist Practice Physicai Therapy • Volume 81 • Number 1 • January 2001

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Procedural Interventions continued

Airway Clearance Techniques

Interventions• Breathing strategies

active cycle of breathing or forced expiratory techniquesassisted cough/huff techniquesautogenic drainagepaced breathingpursed lip breathingtechniques to maximize ventilation (eg,maximum inspiratory hold, staircase breath-ing, manual hyperinflation)

• Manual/mechanical techniquesassistive deviceschest percussion, vibration, and shakingchest vv all manipulationsuctioningventilatory aids

• Positioningpositioning to alter work of breathingpositioning to maximize ventilation andperfusionpulmonary postural drainage

AiMidpatad Gook and ExpiBdad Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.Nutrient delivery to tissue is increased.

- Physicriogical response to increased oxygen demand is improved.- Symptoms associated with increased ox> ;en demand are decreased.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Airway clearance is improved.- Cough is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Exercise tolerance is improved.- Musck performance (strength, power, and endurance) is increased.- Ventilation and respiiution/gas exchange are improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care,

home management, work (job/school/play), community, and leisure isimproved.

- Perfonnance of axid independence in activities of daily living (ADL) andinstriimental activities of daily living (IADL) with or without devices andequijMnent are increased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Preoperative and postoperative complications are reduced.- Risk fiwrtors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impainnent is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Htness is improved.- Health status is improved.- Riysicsd capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in efficient use of health

care dollars.• Patient/client satisfection

- Access, availabiUty, and services provided are acceptable to patient/client.- Administiative manai enwnt of practice is accepttable to patient/cUent.- Clinical profidency (rf physical therapist is acceptable to patient/dient.- Coonteation of care is acceptable to patient/client.- Cost of health carr services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/cUent,

femity, and significant others.- Sense of well-being is improved.

Stressors are decreased.

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions• Biofeedback• Electrical stimulation

electrical muscle stimulation(EMS)

- functional electrical stimulation(FES)transcutaneous electrical nervestimulation (TENS)

Antkipaied Goab and Expected Outcomes• Impact on pathology/paiiiophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- CMeogenic effects are enhanced.- Pain is decreased.- Soft tissue swellii^, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments- Integumentary integrity is improved.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- QuaUty and quantity of movement between and across body s^ments are improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instnmiental

activities of daily living (LADL) with or without devices and equipment areincreased.

- Tolerance of petitions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Complications of immobility are reduced.

Preoperative and postoperative CompUcations are reduced.- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Physical capadty is increased.- Physical function is improved.

• Impact on sodetal resources -- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/client satisfection- Access, availiU ility, and services provided are acceptabk to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical profldency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

significant others.- Sense of well-betoig is improved.- Stressors are deareased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

InterventionsPhysical agents may include:• Cryotherapy

cold packsice massagevapocoolant spray

• Hydrotherapywhirlpool tankspools

• Sound agentsphonophoresisultrasound

• Thermotherapydr\' heathot packsparaffin baths

Mechanical modalities may include:• Compression therapies

compression bandagmgcompression garments

- taping• Gravity-assisted compression devices

standing frame- tilt table

Antictpatsd Goals ond Expected Oukomes• Impact on pathok^/pathophystology (disease, disorder, or condition)

- Edema, tymphedema, or efifusion is reduced.- Joint swelling, infliuiimation, or restjiction is reduced.- Nutrient delivery to tissue is increased.- Pain is decreased.- Soft tissue swelUng, inflammation, or restriction is reduced.- Tissue periusion and oxygenation are enhanced.

• Impact on impairments- Integumentary inte^ty is improved.- Musde performance (strength, power, and endurance) is increased.- Range of motion is improved.- Weight-bearing status is improved.

• Impact on functional limitations- Ability to perform pt ^sical actions, tasks, or activities related to self-care, home

management, woric (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily living (ADL) and instrumen-

tal activities of daily living (IADL) with or without devices and equipment areincreased.

- Tblerance of positions and activities is increased.• Impact on cHsabiUties

- Ability to assume or resume required self<are, h(»ne management, wotkqob/school/play), commuWty, and leisure roles is improved.

• Risk reduction/prevention- CompUcations of soft tissue and circulatory disorders are decreased.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.- Stresses predpitatiiq; injury are decreased.

• Impact on health, welln^s, and fitness- Physical function is improved.

• Impact on sodetal resources- Utilizaticm of physical therapy services is optimized.

• Patient/dient satisfection- Access, availaMity, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/dient.- CUnical profidency of physical therapist is acceptable to patient/dient.- Coordination of caie is acceptable to patient/dient.- Interpersonal skUls of physical therapist are acceptable to patient/dient, family, aad

significant otters.- Sense of weltbeing fe improved.- Stressors are decres^ed.

Guide to Physicai Theiapist Practice Impairments / Nonprogressive GNS Disorders-Adult 381/S373

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ReexaminationReexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modifyor redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed overthe course of a disease, disorder, or condition, which for some patients/cUents may be over the life span. Indications for reexaminationmdude ne v cUnical findings or faUure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are deUneated m shaded boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/cUent 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 thephysical therapy interventions in the foUo ving domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• DisabiUties• Risk reduction/prevention• Health, wellness, and fitness• Societal resources• Patient/cUent satisfaction

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

Criteria for Termination of Physical Therapy ServicesDischarge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when theanticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when apatient is moved from one site to another site w ithm the same setting or across settings during a single episode of care). Although theremay be faciUty-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, dischargeoccurs based on the physical therapist's analysis ofthe achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) thepatient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/cUent is unable to continue to progress towardoutcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/clients who require multiple episodes of care, periodic foUow-up is needed over the life span to ensure safety and effective adajvtation foUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate foUow-up or referral.

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Impaired Motor Function and Sensoryintegrity Associated With ProgressiveDisorders of the Central Nervous System

This preferred practice pattern describes the generally accepted elements of patient/cUent management that physical therapistsprovide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; the pro-fession's code of ethics and standards of practice; and patient/cUent age, culture, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients wiU be classified into this pattern—for impaired motor function and sensory integrity associated with progressivedisorders of the central nervous system—as a result of the physical therapist's evaluation of the examination data.The findingsfrom the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/ patho-physiology, impairments, functional Umitations, or disabiUties or the need for health, weUness, or fitness programs.The physicaltherapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The foUowing examples of examination findmgs may support theinclusion of patients/clients in this pattern:

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

• Acquired immune deficien-cy syndrome

• Alcoholic ataxia• Alzheimer disease• Amyotrophic lateral sclerosis• Basal ganglia disease• CcrebeUar ataxia• CcrebeUar disease

Huntington diseaseIdiopathic progressivecortical disease

Intracranial neurosurgicalproceduresMultiple sclerosisNeoplasmParkinson diseasePrimary lateral palsyProgressive muscularatrophySeizures

Impairments, Functional Limitations, or Disabilities

Difficulty coordinatingmovementDifficulty w t h mampula-tion skillsDifficulty negotiating ter-rainsFrequent fallsIntpaired affectImpaired arousal, attention,and cognitionImpaired enduranceImpaired motor function

Impaired sensory integrit)'Loss of balance during dailyactivitiesProgressive loss of functionInability to keep up withpeersInabiUty to negotiate com-munity environmentInabiUty to performjob/school activitiesLack of safety in homeenvironment

Note:

Some risk factors or consequences of pathology/pathophysiology—such as neoplasm—may be severe and com-plex; however, they do not necessarily exclude patients/clientsfrom this pattern. Severe and complex risk factors or conse-quences may require modification of the frequency of visits andduration of care. (See "Evaluation, Diagnosis, and Prognosis,"pageS381.)

Guide to Physical Therapist Proctice

Exclusion or Multiple-Pattern Classificotion

The following examples of exammation fmdings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/cUent would be moreap]>ropriately managed through (1) classification m aneniirely different pattern or (2) classification in both thisand another pattern.

Findings That May Require Cbssification in aDifferent Pattern• Amputation• Coma

Findings That May Require Classification inAdditional Patterns• Amyotrophic lateral sclerosis with pneumonia• Parkinson disease with arthritis

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/cUent diagnostic classification is based on impairments, fianctional Umitations, and disabiUties—not on codes—patients/clients may be classified into the pattern even though the codes Usted wth the pattern may not apply to those cUents.

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

042 Human immunodeficiency virus [HTV] disease

191 Malignant neoplasm of brain192 Malignant neoplasm of other and unspecified parts of ner-

vous system

237 Neoplasm of uncertain behavior of endocrine glands andnervous system237.5 Brain and spinal cord

303 Alcohol dependence syndrome303.9 Ataxia

331 Other cerebral degenerations

331.0 Alzheimer's disease

331.3 Communicating hydrocephalus

331.4 Obstructive hydrocephalus

332 Parldnson's disease

333 Other extrapyramidal disease and abnormal movement dis-orders

333.0 Other degenerative diseases of the basal gangUa

333.3 Tics of organic origin

333.4 Huntington's chorea

333.9 Other and unspecified extrapyramidal diseasesand abnormal movement disorders

334 SpinocerebeUar disease

334.2 Primary cerebeUar degeneration

334.3 Other cerebeUar ataxia

334.8 Other SpinocerebeUar diseases

335 Anterior horn cell disease

335.0 Werdnig-Hoffmann disease

335.1 Spinal muscular atrophy

335.2 Motor neuron disease

336 Other diseases of spinal cord

336.0 SyringomyeUa and syringobulbia

340 Multiple sclerosis

341 Other demyelinating diseases of central nervous system

341.8 Other demyeUnating diseases of central nervoussystemCentral demyelination of corpus callosum

341.9 DemyeUnating disease of central nervous system,unspecified

345 Epilepsy

345.4 Partial epilepsy, with impairment of consciousnessEpilepsy:

partial:secondarily generalized

345.5 Partial epilepsy, without mention of impairment ofconsciousness

Epilepsy:sensory-induced

348 Other conditions of brain348.9 Unspecified condition of brain

780 General symptoms780.3 Convulsions

781 Symptoms involving nervous and musculoskeletal systems781.2 AbnormaUty of gait

Gait:ataxic

781.3 Lack of coordinationAtaxia, not otherwise specified

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ExaminationExamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Exammation is required prior to the initial intervention and is performed for all patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional Umitations, disabUities, changes in physical function or overaUhealth status, and needs related to restoration of health and to prevention, wellnt ss, and fitness.The physical therapist synthesizes theexamination findings to estabUsh the diagnosis and the prognosis (including the plan of care). The jiatient/client, family, significant others,and caregivers may provide information during the examination process.

Examination has three components: the patient/cUent history, the systems review, and tests and measures.The history is a systematic gath-ering of past and current information (often from the patient/client) related to v hy the patient/cUent is seeking the services of the physi-cal therapist.The systems revieiv is a brief or Umited examination t)f (1) the anatomical and physiological status ofthe cardiovascular/pul-monary, integumentary, mtistuloskeletal, and neuromuscular systems and (2) the communication abiUt)', affect, cognition, language, andlearning style ofthe patient/cUent. Tests and measures are tlie means of gathering data atxjut the patient/cUent.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity' of the problem; stageof recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, w ork (job/school/play), orcommunity situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by^ tests and measures, refer to Chapter 2.

PoHent/Client History

The history may include:

General Demographics• Agf• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beUefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support .systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), commimity, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Stotus (Sel^Report,Family Report, Caregiver Report)• General health perception• Physic;il function (eg, mobiUty, sleep

patterns, restricted bed days)• Psychological function (eg, memory,

reasoning ability, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Functional Stotus and Activity Level• Current and prior functional status in

self-care and home management activi-ties, including activities of daily Uving(ADL) and instrumental activities ofdaily living (L\DL)

• Ctirrent and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications fbr other conditions

Other Clinical Tests• laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other clinical findings (eg,

nutrition and hydration)

Guide to Physicai Therapist Proctice

Social/Health Habits (Past and Current)• Behavioral health risks (t g smoking,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metaboUc• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitaUzations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complalnt(s)• Concerns that led patient/client to seek

the services of a physical therapist• Concerns or needs of pati( nt/client

who reijuires the servict s of a physicaltherapist

• Current therapeutic intei-ventions• Mechanisms of injury or disease, includ-

ing date of onset and course of events• Onset and pattern of symptoms• Pdtient/ciient, family, significant other,

and caregiver expectation^ and goalsfor the therapeutic intervention

• Patient/cUent, family, significant other,and caregiver perceptions of patient's/client s emotional response to the cur-rent clinical situation

• Previous occurrence of chief com-plaint(s)

• Prior therapeutic interventions

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Systems Review

The systems revieiv may include:

Anatomical and Physiological Stotus

• Cardiovascular/Pulmonary- Blood pressure- Edema

Heart rateRespiratory rate

Integumentary- Presence of scar

formationSkin colorSkin integrity

MusculoskeletalGross range of motionGross strengthGross symmetry

- Height- Weight

Neuromuscular- Gross coordinated

movements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs know n• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests ond Meosures

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

Aerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily Uving [ADL] scales, indexes, instrumental activities of dailyliving [IADL] scales, observations)

• Aerobic capacity during standardized exercise test protocols(eg, ergometry, step tests, time/distance walk/run tests, tread-mill tests, wheelchair tests)

• Cardiovascular signs and symptoms in response to increasedoxygen demand "with exercise or activity, including pressuresand flow; heart rate, rhythm, and sounds; and superficial vas-cular responses (eg, angina, claudication, dyspnea, and exer-tion scales; electrocardiography; observations; palpation;sphygmomanometry)

• Pulmonary signs and symptoms in response to increased oxy-gen demand with exercise or activity, including breath andvoice sounds; cyanosis; gas exchange; respiratory pattern, rate,and rhythm; ventilatory flow, force, and volume (eg, ausculta-tion, exertion scales, observations, oximetry, palpation)

Anthropometric Characteristics• Body dimensions (eg, body mass mdex, girth measurement,

length measurement)• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Arousal, Attention, and Cognition• Arousal and attention (eg, adaptability tests, arousal and

awareness scales, indexes, profiles, questionnaires)• Cognition, including ability to process commands (eg, develop-

mental inventories, indexes, interviews, mental state scales,observations, questionnaires, safety checkUsts)

• Communication (eg, functional communication profiles, inter-views, inventories, observations, questionnaires)

• Motivation (eg, adaptive behavior scales)• Orientation to time, person, place, and situation (eg, attention

tests, learning profiles, mental state scales)• Recall, including memory and retention (eg, assessment scales,

inter\'iews, questionnaires)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg,ADL scales, functional scales, LADL scales,interviews, observations)

• Components, aUgnment, fit, and abiUty to care for the assistiveor adaptive devices and equipment (eg, intervie^vs, logs, obser-vations, pressure-sensing maps, reports)

• Remediation of impairments, functional Umitations, or disabiU-ties with use of assistive or adaptive devices and equipment(eg, activity status indexes,ADL scales, aerobic capacity tests,functional performance inventories, health assessment ques-tionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, fall scales, interviews, logs, observations,reports)

Circulation (Arterial, Venous, and Lymphatic)• Physiological responses to position change, including autonom-

ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg,auscultation, electrocardiography, observations, palpation,sphygmomanometry)

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Tests ond Meosures continued

Cranial Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)

• Motor distribution of the cranial nerves (eg, dynamometry, mus-cle tests, observations)

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

• Response to neural provocation (eg, tension tests, vertebralartery compression tests)

• Response to stimuli, including auditory, gustatory, olfactory, pha-ry ngeal, vestibular, and visual (eg, observations, provocationtests)

• Sensory distribution of the cranial nerves (eg, discriminationtests; tactile tests, including coarse and Ught touch, coltl andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, :ind vibration; thoracic outlet tests)

Environmentol, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checkUsts, interviews, obser-

vations, questionnaires)

• Physical space and enviromiient (eg, compUance standards,obsei^ations, photographic assessments, questionnaires, struc-tural specifications, videographic asse.ssments)

Ergonomics and Body Mechanics

Ergonomics• Dexterity and coordination during work (job/school/play) (eg,

hand function tests, impairnient rating scales, manipulative abil-ity tests)

• Safety in work environments (eg, hazard identification clieck-lists, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, workstation checkUsts)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Body mechanics• Body mechamcs during seU-care, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance during functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, LADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) \vith or without the use of assis-tive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observations, photographic assessments, postural control tests)

• (rait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ivt, or prosthetic devices or equipment (eg,ADL scales, gaitl>r<3files, IADL scales, mobility skill profiles, observations, video-graphic assessments)

• (iait and locomotion with or without the use of assistive, adap-tive, (irthotic, protective, supportive, or prosthetic devices or(quipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobility skiU profiles, observations,photographic assessments, technology-assisted assessments,viiieographic assessments, w^eighf-bearing scales, •wheelchairmobility tests)

• Saliety during gait, locomotion, and balance (eg, confidence scales,iliurics, fall scales, functional assessment profiles, logs, reports)

Integumentory Integrity

Assot iatt-d skin• .Vctivities, positioning, and postures that produce or relieve

irjiinia to the skin (eg, observations, pressure-sensing maps,scales)

• .\ssistive, adaptive, orthotic, protective, supportive, or pros-I hctic devices and equipment that may produce or relievetrauma to the skin (eg, observations,pressure-sensing maps,risk assessment scales)

• Skin characteristics, including blistering, continuity of skin< olor, dermatitis, hair growth, mobiUty, nail growth, temper-ature, texture, and turgor (eg, observations, palpation, pho-toj^raphic assessments, thermography)

Motor Function (Motor Learning and Motor Control)• Dexterity, coordination, and agiUty (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,'.ideographic assessments)

• Hlectrophysiological integrity (eg, electroneuromyography )

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

• initiation, mocUfication, and control of movement patterns and'/oluntary postures (eg, activity indexes, developmental scales,jy )ss motor function profiles, motor scales, movement assess-ment batteries, neuromotor tests, observations, physical perfor-mance tests, postural chaUenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Electrophysiological integrity (eg, electroneuromyography)

• (Muscle strength, power, and endurance (eg, dynamometry, man-ual muscle tests, muscle performance tests, physical capacitylests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-tit s (i.-g, ADL scales, functional muscle tests, L\DL scales, obser-V ations, videographic assessments)

• Muscle tension (eg, palpation)

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Tests ond Meosures continued

Neuromotor Development and Sensory Integration• Acquisition and evolution of motor skills, including age-appro-

priate development (eg, activity indexes, developmental mven-tories and questionnaires, infant and toddler motor assess-ments, learning profiles, motor function tests, motor proficien-cy assessments, neuromotor assessments, reflex tests, screens,videographic assessments)

• Oral motor function, phonation, and speech production (eg,interviews, observations)

• Sensorimotor integration, including postural, equilibrium, andrighting reactions (eg, behavioral assessment scales, motor andprocessing skiU tests, postural challenge tests, observations,reflex tests, sensory profiles, temperament questionnaires, visualperceptual skiU tests)

Orthotic, Protective, and Supportive Devices• Components, aUgnment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipment useduring functional activities (eg,ADL scales, functional scales,IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional Umitations, or disabiU-ties with use of orthotic, protective, and supportive devicesand equipment (eg, activity status indexes,ADL scales, aerobiccapacity tests, functional performance mventories, healthassessment questionnaires, IADL scales, pain scales, play scales,videographic assessments)

• Safety during use of orthotic, protective, and supportive devicesand equipment (eg, diaries, faU scales, mterviews, logs, observa-tions, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimination

tests, pain drawings and maps, provocation tests, verbal and pic-torial descriptor tests)

• Pain m specific body parts (eg, pain indexes, pain questionnaires)

Posture• Postural aUgnment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

• Postural alignment and position (static), including symmetry anddeviation from midUne (eg, grid measurement, observations,photographic assessments)

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

Range of Motion (ROM) (Including Muscle Length)• Eunctional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, mdinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibiUty, and flexibiUty (eg, con-tracture tests, goniometry, mdinometry, ligamentous tests, linearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)• Electrophysiological integrity (eg, electroneuromyography)• Postural reflexes and reactions, including righting, equiUbrium,

and protective reactions (eg, observations, postural chaUengetests, reflex profiles, videographic assessments)

• Primitive reflexes and reactions, including developmental (eg,reflex profiles)

• Resistance to passive stretch (eg, tone scales)• Superficial reflexes and reactions (eg, observations, provoca-

tion tests)

Self-Care and Home Management (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability to perform self-care and home management activities

with or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and environ-ments (eg, diaries, faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, ldnesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg, electroneuromyography)

Ventilation and Respiration/Gas Exchange• Pulmonary signs of respiration/gas exchange, including breath

sounds (eg, gas analyses, observations, oximetry)• PuUnonary signs of ventilatory function, including airway pro-

tection; breath and voice sounds; respiratory rate, rhythm, andpattern; ventilatory flow, forces, and volumes (eg, airway clear-ance tests, observations, palpation, pulmonary ftmction tests,ventUatory muscle force tests)

• Pulmonary symptoms (eg, dyspnea and perceived exertionindexes and scales)

Work (Job/School/Play), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), commumty,

and leisure activities with or without assistive, adaptive, orthot-ic, protective, supportive, or prosthetic devices and equipment(eg, activity profiles, disabiUty indexes, functional status ques-tionnaires, LADL scales, observations, physical capacity tests)

• AbiUty to gain access to work (job/school/play), community, andleisure environments (eg, barrier identification, interviews,observations, physical capacity tests, transportation assessments)

• Safety in work (job/school/play), community, and leisure activi-ties and environments (eg, diaries, faU scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make cUnical judgments) based oit ihe data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, social considerations, physical function, and overaU health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examination.The diagnostic lalsel indicates the primary dysfunction(s)toward which the therapist AviU direct interventions. 'ITie prognosis is the determination of the predicted optimal level of improvement infunction and the amount of time needed to reach that level ;mcl may also include a prediction of levels of improvement that may bereached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposett frequency and duration of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies realistic anticipated go;ils and expected outcomes, taking into consideration theexpectations ofthe patient/cUent and appropriate others These anticipated gcals and expected outcomes should be measureable and timelimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode w ith a diminislung intensity of intervention. Frequency and dtiration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related togrowth and development; caregiver coiisistenc7 or expertise; chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; social support; potential discliarge destinations: ()robability of prolonged impairment, functional Umitation, ordisabiUty; and stabilitv of the condition.

Prognosis

Over the course of 12 months, patient/cUent wiU demonstrate optimal motorfunction and sensory integrity and thehighest level of fimctioning in home, work(job/school/play), community, and leisure-environments, within the context of theimpairments, functional limitations, anddisabiUties.

During the episode of care, patient/cUentwiU achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care: antl(2) the global outcomes for patients/cUents who are classified in this pattern.

Expected Ronge of Number of VisitsPer Episode of Core

6 to 50

This range represents the lower andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 6 to 50 visits duringa single cimtinuous episode of care.Frequency of visits and duration of theepisode of care shouki be determined bythe physical therapist to maximize effec-tiveness of care anct efficiency of servicedeUvery.

Foctors Thot Moy Require NewEpisode of Core or Thot Moy ModifyFrequency of Visits/Durotion of Core

• Accessibility and availabiUty ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, CompUcations, or

secondary impairments• Concurrent medical, surgical, and

therapeutic interventions• DecUne in functional independence• Level of impairment• Level of physical function• Living environment• Multisite or multisystem involvement• Nutritional status• OveraU health status• Potential discharge destinations• Premorbid conditions• ProbabiUty of prolonged impairment,

fimctional limitation, or disabiUty• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• Stability of the condition

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InterventionIntervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individualsinvolved in patient/cUent care, usmg various physical therapy procedures and techmques to produce changes in the condition consistentwith the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitormg of patient/cUent response andthe progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/cUent-related instruction are provided for aU patients/cUents across all set-tings. Procedtiral interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the progno-sis, and the anticipated goals and expected outcomes for a particular patient/cUent. For clinical considerations in selecting interventions,listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3-

Coordinotion, Communicotion, ond DocumentoHon

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

advance directives- individuaUzed family service plans GFSPs) or individualized

education plans (IEPs)- informed consent- mandatory communication and reporting (eg, patient advo-

cacy and abuse reporting)• Admission and discharge planning• Case management• CoUaboration and coordination w ith agencies, including:

equipment suppliershome care agenciespayer groups

- schoolstransportation agencies

• Communication across settings, including:case conferencesdocumentationeducation plans

• Cost-effective resource utUization• Data coUection, analysis, and reporting

outcome data- peer review findings

record reviews• Documentation across settings, foUowing APTA's Guidelines

for Physical Therapy Documentation (Appendix 5), including:changes in impairments, functional limitations, anddisabUitieschanges in interventionselements of patient/cUent management (examination, evalu-ation, diagnosis, prognosis, intervention)outcomes of intervention

• InterdiscipUnary teamworkcase conferencespatient care roundspatient/client family meetmgs

• Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes• AccountabiUty for services is increased.• Admission data and discharge planning are completed.• Advance directives, individuaUzed femily service plans (IFSPs)

or individuaUzed education plans (IEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximaUy utilized.• Care is coordinated with patient/cUent, family, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occurs with agencies, includ-

ing equipment suppUers, home care agencies, payer groups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Communication occurs across settings through case confer-

ences, education plans, and documentation.• Data are coUected, analyzed, and reported, induding outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding on health, wellness,

and fitness needs.• Decision making is enhanced regarding patient/cUent health

and the use of health care resources by patient/client, family,significant others, and caregivers.

• Documentation occurs throughout patient/dient managementand across settings and foUows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary CoUaboration occurs through case confer-ences, patient care rounds, and patient/cUent family meetings.

• Patient/cUent, femily, significant other, and caregiver under-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resources are utiUzed in a cost-effective way.

S 3 8 2 / 3 9 0 Guide to Physicol Therapist Proctice Physical Theropy • Volume 81 • Number 1 • Jonuory 2001

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Potient/Clien^Reloted Instruction

Patient/cUent-related instruction may include:

Interventions

• Instruction, education and training of patients/clients andcaregivers regarding:- current condition (pathology/pathophysiology [disease,

disorder, or condition], impairments, functional Umitations,or disabilities)enhancement of performance

- health, wellness, and fitness programsplan of carerisk factors for pathology/pathophysiology (disease, disor-der, or condition), impairments, fimctional limitations, ordisabilitiestransitions across settingstransitions to new roles

ls and Expectod OutcomesAbility to perform physical actions, tasks, or activities isimproved.Awaiseness and use of community resources are improved.Behaviors that foster healthy habits, wellness, and preventionare acquired.Decision making is enhanced regarding patient/cUent healthand the use of health care resources by patient/cUent, femily,g^nificant others, and caregivers.DisalMUty associated with acute or chronic illnesses isreduced.Fimctional independence In activities of daily Uving (ADL)and instrumental activities of daily Uving (IADL) is increased.Health status is improved.Intensity of care is decreased.Level of supervision required for task performance isdecreased.Patient/client, femity, s^nificant other, and caregiver knowl-edge and awareness ofthe diagnosis, prognosis, interventions,and anticipated goals and expected outcomes are increased.I^tient/dient knowledge of personal and environmental fec-tors associated with the condition is increased.Perfiairmance levels in sdf-care, home management, work(joh/school/play), community, or leisure actions, tasks, or activ-ities are improved.Wjyslcal function is improved.Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safety of patient/cUent, femity, s^ifficant others, and care-givers is improved.Self-management of symptoms is improved.Utilization and cost of health care services are decreased.

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Procedurol Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions• Aerobic and endurance conditioning or

reconditioningaquatic programsgait and locomotor trainingincreased workload over time

- walking and wheelchair propulsion pro-grams

• Balance, coordination, and agiUty tramingdevelopmental activities training

- motor function (motor control and motorlearning) training or retrainingneuromuscular education or reeducationperceptual trainingposture awareness training

- standardized, programmatic, complemen-tary exercise approachessensory training or retrainingtask-specific performance trainingvestibular training

• Body mechanics and postural stabilization- body mechanics training- posture awareness training

postural control trainingpostural stabilization activities

• FlexibiUty exercisesmuscle lengtheningrange of motionstretching

• Gait and locomotion trainingdevelopmental activities traininggait trainingimplement and dev ice trainingperceptual training

- standardized, programmatic, complemen-tary exercise approaches

- wheelchair training• Neuromotor development

developmental activities trainingmotor trainingmovement pattern trainingneuromuscular education or reeducation

• Relaxationbreathing strategiesmovement strategiesrelaxation techniquesstandardized, programmatic, complemen-tary exercise approaches

• Strength, pow^er, and endurance training forhead, neck, limb, pelvic-floor, trunk, and ven-tilatory muscles

active assistive, active, and resistive exer-cises (including concentric, dynamic/iso-tonic, eccentric, isokinetic, isometric, andplyometric)aquatic programsstandardized, programmatic, complemen-tary exercise approachestask-specific performance training

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, itiflammation, or restriction is reduced.Nutrient deUvery to tissue is increased.

- Osteogenic effects of exercise are maximized.- Pain is decreased.

Physiological response to mcreased oxygen demand is improved.- So:ft tissue swelling, inflammation, or restriction is reduced.- Symptoms associated with mcreased oxygen demand are decreased.- Tissue perfusion and oxygenation are enhanced.

• Impact on impairments:- Aerobic capacity is mcreased.

Balance is improved.Endurance is increased.

- Energy expenditure per unit of work is decreased.Gait, locomotion, and balance are improved.Integumentary integrity is improved.

- Joint integrity and mobiUty are improved.- Motor function (motor control and motor learning) is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- QuaUty and quantity of movement between and across body segments are

improved.- Range of motion is improved.

Relaxation is mcreased.Sensory awareness is increased.

- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional Umitations- Ability to perform physical actions, tasks, or activities related to self-care,

home management, work (job/school/play), community, and leisure isimproved.Level of supervision required for task performance is decreased.Performance of and independence m activities of daily Uving (ADL) andmstrumental activities of daily Uving (IADL) with or without devices andequipment are increased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Risk factors are reduced.

Risk of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, w^ellness, and fitnessFitness is improved.Health status is improved.

- Physical capacity is increased.Physical function is improved.

• Impact on societal resourcesUtilization of physical therapy seiTdces is optimized.

- UtiUzation of physical therapy services results in efficient use of health caredollars.

• Patient/cUent satisfection- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.

CUnical profidency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.

Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal sidlls of physical therapist are acceptable to patient/dient, femily,

and significant others.- Sense of well-being is improved.

Stressors are decreased.

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Procedurol Interventions conHnued

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

Interventions

• ADL trainingbathmgbed mobility ;ind transfer trainingdevelopmental activitiesdressingeatinggroomingtoileting

• Devices and equipment use andtraining- assistive and adaptive device or

equipment training dtiring ADLand L\DL

- orthotic, protective, or supportivedevice or equipment training dur-ing ADL and L\DL

• Functional training programssimulated environments and tasks

- ta.sk adaptationtravel training

• IADL trainingcaring for dependentshome maintenance

- household choresshoppingstnicttired play for infants and chil-drenyard work

• Injury prevention or reductioninjury prevention educationduring self-care and homemanagementinjury prevention or reductionwth use of devices and equipmentsafety awareness training duringself-care and home management

Anticipated Goals and Expectsd Outcomes

• Impact on pathology/pathophysiology (disease, disorder, or condition)- Pain is decreased.- Physiological response to increased oxygen demand is improved.- Symptoms associated with increased oxygen demand are decreased.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expemUture per unit of work is decreased.- Motor function (motor control and motor learning) is impioved.- Muscle perfonnance (strength, power, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.- Workof breathing is decreased.

• Impact on functional Umitations- Ability to perform ptiysical actions, tasks, or activities related to self-care and home

management is improved.Level of supervision required for task performance is decreased.

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

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/prevention- Risk factors are reduced.- Risk of secondary impainnents is reduced.- Safety is improved.

Self-management of symptoms is improved.• Impact on health, wellness, and fitness

- Health status is impioved.- Physical capadty is increiised.- Physical function is improved.

• Impact on sodetal resourcesUtilization of physical therapy services is optimized.

- Utili2ation of ptiysical therapy services results in efHdent use of health care doUars.• Patient/cUent satisfection

- Access, availaMity, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/dient.- Clinical proficiency of physical therapist is accqjtable to patient/dient.- CoottJkmtion of care is acceptable to patient/cUent.- Cost of health care services is decreased.

Intensity of care is decreased.- Interpersonal sidlls of physical ttierapist are acceptable to patient/cUent, femily, and

Sense of well-being is improved.Stressors are (tecreased.

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Procedurol Interventions continued

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

Interventions• Devices and equipment use and training

assistive and adaptive device or equipment train-ing during IADL

- orthotic, protective, or supportive device orequipment training during LADL

• Functional training programs- job coaching

simulated environments and taskstask adaptation

- task training- travel training

• IADL trainingcommunity service training involving instru-mentsschool and play activities training including toolsand instrumentswork training with tools

• Injury prevention or reductioninjury prevention education during work(job/school/play), community, and leisureintegration or reintegration

- injury prevention or reduction with use ofdevices and equipmentsafety awareness training during work(job/school/play), community, and leisureintegration or reintegration

• Leisure and play activities training

Anticipated Goals and Expected Outcomes

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

- Physiological response to increased oxygen demand is improved.- Symptoms associated with increased oxygen demand are

decreased.• Impact on impairments

Balance is improved.- Endurance is mcreased.- Energy expenditure per imit of work is decreased.- Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is

increased.Postural control is improved.Sensory awareness is mcreased.

- Weight bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to

woric (job/school/play), commmiity, and leisure integration or rein-tegration is improved.

- Level of supervision required for task performance is decreased.- Perfonnance of and independence in IADL with or without

devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assimie or resume required woik (job/school/play), com-

munity, and leistire roles is improved.• Risk reduction/prevention

Risk fectors are reduced.Risk of secondary impairment is reduced.Safety is improved.Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Costs of work-related injury or disabiUty are reduced.

Utilization of physical therapy services is optimized.UtiUzation of physical therapy services results in efficient use ofhealth care doUars.

• Patient/client satisfection- Access, availabiUty, and services provided are acceptable to

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

patient/cUent.- Clinical profidency of physical therapist is acceptable to

patient/cUent.Coordination of care is acceptable to patient/cUent.

- Cost of health care services is decreased.Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable topatient/cUent, family, and significant others.Sense of weU-beii^ is improved.Stressors are decreased.

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Procedurol Interventions continued

Manual Therapy Techniques (Including AAobilization/Manipulation)

Interventions• Manual traction• Massage

connective tissue massagetherapeutic massage

• Mobilization/manipulationsoft tissue

• Passive range of motion

Anticipated Goo^ and Expttded Otrtcomes• Impact on pathotc^/pattioptiy^ology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Mn is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments- Balance is improved.- Enei^ expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Musde performance (strength, power, and endurance) is increased.- Postund contiol is improved.- Quality and quantity of movement between and across body segments are

improved.- Rang^ of motion is improved.- Relaxation is increased.

Sensory awareness is increased.- Weight-bearing ^atus is im|)iroved.- Work of breattili^ is decreased.

• Impact on functional limitations- AbiUty to perform movement tsmks is improved.- Ability to perform physical actions, taslra, or activities related to self-care, home man-

cement, work Qob/school/play), community, and leisure is improved.- Tolerance of positions and ^rtivities is increased.

• Impact on disabilities- Ability to assunie or resume required selfcare, home management, woik

(job/school/play), community, and leisure roles is improved.• Risk reduction/prevention

- Risk Ikctors are reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Physical fimction is improved.

• Impact on sodetai resources- Utilization of physicat therapy services is optimized.

• Patient/cUent satisfection- Access, availability, and serrtqes provided are acceptable to patient/cUent.- Administrative managjement of practice is acceptable to patient/dient.- CUnical proficiency of physkal ttieraf^t is acceptable to patient/dient.- Coontoation of care is acceptable to patient/cUent.- Cost of healtii care services is decreased.- Intensity of care is decreased.- Interpersonal skills of ptJysiCal therapist are acceptable to patient/cUent, femity, and

significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedurol Interventions continued

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

Interventions• Adaptive devices

environmental controlshospital beds

- raised toilet seatsseating systems

• Assistive devicescanes

- crutcheslong-handled reacherspow er devicesstatic and dynamic splintswalkerswheelchairs

• Orthotic devices- braces

castsshoe insertssplints

• Protective devices- braces

cushionshelmetsprotective taping

• Supportive devicescompression garmentscorsetselastic wrapsmechanical ventilatorsneck collarsserial castsslings

- supplemental oxygensupportive tapmg

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelUng, inflammation, or restriction is reduced.

Pain is decreased.- Ptiysiotogical response to increased oxygen demand is improved.

Soft tissueiswelUng, inflammation, or restriction is reduced.- Symptoms assodated with increased oxygen demand are decreased.

• Impact on impairments- Balance is impioved.- Endurance is increased.- Eneigy expenditure per unit of work is decreased.

Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint StabiUty is increased

Motor function (motor control and motor learning) is improved.- Musde performance (strength, power, and endurance) is increased.- Optimal joint alignment is achieved.- Optimal loading on a body part is adiieved.- Postural control is improved.

QuaUty and quantity of movement between and across body segments areimproved.

- Range of motion is improved.- Weight-bearii^ status is improved.- Work of breathing is decreased.

• Impact on functional Umitations- AbiUty to perform physical actions, tasks, or activities related to self-care, home man-

agement, work (job/school/play), community, and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL) and instrumental

activities of daily Uving (LADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is improved.• Impact on disabiUties

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

• Risk reduction/preventionPressure on txxly tissues is reduced.

- Protection of body parts is increased.- Risk fectors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.

Self-management of symptoms is improved.- Stresses predpitating injury are decreased.

• Impact on health, wellness, and fitness- Health status is improved.

Physical capacity is increased.- Physical function is improved.

• Impact on sodetal resources- UtiUzation of.physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health care dollars.

• Patient/dient satisfection- Access, availability, and services provided are acceptable to patient/cUent.- Admitiistrative management of practice is acceptable to patient/cUent.- CUnical profidency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/cUent.

Cost of health care services is decreased.- Intensity of care is decreased.

Interpersonal skills of physical therapist are acceptable to patient/cUent, family, andsignificant others.

- Sense of weU-b)eing is improved.Stressors are decreased.

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Procedural Interventions continued

Airway Clearance Techniques

Interventions• Breattiing strategies

active cycle of breathing or forced expiratorytechniques

- assisted cough/huff techniquesautogenic drainagepaced breathingpursed Up breathingtechniques to maximize ventilation (eg, maxi-mum inspiratory hold, staircase breathing,manual hyperinflation)

• Manual/mechanical techniquesassistive devices

- chest percussion, vibration, and shaking- chest waU manipulation- suctioning- ventilatory aids

• Positioningpositioning to alter work of breathingpositioning to maximize ventilation andperfusion

- pulmonary postural drainage

Aitficipaisd Goals and Expedtd Outcomes• Impact on pathology/patiioptiysiology (cUsease, disorder, or condition)

- Atekctasis is decreased.- Nutrient delivery to tissue is increased.- Physiological response to increased oxygen demand is improved.- Symptoms associated with increased oxygen demand are decreased.- Tissue perfusion and oxygenation are entianced.

• Impact on impairments- Airway clearance is improved.- Cou^ is improved,- Enidurance is increased.- toetgy expeodititte per unit of woik is ttecreased.- Exercise tolerance is improved.- Muscle performance (strength, power, and endurance) is increased.- Ventilation and respiration/gas exctiange are improved.- Work of lireattiing is decreased.

• Impact on functional limitations- Ability to perform physical actions, tasks, or activities related to setf-care,

home management, woik (job/ sctiool/ play), community, and leisure isimpi'oved.

- Performance of and independence in activities of daily living (ADL) andin^xumental activities of daily living (IADL) with or without devices andequipment are increased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Ri^ reduction/prevention- R t t fectors are reduced.- Wesk of secondary impainnent is reduced.- Safety is improved.- Sdteiuiaiement of symjKoms is improved.

• Impact on health, wellness, and fitness- Health status is improved.- Physical function is Improved.

• Impact on sodetal resourees- Utilization of physical th«apy services is optimized.- Utiliration of physical therapy services rraults in effldent use of health

catecbllars.• Piattent/cUent satisfection

- Access, availability, and services provided are acceptable to patient/dient.' Adtninistrative management of practice is acceptaMe to patien^cUeat.- Clinical proficiency of piiysical ttterapi^ is acceptatde to patient/cHent.- Cooidinaticm of care is acceptable to patient/cUent.- Cost of health cate services is decreased.- Intcansity of care is ckcreased.- Intetpersonal skills of physicat therapi^ are acceptaMe to patient/dient,

feiiijty, and significaiu odiers.- Sense of welHieing is improved.- Stiessors are decieased.

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Procedurol Interventions continued

Electrotherapeutic Modalities

Interventions• Electrotherapeutic deUvery of medications

iontophoresis• Electrical stimulation

electrical muscle stimulation (EMS)- functional electrical stimulation (FES)

neuromuscular electrical stimulation (NMES)transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology

- Edema, lymphedema, or effusion is reduced.- Joint sweUing, itiflammation, or restriction is reduced.

Nutrient delivery to tissue is increased.- Osteogemc effects are enhanced.- Pain is decreased.- Soft tissue swelUng, inflammation, or restriction is reduced.- Tissue peifusion and oxygenation are enhanced.

• Impact on impairments- Integumentary integrity is improved.- Motor function (motor control and motor learning) is improved.- Musde perfonnance (strength, power, and endurance) is mcreased.- Postural control is improved.- QuaUty and quantity of movement between and across body seg-

ments are improved.Range of motion is improved.

- Relaxation is increased.- Sensory awareness is increased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self-

care, home management, community, work (job/ school/play), andleisure is improved.

- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily Uving (ADL)

and instrumental activities of daily living (LADL) with or withoutdevices and equipment are increased.

- Tolerance of positions and activities is increased.• Impact on disabiUties

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

• Risk reduction/preventionCompUcations of immobiUty are reduced.Risk fectors are reduced.Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.• Impact on health, weUness, and fitness

Physical capacity is increased.Physical function is improved.

• Impact on societal resourcesUtiUzation of physical therapy services is optimized.Utilization of physical therapy services results in efficient use ofhealth care doUars.

• Patient/client satisfection- Access, availabiUty, and services provided are acceptable to

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

patient/cUent.CUnical proficiency of physical therapist is acceptable topatient/cUent.

- Coordination of care is acceptable to patient/cUent.Interpersonal skills of physical therapist are acceptable topatient/cUent, family, and significant others.

- Sense of well-being is improved.Stressors are decreased.

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Procedurol Intervenrions conrinuedPhysical Agents and Mechanical Modalities

Interventions

Physical agents may mdude:• Cryotherapy

cold packsice massagevapocoolant spray

• Hydrotherapywhirlpool tankspools

• Thermotherapydry heat

- hot packsparaffin baths

Mechanical modalities may include:• Compression therapies

compression bandagingcompression garments

- taping• Gravity-assisted compression devices

standing frametilt table

Anticipated Goals and Expected• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Pain is decreased.- Soft tissue sweUing, inflammation, or restriction is reduced.- Tissue perfusion and oxygenation are entianced.

• Impact on impairments:- Integumentary integrity is improved.- Muscle performance (strength, power, and endurance) is increased.

Range of motion is improved.- We^t-bearing status is improved.

• Impact on functional Umitations- Ability to perform physical actions, tasks, or activities related to self-care, home

management, woik (job/school/play), community, and leisure is improved.- Performance of and independence in activities of daily Uving (ADL) and instrumen-

tal activities of daily Uving (IADL) with or without devices and equipment areincreased.

- Tolerance of positions and activities is increased.• Impact on disabilities

- AbiUty to assume or resume required self<are, home management, work(job/school/ptay), community, and teisure roles is improved.

• Risk reduction/prevention- Complications of soft tissue and circulatory disorders are decreased.- Risk of secondary impairments is reduced.- Self-management of symptoms is improved.

• Impact on societat resources- Utiti2ation of ptiysical therapy services is optimized.

• Patient/dient satisfection- Access, avaitabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.- CUnical proficiency of physical therapist is acceptable to patient/cUent.- Coordination of care is acceptable to patient/cUent.- Interpersonal skills of physical therapist are acceptable to patient/cUent, family, and

significant others.Sense of weU-tieing is improved.Stressors are decreased.

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

Global Outcomes for Patients/Clients in This PatternThroughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each interven-tion. These anticipated goals and expected outcomes are deUneated in shaded boxes that accompany the Usts of interventions in eachpreferred practice pattern. As the patient/cUent 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 thephysical therapy interventions in the follow ing domains:

• Pathology/pathophysiology (disease, disorder, or condition)• Impairments• Functional limitations• Disabilities• Risk reduction/prevention• Health, w eUness, and fitness• Societal resources• Patient/cUent satisfaction

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

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

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care w hen (1) thepatient/cUent, caregiver, or legal guardian decUnes to contmue intervention; (2) the patient/cUent is unable to continue to progress towardoutcomes because of medical or psychosocial CompUcations or because financial/insurance resources have been expended; or (3) the phys-ical therapist determines that the patient/cUent will no longer benefit from physical therapy. When physical therapy services are terminatedprior to achievement of anticipated goals and expected outcomes, patient/cUent status and the rationale for termination are documented.

For patients/cUents "who require multiple episodes of care, periodic foUow-up is needed over the life span to ensure safety and effective adap-tation foUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in con-sideration of the outcomes, the physical therapist plans for dischai^e or discontinuation and provides for appropriate foUow-up or referral.

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Impaired Peripheral Nerve Integrity andMuscle Perfarmance Associatea WithPeripheral Nerve Injury

This preferred practice pattern describes the generally accepted elements of patient/cUent management that physical therapistsprovide for patients/cUents who are classified in this pattern. The pattern titie reflects the diagncisis made by the physical thera-pist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of anumber of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the pro-fession s code of ethics and standards of practice; and patient/client age. cultnre, gender roles, race, sex, sexual orientation, andsocioeconomic status.

Patient/Client Diagnostic ClassificationPatients/clients wiU be classified into this pattern—for impaired peripheral nerve integrity and muscle performance associatedwith peripheral nerve injury—as a result of the physical therapist s evaluation of the examination data. The findmgs ftom theexamination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology(disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for heaith, wellness, or fitness pro-grams.The physical therapist integrates, synthesizes, and inti rprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support theinclusion of patients/cUents in this pattern:

Risk Factors ar Consequences af Pathalogy/Pathophysialagy(Disease, Disorder, ar Candition)• Neuropathies

(Carpal tunnel syndrome- Cubital tunnel syndrome- Erb palsy

Radial tunnel syndromeTarsal tunnel syndrome

• Peripheral vestibular disordersLabyrinthitisParoxysmal positional vertigo

• Surgical nerve lesions• Traumatic nerve lesions

Impairments, Functianal Limitations, or Disabilities• Difficulty with manipulation skiUs• Decreased muscle strength• Impaired peripheral nerve integrity• Impaired proprioception• Impaired sensory integrity• Loss of balance during daily activities• InabiUty to negotiate community environment• lack of safiety in home environment

Note:

Some risk factors or consequences of pathology/pathophysiology—such as peripheral vascular disease—maybe severe and complex; however, they do not necessarilyexclude patients/clients from this pattern. Severe and complexrisk factors or consequences may require modification of thefrequency of visits and duration of care. (See "Evaluation,Diagmisis, and Prognosis," page S399.)

Exclusion or Multiple-Pattern ClassificaHon

The following examples of examination findings may sup-port exclusion from this pattern or classification into addi-tional patterns. Depending on the level of severity or com-plexity of the examination findings, the physical therapistmay determine that the patient/client would be moreappro]iriately managed through (1) classification in anentirely different pattern or (2) classification in both thisand .mother pattern.

Findings That Atoy Require Classification in aDifferent Pattern• Impairments associated with Bell palsy• Imjiairments ass(x:iated with demyeUnating disease• R;iclictiiopathies

Findings That May Require Classification inAdditional Patterns

• Deciibitis ulcer• Reflex sympathetic dystrophy syndrome

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ICD-9-CM CodesThe Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practicepattern. Because patient/cUent diagnostic classification is based on impainnents, functional limitations, and disabiUties—not on codes—patients/cUents may be classified into the pattern even though the codes Usted w ith the pattern may not apply to those cUents.

This Usting is mtended for general information only and should not be used for coding purposes. The codes should be confirmed by refer-ring to the World Health Organizations International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001),Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding man-uals that contain exclusion notes and instructions regarding fifth-digit requirements.

225 Benign neoplasm of brain and other parts of nervoussystem

225.1 Cramal nerves

350 Trigeminal nerve disorders

350.1 Trigeminal neuralgia

352 Disorders of other cranial nerves

352.4 Disorders of accessory [11th] nerve

352.5 Disorders of hypoglossal [12th] nerve

352.9 Unspecified disorder of cranial nerves

353 Nerve root and plexus disorders

353.0 Brachial plexus lesions

353.1 Lumbosacral plexus lesions

353.6 Phantom limb (syndrome)

354 Mononeuritis of upper limb and mononeuritis multiplex

354.0 Carpal tunnel syndrome

354.2 Lesion of ulnar nerve

354.3 Lesion of radial nerve

355 Mononeuritis of lower Umb

357 Inflammatory and toxic neuropathy

357.1 Polyneuropathy in coUagen vascular disease*

386 Vertiginous syndromes and other disorders of vestibular

system

386.0 Meniere's disease

386.03 Active Meniere's disease, vestibular

386.1 Other and unspecified peripheral vertigo

386.3 Labyrinthitis

767 Birth trauma767.6 Injury to brachial plexus

Palsy or paralysis:Erb (Duchenne)

* Not a primary diagnosis

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ExaminationExamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to areferral to another practitioner. Examination is required prior to the initial intervention and is performed for aU patients/cUents.Throughthe examination, the physical therapist may identify impairments, functional limitations, disabiUties, changes in physical function or overallhealth status, and needs related to restoration of health and to prevention, weOness, and fitness.The physical therapist synthesizes theexamination findings to estabUsh the diagnosis and the prognosis (including the pian of care). The patient/client, family, significant others,and caregivers may provide information during the examination process.

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

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stageof recovery (acute, subacute, chrome); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), orcommunity situation; atid other relevant factors. Far clinical indicati<ms in selecting tests and measures and for listings of tests andmeasures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics• Age• Sex• Race/ethnicity• Primary language• Education

Social History• Cultural beUefs and behaviors• Family and caregiver resources• Social interactions, social activities, and

support systems

Employment/Work (Job/School/Play)• Current and prior work

(job/school/play), community, andleisure actions, tasks, or activities

Growth and Development• Developmental history• Hand dominance

Living Environment• Devices and equipment (eg, assistive,

adaptive, orthotic, protective, support-ive, prosthetic)

• Living environment and communitycharacteristics

• Projected discharge destinations

General Health Status (Self-Report,Family Report, Caregiver Report)• General health perception• Physical function (eg, mobility, sleep

patterns, restricted bed days)• Psychological fimction (eg, memory,

reasoning abiUty, depression, anxiety)• Role function (eg, community, leisure,

social, work)• Social function (eg, social activity, social

interaction, social support)

Social/Health Habits (Past and Current)• Behavioral health risks (eg smokmg,

drug abuse)• Level of physical fitness

Family History• FamiUal health risks

Medical/Surgical History• Cardiovascular• Endocrine/metaboUc• Gastrointestinal• Genitourinary• Gynecological• Integumentary• Musculoskeletal• Neuromuscular• Obstetrical• Prior hospitalizations, surgeries, and

preexisting medical and other health-related conditions

• Psychological• Pulmonary

Current Condition(s)/Chief Complaint(s)• Concerns that led patient/client to seek

the services of a physical tht rapist• Concerns or needs of patient/client

who requires the services of a physicaltherapist

• Current therapeutic interventions• Mechanisms of injury or diseast', includ-

ing date of onset and course of events• Onset and pattern of symptoms• Patient/client, family, significiint other,

and caregiver expectations and goalsfor the therapeutic intervention

• Patient/client, family, significant other,and caregiver perceptions of patient's/client's emotional response to the cur-rent clinical situation

• Previous ot cuirence of chief com-plaint(s)

• Prior therapeutic interventions

Functianal Status and Activity Level• Ctirrent and prior functional status in

self-care and home management activi-ties, including activities of daily Uving(ADL) and instrumental activities ofdaily Uving (L\DL)

• CXirrent and prior functional status inwork (job/school/play), community,and leisure actions, tasks, or activities

Medications• Medications for current condition• Medications previously taken for cur-

rent condition• Medications for other conditions

Other Clinical Tests• Laboratory and diagnostic tests• Review of available records (eg, med-

ical, education, surgical)• Review of other cUnical findings (eg,

nutrition and hydration)

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Systems Review

The systems review may include:

Anatamical and Physiological Status

• Cardiovascular/PulmonaryBlood pressure

- Edema- Heart rate- Respiratory rate

IntegumentaryPresence of scarformationSkin colorSkin integrity

MusculoskeletalGross range of motion

- Gross strength- Gross symmetry- Height- Weight

Neuromuscular- Gross coordmated

movements(eg, balance, locomotion,transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

• AbiUty to make needs known• Consciousness• Expected emotional/behavioral responses• Learning preferences (eg, education needs, learning barriers)• Orientation (person, place, time)

Tests and Measures

Test and measures for this pattern may mdude those that characterizeAerobic Capacity and Endurance• Aerobic capacity during functional activities (eg, activities of

daily Uving [ADL] scales, indexes, instrumental activities of dailyliving [IADL] scales, observations)

Anthropometric Characteristics• Body dimensions (eg, body mass mdex, girth measurement,

length measurement)• Edema (eg, girth measurement, palpation, scales, volume mea-

surement)

Assistive and Adaptive Devices• Assistive or adaptive devices and equipment use during func-

tional activities (eg, ADL scales, functional scales, IADL scales,interviews, observations)

• Components, alignment, fit, and ability to care for the assistiveor adaptive devices and equipment (eg, interviews, logs, obser-vations, pressure-sensing maps, reports)

• Safety during use of assistive or adaptive devices and equip-ment (eg, diaries, faU scales, interviews, logs, observations,reports)

Circulation (Arterial, Venous, and Lymphatic)• Cardiovascular signs, induding heart rate, rhythm, and sounds;

pressures and flow; and superficial vascular resp>onses (eg, aus-cultation, claudication scales, girth measurement, palpation,sphygmomanometry, thermography)

• Physiological responses to position change, includmg autonom-ic responses, central and peripheral pressures, heart rate andrhythm, respiratory rate and rhythm, ventilatory pattern (eg,auscultation, observations, palpation, sphygmomanometry)

or quantify;Cranial and Peripheral Nerve Integrity• Electrophysiological integrity (eg, electroneuromyography)• Motor distribution of the cranial nerves (eg, dynamometry, mus-

cle tests, observations)• Motor distribution of the peripheral nerves (eg, dynamometry,

musde tests, observations, thoracic outlet tests)• Response to neural provocation (eg, tension tests, vertebral

artery compression tests)• Response to stimuU, includmg auditory, gustatory, olfactory, pha-

ryngeal, vestibular, and visual (eg, observations, provocationtests)

• Sensory distribution of the cranial nerves (eg, discriminationtests; tactile tests, including coarse and Ught touch, cold andheat, pain, pressure, and vibration)

• Sensory distribution of the peripheral nerves (eg, discrimina-tion tests; tactile tests, including coarse and Ught touch, coldand heat, pain, pressure, and vibration; thoracic outlet tests)

Environmental, Home, and Work (Job/School/Play) Barriers• Current and potential barriers (eg, checkUsts, interviews, obser-

vations, questionnaires)

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Tests and Measures continued

Ergonomics and Body MechanicsErgonomics• Dexterity and coordmation durmg work (job/school/play)

(eg, hand function tests, impairment ratmg scales, manipula-tive ability tests)

• Functional capacity and performance during work actions,tasks, or activities (eg, accelerometry, dynamometry, electroneu-romyography, endurance tests, force platform tests, goniometry,interviews, observations, photographic assessments, physicalcapacity tests, postural loading analyses, technology-assistedanalyses, videographic assessments, work analyses)

• Safety in work environments (eg, hazard identification check-Usts, job severity indexes, lifting standards, risk assessmentscales, standards for exposure limits)

• Specific work conditions or activities (eg, handUng checklists,job simulations, lifting models, preemployment screenings, taskanalysis checklists, w^orkstation checklists)

• Tools, devices, equipment, and workstations related to workactions, tasks, or activities (eg, observations, tool analysis check-lists, vibration assessments)

Body mechanics• Body mechanics during self<are, home management, work,

community, or leisure actions, tasks, or activities (eg,ADL scales,IADL scales, observations, photographic assessments, technolo-gy-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance• Balance duhng functional activities with or without the use of

assistive, adaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg,ADL scales, IADL scales, observa-tions, videographic assessments)

• Balance (dynamic and static) with or without the use of assis-tive, atlaptive, orthotic, protective, supportive, or prostheticdevices or equipment (eg, balance scales, dizziness inventories,dynamic posturography, fall scales, motor impairment tests,observafions, photographic assessments, postural control tests)

• Gait and locomotion during functional activities with or with-out the use of assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices or equipment (eg,ADL scales, gaitprofiles, IADL scales, mobiUty skill profiles, observations, video-graphic assessments)

• Gait and locomotion with or without the use of assistive, adap-tive, orthotic, protective, supportive, or prosthetic devices orequipment (eg, dynamometry, electroneuromyography, foot-print analyses, gait profiles, mobiUty skiU profiles, observations,photographic assessments, technology-assisted assessments,videographic assessments, weight-bearing scales, wheelchairmobility tests)

• Safety during gait, locomotion, and balance (eg, confidencescales, diaries, fiiU scales, functional assessment profiles, logs,reports)

Integumentary Integrity

Associated sidn• Activities, positioning, and postures that produce or relieve

trauma to the skin (eg, observations, pressure-sensing maps,scales)

• Assistive, adaptive, orthotic, protective, supportive, or prosthet-ic devices and equipment that may produce or relieve traumato the skin (eg, observations, pressure-sensing maps, risk assess-ment scales)

• Skin characteristics, including bUstering, continuity of skincolor, dermatitis, hair growth, mobiUty, nail growth, tempera-tun, texture, and turgor (eg, observations, palpation, photo-graphic assessments, thermography)

Joint Integrity and Mobility• Si)ecific body parts (eg, apprehension, compression and distrac-

tion, drawer, glide, impingement, shear, and valgus/varus stresstests: arthrometry)

Motor Function (Motor Control and Motar Learning)• Dexterity, coortlination, and agility (eg, coordination screens,

motor impairment tests, motor proficiency tests, observations,videographic assessments)

• Hand function (eg, fine and gross motor control tests, fingerdexterity tests, manipulative ability tests, observations)

• Initiation, modification, and control of movement patterns andvoluntary postures (eg, activity indexes, developmental scales,gross motor function profiles, motor scales, movement assess-ment batteries, neuromotor tests, observations, physical perfor-mance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)• Elet trophysiological integrity (eg, electroneuromyography)• Mascle strength, power, and endurance (eg, dynamometry, man-

ual musde tests, musde performance tests, physical capacitytests, technology-assisted analyses, timed activity tests)

• Muscle strength, power, and endurance during functional activi-ties (eg, ADL scales, functional muscle tests, IADL scales, obser-vatii)ns, videographic assessments)

• Muscle tension (eg, palpation)

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Tests and Measures conrinued

Orthotic, Protective, and Supportive Devices• Components, alignment, fit, and ability to care for orthotic, pro-

tective, and supportive devices and equipment (eg, Interviews,logs, observations, pressure-sensing maps, reports)

• Orthotic, protective, and supportive devices and equipment useduring functional activities (eg,ADL scales, functional scales,IADL scales, interviews, observations, profiles)

• Remediation of impairments, functional limitations, or disabili-ties with use of orthotic, protective, and supportive devices andequipment (eg, activity status indexes, ADL scales, aerobic capac-ity tests, functional performance inventories, health assessmentquestionnaires, IADL scales, pain scales, play scales, videographicassessments)

• Safety during use of orthotic, protective, and supportive devicesand equipment (eg, diaries, fall scales, interviews, logs, observa-tions, reports)

Pain• Pain, soreness, and nociception (eg, analog scales, discrimination

tests, pain draw ings and maps, provocation tests, verbal and pic-torial descriptor tests,)

• Pain in specific body parts (eg, pain indexes, pain question-naires, structural provocation tests)

Posture• Postural alignment and position (dynamic), including symmetry

and deviation from midline (eg, observations, technology-assist-ed analyses, videographic assessments)

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

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

Ronge of Motion (ROM) (Including Muscle Length)• Functional ROM (eg, observations, squat tests, toe touch tests)• Joint active and passive movement (eg, goniometry, inclinome-

try, observations, photographic assessments, videographicassessments)

• Muscle length, soft tissue extensibility, and flexibility (eg, con-tracture tests, goniometry, inclinometry, ligamentous tests, Unearmeasurement, multisegment flexibility tests, palpation)

Reflex Integrity• Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)• Electrophysiological integrity (eg, electroneuromyography)• Postural reflexes and reactions, including righting, equilibrium,

and protective reactions (eg, observations, postural challengetests, reflex profiles, videographic assessments)

• Superficial reflexes and reactions (eg, observations, provocationtests)

Sel^Core ond Home Manogement (Including ADL and IADL)• Ability to gain access to home environments (eg, barrier identifi-

cation, observations, physical performance tests)• Ability to perform self-care and home management activities

w ith or without assistive, adaptive, orthotic, protective, support-ive, or prosthetic devices and equipment (eg,ADL scales, aero-bic capacity tests, IADL scales, interviews, observations, profiles)

• Safety in self-care and home management activities and environ-ments (eg, diaries, faU scales, interviews, logs, observations,reports, videographic assessments)

Sensory Integrity• Combined/cortical sensations (eg, stereognosis, tactile discrimi-

nation tests)• Deep sensations (eg, kinesthesiometry, observations, photo-

graphic assessments, vibration tests)• Electrophysiological integrity (eg,electroneuromyography)

Work (Job/School/Ploy), Community, and Leisure Integration orReintegration (Including IADL)• Ability to assume or resume work (job/school/play), community,

and leisure activities with or without assistive, adaptive, orthot-ic, protective, supportive, or prosthetic devices and equipment(eg, activity profiles, disability indexes, functional status ques-tionnaires, LADL scales, observations, physical capacity tests)

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

• Safety in work (job/school/play), community, and leisxire activi-ties and environments (eg, diaries, fall scales, interviews, logs,observations, videographic assessments)

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Evaluation, Diagnosis, and Prognosis (Including Plan of Care)Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and testsand measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis(including the plan of care). Factors that inftuence the complexity of the evaluation include the clinical findings, extent of loss of func-tion, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential dischargedestination, sociat considerations, physical function, and overall health statvis

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnosticprocess, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s)toward ^vhich the therapist wilt direct interventions. The prognosis is the determination of the predicted optimal tevet of improvement infunction and the amount of time needed to reach that levet and may also include a prediction of tevets of improvement that may t5ereached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care.The plan of care identifies specific interventions, proposed frequency and dimition of the interventions, anticipated goals, expected out-comes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, takii^ into consideration theexpectations of the patient/client and appropriate others.'rhese anticipated goiils lind expected outcomes should be measureable and timeLimited.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longerepisode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a varietyof factors that the physical therapist considers throughout the evaluation proc ess, such as anatomical and physiological changes related togrowth and development; caregiver consistency or expertise, chronicity or severity of the current condition; living environment; multisiteor multisystem involvement; sociat support; potential discharge destinations; probability of prolonged impairment, functional limitation, ordisability; and stability of the condition.

PrognosisExpected Ronge of Number of VisitsPer Episode of Core

Over the course of 4 to 8 montlis,patient/client will demonstrate optimalperipheral nerve integrity and muscle per-formance and the highest level of func-tioning in home, work (job/school/play),community, and leisure environments,within the context of the impairments,functional limitations, and disabilities.

During the episode of care, patient/clientwilt achieve (1) the anticipated goals andexpected outcomes of the interventionsthat are described in the plan of care and(2) the global outcomes for patients/clients who are classified in this pattern.

12to56This range represents the low«;r andupper limits of the number of physicaltherapist visits required to achieve antici-pated goals and expected outcomes. It isanticipated that 80% of patients/clientswho are classified into this pattern willachieve the anticipated goals and expect-ed outcomes within 12 to 56 t'isits dur-ing a single continuous episode of care.Frequency of visits and duration of theepisode of care should be determined byttie physical therapist to maximize effec-tiveness of care and efficient y of servicedelivery.

Foctors That May Require NewEpisode of Care or That May ModifyFrequency of Visits/Duration of Care

• Accessibility and availability ofresources

• Adherence to the intervention program• Age• Anatomical and physiological changes

related to growth and development• Caregiver consistency or expertise• Chronicity or severity of the current

condition• Cognitive status• Comorbitities, complications, or

secondary impairments• Conctirrent medical, surgical, and

therapeutic interventions• Decline in functional independence• Level of impairment• Level of physical function• Uving environment• Multisite or mtiltisystem involvement• Nutritional status• Overall health status• Potential discharge destinations• Premorbid conditions• Probability of prolonged impairment,

functional limitation, or disability• Psychological and socioeconomic

factors• Psychomotor abilities• Social support• Stability of the condition

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InterventionIntervention is the purposeful interaction of the physical therapist with the patient/client and, w hen appropriate, with other individualsinvolved in patient/client care, using various physical therapy procedtires and techniques to produce changes in the condition consistentw ith the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response andthe progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/ctient-retated instruction are provided for atl patients/cUents across all set-tings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the progno-sis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions,listings of interventions, and listings of anticipated goats and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions• Addressing required functions

advance directives- individualized family service plans (IFSPs) or individualized

education plans GEPs)informed consentmandatory communication and reporting (eg, patient advo-cacy and abuse reporting)

• Admission and discharge planning• Case management• Collaboration and coordination with agencies, includir^:

equipment supptiers- home care agencies

payer groupsschootstransportation agencies

• Communication across settings, inctuding:case conferencesdocumentation

- education plans• Cost-effective resource utilization• Data collection, analysis, and reporting

- outcome datapeer review findingsrecord reviews

• Doctimentation across settings, following APTA's Guidelinesfor Physical Therapy Documentation (Appendix 5), including:- changes in impairments, functional limitations, and

disabilitieschanges in interventionselements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)outcomes of intervention

• Interdisciplinary teamworkcase conferencespatient care roundspatient/client family meetings

• Referrals to other professionals or resources

Anticipated Goals ond Expected Outcomes• Accountability for services is increased.• Admission data and discharge planning are completed.• Advance directives, individualized family service plans (IFSPs)

or individualized education plans GEPs), informed consent, andmandatory communication and reporting (eg, patient advoca-cy and abuse reporting) are obtained or completed.

• Available resources are maximally utilized.• Care is coordinated with patient/client, family, significant oth-

ers, caregivers, and other professionals.• Case is managed throughout the episode of care.• Collaboration and coordination occtirs with agencies, includ-

ing eqtiipment suppliers, home care agencies, payer gtoups,schools, and transportation agencies.

• Communication enhances risk reduction and prevention.• Commtmication occurs across settings through case confer-

ences, education plans, and doctimentation.• Data are collected, analyzed, and reported, including outcome

data, peer review findings, and record reviews.• Decision making is enhanced regarding on health, weUness,

and fitness needs.• Decision making is enhanced regarding patient/client health

and the use of health care resotirces by patient/client, family,significant others, and caregivers.

• Documentation occtirs throughout patient/cUent managementand across settings and follows APTA's Guidelines for PhysicalTherapy Documentation (Appendix 5).

• Interdisciplinary collaboration occtirs through case confer-ences, patient care rounds, and patient/dient family meetings.

• Patient/cUent, femily, significant other, and caregiver tmder-standing of anticipated goals and expected outcomes isincreased.

• Placement needs are determined.• Referrals are made to other professionals or resources when-

ever necessary and appropriate.• Resotirces are utilized in a cost-effective way.

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Patient/Clien^Related Instruction

Patient/client-related instruction may include:

Interventions• Instruction, education and training of patients/clients and

caregivers regarding:current condition (pathology/pathophysiology [disease,disorder, or condition], impairments, functional limitations,or disabilities)enhancement of performance

- health. welUiess, and fitness pn)grams- plan of care

risk factors for pathotogj/pathophysiology (disease, disor-der, or condition), impairments, functional Umitations, ordisabilitiestransitions across settingstransitions to new roles

Aiitid|M)Atd Goob and Expeded Outcomes• AbiUtf to perform physical actions, tasks, or activities is

• Awareness and use of community resources are improved.• Behaviors that foster healthy habits, wellness, and prevention

are atpquired.• Decision making is enhanced r^aiding patient/cUent health

«nd the use of health care resources by patient/cUent, family,significant others, and caiegivers.

• EMSattfity a^ociated with actrte or chronic illnesses isreduced.

• Pimcttonal independence in acti^ttes of daily Uvii^ (ADL)and instrumental activities of daily living (IADL) is increased.

• Health stattis is improved.• Intensity of care is decreased.• Level of supervision required for task performance is

decreased.• Patierat/dient, family, significant other, and caregiver knowl-

edige and awareness of the di^no^s, prognosis, interventions,and ainticipated goals aiuJ expected outcomes are increased.

• I^tient/dient knowlec^e of personal and environmental fac-tors associated with the condition is increased.

• Perfofmance levels in self-care, home management, work(job/jchool/play), community, or ktsuie actions, tasks, or activ-ities ire improved.

• WiysiCal ftmction is improved.• Risk of recurrence of condition is reduced.• Risk of secondary impairment is reduced.• Safety of patient/dient, femily, significant others, and care-

givers is Improved.• Self-management of symptoms is improved.• Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include:

Theropeutic Exercise

Interventions• Aerobic and endurance conditioning or

reconditioningaquatic programs

- gait and tocomotor training- increased workload over time

walking and w^heelchair propulsion pro-grams

• Balance, coordination, and agiUty trainingdevelopmental activities training

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

- neuromuscular education or reeducationperceptual trainingposture awareness trainingstandardized, programmatic, comple-mentary exercise approachessensory training or retrainingtask-specific performance trainingvestibutar training

• Body mechanics and postural stabilization- body mechanics training- posture awareness training- postural control training- postural stabiUzation activities

• Flexibility exercisesmuscle lengtheningrange of motion

- stretching• Gait and locomotion training

- developmental activities traininggait trainingimplement and device trainir^

- perceptual trainingstandardized, programmatic, comple-mentary exercise approaches

- wheelchair training• Strength, power, and endurance training for

head, neck, limb, pelvic-ftoor, trunk, andventilatory muscles

active assistive, active, and resistive exer-cises (including concentric,dynamic/isotonic, eccentric, isokinetic,isometric, and plyometric)aquatic programsstandardized, programmatic, comple-mentary exercise approaches

- task-specific performance training• Relaxation

breathing strategies- movement strategies

relaxation techniques

Anticipated Goals and Expected Outcomes• Imi»ct on pathology/pathophysiolc^y (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.- Nutrient delivery to tissue is increased.- Osteogenic effects of exercise are maximized.- Pain is decreased.- Physiological response to increased oicygen demand is improved.- Soft tissue swelling, inflammation, or restriction is reduced.- Tissue perfusion and ox)^nation are enhanced.

• Impact on impairments- Aerobic capacity is increased.- Balance is improved.- Endtuance is increased.- Energy expenditure per tmit of woric is decreased.- Gait, locomotion, and balance are improved.- Integumentary integrity is improved.- Joint integrity and mobility are improved.- Motor function (motor control and motor learning) is Improved.- Musde performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body segments are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional Umitations- Ability to perform physical actions, tasks, or activities related to self-care, home

man^ement, work (job/school/play), commtmit>', and leisure is improved.- Level of supervision required for task performance is decreased.- Performance of and independence in activities of daily living (ADL) and instru-

mental activities of daily living (IADL) with or without devices and equipmentare increased.

- Tolerance of positions and activities is increased.• Impact on disabilities

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

• Risk reduction/prevention- Preoperative and postoperative complications are reduced.- Risk fectors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- Utilization of physical therapy services is optimized.- Utilization of physical therapy services results in effident tise of health caie dollars.

• Patient/dient satisfaction- Access, availability, and services provided are acceptable to patient/dient.- Administrative management of ptactice is acceptable to patient/dient.- Clinical proficiency of physical therapist is acceptable to patient/dient.- Coordination of care is acceptable to patient/dient.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal stalls of physical therapist are acceptable to patient/dient, family,

and significant others.- Sense of well-being is improved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• ADL training

- bathing- bed mobility and transfer training

developmental activitiesdressingeating

- groomingtoileting

• Functional training programssimulated environments and taskstask adaptationtravel training

• IADL training- caring for dependents- home maintenance

household choresshoppingstructured play for infants and childrenyard work

• Injury prevention or reduction- injurj' prevention education during self-care

and home managementinjury' prevention or reduction ^vith use ofdevices and equipmentsafety a'wareness training during setf<;areand home management

Anicipatad Gods and Expecfod Ouicomes• Impact on pathology/pathophysiology (disease, djsoidei; or condMon)

- Pain is decreased.- Physiological response to increased oxygrai demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Eneigy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle perfomuuicc (strength, ix)wer, and endurance) is increased.- Postural control is improved.- Sensory awareness is increased.- Weight-bearing status is improved.- Woik of breathing is decreased.

• Impact on functional limitations- AbiUty to perform physical actions, tasks, or activities related to self<arc

and hcHnme management is improved.- Level of supervision required fbr task performance is decreased.- Performance of and independence in ADL and IADL with or without

devices and equipment are increased.- Tolerance of positions and activities is increased.

• Impact on disabilities- Ability to assume or resume required seif-care and home management

roles is imprtwcd.• Risk reduction/prevention

• tRisk foctors axe reduced.- tU&k of secondary impairments is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources- UtiUzation of physical therapy services is optimized.- UtiUzation of physical therapy services results in efficient use of health

care dollars.• Patient/dient satis&ction

- Access, availabiUty, and services provided are accq)tabile to patient/cUemt.- Administrative management of practice is accc{>tabte to patient/dient.- CUnical proficiency of physical therapist is succeptaUe to patient/dient- Coordination of care is acceptable to patient/dient.- Cost of heahh care services is decreased.- Intensity of care is decreaised.- Interpersonal skills of physical tiierapist are acceptatde to patienl/cUent,

family, and signiil^ant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Interventions continued

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

Interventions• Functional training programs

- back schoolsjob coachingsimulated environments and taskstask adaptation

- task training- travel training

• IADL trainingcommunity service training involv-ing instrumentsschool and play activities trainingincluding tools and instruments

- work training with tools• Injury prevention or reduction

injury prevention educationduring work (job/school/play),community, and leisure integra-tion or reintegration

- injury prevention or reductionwith use of devices and equipmentsafety awareness trainingduring work (job/school/play),community, and leisureintegration or reintegration

• Leisure and play activities training

Anticipated Goals and Expected Outcomes• Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.- Physiological response to increased oxygen demand is improved.

• Impact on impairments- Balance is improved.- Endurance is increased.- Energy expenditure per unit of work is decreased.- Motor function (motor control and motor learning) is improved.- Muscle perfonnance (strength, power, and endurance) is increased.

Postural control is improved.Sensory awareness is increased.

- Weight-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform physical actions, ta^cs, or activities related to work

(job/school/play), community, and leisure integration or reintegration is Improved.- Level of supervision required for task performance is decreased.- Performance of and independence in IADL with or without devices and equipment

are increased.- Tolerance of positions and activities is increased.

• Impact on disabiUties- AbiUty to assimie or resume required work (job/school/play), community, and leisure

roles is improved.• Risk reduction/prevention

- Risk factors are reduced.- Risk of secondary impairment is reduced.- Safety is improved.- Self-management of symptoms is improved.

• Impact on health, weUness, and fitness- Fitness is improved.- Health status is improved.- Physical capacity is increased.- Physical function is improved.

• Impact on societal resourees- Costs of work-related injury or disabiUty are reduced.- Utilization of physical therapy services is optimized.- UtiUzation of physical therapy services results in effident use of health care doUars.

• Patient/cUent satis&ction- Access, availabiUty, and services provided are acceptable to patient/dient.- Administrative management of practice is acceptable to patient/dient.- CUnical proficiency of physical therapist is acceptaMe to patient/dient.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- Intensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, &mily, and

significant others.- Sense of weU-being is improved.- Stressors are decreased.

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Procedural Intervenrions continued

Manual Therapy Techniques (Including Mobilization/Manipulatian)

Interventions• Massage

- connective tissue massage- therapeutic mass^e

• Mobilization/manipulation- soft tissue

• Passive range of motion

Anticipated Goals and E; >ected Outcomes• Impact on pathoiogy/pathophysiotogy (disease, disorder, or condition)- Edema, lymphedema, or effusion is reduced.- Joint swelUng, inflammation, or restriction is reduced.- Pain is decreased.- Soft tissue swelling, inflammation, or restriction is reduced.

• Impact on impairments-. Balance is improved.- Energy expenditure per unit of work is decreased.- Gait, locomotion, and balance are improved.• Integumentary integrity is improved.- Muscle performance (strength, power, and endurance) is increased.- Postural control is improved.- Quality and quantity of movement between and across body se^nents are

improved.- Range of motion is improved.- Relaxation is increased.- Sensory awareness is increased.- Wei^t-bearing status is improved.- Work of breathing is decreased.

• Impact on functional limitations- Ability to perform movement tasks is improved.

• i | - Ability to perform physical actions, tasks, or activities related to self-care, home man^ ^ agement, worit (joh/school/play), community, and leisure is improved.

- Tolerance of positions and activities is increased." Impact on disabilities

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

• Risk reduction/prevention- Risk fectors are reduced.- Risk of recurrence of condition is reduced.- Risk of secondary impairment is reduced.- Self-management of symptoms is improved.

• Impact on health, wellness, and fitness- Physical capacity is increased.- Physical function is improved.

• Impact on societal resources• Utilization of physical therapy services is optimi2ed.- Utilization of physical therapy services results in efficient use of health care doUars.- Access, availabiUty, and services provided are acceptable to patient/cUent.- Administrative management of practice is acceptable to patient/cUent.• CUnical proficiency of physical therapist is acceptable to padent/cUent.- Coordination of care is acceptable to patient/cUent.- Cost of health care services is decreased.- bitensity of care is decreased.- Interpersonal skills of physical therapist are acceptable to patient/dient, family, and

significant others.- Sense of weU-being is improved. :- Stressors are decreased. :

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