PART TWO:

Ml

Preferred Practice

') /
/
--y

MusculoskeletoJ
r "- V

Neuromuscular

Cardiovascular/ Pukiiionary

Integumentary

How to Use the Preferred Practice Patterns

art Two contains the preferred practice patterns, which are grouped under four 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; on the following pages, take a walk through one exampte of how physical therapists may use Part Two in the management of patients/clients.

Contents of Each Pattern at a Glance

Patient/Client Diagnostic Classification Criteria for irKlusion (based on examination findings regarding risk factors or consequences of patfiology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities] Criteria for exclusion from pattern or for muhiple-pattem classification (based on examination findings] ICD-9-CM Codes

2
Codes that may relate to the practice pattern intended only for information purposes, not for coding purposes

The Five Elements of Patient/Client Management

Examination Evaluation, Diagnosis, 4 and Prognosis (Including Plan af Care) Description of the evaluation, diagnostic, and prognostic processes, including the expected range of number of visits and factors that may require a new episode of care or that may modify frequency of visits and duration of the episode

3
Description 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

Reexaminatian, Global A Outcomes, and Criteria for Termination of Physical Therapy Services Description of when reexamination is indicated; measurement of global outcomes of physical therapy services in 8 domains; the 2 ways in which physical therapy services are terminated

5
A listing of the interventions that may be used for patients/clients who are classified in the pattern

Guide to Physical Therapist Practice

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Examination
First, the patient/client provides a history.Through the history, the physical therapist gathers datafrom 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 complaints of the patient/ctientin this example, the inability to walk without pain and a sensation of "buckling" in both knees and the inability to participate in recreational sports.

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

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

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

During the evaluation process, all data from the history, systems review, and tests and measures are synthesized to establish the diagnosis and the prognosis, including the plan of care. In this example, based on the evaluation of the history, systems review, and tests and-measures data, the physical therapist determines that the patient/ctient has the following primary impairments: impaired joint integrity and mobility in the knees; decreased muscle performance; decreased range of motion; and decreased aerobic capacity/endurasice with ambulation.The physical therapist hypothesizes that the morbid obesity maj- be contributing to the knee pain as well as to the decrease in aerobic capacity/endurance, 1 he physical therapist notes the following functional limitations: difficulty in performing ADL and IADL, inability to run bases during softball league games, and inability to jierform heavy household chores. Disability is noted in the following roles: community/leisure (inability to participate on the league softball team), work (job/school/play) (inability to walk to different work sites within the same plant), and home management (inability to perform as homemaker). Even though patients/cUents may be referred to physical therapy services with a medical diagnosis, that does not tell the physical therapist how to manage the patient/client.The medical diagnosis is a diagnostic label that identifies disease at the tevel of the cell, tissue, organ, or system. In this case, for instance, the medical diagnosis may be osteoarthritis of ihe knees. The physical therapist s diagnosis, however, is a diagnostic label that identifies the impact of a condition on funetion at the level ofthe system (especially the movement system) and at the level ofthe whole person. The physical therapist s goal is to restore function, and therefore the physical therapist s examination, evaluation, and interventions focus on impairments, functional limitations, disabilitit s, risk factor reduction, and prevention. In this example, the physical therapist determines that decreased muscle performance, decreased range of motion, and pain are the primary contributors to the identified functional limitations,The physical therapist also has noted that the patient/client has decreased aerobic/capacity endurance,The physical therapist therefore focuses on lour preferred practice patterns: "Impaired Muscle Performance" (Pattern 4C) "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction" (Pattern 4D) "Impaired Joint Mobility, Motor I'unction, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4E) and "Impaired Aerobic Capacitv/Endurance Associated With Deconditioning" (Pattern 6B),

nn Om Mi^ ii^Mn h4n

CHAPTER 4

Preferred Practice Pattern

Musculo kcletai

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Evaluation continued
Impaired Muscle Performance

The physical therapist considers the primary impairments to determine which of the four possible patterns may be the most appropriate classification for the patient/client.The physical therapist scans the inclusions and exclusions for each pattern and the ICD-9-CM codes that are listed in each pattern. If the physical therapist remains uncertain about patient/client classification, the tests-and-measures sections of the individual patterns may suggest additional tests and measures that the physical therapist can perform to confirm placement of the patient/client into a pattern. In this example, the history and systems review show signs and symptoms of joint effusion but indicate that joint integrity and mobility are not contributing factors.The physical therapist therefore classifies the patient/ client in "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation" (Pattern 4F). The patient/client also has a history of diabetes. If the physical therapist determines that patient/client monitoring for primary prevention of lower-extremity vascular problems and the need to increase aerobic capacity are high priorities, the physical therapist may place the patient/client in an additional pattern: "Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders" (Pattern 6B). Based on the evaluation, the physical therapist makes the prognosisthat is, determines the predicted optimal level of improvement in function and the amount of time needed to reach that level.The physical therapist refers to the evaluation section of the selected pattern to ascertain whether the therapist s prediction of improvement, frequency of visits, and duration of episode of care are consistent with the expected prognosis and range of number of visits for patients/clients who are classified in that pattern.The physical therapist also notes any factors (eg, age, chronicity or severity of the current condition, adherence to the intervention program) that may modify the frequency of visits or duration of the episode. In this example, on the basis of such modifying factors as extremely high patient/client motivation, the physical therapist may determine that the patient/client ^vill require fewer visits than are expected to achieve the anticipated goals and expected outcomes for 80% of patients/clients who are classified in the pattern. On the other hand, the presence of morbid obesity may indicate that the patient/client may not be able to improve aerobic capacity/endurance at an expected rate. In addition, if the hypertension and diabetes become uncontrolled, the ability of the patient/client to participate in physical therapy may be affected.

Impaired Joinf Mobility, Motor Function, Muscle Performance, and Range of Motion Associaled Wiih Connective Tissue Dysfunction

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

Impofred Aerobic Capacity/Endurance Associated With Deconditioning

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Intervention
As part of the prognostic process, the physical therapist develops a plan of care,This plan delineates the types of interventions (physical therapy procedures and techniques) to be used to produce changes in the condition and in patient/client status, the frequency and duration of those interventions, anticipated goals, expected outcomes, and discharge plans. Anticipated goals and expected outcomes should be measurable and time limited. Each pattern contain.'^ a listing of interventions that are likely to be used for patients/clients who are classified in the pattern. Coordination, communication, and documentation and patient/ciient-related instruction are interventions that are provided to all patients/clients across all settings. The use of procedural interventions varies for the particular patient/client in the specific pattern. (For examples of clinical considerations for the use of procedural interventions, refer to Chapter 3,) In this example, the physical therapist might select interventions that emphasize therapeutic exercise, functional training in self-care and home management (including ADL ,ind IADL), and functional training in community and work (job/school/play) integration or reintegration (including IADL, w^ork hardening, and work conditioning) in addition to interventions to modulate piiin and diminish the effects of joint effusion.

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h o w to Use the Preferred Proctice Patterns 1 3 7 / S 1 2 9

Reexamination, Global Outcomes, and Criteria for Termination of Physical Therapy Services
Reexaminationthe process of performing selected tests and measures after the initial examination to determine progress and modify or redirect interventionsmay be indicated more than once during a single episode of care. In this example, the physical therapist may decide to perform a reexamination if the patient/client develops a ne^w condition or shows no progress. Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These goals and outcomes are delineated in the shaded boxes that accompany each list of interventions in each pattern. As the patient/ client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes (that is, the impact) of the physical therapy services in the following domains: pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/prevention; impact on health, wellness, andfitness;societal resources; and patient/client satisfaction. The physical therapist uses two processes for terminating physical therapy services: discharge and discontinuation, tf the physical therapist determines that the anticipated goals and expected outcomes have been achieved, the patient/client is discharged from physical therapy services. Physical therapy services are discontinued (1) when the patient/client declines to continue intervention, (2) when the patient/client is unable to continue to progress toward the anticipated goals and expected outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended, or (3) when the physical therapist determines that the patient/client witl no longer benefit from physical therapy, A template for documenting all aspects of patient/client management, including termination of physical therapy services, is provided in Appendix 6, t^tient/client satisfaction outcomes may be collected using the Patient/Client Satisfaction Questionnaire in Appendix 7,

Global Outcomei for Patienb/ClMnti in This Pottem

Critrio for lenninotion of Ptiysicaj Hierapy Services

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CHAPTER 4 Preferred Practice Patterns: Musculoskeletal

Preferred practice patterns describe the five elements of patient/ciient management that are provided by physical therapists: examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis (including plan of care), and intervention (with anticipated goals and expected outcomes). Each pattern also addresses reexamination, global outcomes, and criteria for termination of physical therapy services. Examples of ICD-9-CM codes are included.

Pattern A: Primar>' Prevention/Risk Reduction for Skeletal Demineralization PaHern B: Impaired Posture Pattern C: Impaired Muscle Performance Pattern D: Impaired Joint Mobility Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction Pattern E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation Pattern F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associate d With Spinal Disorders Pattern G: impaired Joint Mobility. Muscle Performance, and Range of Motion Associated With Fracture Pattern H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Aithroplasty Pattern I: Impaired Joint Mobility Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery Pattern J: Impaired Motor Function, Muscle Performance, Range of Motion, Gait, Locomotion, and Balance Associated With Amputation SI33 S145 S161

SI 79

SI97

S215 S233

S251

S269

S287

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139/S131

Primary Preventian/Risk Reduction far Skeletal Demineralizatian

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide 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 number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status,

Patient/Client Diagnostic Classification

Patients/clients will be classified in this primary prevention/risk reduction pattern as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the need for a prevention/risk reduction program or for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

inclusion

The following examples of examinationfindingsmay support the inclusion 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 patterns. Patients/clients included in this pattern are in need of primary prevention/risk reduction only.

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ICD-9 CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those patients/clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 138 262 263 268 269 275 337 Late effects ol acute poliornyelitis Other severe, protein-calorie malnutrition Other and unspecified protein-calorie malnutrition Vitamin D deficiency Other nutritional deficiencies Disorders of mineral metabolism Disorders of the autonomic nervous system 337.2 344 Reflex sympathetic dystrophy 733 732 731 729 Other disorders of soft tissues 729.9 Other and unspecified disorders of soft tissue Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 Osteitis deformans wthout mention of bone tumor Paget's disease of bone Osteochondropathies 732.0 Juvenile osteochondrosis of spine 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 Curvature of spine 737.3 Kyphoscoliosis and scoliosis 737.4 Curvature of spine associated with other conditions* Other congenital musculoskeletal anomalies 756.5 Osteodystrophies 756.51 Osteogenesis imperfecta

Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia 344.3 Monoplegia of lower limb Disorders resulting from impaired renal function Menopausal and postmenopausal disorders Rheumatoid arthritis and other inflammatory polyarthropathies 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 joint Calcification of joint Disorders of muscle, ligament, and fescia 728.2 Muscular wasting and disuse atrophy, not elsew^here classified 728.3 Other specific muscle disorders Arthrogryposis

588 627 714 719

737

756

728

Not a primary diagnosis

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Examination
Examination is a comprehensive screening and specific testing pnjcess that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner Examination is required prior to the initial intervention and is performed for all patients/clients,Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness,The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, 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 gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist,The systems review is a brief or limited examination of (1) the anatomical and physiological status ofthe cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors, /-or clinicat indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by teat.'; and measures, refer to Chapter 2. Patient/Client History The history may include:
General Demographics Social/Health Habits (Past ond Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected dischai^^e destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Mu.sculoskeletal Neuromuscular Obstetriciil Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary
Current CondiKon(s)/Chief Complaint(s)

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of cliiily living (IADL) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications tor other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

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)

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 physical therapist Current therapeutic interventions Mechanisms of injury or cli,sea,se, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions < if patient's/ client's emotional response to the current clinical situation Previous occurrence of chit;f complaint(s) Prior therapeutic interventions
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Systems Review

The systems review may include:

Anatomical and Physiological Status

Cardiovascular/Pulmonary Blood pressure Edema Heart rate Respiratory rate

Integtimentary Presence of scar formation - Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:
Aerobic Capacity and Endurance Gait, Locomotion, and Balance

Aerobic capacity during standardized exercise test protocols (eg, er^ometry, step tests, time/distance walk/rtm tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Body dimensions (eg, body mass index, girth measurement, length measurement)
Arousal, Attention, and Cognition

Motivation (eg, adaptive behavior scales)

Environmental, Home, and Work (Job/School/Play) Barriers

Balance during functional activities -with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Motor Function (Motor Control and Motor Learning)

Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, activities of daily Uving [ADL] scales, instrumental activities of daily living [LVDL] scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

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, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

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Tests and Measures continued

Posture Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, videogra|>hic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations; photographic assessments) Range of Motion (ROM) (Including Muscle Length) Functional ROM (eg, observations, squat tests, tt>e touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Self-Care and Home A^nagement (Including ADL and IADL) Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) . Saft ty in self-care and home management activities and environmeats (eg, fall scales, interviews, observations) 1 , 1 / ^ 1 1 / 1 , ^ . . Work (Job/Schoo /P ay) Community, and Leisure Integration or Reintegration (Including IADL) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, oliservations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activiti< s 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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status, A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination,The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination ofthe predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others,These anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode -with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.
Expected Ranqe of Number of Visits Per Episode of Care 3to18 Factors Thot May Modify Frequency of Visits

Prognosis

Patient/client will reduce the risk of skeletal demineralization through strengthtraining and weight-bearing therapeutic exercise programs and through lifestyle modifications.

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% ofpatients/ clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 3 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, complications, or secondary impairments Concurrent medical, surgical, and therapeutic interventions Decline in functional independence Level of impairment Level of physical function Living environment Multisite or multisystem involvement Nutritional status Overall health status Potential discharge destinations Premorbid conditions Probability of prolonged impairment, functional limitation, or disability Psychological and socioeconotnic factors Psychomotor abilities Social support Stability of the condition

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved with the patient/client, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made tow^ard achieving the anticipated goals and expected oxitcomes, (>>mmunication, coordination, and documentation and patient/ciient-related instruction are provided for all patients/clients. Procedural interventions are selected or modified based on the examination data, the eviiluation, the diagnosis, the prognosis, and the anticipated goals and expected outcomes for a particular patient/client For clinical consitlerations in selecting interventions, listings of interventions, 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: Interventions Addressing required functions individualized family service plans (IFSPs) or individualized education plans (IEPs) informed consent mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) Collaboration and coordination with agencies, including: equipment suppliers home care agencies payer groups schools transportation agencies Communication, including: education plans documentation Data collection, analysis and reporting outcome data peer review tlndings record reviews Documentation elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Referrals to other professionals or resources
Patient/Client-Related Instruction

Anticipated Goals and Expected Outcomes Accountability for services is increased. Individualizedfemilyservice plans (IFSPs) or individualized education plans (IEPs), infbrmed consent, and mandatory communication arid reporting (eg, patient/client advocacy and abuse reportirig) are obtained or completed. Available resources are maximally utilized. Collaboration and coordination occurs with agencies, including equipment suppliers, home cate agencies, payer groups, schools, and transportation agencies. Communication occurs through education plans and documentation. Data are collected, analyzed, and reported, includii^ outcome data, peer review findings, and record reviews. Decision making is enhanced regarding patient/client healtini and the use of health care resources by patient/client,fiunlly,significant others, and caregivers. Documentation occurs throughout patient/client management andfollowsAPTA s Guidelines for Physical Therapy Documentation (Appendix 5). Patient/client,femily,significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utilized in a cost-effective way.

Patient/ciient-related instruction may include: Interventions Anticipated Gods and Expected Outcomes Instruction, education, and training of Ability to perform physical actions, tasks, or activities is improved. patients/clients and caregivers Awareness and use of community resources are improved, regarding: Behaviors that foster healthy habits, wellness, and prevention are acquired. enhancement of performance Decision making is enhanced iegatding patient/client health and the use of health health, wellness, and fitness care resources by patient/cUent,femily,significant others, Mid caregivers. programs Health status is improved, plan for intervention Patient/client, family, significant other, and caregiver knowledge and awareness of the - risk factors for pathology/ diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are pathophysiology (disease, disorder, increased, or condition), impairments, func Patient/dient knowledge of personal and environmental fectors associated with the tional limitations, or disabilities condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced, Safety of patient/client,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 Anticipated Goals and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning aquatic programs gait and locomotor training increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agility training developmental activities training motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation - posture awareness training standardized, programmatic, complementary exercise approaches task-specific performance training Body mechanics and postural stabilization - body mechanics training - posture awareness training postural control training - postural stabilization activities Flexibility exercises muscle lengthening range of motion - stretching Gait and locomotion training developmental activities training gait training - implement and device training - perceptual training standardized, programmatic, complementary exercise approaches Relaxation breathing strategies movement strategies relaxation techniques standardized, programmatic, complementary exercise approaches Strength, pow^er, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles - active assistive, active, andresistiveexercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs - standardized, programmatic, complementary exercise approaches - task-specific performance training

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 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 dally 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), commimity, and leisure roles is improved. Risk reduction/prevention Risk 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 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/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] and Instrumentol Activities of Daily Living [IADL]) Interventions Antkipotsd Goals and Expected Outcomes

Barrier accommodations or modifications Injury prevention or reduction injury prevention education during seU-care and home management injury prevention or reduction with use of devices and equipment - safety awareness training during self<:are and home management

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 selfcare 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 management 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 to patient/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 to patient/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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Anticipated Goals and Outcomes

Barrier accommodations or modifications Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment - safety awareness training during work (job/school/play), community, and leisure integration or reintegration

Impact on pathology/pathophysiology (disease, disorder, or condition) Physiological response to increased oxygen demand is improved. Impact on impairments - Postural control is improved, - Weight-bearing status is improved. Impact on functional limitations - AbiUty to perform physical actions, tasks, or activities related to work (job/school/play), commimity, and leisure integration or reintegration is improved, - 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 disabilities - Ability to assume or resume required 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. Impact on health, wellness, and fitness Fitness 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 to patient/client, - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client, - Cost of health care services is decreased. - Interpersonal skills of physical therapist are acceptable to patient/client,femily,and significant others. Sense of well-being is improved. - Stressors are decreased.

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of 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 ofthe physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facilitj'-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; < 2 > the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or becausefinamial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/ciient status and therationalefor termination are documented. For patients/clients who require multiple epistxles of care, periodicfollow-upi * needed over the life span to ensure safety and effective adap* tationfollowingchanges in physical status, caregivers, environment, or t;isk demands. In consultation with appropriate individuals, and in consideration 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 therapists provide tor patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist, APTA emphasizes that preferred practice patterns art- the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles,race,sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified in this pattern for impaired posture as a rt suit of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or comlition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the examination data to determine the diagnostic classification.
Inclusion

Exclusion or Multiple-Pattern Classification The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

The following examples of examinationfindingsmay support the 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 Impaired joint mobility Inability to tolerate prolonged sitting Leg length discrepancy Muscle imbalance Muscle weakness

Impairments, Functional Limitations, or Disabilities

Impairments associated with chronic obstructive pulmonary disease with kyphosis Impairments associated with spinal stabilization surgery Radicular signs
Findings Thot May Require Classification in Additionol Patterns

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as primary posture impairment associated with cerebral patsymay be severe and complex; however, ^/bey do not necessarily exclude patients/clients from tbis pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care (See "Evaluation, Diagnosis, and Prognosis,' page SI50,)

Impairments associated with scoliosis, with contusion of the thigh

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ICD-9-CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 524 568 718 719 Dentofecial anomalies, including malocclusion 524.6 Temporomandibular joint disorders Other disorders of peritoneum 568.0 Peritoneal adhesions (postoperative) (postinfection) Other derangement of joint 718.8 Other joint derangement, not elsewhere classified Other and tmspecified disorders of joint 719.5 Stiffness of joint, not elsewhere classified 719.7 Difficulty in walking Intervertebral disk disorders 722.4 Degeneration of cervical intervertebral disk 722.5 Degeneration of thoracic or lumbar intervertebral disk 722.6 728 Disorders of muscle, ligament, and fascia 728.2 Muscular w^asting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 729.9 Other and unspecified disorders of soft tissue Osteochondropathies 732.0 Juvenile osteochondrosis of spine Other disorders of bone and cartilage 733.0 Osteoporosis Other acquired deformities of limbs 736.3 Acquired deformities of hip 736.4 Genu valgtim or varum 736.7 Other acquired deformities of ankle and foot 736.8 Acquired deformities of other parts of limbs 736.81 Unequal leg length (acquired) Curvature of spine 737.1 Kyphosis (acquired) 737.2 Lordosis (acquired) 737.3 Kyphoscoliosis and scoliosis Other acquired deformity 738.4 Acquired spondylolisthesis 738.6 Acquired deformity of pelvis Other congenital musculoskeletal anomalies 756.1 Anomalies of spine Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait 781.9 Other symptoms involving nervous and musculoskeletal systems 781.92 Abnormal posture

729

732 733 736

722

Degeneration of intervertebral disk, site unspecified 723 Other disorders of cervical region 723.1 Cervicalgia 723.5 Torticollis, tinspeclfled 724 Other and tmspecified disorders of back 724.1 Pain in thoracic spine 724.2 Lumbago Low back pain Low back syndrome Lumbalgia 724.6 Disorders of sacrum 724.9 Other unspecified back disorders Ankylosis of spine, not otherwise specified Compression of spinal nerve root, not else where classified Spinal disorders, not otherwise specified 725 Polymyalgia rheumatica

737

738

756 781

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Examination
Fxamination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner Examination is required prior to the initial intervention and is performed for all patients/clients.Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness.The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components; the patient/client history, the systems review, and tests and measures,The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems revieiv is a brief or limited examination of (1) the anatomical and physiological status ofthe cardiovascular/pulmonary, integtimentary, musctiloskeletal, and neuromuscular systems and (2) ttie crommtinication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination v;u7 ba.sed on patient/ciient age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (earh', intermediate, late, rettirn to activity); home, work (job/school/play), or community sittiation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2. Patient/Client History The history may include;
General Demographics Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medicol/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Uving environment and community characteristics Projected discharge destinations
General Health Status (Self Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Ciastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Netiromtisctilar Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary 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 physical therapist Ctirrent therapeutic interventions Mechanisms of injury or disease. Including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response; to the current clinical sittiation Previous occurrence of chief complaint(s) Prior therapeutic interventions

Current and prior fimctional stattis in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) C-urrent and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications fbr current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

Current Condition(s)/Chief Complaint(s)

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)

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Systems Review

The systems review may include:

Anatomical ond Physiological Status

Cardiovascular/Ptilmonary Blood pressure Edema Heart rate Respiratory rate

Integtimentary - Presence of scar formation Skin color Skin integrity

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

Neuromuscular - Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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

Tests and Measures

Tests and measures 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 functional activities (eg, activities of daOy living [ADL] scales, functional scales, instrtimental activities of daily living [IADL] scales, interviews, observations) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, intervie^vs, logs, observations, reports)
Ergonomics and Body Mechanics

Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Motor Function (Motor Control and Motor Learning)

Ergonomics Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endtirance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in w^ork environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg,ADL scales, LVDL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)
Goit, Locomotion, and Bolance

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes)
Muscle Performance (Including Strength, Power, and Endurance)

Electrophysiological integrity (eg, electronetiromyography) Muscle strength, po^ver, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments)

Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

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Tests and Measures continued

Pain

Self-Care and Home Management (Including ADL and IADL)

Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Safety in self-care and home management activities and environments (eg, diaries, fall scales, intervie^vs, logs, observations, reports, videographic assessments)
Sensory Integrity

D ep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

Work (Job/School/Play), Community, and Leisure Integration or Reintegration (including IADL)

Postural alignment and position (dynamic), including syntmetry and deviation from midline (eg, observations, technology assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations; photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional te.sts)
Range of Motion (ROM) (Including Muscle Length)

Sa(et>' in work (job/school/play), community, and leisure activities and environments (eg, diaries,fellscales, interviews, logs, observations, videographic assessments)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, int liiiometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, Ugamentous tests, linear measurement, 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 revie^w, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status, A diagnosis is a label encompassing a cluster of signs and sj'mptoms, syndromes, or categories. It is the restilt of the systematic diagnostic process, 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 in function and the amotmt of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the 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 outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the ctirrent condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Expected Range of Number of Visits Per Episode of Care 6 to 20

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode

Over the course of 3 to 6 months, patient/client will demonstrate the ability to maintain an optimal posture and the highest level of functioning in home, w^ork (job/school/play), community, and leisure environments. During the episode of care, patient/client w^ill achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 20 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, complications, or secondary impairments Concurrent medical, surgical, and therapeutic interventions Decline in functional independence Level of impairment Level of physical function Living environment Multisite or multisystem involvement Nutritional status Overall health status Potential discharge destinations Premorbid conditions Probability of prolonged impairment, functional limitation, or disability Psychological and socioeconomic factors Psychomotor abilities Social support Stability of the condition

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and documentation and patient/ciient-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation Coordination, communication, and documentation may include;

Interventions
Addressing required fimctions advance directives individualized family service plans (IFSPs) or individualized education plans GEPs) - infbrmed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning C^ase management Collaboration and coordination with agencies, including; equipment suppliers home care agencies - payer groups - schools transportation agencies Communication across settings, including; case conferences documentation education plans (;ost-effective resource utilization Data collection, analysis, and reporting outcome data peer review findings record reviews Documentation across settings, following APTA's Guidelines fbr Physical Therapy Documentation (Appendix 5), including; - changes in impairments, functional limitations, and disabilities changes in interventions elements of patient/client management (examination, evalviation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences patient care rounds patient/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, and mandatory ccmuntinication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized. Care is coordinated with patient/client, amity, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including equipment suppliers, home care ^encies, payer gtoups, schools, and transportation agencies. Commtmication enhances risk reduction and prevention. Communication occurs across settings through case conferences, 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. Decion 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 management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client femily meetings. Patient/client, family, significant other, and caregiver understan<ling of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources wherjever 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 Anticipated Goals and Expected Outcomes

Instruction, education, and training of patients/cUents and caregivers regarding; - current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities) enhancement of performance health, w^ellness, and fitness programs plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, fimctional limitations, or disabilities transitions across settings transitions to new roles

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 prevention are acquired. Decision, making is enhanced regarding patient/ciient health and the use of health care resources by patient/client,femity,significant others, and caregivers. Disability associated with acute or chronic illnesses is reduced, Ftmctional independence in activities of daily living (ADL) and instrumental activities of daily living (LADL) is increased. Health status is improved. Intensity of care is decreased. Level of supervision required for task performance is decreased. Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/client knowledge of personal and environmental factors associated with the condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/client, family, significant others, and caregivers is improved. Self-management of symptoms is improved. Utilization and cost of health care services are decreased.

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Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise
Interventions Anticipatd Goals and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning - aquatic programs - gait and locomotor training increased workload over time walking and \vheelchair propulsion programs Balance, c<x)rdination, and agility training - developmental activities training motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation percepttial training posture awareness training - standardized, programmatic, complementary exercise approaches task-specitic performance training Body mechanics and posttiral stabilization body mechanics training posture awareness training postural control training postural stabilization activities Flexibility exercises muscle lengthening range of motion stretching RelaxatioiT breathing strategies movement strategies relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches - task-specific performance training

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 instrumental activities of daily living (IADL) with or wiliiout 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), 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]) and Instrumental Activities of Daily Living [IADL]) Interventions Anticipated Goals and Expected Outcomes

ADL training bathing bed mobility and transfer training developmental activities dressing - eating - grooming toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and LADL - orthotic, protective, or supportive device or equipment training 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 children yard work Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safet>' awareness training during seU-care and home management

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 management roles is improved. Risk reduction/prevention Risk factors are reduced. Risk of secondary impairments is reduced. - Safety is improved. - Self-management of symptoms is improved. Impact on health, wellness, and fitness - 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 to padent/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 Intervenrions 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 Anticipated Gods and Expacted Ovtcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL Functional training programs back schools job coaching simulated environments - task simulation and adaptation task training IADL training community service training involving instrtiments school and play activities training including tools and instruments work training with tools Injur>' prevention or reduction injury prevention education during work (job/school/play), community; and leisure integration or reintegration injury prevention or reduction with use of devices and equipment - safety awareness training during w^ork (job/school/play), communit>, and leisure integration or reintegration Leisure and play activities and training

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 iiniitatiis - 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. - Toletance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required work (job/school/play), conimunity, 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 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 Anticipated Goals and Expected Outcomes

Manual traction Massage connective tissue massage therapeutic massage Mobilization/manipulation - soft tissue spinal and peripheral joints Passive range of motion

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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Procedural Interventions continued

,p

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Interventions Antic^xited Gods (sid Expsdad OuMEXMnes

Adaptive devices seating systems Assistive devices canes - crutches - power devices static and dynamic splints walkers wheelchairs Orthotic devices braces casts - shoe inserts splints Protective devices braces cushions protective taping Supportive devices corsets - neck collars serial casts - slings supportive taping

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

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Procedural Interventions continued

Electrotherapeutic Modalities

Interventions

Anticipated Goals and Expected Outcomes

Biofeedback Electrical stimulation - electrical muscle stimulation (EMS) - functional electrical stimulation (FES) transcutaneous electrical nerve stimulation (TENS)

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 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 management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and eqtiipment 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 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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Physical Agents and Mechanical Modalities

Interventions

Goab ond Ejqieded Outcomes

Physical agents may include: Sound agents phonophoresis ultrasound Cryotherapy - cold packs - ice massage vapocoolant spray Thermotherapy dry heat hot packs paraffin baths Mechanical modalities may include: Traction devices intermittent positional sustained

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 impairments 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/piay), community, and leisure is improved. - Performance of and independence in activities of daily livii^ (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention - Complications of soft tissue and 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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once dtiring a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinicalfindingsor failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/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 the physical therapy interventions in the following domains: Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, wellness, and fitness Societal resources Patient/client satisfaction

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

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facUity-specific or payer-specific requirements for doctmientation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/cMents who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation follow^ing changes in physical status, caregivers, environment, or task demands. In consultation \vith appropriate individuals, and in consideration 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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Impaired Muscle Performance

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

Patient/Client Diagnostic Classification

Patients/clients will be classified in this pattern for impaired muscle performance as a result of the physical therapist's evaluation of the examination data.The findings from the examination (history, systems leview, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification. Inclusion The following examples of examination findings may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity c if the examination findings, the physical therapist may dt ti^rmine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and anoiher pattern.
Findings That May Require Classification in a Different Pattern

Acquired immune deficiency syndrome (;hronic musculoskeletal dysfunction C^hronic neuromuscular dysfunction Diabetes Down syndrome Pelvic floor dysfunction Renal disease Va.si ular instifficiency 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

Impairments, Functional Limitations, or Disabilities

Frai tiire Imjiairments associated with amputation Impairments associated with primary capsular restriction Impairments associated with primary joint arthroplasty Impairments associated with primary localized inflammation Muscular pain due to cesarean delivery Ret ent bony sui^ery

Findings That May Require Classification in Additional Patterns

Post-j)olio syndrome with bursitis

Note:
Some risk factors or consequences of pathology/ pathophysiologysuch as myositis with acute exacerbation may be severe and complex; however, they do not necessarily e.xclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis, page SI67.)

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ICD-9 CM Codes
The listing below contains the ctirrent (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 042 250 359 443 564 569 Human immunodeficiency virus [HIV] disease Diabetes mellitus Muscular dystrophies and other myopathies 359.9 Myopathy, unspecified Other peripheral vascular disease Functional digestive disorders, not elsewhere classified 564.0 Constipation Other disorders of intestine 569.4 Other specified disorders of rectum and anus 569.42 Anal or rectal pain Nephrotic syndrome Chronic glomerulonephritis Nephritis and nephropathy, not specified as acute or chronic Disorders resulting from impaired renal function Genital prolapse 618.0 Prolapse of vaginal walls without mention of uterine prolapse Cystocele Rectocele 618.1 Uterine prolapse without mention of vaginal wall prolapse 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 Noninflammatory disorders of vagina 623.4 Old vaginal laceration Noninflammatory disorders of vulva and perineum 624.4 Old laceration or scarring of vulva Pain and other symptoms associated with female genital organs 728 Disorders of muscle, ligament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 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

729 733

581 582 583 588 618

733.0

Osteoporosis

739 758 780 781

623 624 625

799

733.1 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 Abnormality of gait 781.2 781.3 Lack of coordination Ataxia, not otherw^ise specified Muscular incoordination 781.4 Transient paralysis of Umb 781.9 Other symptoms involving nervous and musculoskeletal systems 781.92 Abnormal posture Other ill-defined and unkno-wn causes of morbidity and mortalit}' 799.3 Debility, unspecified

625.0
625.1

Dy^spareunia
Vaginismus

625.6
714

Stress incontinence, female

715 719

Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis Osteoarthrosis and allied disorders Other and unspecified disorders of joint 719.7 Difficulty in walking

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients.Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, weUness, and fitness.The physical therapist synthesizes the examination 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 gathering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physical therapist.The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the c ommunication ability, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors, i-br clinicat indications in selecting tests and measures and for listings of tests and measure.% 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 Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primar)' language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

Social History

Cultural beliefs and behaviors Family and caregiver resources Social interactions, social activities, and support systems
Employment/Work (Job/School/Play)

Current and prior work (job/school/play), community, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromu.scular Obstetrical Prior hospitaUzations, surgeries, and preexisting medical and otlier healthrelated conditions Psychological Pulmonary
Current Condition(s)/Chief Complaint(s)

Current and prior ftmctional status in self-care and home management activities, including activities of daily Uving (ADL) and instrumental activities of daily living (IADL) Current and prior functional status in work (job/school/play), conimunity, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, sui^ical) Review of other clinical findings (eg, nutrition and hydration)

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)

Concerns that led patient/client to seek the services of a physical therapist Concerns or needs of patient/client who requires the .services of a physical therapisr Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic inter\ention Patient/i lient, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
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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 scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrtmiental activities of daily living [IADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergon\etry, step tests, time/distance walk/run tests, treadmill tests, ^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

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations) Components, alignment,fit,and ability to care for assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Ctirrent and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechonics

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, w^ork analyses) Safet)' in w^ork environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific w^ork conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis 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, technology-assisted analyses, videographic assessments)
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Tests and Measures continued

Goit, Locomotion, and Bolance

Orthotic, Protective, and Supportive Devices

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessment.s) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control lests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobiUty skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry; electroneuromyography, footprint analyses, gait profiles, mobility' skiU profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, w^eight-bearing scales, wheelchair mobility' tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Motor Function (Motor Control and Motor Leorning]

Components, aUgnment, fit, and abiUty to care for orthotic, protective, and supportive tlevices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabilitit s with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health asst ssrnent questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devtces and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)
Poin

Pail I, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

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 dexterity tests, manipulative ability tests, observations) Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, gross motor function profiles, movement assessment batteries, observations, physical performance tests, videographic assessments)
Muscle Performance (Including Strength, Pov/er and Endurance)

PosEural alignment and position (dynamic), including symmetry and deviation from midline (eg, obseir^ations, technology-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Siiecific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Work [Job/School/Play), Community, and Leisure Integration or Reintegration (Including lADl)

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capac ity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)

Abiiity to asstime or resume work (job/school/play), commtmit) and leisure activities with or without assistive, adaptive, ortliotic, (protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status ([uestionnaires, IADL scales, observations, physical capacit>' tests) Ability' to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Saft ty in work (jt)b/school/play), community, and leisure activititis 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)

Self-Care and Home Management (Including ADL and IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibiUty tests, palpation)
Reflex Integrity

Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) Electrophysiological integrity (eg, electroneuromyography)

AbiUty to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg,electroneuromyography)
Ventilation and Respiration (Gas Exchange)

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

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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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluatit)n include the clinical findings, extent of loss of function, chronicity or severity t>f the problem, possibility of multisite or multisystera involvement, preexisting condition(s), potential discharge destination, 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 diagnostic process, 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 in function and the amount of time needed to reach that level and may also include a prediction of levels of imprtwement that may be reached 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 outcomes, and discharge plans. Tlie plan of care identifies reiilistic anticipated goals and expected outcomes, taking into consideration the expectations ofthe patient/ciient and appropriate others.These anticipated gt)als and expected outcomes should be measureable and time Umited. 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 longer episode with a diminishing intensity of intervention. Frequent y and duration may vary greatly among patients/clients based tjn a variety of factors that the physical therapist considers tliroughtmt the evaluation procc ss, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise: chronicity or sevt rit> t)f the ctirrent condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis Over the course t)f 2 to 6 montlis, patient/cUent will demonstrate optimal muscle performance and the highest level t)f ftmctioning in home, work (jt)b/ school/play), community, and leisure environments. During the episode of care, patient/cUent will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in tliis pattern.

Expected Range of Number of Visits Per Episode of Care 6 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80"/o of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of t are should be determined by the physical therapist to maximize effectiveness of t are and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode Accessibility and availability of resources 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent vk'ith the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent response and the 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 settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.
Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions Anticipated Goals and Expected Outcomes

Addressing required functions advance directives - individuaUzed family service plans OFSPs) or individualized education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including: equipment 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 data peer revieiv findings record reviews Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: changes in impairments, functional limitations, and disabilities changes in interventions elements of patient/cUent management (examination, evaluation, diagnosis, prognosis, intervention) - outcomes of intervention Interdisciplinary teamwork case conferences patient care rounds patient/cUent family meetings Referrals to other prtifessionals or resources

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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized. Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. CoUaboration and coordination occurs with agencies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Communication occurs across settings through case conferences, education plans, and documentation. Data are coUected, analyzed, and reported, including outcome data, peer reviewfindings,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 management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occtirs through case conferences, patient care rounds, and patient/cUent family meetings. Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resovirces whenever 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

Antkifxitsd Goals and Expected Outcomes

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 programs plan of care risk factors for patholt)gy/pathophysiology (disease, disorder, or conditit)n), impairments, functional limitations, or disabilities transitions across settings transitions tt) new roles

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 is reduced. 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 knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/cUent knowledge of personal and environmental factors associated with the condition is increased. Performance levels in seif-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities 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 caregivers 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

Anticipated Gools and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning - aquatic programs - gait and locomotor training increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agilitj' training developmental activities training motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation - perceptual training - posture awareness training - standardized, programmatic, complementary exercise approaches task-specific performance training Body mechanics and postural stabilization body mechanics training - posture awareness training postural control training postural stabilization activities Flexibility exercises muscle lengthening range of motion stretching Gait and locomotion training - developmental activities training - gait training - implement and device training perceptual training standardized, programmatic, complementary exercise approaches - w^heelchair training Relaxation breathing strategies movement strategies relaxation techniques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, Umb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/iso tonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches - task-specific performance training

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 management, work (job/school/play), community, and leisure is improved. Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention Risk factors are reduced. Risk of 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 fitness Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. Patient/client satisfaction Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/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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Procedural inlervenrions continued Functional Training in Sel^Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Uving [IADL]] Interventions ADL training bathing - bed mobility and transfer training developmental activities dressing eating grooming toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and IADL orthotic, protective, or supportive device or equipment training during ADL and IADL prosthetic device or equipment training during ADL and IADL Functional training programs back schools simulated environments and tasks task adaptation IADL training - caring for dependents - home maintenance - household chores shopping structured play for infants and children yard w^ork Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during seltK:are and home management Goals and ExpwtocI Outconws Impact 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 selfcare 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.

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Procedural Interventions continued Functional Training in Work (Job/Schod/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Anticipated Goals and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL prosthetic device or equipment training during IADL Functional training programs - back schools - job coaching - simulated environments and tasks - task adaptation task training IADL training - community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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.

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Procedural Interventions continued Manual Therapy Techniques (Including Mobilization/Manipulation)

tntervenrions Manual traction Massage - connective tissue massage - therapeutic massage Mobilization soft tissue Passive range of motion

I G o d s CHKI ExfMcMcl OuteOBMi Impact 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 acceiable 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.

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Procedural Interventions continued

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

>^4kipated Goab ond i}qcted Oulcomes

Adaptive devices environmental controls raised toilet seats seating systems Assistive devices - canes - crutches iong-handled reachers power devices static and dynamic splints walkers - wheelchairs Orthotic devices braces - casts shoe inserts splints Prosthetic devices (lowerextremity and upper-extremity) Protective devices - braces - cushions protective taping Supportive devices compression garments corsets elastic wraps - neck coUars - serial casts - slings supportive taping

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, orrestrictionis 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 activitiesrelatedto self-care, home mana^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. Riskfiictorsare 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 significant others. - Sense of well-being is improved. - Stressors are decreased.

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Procedural Interventions continued

Eiectrotherapeutic Modalities

Interventions

Gocds ond Expected Outomws

Biofeedback Electrical stimulation - electrical muscle stimulation (EMS) - functional electrical stimulation (FES) neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS)

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 instrumental activities of daily living CtAJDL) 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, 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

Anticipoled Gools and Expected Outcomes

Physical agents may include: Cryotherapy - cold packs ice massage vapocoolant spray Hydrotherapy pools Sound agents - phonophoresis ultrasound Thermotherapy dry heat hot packs paraffin baths Mechanical modalities may include: Compression therapies - taping Gravity-assisted compression devices standing frame - tilt table Traction devices - intermittent positional sustained

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 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/schoot/play), community, and leisure roles is improved. Risk reduction/prevention Complications of soft tissue and circulatory disorders are decreased. - Risk of secondary impairments is reduced. - Self-management of symptoms is improved. Impact on health, wellness, and fitness - Physical function is improved. Impact on societal resources Utilization of physical therapy services is optimized. Patient/client satisfaction Access, availability, and services provided are acceptable to patient/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, and significant others. - Sense of welt-being is improved. Stressors are decreased.

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

Global Outcomes for Patienh/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the iinticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shadeil boxes that accompany the Usts of interventions in each preferred 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 the physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status ;nd health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been prov ided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for tiocumentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because finamial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/cUents who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task dcniaiids. In consultation with appropriate individuals, and in consideration 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 Muscle Performance 185/S177

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as indiy-idual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patienf/Client Diagnostic Classification

Patients/clients will be classified into this patternfor impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunctionas a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/ pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs, ITie physical therapist integrates, synthesizes, and interprets iJie data to determine the diagnostic classification. Inclusion The following examples of examinationfindingsmay support the inclusion of patients/clients in this pattern;
Ri5k Factors or Consequences of Pathology/Paihophysiology (Disease, Disorder, or Condition)

Exclusion or Multiple-PaHern Classification The following examples of examination findings may support s'xclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Joint subluxation or dislocation Ligamentous sprain Musculotendinous strain Pregnancy Prolonged joint immobilization Rheumatoid arthritis Scleroderma Systemic lupus erythematosus Temporomandibular joint syndrome Decreased range of motion Inabilit)' to squat due to joint instability Muscle guarding or weakness Pain Postpartum sacroiliac dysfunction Swelling or effusion

Impairmenb, Functional Limitations, or Disabilities

Fracture Immobility as a primary result of prolonged bed rest lack of voluntary movement Radiculopathy

Findings That May Require Classification in Additional Patterns

Abrasion or wound

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as impairments associated with Joint hemarthrosis and neuromuscutar dysfunctionmay be severe and complex; however, they do not necessarily exctude patients/ctients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care, (See "Evaluation, Diagnosis, and Prognosis," page S185,)

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ICD-9 CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICE)-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization s International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, III; American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 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 andfibrosisof skin 710 Diffuse diseases of connective tissue 710.0 Systemic lupus erythematosus 710.3 Dermatomyositis 710.4 Polymyositis 714 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 sacrum 724.9 Other unspecified back disorders Ankylosis of spine, not otherwise specified Compression of spinal nerve root, not elsewhere classified Spinal disorder, not otherwise specified 726 Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.2 Other affections of shoulder region, not elsewhere classified 726.9 Unspecified enthesopathy 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 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 Other disorders of soft tissues 729.1 Myalgia and myositis, unspecified 729.8 Other musculoskeletal symptoms referable to limbs 729.9 Other and unspecified disorders of soft tissue Osteomyelitis, periostitis, and other infections involving bone Other disorders of bone and cartilage Dislocation of jaw Dislocation of shoulder Dislocation of elbow Dislocation of wrist Dislocation of knee Dislocation of ankle Dislocation of foot Other, multiple, and ill-defined dislocations 839.0 Cervical vertebra, closed 839.8 Multiple and ill-defined, closed Arm Back Hand Multiple locations, except fingers or toes alone Other ill-defined locations Unspecified location

727

728

729

730 733 830 831 832 833 836 837 838 839

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ICD-9-CM Codes continued 840 sprains and strains of shoulder and upper arm 840.4 Rotator cuff (capsule) 841 Sprains and strains of elbow and forearm 842 Sprains and strains of wrist and hand 843 Sprains and strains of hip and thigh 844 Sprains and strains of knee and leg 845 Sprains and strains of ankle and foot 846 Sprains and strains of sacroiliac region 847 Sprains and strains of other and unspecified parts of back 848 Other and ill-defined sprains and strains 848.1 Jaw 848.3 Ribs 848.4 Sternum 848.5 Pelvis Symphysis pubis 905 Late effects of musculoskeletal and connective tissue injuries 905.6 Late effect of dislocation 905.7 Late effect of sprain and strain without mention of tendon injury

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Impairments / Connective Tissue Dysfunction

1 89/'S181

Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients,Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, andfitness.The physical therapist synthesizes the examinationfindingsto establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components; the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to w^hy the patient/client is seeking the services of the physical therapist,The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community sittiation; and other relevant factors,/br clinical indications in selecting tests and measures and for listings of tests and measures, 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 Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medical/Surgical History

Social History

Cultural beliefs and behaviors Family and caregiver resources Social interactions, social activities, and support systems
Employment/Work (Job/School/Play)

Current and prior work (job/school/play), community, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary
Current Condition(s)/Chief Complaint(s)

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinicalfindings(eg, nutrition and hydration)

General health perception Physicalfianction(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)

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 physical therapist Ctirrent therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
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Systems Review The systems review may include;

Anatomical and Physiological Status

Cardiovascular/Pulmonar>' Blood pressure Edema - Heart rate - Respiratory rate

Integumentary Presence of scar formation - Skin color - Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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

Tests and Measures Tests and measures for this pattern may include those that characterize or quantify';
Anthropometric Characteristics

Edema (eg, girth measurement, palpation, scales, volume measurement)

Assistive and Adaptive Devices

Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daily living flADL] scales, interviev/s, observations) Components, alignment, fit, and ability' to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, LADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Cranial and Peripheral Nerve Integrity

functional capacity and perfonnance during work actions, iasks, or activities (eg, accelerometr>, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, inierviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment S lies, standartls for exposure limits) C .Specific work conditions or activities (eg, handling checklists, lob simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists) r<:>ols, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, 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, technology -assisted analyses, videographic assessments)
Gait, Locomotion, and Balance

Motor distribution of the peripheral nerves (eg, dynamometrj', muscle tests, observations, thoracic outlet tests) Response to neural provocation (eg, tension tests, vertebral artery compression tests) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)
Guide to Physical Therapist Practice

Bidance during functional activities with or without the use of Assistive adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistiA'e, adaptive, orthotic, protective, supportive, or prosthetic dt'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^ithout the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

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: Impairme'nts / Connective Tissue Dysfunction

19 1 / S I 8 3

Tests and Measures continued

Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Joint Integrity and Mobility

Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Range of Motion (ROM) (Including Muscle Length)

Joint play movements, including end feel (all joints of the axial and appendicular skeletal system) (eg, palpation) Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry)
Motor Function (Motor Control and Motor Learning)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)
Reflex Integrity

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Hand function (eg,fineand gross motor control tests, finger dexterity tests, manipulative ability tests, observations)
Muscle Performance (Including Strength, Power, and Endurance)

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)

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during fimctional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, fall scales, intervie'ws, logs, observations, reports, videographic assessments)
Sensory Integrity

Components, alignment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Pain

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)
Ventilation and Respiration/Gas Exchange

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests) Pulmonary' symptoms (eg, dyspnea and perceived exertion indexes and scales)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain draw^ings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)
SI84/192 Guide to Physical Therapist Proctice

Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)
Physical Therapy Volume 81 Number 1 January 2001

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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination,The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic: process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others, Iliese anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or ,severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Expected Range of Number of Visits Per Episode of Care 3 to 36

Factors That May Require Episode of Care or That M o / Modify Frequency of Visits/ Duration of Episode

Over the course of 2 weeks to 6 months, patient/client will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of functioning in home, work (job/ school/play), community, and leisure environments. During the episode of care, patient/client wiU achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

This range represents the lower and upper limits of the number ol physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern wilt achieve the anticipated goah and expected outcomes within 3 to J6 tHsits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiencif of service deliverv

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status (^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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, -when appropriate, 'with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in 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 Anticipated Goals and Expected Outcomes

Addressing required functions advance directives - individualized family service plans (IFSPs) or individualized education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including; equipment suppliers home care agencies payer groups schools transportation agencies Communication across settings, including; - case conferences - documentation education plans Cost-effective resource utilization Data collection, analysis, and reporting - outcome data - peer review findings - record reviews Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including; changes in impairments, functional limitations, and disabilities - changes in interventions - elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences - patient care rounds patient/client family meetings Referrals to other professionals or resources

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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed, Available resources are maximally utilized, Care is coordinated with patient/client, fanuly, significant others, caregivers, and other professionals, Case is manned throughout the episode of care, Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies, Commiuiication enhances risk reduction and prevention, Communication occurs across settings through case conferences, education plans, and documentation, Data are collected, analyzed, and reported, including outcome data, peer reviewfindings,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 management and across settings andfollowsAPTA's Guidelinesfin-Physical Therapy Documentation (Appendix 5), Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings, Patient/client,fomily,significant other, and caregiver understanding of anticipated goals and expected outcomes is increased, Placement needs are determined, Referrals are made to other professionals or resources whenever necessary and appropriate, Resources 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 performance health, wellness, and fitness programs plan of care risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities transitions across settings transitions to new roles
Goals and Expected Outcomes

to perform physical actions, tasks, or activities is improved. Awareness and use of community resources are improved. Behaviors that foster healthy habits, weltaesst and prevention are acquired. Decision making is enhanced regartlii^ patient/client health and the use of health care resources by patient/dient, femily, signilieant others, and caregivers. Disability associated widi acute or chronic illnesses is reduced. Functional independence in activities of daily Mving (ADL) and instrumental activities of daily living (IADL)toincreased. 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 knowledge and awareness of the (Uagno^, prognosis, interventions, aiid anticipated goals and expected outcomes are increased. Patient/client knowle(%e of personal and environmental feetors associated with the concUtktn is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/cUem, family, s^nificant others, and caregiVers 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 reconditioning aquatic programs - gait and locomotor training - increased workload over time walking and wheelchair propulsion programs Balance, coordination, and agility training developmental activities training motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation - perceptual training - posture awareness training standardized, programmatic, complementary exercise approaches sensory training or retraining task-specific performance training Body mechanics and postural stabilization - body mechanics training - posture awareness training postural control training postural stabilization activities Flexibility exercises muscle lengthening range of motion stretching Gait and locomotion training - developmental activities training - gait training implement and device training perceptual training standardized, programmatic, complementary exercise approaches - wheelchair training Relaxation breathing strategies movement strategies relaxation techmiques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs - standardized, programmatic, complementary exercise approaches task-specific performance training

Anticipated Goals and Expected Outcomes Impact on 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 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 selfcare, home management, work (job/school/play), community, and leisure is improved, - Level of supervision required for task performance is decreased, - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased, - Tolerance of positions and activities is increased, Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved, Risk reduction/prevention - Preoperative and postoperative complications are reduced, - Risk factors are reduced. Risk of recurrence of condition is reduced. Risk of secondary impairments is reduced. - Safety is improved, - Self-management of symptoms is improved, Impact on health, wellness, and fitness Fitness is improved. Health status is improved, - Physical capacity is increased, - Physical function is improved. Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. Patient/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) and Instrumental Activities of Daily Living (IADL)] Interventions Anticipated Goals and Exptded Outcomes

ADL training - bathing bed mobility and transfer training developmental activities dressing eating grooming toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and IADL orthotic, protective, or supportive device or equipment training during ADL and IADL Functional training programs back schools simulated environments and tasks task adaptation LADL training - caring for dependents home maintenance household chores shopping structured play for infants and children - yard work Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during selfcare and home management

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 and eqiripment are increased, Tolerance of positions and activities is increased, Impact on disabilities - AbiHty to assimie or resume required self-care and home management roles is improved, Risk reduction/prevention - Risk factors are reduced, - Risk of secondary impairments is reduced, - Safety is improved, - Self-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;es

Utilization 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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Anticipated Goals and Eiqiected Outcomes

Devices and equipment use and training - assistive and adaptive device or equipment training during IADL orthotic, protective, or supportive device or equipment training during IADL Functional training programs back schools job coaching - simulated environments and tasks - task adaptation task training IADL training community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment - safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 orreintegrationis improved, - 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 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, 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

Anticipated Goals and Expected Outcomes

Manual traction Massage connective tissue massage therapeutic massage Mobilization/manipulation - soft tissue - spinal and peripheral joints Passive range of motion

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 management, "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 Anticipated Goals and Expected Outcomes

Adaptive devices - raised toilet seats - seating systems Assistive devices - canes crutches long-handled reachers power devices static and dynamic splints - walkers - w^heelchairs Orthotic devices braces casts shoe inserts splints Protective devices braces - cushions - protective taping Supportive devices compression garments corsets - elastic wraps - neck collars - serial casts - slings supportive taping

Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is reduced, - Joint swelling, inflammation, or restriction is reduced. - Pain is decreased, - Soft tissue swelling, inflammation, or restriction is reduced, Impact on impairments Balance is improved. - 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 management, 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 significant others. Sense of well-beir^ is improved. - Stressors are decreased.

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Procedural Interventions continued Electrotherapeutic Modalities

Interventions

Anticipoted Goals and Expected Outcomes

Biofeedback Electrotherapeutic delivery of medications - iontophoresis Electrical stimulation electrical muscle stimulation (EMS) neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS)

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 impairments Integumentary 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 management, 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 instrumental activities 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, - Riskfactorsare reduced. - Risk of secondary impairment is reduced, - Self-management of symptoms is improved. Impact on health, wellness, and fiitness Physical 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 Anticipated Goals and Expected Outcomes

Interventions

Physical agents may include; Athermal agents - pulsed electromagnetic fields Cryotherapy cold packs ice massage vapocoolant spray Hydrotherapy whirlpool tanks contrast bath pools Light infrared laser Sound agents phonophoresis ultrasound Thermotherapy dry heat hot packs paraffin baths Mechanical modalities may include; Compression therapies - taping vasopneumatic compression devices Mechanical motion devices continuous passive motion (CPM) Traction devices - intermittent - positional sustained

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 is improved. Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (LADL) with or without devices and equipment are increased, - Tolerance of positions and activities is increased, Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved, Risk reduction/prevention Complications of soft tissue and circulation disorders, - Risk of secondary impairments 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/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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated nujre than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinicalfindingsor failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy st rvices by characterizing or quantifying the impact of the physical therapy interventions in the following domains; Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, wellness, and fitness Societal resources Patient/client satisfaction

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

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or becausefinancial/insuranceresources have been expended; or (3) the physical therapist determines that the patient/client wiO no longer benefit from physical therapy When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adaptation following changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for 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 Motion Associated With Localized Inflammation
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are i;he boundaries viithin which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified into this patternfor impaired joint mobility; motor function, muscle performance, and range of motion as,sociated with localized inflammationas a result of the physical therapist's evaluation of the examination data,The findings from the examination (history, systems review, and te,sts and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs,The physical therapist integrates, synthesizes and interprets the data to determine the diagnostic classification.

Inclusion
The following examples of examination findings may support the inclusion of patients/cUents in this pattern;
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

Exclusion or Multipie-Pottern Classification

The following examples of examination findings may support exclusion from this pattern or classification into addition:il patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client v^'ould be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and ,inother pattern.
Findings That May Require Classification in a Different Pattern

Abnormal response to provocation Ankylosing spondylitis Bursitis Capsulitis Epicondylitis Fasciitis Gout Osteoarthritis Prenatal and postnatal soft tissue inflammation Synovitis Tendinitis 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

Dei:p vein thrombosis Fracture Impairments associated with dislocation Impairments associated w^ith hemarthrosis Surgery

Impairments, Functional Limitations, or Disabilities

Findings That May Require Classification in Additional Patterns

Open wound

Note:
Some risk factors or consequences of pathology/ pathophysiologysuch as systemic disease processesmay be severe and complex; however, they do not necessarily exclude patients/ clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis,'page S203,)

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ICD-9 CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, 111; American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 274 350 353 Gout 274.0 Gouty arthropathy Trigeminal nerve disorders 350.1 Trigeminal neuralgia Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.4 Lumbosacral root lesions, not elsewhere classified Mononeuritis of upper limb and mononeuritis multiplex 354.0 Carpal tunnel syndrome 354.2 Lesion of ulnar nerve Cubital tunnel syndrome Mononeuritis of lower limb 355.5 Tarsal tunnel syndrome 355.6 Lesion of plantar nerve Morton's metarsalgia, neuralgia, or neuroma Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders Other cellulitis and abscess Arthropathy associated with infections Osteoarthrosis and alUed disorders Other and unspecified arthropathies 716.6 Unspecified monoarthritis 716.9 Arthropathy, unspecified Inflammation of joint, not otherwise specified Internal derangement of knee 7\7.7 Chondromalacia of patella Other derangement of joint 718.8 Other joint derangement, not elsewhere classified Instability of joint Other and unspecified disorders of joint 719.0 Effusion of joint 719.2 Villonodular synovitis Ankylosing spondylitis and other inflammatory spondylopathies 720.2 Sacroiliitis, not elsewhere classified Intervertebral disk disorders Other and unspecified disorders of back 724.0 Spinal stenosis, other than cervical 724.2 Lumbago Low back pain Low back syndrome Lumbalgia Peripheral enthesopathies and allied syndromes 726.0 Adhesive capsulitis of shoulder 726.1 Rotator cuff syndrome of shoulder and allied disorders 726.10 Disorders of bursae and tendons in shoulder region, unspecified 726.2 Other affections of shoulder region, not elsewhere 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 fibromatosis Plantar 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

354

355

524 682 711 715 716

717 718

719

720

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner Examination is required prior to the initial intervention and is performed for all patients/clients,Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, andfitness,Thephysical therapist synthesizes the examination 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 gathering of past and ctirrent information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist.The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For ctinicat indications in setecting tests and measures and for listings of tests and measures, 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 Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Eamilial health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary
Current Condition(s)/Chief Complaint(s)

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinicalfindings(eg, nutrition and hydration)

General health perception Physical function (eg, mobility, sleep patterns,restrictedbed 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)

Concerns that led patient/client to seek the services of a physical therapist Concerns or needs of patient/client who requires the services of a physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complain t(s) Prior therapeutic interventions
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Systems

The systems review may include;

Anatomical and Physiological Status

Cardiovascular/Pulmonary Blood pressure Edema Heart rate Respiratory rate

Integumentary Presence of scar formation Skin color Skin integrity

Musculoskeletal Gross range of motion Gross strength Gross symmetr}' - Height - Weight

Neuromuscular Gross coordinated 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

Tests and measures for this pattern may include those that characterize or quantify;
Aerobic Capacity and Endurance Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance ^valk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Edema (eg, girth measurement, palpation, scales, volume measurement)

Assistive and Adaptive Devices

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations) Components, alignment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, intervie^vs, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities 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 equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry', muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to neural provocation (eg, tension tests, vertebral artery compression tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

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Tests and Measures continued

Ergonomics and Body Mechanics

Integumentary Integrity

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability' tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safet)' in w^ork environments (eg, hazard identification checklists, job .severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, w^orkstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics Body mechanics during selfcare, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technologyassisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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 skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic 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 distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; 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,fineand gross motor control tests, finger dexterity tests, manipulative ability tests, observations)
Muscle Performance (Including Strength, Power, and Endurance)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, pnrtective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during fimctional activities with or without the use of assistive, adaptive, orthotic, protective, stipportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADI. scales, mobility skill profiles, observations, \ ideographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall ,scales, functional assessment profiles, logs, reports)

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity test;s, technology-assisted analyses, timed activity tests) Muscle strength, pow^er, and endurance during functional activities (eg,ADL scales, functional muscle tests, LADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

Cosiiponents, alignment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment list during functional activities (eg, ADL scales, functional scales. IADL scales, interviews, observations, profiles) Remediation of impairments, fimctional limitations, or disabiUtie^ with use of orthotic, protective, and supportive devices and equipment (eg, activity' status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive de\ ices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Pain

Pain, soreness, and nociception (eg, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation t[-sis, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

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Tests and Measures continued

Posture

Sensory Integrity

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural aUgnment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Range of Motion (ROM) (Including Muscle Length)

Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg, sensory nerve conduction tests)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)
Reflex Integrity

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 questionnaires, IADL scales, observations, physical capacity tests) Ability' to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in w^ork (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

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 identification, observations, physical performance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

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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, systemsreview,and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, 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 in function and the amount of time needed to reach that level ;ind may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and dischai^e plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others,These anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention, Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity- or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; piobability of prolonged impairment, functional limitation, or disability; and stability of the condition.
Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode

Prognosis

Expected Range of Number of Visits Per Episode of Care 6 to 24

Over the course of 2 to 4 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), communit)', and leisure environments. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

This range represents the lowt r and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/ctients who are classified into this pattern will achieve the anticipated goats and expected outcomes within 6 to 24 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be dett rmined by the physical therapist to maximize effectiveness of care and efficiency <rf service delivery.

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status 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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Intervention
Intervention Is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 individualized education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including: equipment suppliers home care agencies - payer groups schools - transportation agencies Communication across settings, including: - case conferences documentation education plans Cost-effective resource utilization Data collection, analysis, and reporting outcome data peer review^ findings record reviews Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: - changes in impairments, functional limitations, and disabilities changes in interventions elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences - patient care rounds patient/client family meetings Referrals to other professionals or resources 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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized. Care is coordinated with patient/client, fanuly, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Communication occurs across settings through case conferences, education plans, and documentation. Data are collected, analyzed, and reported, including outcome data, peer reviewfindings,and record reviews. Decision making is enhanced regarding health, wellness, and fitness needs. Decision making is enhanced regarding patient/client health and the use of health care resources by patient/dient, family, significant others, and caregivers. Documentation occurs throi^out patient/client managjement and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/cHentfamilymeetings. Patient/client,family,significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utilized in a cost-effective way.

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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 performance health, wellness, and fitness plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities transitions across settings transitions 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 is reduced. 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 knowledge and awareness of d}e diagno^, prc^nosis, interventions, and antidpated goals and expected outcomes are increased. Patient/client knowledge of personal and envircmmental factors associated with the condition is increased. Performance levels in self-care, home management, work ()ob/school/play), community, or leisure actions, tasks, or activities 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 caregivers 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 include:

Therapeutic Exercise

Interventions Aerobic capacity/endurance conditioning or reconditioning aquatic programs - gait and locomotor training - increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agility training developmental activities training - motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation - perceptual training - posture awareness training - standardized, programmatic, complementary exercise approaches task-specific performance training Body mechanics and postural stabilization - body mechanics training posture aw^areness training postural control training postural stabilization activities Flexibility exercises muscle lengthening - range of motion stretching Gait and locomotion training developmental activities training gait training implement and device training - perceptual training - standardized, programmatic, complementary exercise approaches wheelchair training Relaxation - breathing strategies - movement strategics relaxation techniques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training

Anticipated 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 management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required self<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 WltK^MrtM GOQIS CMS

ADL training - bathing bed mobility and transfer training - developmental activities dressing eating grooming - toileting Devices and equipment use and training - assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and IADL Functional training programs back schools simulated environments and tasks task adaptation IADL training caring for dependents home maintenance household chores - shopping - structured play for infants and children yard work Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction w^ith use of devices and equipment - safety awareness training during self-care and home management

Impact cm pathology/pathoplij^ilolqgy (disease, disoKler, - Pain is decreased. Impact on impAinaents - Balance is improved. - Endurance te incre^edi - Ehergy expeniture 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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Anticipated Goals and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL Functional training programs back schools job coaching simulated environments and tasks - task adaptation - task training IADL training - community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction - injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction w^ith use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 - Riskfoctorsare reduced. - Risk of secondary impairment is reduced. Safety is improved. Self-man^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 - 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 continued Manual Therapy Techniques (Including Mobilization/Manipulation)

^J J

Interventions Manual traction Massage - connective tissue massage - therapeutic massage Mobilization/manipulation soft tissue spinal and peripheral joints Passive range of motion

Goals and Ejcpactad Oulemnes Impact 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 conHnued

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Interventions Anticipated Goals and Expected Outcomes

Adaptive devices - raised toilet seats - seating systems Assistive devices canes crutches - long-handled reachers - power devices - static and dynamic splints - walkers - w^heelchairs Orthotic devices braces casts shoe inserts - splints Protective devices braces cushions protective taping Supportive devices compression garments corsets - elastic wraps - neck coUars - serial casts - slings supportive taping

Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is reduced. - Joint swelling, inflammation, or restriction is reduced. - Pain is decreased. - Soft tissue swelling, inflammation, or restriction is reduced. Impact on impairments Balance is improved. 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 are improved. - 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, 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 instrumental activities of daily Uving (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 self-care, home management, work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention Pressure on body tissues is reduced. Protection of body parts is increased. - Risk factors are reduced. - Risk of recurrence of condition is reduced. - Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. - Stresses precipitating 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

Anticipated Goals and Expaded

Electrotherapeutic delivery of medications iontophoresis Electrical stimulation - electrical muscle stimulation (EMS) functional electrical stimulation (FES) high voltage pulsed current (HVPC) - neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS)

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 tissuefeincreased. - 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 management, 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 instrumental activities ctf daily living (IA0L) with or without devices and equipment are increased. - 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 Anticipated Goals and Expected Outcomes

Physical agents may include: Athermal agents - pulsed electromagnetic fields Cryotherapy - cold packs - ice massage - vapocoolant spray Hydrotherapy w^hirlpool tanks contrast bath pools light agents infrared laser Sound agents - phonophoresis ultrasound Thermotherapy dry heat hot packs - paraffin baths Mechanical modalities may include: Compression therapies - taping Mechanical motion devices continuous passive motion (CPM)

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. ITiese anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains: Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, wellness, and fitness Societal resources Patient/client satisfaction

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

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, disckiarge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (21 the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because fLnant:ial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/cUents who require multiple episodes of care, periodic fbUow-up i,s needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, envin>nment, or task demands. In consultation with appropriate individuals, and in consideration 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, and Reflex Integrity Associated With Spinal Disorders
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of lac(ors, such as individual patient/cUent needs; the profession s code of ethics and standards of practice; and patient/cUent age, culture, gender roles, nice, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified into this patternfor impaired joint mobiUty, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disordersas a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, weUness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion
The following examples of examination findings may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/Pathophysidogy (Disease, Disorder, or Condition)

Exclusion or Multiple-Pattern Classification

The foUowing examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and .mother pattern.
Findings That May Require Cbssificatian in a Different Pattern

Degenerative disk disease Disk herniation History of spinal surgery Spinal stenosis SpondyloUsthesis 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

Impairments, Functional Limitations, or Disabilities

Fracture Impairments associated with systemic conditions (eg, ankylosing spondyUtis, Scheurermann disease, juvenile rheumatoid arthritis) Impairments associated with traumatic spinal cord injury
Findings That May Require Classification in Additional Patterns

Neuromuscular disea.se

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as neoplasmmay be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," pageS221.)

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ICD-9-CM Codes
The Usting below contains the ctirrent (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/cUent diagnostic classification is based on impairments, functional limitations, and disabiUtiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 353 Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.2 Cervical root lesions, not elsewhere classified 353.4 Lumbosacral root lesions, not elsewhere classified 715 Osteoarthrosis and alUed disorders 716 Other and unspecified arthropathies 716.9 Arthropathy, unspecified Inflammation of joint, not otherwise specified 718 Other derangement of joint 718.3 Recurrent dislocation of joint 718.9 Unspecified derangement of joint 719 Other and unspecified disorders of joint 719.8 Other specified disorders of joint Calcification of joint 720 Ankylosing spondylitis and other inflammatory spondylopathies 721 Spondylosis and alUed disorders 721.1 Cervical spondylosis with myelopathy 721.4 Thoracic or lumbar spondylosis with myelopathy 722 Intervertebral disk disorders 722.4 Degeneration of cervical intervertebral disk 722.5 Degeneration of thoracic or lumbar intervertebral disk 722.6 Degeneration of intervertebral disk, site unspecified 722.7 Intervertebral disk disorder with myelopathy 722.8 Postlaminectomy syndrome 723 Other disorders of cervical region 723.0 Spinal stenosis in cervical region 723.1 Cervicalgia 724 Other and unspecified disorders of back 724.0 Spinal stenosis, other than cervical 724.2 Lumbago Low back pain Lo'w back syndrome Lumbalgia 724.3 Sciatica 724.9 Other unspecified back disorders 727 Other disorders of synovium, tendon, and bursa 727.0 Synovitis and tenosynovitis 728 Disorders of muscle, Ugament, and fascia 728.2 Muscular wasting and disuse atrophy, not elsewhere classified 728.8 Other disorders of muscle, ligament, and fascia 728.85 Spasm of muscle 728.9 Unspecified disorder of muscle, Ugament, and iascia 733 Other disorders of bone and cartilage 733.0 Osteoporosis 738 Other acquired deformity 738.4 Acqtiired spondylolisthesis 738.5 Other acquired deformity of back or spine 756 Other congenital musculoskeletal anomalies 756.1 AnomaUes of spine 756.11 Spondylolysis, lumbosacral region 756.12 SpondyloUsthesis 846 Sprains and strains of sacroiliac region 846.0 Lumbosacml (joint) (Ugament) 847 Sprains and strains of other and unspecified parts of back 922 Contusion of trunk 922.3 Back

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Examination
Examination is a comprehensive screening and specific testing process that lc:ads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/cUents.Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wt-llness, and fitness.The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components: the patient/client historj; the systems review, and tests and measures.The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist.The systems review is a brief or Umited examination of (1) the anatomicat and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) ttie communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in .selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by te.sty and measures, refer to Chapter 2. Patient/Client History The history may include:
General Demographics Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living envin;)nment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary
Current Condition(s)/Chief Complaint(s)

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (L\DL) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinicalfindings(eg, nutrition and hydration)

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)

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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/dient, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client s emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
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Systems Review

The systems review may include:

Anatomical and Physiological Status

Cardiovascular/I*ulmonary Blood pressure Edema - Heart rate - Respiratory rate

Integumentary Presence of scar formation - Skin color - Skin integrity

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

Neuromuscutar Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:
Aerobic Capacity and Endurance Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [LADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Body dimensions (eg, body mass index, girth measurement, length measurement)
Assistive and Adaptive Devices

Assistive or adaptive devices and eqtiipment use during functional activities (eg,ADL scales, functional scales, LADL scales, intervie'ws, observations) Components, alignment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, reports) Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, LADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, obset^ations, reports)

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to neural provocation (eg, tension tests, vertebral artety compression tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Ploy) Barriers

Current and potential barriers (eg, checklists, interviews, observations, questionnaires) Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

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Tests and Measures continued

Ergonomics and Body Mechanics

Joint Integrity and Mobility

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand fimction tests, impairment rating scales, manipulative ability tests) Eunctional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in w^ork environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics Body mechanics during self-care, home management, work, commtmity, or leisure actions, tasks, or activities (eg, ADL scales. LADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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, finger dexterity tests, manipulative ability tests, observations)

Muscle Performance (Including Strength, Power, and Endurance)

Electrophysiological integrity' (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, mantial muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Mtiscle strength, power, and endurance during functional activities (eg,ADL scales, functional muscle tests, LADL scales, obser\ alions, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, LADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during ftmctional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, LADL scales, mobility skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, tbotprint analyses, gait profiles, mobility' skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, ^veight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional as.sessment profiles, logs, reports)

(Components, alignment, fit, and ability to care for orthotic, protec tive, and supportive devices and eqtiipment (eg, interviews, logs, observations, pressure-sensing maps, reports) ()rthotic, protective, and supportive devices and eqtiipment use during ftinctional activities (eg, ADL scales, functional scales IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabililies with use of orthotic, protective, and supportive devices und equipment (eg, activity status indexes,ADL scales, aerobic t apacity tests, functional performance inventories, health assessment questionnaires, LADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, ()bser\'ations, reports)
Pain

in, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and tnaps, provocation tests, verbal and pictorial descriptor tests) J^in m specific bodj' parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry ind deviation from midline (eg, observations, technology-assisteci analyses, videographic assessments) Posttiral alignment and position (static), including symmetry iind deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)

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Tests and Measures continued

Range of Motion (ROM) (Including Muscle Length) Sensory Integrity

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, Ugamentous tests, linear measurement, multisegment flexibility tests, palpation)
Reflex Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg, electroneuromyography)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

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 identification, observations, physical performance tests) Ability to perform setf-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, LADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

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 questionnaires, IADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), commtmity, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), commtmity, and leisure activities 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 gatheredfiromthe history, systems review, and tests and 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 clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of mtJtisite or mtiltisystem involvement, preexisting condition(s), potential discharge destination, 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 diagnostic process, which includes integrating and evaluating the data from the examination The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.lliese anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Erequency and dtiration may vary greatly among patients/cUents based on a variety of factors that the physical therapist cotisiders throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations: probability of prolonged impairment, ftmctional limitation, or disability; and stability of the condition. Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Durarion of Episode Accessibility and availability of resotirces 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

Prognosis Over the course of 1 to 6 months, patient/client wilt demonstrate optimal joint mobility, motor function, muscle performance, range of motion, and reflex integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

8ta24
This range represents the lower and upper limit* of the number of physical therapist visits reqtiired to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 8 to 24 visits during a single continuous episode of care. Frequency of visits and dunition of the episode of care should be detennined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and doctimentation and patient/client-related instruction are provided for all patients/cUents across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, commtmication, and documentation may include:

Interventions Anticipated Goals and Expected Outcomes

Addressing required functions advance directives individualized fatnUy service plans (IFSPs) or individualized education plans (IEPs) - informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including: equipment suppliers home care agencies payer groups - schools - transportation agencies Communication across settings, including: case conferences documentation - education plans Cost-effective resource utilization Data collection, analysis, and reporting - outcome data - peer review findings record reviews Documentation across settings, following APTA's Guidelines for Physical Therafjy Documentation (Appendix 5), including: changes in Impairments, functional limitations, and disabilities changes in interventions elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences - patient care rounds - patient/client family meetings Referrals to other professionals or resources

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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized. Care is coordinated with patient/client, family, sigtilficant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including eqtiipment suppliers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Commtmication occurs across settings t h r o i ^ case conferences, education plans, and documentation. Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews. Decision making is enhanced regarding health, wellness, and fitness needs. Decision making is enhancedregarditigpatient/client health and the tise of health care resources by patient/dient, family, significant others, and caregivers. Documentation occurs throughout patient/cUent management and across settings andfollowsAPTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case confierences, patient care rounds, and patient/client family meetings. Patient/cUent, jfamily, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. 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 programs plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities transitions across settings transitions to ne-w roles
6edb cmd Expctd 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 c a n c e r s . Dii^btety associated 'with acute or chronic itinesses is reduced. 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 knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes aie increased. Patient/dient knowledge of personal and environmental foetors associated with the condition is increased. Perfomunce levels in self<are, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Kiysicalfiinctionisimproved. Bisk of recirence of comUtion is reduced. KMc of secondary impairment is reduced. Safety; of pxtlent/dient, uaily, s%nificant others, and careis 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 conditioning or reconditioning - aquatic programs gait and locomotor training increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agility training developmental activities training motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation - perceptual training posture awareness training standardized, programmatic, complementary exercise approaches sensory training or retraining - task-specific performance training Body mechanics and postural stabilization - body mechanics training posture awareness training postural control training postural stabilization activities Flexibility exercises muscle lengthening range of motion - stretching Gait and locomotion training developmental activities training gait training implement and device training - perceptual training - standardized, programmatic, complementary exercise approaches - wheelchair training Relaxation breathing strategies movement strategies relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training

Anticipated 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 instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention - Preoperative and postoperative complications are reduced. - Risk factors are reduced. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety is improved. - Self-management of symptoms is improved. Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. Physical capacity is increased. Physical function is improved. Impact on societal resources - Utilization of physical therapy services is optimized. - Utilization of physical therapy services results in efficient use of health care dollars. Patient/client 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.
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Procedural Interventions continued Functional Training in Self-Gire and Home Management (Including Acriviries of Daily Living [ADL] and Instrumental Acrivities of Daily Living [IADL]| Intervenrions Anticipated Gods and Expaded Outnames

ADL training bathing bed mobility and transfer training - developmental activities dressing - eating grooming toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and IADL Functional training programs back schools simulated environments and tasks task adaptation IADL training caring for dependents home maintenance - household chores shopping structured play for infants and children yard work Injury prevention or reduction - injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during self-care and home management

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 selfcare 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 to patient/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 Activiries of Daily Living [IADL], Work Hardening, and Work Conditioning) Intervenrions Anricipated Goals and Exprcted Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL Functional training programs back schools - job coaching - simulated environments and tasks task adaptation task training IADL training community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment safety aw^areness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention Risk factors are reduced. Risk of secondary impairment is reduced. - Safety is improved. - Self-management of symptoms is improved. Impact on health, wellness, and fitness - Fitness is improved. - Health status is improved. - Physical capacity is increased. - Physical function is improved. Impact on societal resources - Costs of 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 ^ t o r s 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 a c c e p t ^ 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 conHnued

Prescriprion, Application, and, as Appropriate, Fabricarion of Devices and Equipment (Assisrive, Adaprive, Orthotic, Protecrive, Supportive, and Prostheric) Interventions

Anlic^ted Gods and ExfwdiKi Oulcames

Adaptive devices - hospital beds - raised toilet seats - seating systems Assistive devices canes crutches - long-handled reachers - power devices static and dynamic splints w^alkers wheelchairs Orthotic devices braces - casts shoe inserts splints Protective devices braces cushions protective taping Supportive devices compression garments - corsets - elastic wraps - neck coUars serial casts sUngs supportive taping

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, home management, 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 instrumental activities of daily living (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 self-care, home man^ement, woric (job/school/play), ajmmunity, and leisure roles is improved. Risk reduction/prevention Pressure 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.
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Procedural Interventions continued Electrotherapeuric Modaliries

Interventions Electrotherapeutic deUvery of medications iontophoresis Electrical stimulation electrical muscle stimulation (EMS) - functional electrical stimulation (FES) high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (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 instrumental activities of daily living (IADL) with or without devices and equipment are increased. - 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

Intervenrions

Anticipated Gods and Expected Oukomes

Physical agents may include: Athermal agents pulsed electromagnetic fields Cryotherapy cold packs ice massage vapocoolant spray Hydrotherapy whirlpool tanks - contrast bath - pools light agents infrared laser Sound agents - phonophoresis - ultrasound Thermotherapy - dry heat hot packs paraffin baths Mechanical modalities may include: Compression therapies taping Traction devices intermittent - positional - sustained

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains: Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality' of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been providetl during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress tow^ard outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/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 adaptation fbUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

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4F Impairments / Spinal Disorders 239/S231

Impaired Joint Mobility, Muscle Performance^ and Range of Motion Associated With Fracture
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; the profession s code of ethics and standards of practice; and patient/client age, culturt:, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified into this patternfor impaired joint mobiUty, muscle performance, and range of motion associated with fractureas a result of the physical therapist's evaluation of the examination data.The findings lrom the examination (history', systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification. Inclusion The following examples of examination findings may support the inclusion of patients/cUents in this pattern;
Risk Factors or Consequences of Pathology/Pathophysioiogy (Disease, Disorder, or Condition)

Exclusion or Mulriple-PqHern Clossification The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may d,'termine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in o Different Pattern

Bone demineralization Fracture Hormonal changes Medications (eg, anti-epileptic medications, steroids, thyroid hormone) Menopause Nutritional deficiency Prolonged non-weight-bearing state Trauma Inabilit>' to access community Umited range of motion Muscle weakness from immobilization Pain with functional movements and activities

Flail cliest
Findings That May Require Classification in Additional Patterns

Impairments, Functional Limitations, or Disabilities

Osteogencsis imperfecta

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as neoplasmmay be severe and complex; however, they do not necessarily exclude patients/ciients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis ' page S239.)

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Impairments / Practure 241/S233

ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 170 213 262 263 268 269 275 627 715 719 Malignant neoplasm of bone and articular cartilage Benign neoplasm of bone and articular cartilage Other severe, protein-calorie malnutrition Other and unspecified protein-calorie maUiutrition Vitamin D deficiency Other nutritional deficiencies Disorders of mineral metabolism Menopausal and postmenopausal disorders Osteoarthrosis and aUied disorders 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 Disorders of muscle, ligament, and fascia 728.1 Muscular calcification and ossification Other disorders of soft tissues 729.9 Other and unspecified disorders of soft tissue Osteomyelitis, periostitis, and other infections involving bone Osteochondropathies 732.4 Juvenile osteochondrosis of lower extremity, excluding foot 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 and cartilage Other acquired deformities of limbs 736.8 Acquired deformities of other parts of limbs Fracture of face bones Fracture of vertebral column w^ithout mention of spinal cord injury 805.6 Sacrum and coccyx, closed Fracture of pelvis Fracture of clavicle Fracture of scapula Fracture of humerus Fracture of radius and ulna 813.4 Lower end, closed 813.5 Lower end, open Fracture of carpal bone(s) Fracture of metacarpal bone(s) Fracture of one or more phalanges of hand Multiple fractures involving both upper Umbs, and upper limbs with ribs(s) and sternum Fracture of neck of femur Fracture of other and unspecified parts of femur Fracture of patella Fracture of tibia and fibula Fracture of ankle Fracture of one or more tarsal and metatarsal bones Fracture of one or more phalanges of foot Other, multiple, and iU-defined fractures of low^er limb Multiple fractures involving both lower limbs, low^er -with upper Umb, and lower Umb(s) with rib(s) and sternum Fracture of unspecified bones

802 805

808 810 811 812 813

728 729 730 732

814 815 816 819 820 821 822 823 824 825 826 827 828 829

733

736

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Examination
Fxamination is a comprehensive screening and specific testing process that lt'ads to a diagnostic classification or, w^hen appropriate, to a referral to another practitioner Examination is required prior to the initial intei-vention and is performed for aU patients/clients.Through the examination, the physical therapist may identify impairments, fimctional Umitations, disabilities, changes in physical function or overall health stanis, and needs related to restoration of health and to prevention, weUness, and fitness.The physical therapist synthesizes the examination 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 gathering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physical therapist.The systems review is a brief or limited examinati<in ot (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) tlte c ommimication abiUty, affiect, cognition, language, and learning 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; .stage of recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors./-'or clinical indications in selxting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2. Patient/Client History The history may include;
General Demographics Social/Heahh Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

Social History

Cultural beliefs and behaviors Family and caregiver resources Social interactions, social activities, and support systems
Employment/Work (Job/School/Play)

Current and prior work (job/school/play), community, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological
Pulmonary-

Current and prior ftmctional status in seU-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily Uving (LADL) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition MecUcations previously taken for current condition Medications for other conditions
Other Clinical Tests

i^boratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

Devices and equipment (eg, a,ssistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Current Condition(s)/Chief Complaint(s)

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)

Concerns that led patient/client to seek the servin-s of a physical therapist Concerns or needs of patient/client who requires the services of a physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and cours<' of events Onset and pattern of symjitoms Patient/cUent, family, signilic ant other, and caregiver expectations and goals for the therapeutic intervt ntion Patient/client, family, signitic ant other, and caregiver perceptions of patient's/ client s emotional response to the current clinical situation Previous occurrence of chit f complaint(s) Prior therapeutic interventions
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5uide !o Physical Therapist Practice

Systems Reviev/
The systems review may include; Anatomical and Physiological Status

Cardiovascular/Pulmonary Blood pressure Edema Heart rate Respiratory rate

Integumentary - Presence of scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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

Tests and Meosures

Tests and measures for this pattern may include those that characterize or quantify;
Aerobic Capacity and Endurance

Cranial ond Peripheral Nerve Integrity

Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Body dimensions (eg, body mass index, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Assistive and Adaptive Devices

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic oudet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily Uving [ADL] scales, functional scales, instrumental activities of daily living [IADL] scales, interviews, observations) Components, alignment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, interview's, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabiUties with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)

Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in w^ork environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments)

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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, technologyassisted analyses, videographic assessments)
Gait, Locomotion, and Balance Muscle Performance (Including Strength, Power, and Endurance)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography,feUscales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dy namometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, <;ibservations, photographic assessments, technology-assisted assessments, videographic assessments, weight-beadng scales, wheelchair mobiUty tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Integumentary Integrity

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength,power, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

Comptjnents, aUgnment,fit,and abiUty to care for orthotic, proteciive, and supportive devices and equipment (eg, interviews, log^, observations, pressure-sensing maps, reports) Ortholic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional sc aies, IADL scales, interviews, observations, profiles) Remediation of impairments, functional Umitations, or disabUitit's with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health asst ssment questionnaires, LADL scales, pain scales, play scales, videographic assessments) Saftty during use of orthotic, protective, and supportive di'vices and equipment (eg, diaries,feUscales, interviews, logs, observatit)ns, reports)
Pain

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 prosthetic devices and equipment that may produce or reUeve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Skin characteristics, including bUstering, continuity of skin color, dermatitis, hair growth, mobiUty, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)
Joint Integrity and Mobility

Paiii, soreness, and nociception (eg,analog scales,discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Riiii in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted imalyses, videographic assessments) Postural aUgnment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Range of Motion (ROM) (Including Muscle Length)

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)

Functioaal ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibiUty, and flexibiUty (eg, contracture tests, goniometiy, inclinometry, Ugamentous tests, linear measurement, multisegment flexibility tests, palpation)

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Hand function (eg,fineand gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

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Tests a n d 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 identification, observations, physical performance tests) AbiUty to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments) bensory Integrity . Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg,electroneuromyography)
Ventilation and Respiration/Gas Exchange

Reintegration (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, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests) * Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activi^^^^ ^^^^ environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) Pulmonary signs of ventilatory function, including airw^ay protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests) Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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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 tests and 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 cUnicalfindings,extent of loss of function, chronicity or severity of the problem, possibiUty of multisite or multisystt m involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status A diagnosis is a label encompassing a cluster of signs and symptoms, syndrome s, or categories. It is the result of the systematic diagnostic process, 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 in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the 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 outcomes, and discharge plans. The plan of care identifies reaUstic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.Tlit se anticipated g<3;ils and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; Uving environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stabiUty of the condition.

Prognosis
Over the course of 3 to 6 months postfracture, patient/cUent will demonstrate optimal joint mobility, muscle performance, and range of motion and the highest level of fimctioning in home, work (job/school/play), community, and leisure environments. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode or Care 6to 18 This range represents the Xov^cx and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 18 tisits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficieniy of service delivery.

Factors That May Require New Episode of Care or That May AAodify Frequency of Visits/ Duration of Episode AccessibiUty and availabiUty of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and,w^hen appropriate, w^ith other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and documentation and patient/client-related instruction are provided for aU patients/clients across aU settings. Procediual interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 Anticipated Goals and Expected Outcomes

Addressing required functions - advance directives individuaUzed family service plans GFSPs) or individuaUzed education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management CoUaboration and coordination with agencies, including; equipment suppUers home care agencies payer groups - schools transportation agencies Communication across settings, including; case conferences - documentation education plans Cost-effective resource utilization Data collection, analysis, and reporting outcome data - peer review findings record revievvs Documentation across settings, foUowing APTA's Guidelines for 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

AccountabiUty for services is increased. Admission data and discharge planning are completed. Advance directives, individualizedfiimityservice plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utiUzed. Care is coordinated with patient/cUent,fiuiuly,significant others, 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 conferences, education plans, and documentation. Data are collected, analyzed, and reported, including outcome data, peer reviewfindings,and record reviews. Decision making is enhanced regarding health, weUness, and fitness 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 management and across settings andfollowsAPTA's Guidelines for Physical Therapy Documentation (Appendix 5). InterdiscipUnary collaboration occurs through case conferences, patient care rounds, and patient/cUent family meetings. Patient/cUent, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utiUzed in a cost-effective way.

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Patient/ClienhRelated Instruction

Patient/cUent-related instruction may include;

Interventions

Goat* and Expwted Outcomes

Instruction, education and training of patients/clients and caregivers regarding; - current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional Umitations, or disabilities) enhancement of performance health, wellness, and fitness programs plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional Umitations, or disabiUties - transitions across settings transitions to new roles

AblUtf to perform physical actions, tasks, or activities is iaipforved. Awareness and use of community resourees are improved. Behaviors that foster healthy habits, wellness, and prevention Decision making is enhanced F^arding patient/dient health and the use of health care tesources by patient/client, femily, signifilcant others, and caregivers. Disab^ty associated with acute or chronic illnesses is reducied. Functional independence in activities of daily living (ADL) and iiistnunental activities of daily Uving (IADL) is increased. Healtli status is improved. Intensity of care is decreasoJ. Level of supervision required for task performance is decreased. P^tient/di^nt, family, significant other, and caregiver knowledge And awareness of the diagnosis, pn^nosis, interventions, and anticipated ^als and expected outcomes are increased. I^tient/cUent knowledge of personal and envteonmental fectors associated with the condition is increased. Perfofmance levels in self-care, home management, woik (Job/school/play), community, ortefexireactions, tasks, or activities 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 caregivers 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 Anticipated Goals and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning - aquatic programs - gait and locomotor training increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agility training developmental activities training motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation perceptual training posture awareness training - standardized, programmatic, complementary exercise approaches task-specific performance training Body mechanics and postural stabilization body mechanics training posture awareness training postural control training - postural stabilization activities Flexibility exercises muscle lengthening range of motion stretching Gait and locomotion training - developmental activities training - gait training implement and device training perceptual training standardized, programmatic, complementary exercise approaches - wheelchair training Relaxation - breathing strategies movement strategies relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance exercises for head, neck, Umb, pelvicfloor, trunk, and ventilatory muscles - active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) - aquatic programs standardized, programmatic, complementary exercise approaches - task-specific performance training

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 are improved. - 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 instrumental activities of daily Uving (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 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] and Instrumental Activities of Daily Living [IADL] Interventions

ADL training - bathing bed mobiUty and transfer training developmental activities dressing eating grooming - toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and IADL prosthetic device or equipment training during ADL and L D AL 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 children - yard work Injury prevention or reduction injury prevention education during self-care and home management - injury prevention or reduction with use of devices and equipment safety awareness training during self<;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 pfeirraance (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 requiredfortask 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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Anticipated Goats and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during LADL prosthetic device or equipment training during IADL Functional training programs - back schools - job coaching - simulated environments and tasks - task adaptation - task training IADL training community service training involving instruments - school and play activities training including tools and instruments work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 orreintegrationis improved. - 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), community, 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 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/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 Anticipated Goals and Expected Outcomes

Adaptive devices - environmental controls - hospital beds raised toilet seats seating systems Assistive devices canes - crutches - long-handled reachers pow^er devices static and dynamic splints walkers - wheelchairs Orthotic devices - braces - casts shoe inserts splints Protective devices - braces - cushions helmets protective taping Supportive devices compression garments corsets elastic wraps - neck collars - serial casts - slings supportive taping

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 instrumental activides of daily Uving (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 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

Goals ond EiqMdad Owtcomes

Electrical stimulation electrical mu.scle stimulation (EMS) - high voltage pulsed current (HVPC) - neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (TENS)

Impact 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 mana^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 instrumental SKCtivities of daily Uvii^i (IADL) with or without devices and eqtiipmoit are increased. - Totentnce erf posititms and activities is increased. Impact on disatriUties - AMIty to assume orresufljierequired 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 Anticipated Goals and Expected Outcomes

Physical agents may include: Athermal agents pulsed electromagnetic fields 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: Gravity-assisted compression devices - tilt table

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 impairments Integumentary 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 instrumental activities of daily Uving (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 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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect intervention.s. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinicalfindingsor failure to respond to physical therapy inten entions

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goaLs and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of 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 the physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of hoth health status and health-related quaUty of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge doe^ not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements fbr documentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or bet ause frnanc ial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. Wlien physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and therationalefor 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 adaptation 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 Motion Associated With Joint Arthroplasty
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/cUents who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, c ulture. gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/cUents wiU be classified into this patternfor impaired joint mobility, motor function, muscle performance, and range of motion associated with joint arthroplastyas a result of the physical therapist s evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, w^ellness, or fitness programs,The physical therapist integrates, synthesizes, and interprets the ttata to determine the diagnostic classification.
Inclusion

Exclusion or Multiple-Pattern Classification The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examinationfindings,the physical therapist may determine that the patient/cUent would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings Thot May Require Classification in a Different Pattern

The following examples of examinationfindingsmay support the inclusion 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 Decreased range of motion Inability to access transportation InabiUty to dress Muscle guarding Muscle weakness Pain

Impairments associated with multisite trauma

Findings That May Require Classification in Additional Patterns

Impairments, Functional Limitations, or Disobilities

Rheumatoid arthritis with deconditioning

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as muttipte joint replacement, recurrent postoperative dislocation, and secondary postoperative infectionmay be severe and compXes., however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S297.)

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ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, fimctional Umitations, and disabUitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. Malignant neoplasm of bone and articular cartilage MaUgnant neoplasm of connective and other soft tissue Benign neoplasm of bone and articular cartilage Other benign neoplasm of connective and other soft tissue Dentofacial anomalies, including malocclusion 524.6 Temporomandibular joint disorders 714 Rheumatoid arthritis and other inflammatory polyarthropathies 714.0 Rheumatoid arthritis 714.3 Juvenile chronic polyarthritis 714.30 Polyarticular juvenUe rheumatoid arthritis, 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 joint Calcification of joint 729 Other disorders of soft tissues 729.8 Other musculoskeletal symptoms referable to limbs 730 Osteomyelitis, periostitis, and other infections involving bone 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 Osteitis deformans without mention of bone tumor Paget's disease of bone 170 171 213 215 524 733 Other disorders of bone and cartilage 733.1 Pathologic fracture 733.8 Malunion and nonunion of fracture Fracture of pelvis 808.0 Acetabulum, closed Fracture of humerus 812.0 Upper end, closed Fracture of metacarpal bone(s) Fracture of neck of femur 820.8 Unspecified part of neck of femur, closed 820.9 Unspecified part of neck of femur, open Fracture of ankle Dislocation of hip Dislocation of knee 836.5 Other dislocation of knee, closed Dislocation of ankle Certain early CompUcations of trauma 958.3 Posttraumatic wound infection, not elsewhere classified

808 812 815 820

824 835 836 837 958

Supplemental Classification of Factors Influencing Health Status and Contoct With Health Services

V43 Organ or tissue replaced by other means V43.6 Joint V43.61 Shoulder V43.64 Hip V43.65 Knee V43.66 Ankle V43.70 limb

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed fbr aU patients/clients,Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overaU health status, and needs related to restoration of health and to prevention, welUiess, and fitness.The physical therapist synthesizes the examination 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 gathering of past and current information (often from the patient/client) related to why the patient/cUent is seeking the services of the physical therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary; integumentary, musculoskeletal, and neuromtiscular systems and (2) the communication ability, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For ctinical indications in selecting tests and measures and for listings of tests and measures, 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 Sociol/Health Habits (Past and Current) Functional Stotus ond Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (t-g, smoking, drug abuse) Level of physical fitness
Family History

FamiUal liealth risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Enviranment

Devices and eqtiipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Sel^Report, Family Report, Caregiver Report)

Cardiovasctilar Endocrine/metabolic Gastnjintestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary 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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals fbr the therapeutic intervention Patient/client, family, significant other, and carejjiver perceptions oi patient's/ client's emotional response to the current clinical sittiation Previous occurrence of chief complaint(s) Prior therapeutic interventions

Current and prior functional status in self-care and home management activities, including activities of daily Uving (ADL) and instrumental activities of daily Uving (LADL) Current and prior functional status in w^ork (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

Current Condition(s)/Chief Complaint(s)

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)

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Systems Review The systems revie-w may include:

Anatomical and Physiological Status

Cardiovascular/Pulmonary Blood pressure Edema Heart rate Respiratory rate

Integumentary - Presence of scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 Copacity and Endurance Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily Uving [IADL] scales, observations)
Anthropometric Choracteristics

Body dimensions (eg, body mass index, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Assistive and Adaptive Devices

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, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, LADL scales, interviews, observations) Components, alignment, fit, and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities w^ith use of assistive or adaptive devices and eqtiipment (eg, activity status indexes, ADL scales, aerobic capacity tests, ftmctional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Current and potential barriers (eg, checkUsts, interviews, observations, questionnaires Physical space and environment (eg, compUance standards, observations, photographic assessments, questionnaires, structural 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 ability tests) Ftmctional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interview's, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checkUsts, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, 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, technology-assisted analyses, videographic assessments)

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Tests and Measures continued

Gait, Locomotion, and Balance

Muscle Performonce (Including Strength, Power, and Endurance)

Balance duringfimctionalactivities with or without the tise of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, LADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)
Integumentary Integrity

Bkctrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during ftmctional activities (eg, ADL scales, functional muscle tests, LADL scales, observaiions, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

(ximponents, alignment,fit,and abiUty to care for orthotic, protet tive, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) C )rthotic, protective, and supportive devices and equipment tise during functional activities (eg, ADL scales, ftmctional .scales, IADL scales, interviews, observations,profiles) Remediation of impairments, functional limitations, or disabiUties with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventorfes, health assessment questionnaires, IADL scales, pain scales, play scales, \ ideographic assessments) Salety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)
Pain

Associated skin Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales) Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or reUeve trauma to the .skin (eg, observations, risk assessment scales) Skin characteristics, including bUstering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic 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)

l^in, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descrfptor tests) I'ain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural aUgnment and position (static), including symmetry ami deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, obsen'ations, palpation, positional tests)
Ronge of Motion (ROM) (Including Muscle Length)

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Hand function (eg,fineand gross motor control tests, finger dexterity tests, manipulative ability tests, observations)

Functional ROM (eg, ob,sei-vations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibiUty (eg, contracture tests, goniometry, inclinometry, Ugamentous tests, linear measurement, multisegment flexibility tests, palpation)

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Tests and Measures continued

Reflex Integrity

Sensory 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)

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Ability to gain access to home environments (eg, barrfer identification, observations, physical performance tests) AbiUty to perform self<are and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interview's, logs, observations, reports, videographic assessments)

Ability to assume or resume work (job/school/play), community, and leisure activities with or w^ithout assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, 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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or mtiltisysteni involvement, preexisting condition(s), potential disch;irge destination, social considerations, physicalfimction,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 diagnostic process, 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 in fimction and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goids and expected outcomes, takii^ into consideration the expectations of the patient/cUent and appropriate others.These anticipated goals and expected outcomes should be measureable and time Umited. Thefi*;quencyof visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or sevt:rity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; |>robability of prolonged impairment, functional limitation, or disability; and stabiUty of the condition.

Prognosis

Expected Range of Number of Visits Per Episode or Core 12to60

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode

Over the course of 6 months, patient/ cUent will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, w^ork (job/school/play), community, and leisure environments. During the episode of care, patient/cUent will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ cUents who are classified in this pattern.

This range represents the lower and upper limits of the number of physical therapist vi.sits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/ctients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 12 to 60 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficient:} of service delivery.

AccessibiUty and availabiUty of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, usir^ various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and "the progress made toward achieving the anticipated goals and expected outcomes. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter J.

Coordinarion, Communication, and Documentarion

Coordination, commtmication, and documentation may include:
Interventions Anticipated Goals and Expected Outcomes

Addressing required functiotis - advance directives - individualized family service plans (IFSPs) or individualized education plans (IEPs) - informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including: - equipment 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 Guidelines for 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

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, including equipment suppliers, home care agencies, payer groups, 1 schools, and transportation agencies. ;i Communication enhances risk reduction and prevention. * Communication occurs across settings through case conferences, education plans, and documentation. Data are collected, analyzed, and reported, including outcome data, peer review 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 management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.' Patient/cUent, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. " Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utilized in a cost-effective way.

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Patienf/Client-Related Instruction Patient/client-related instruction may include;

Interventions

Anticipated Goals and Expected Outcomes

Instruction, education and training of patients/clients and caregivers regarding: - current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities) - enhancement of performance - health, wellness, and fitness programs - plan of care - risk fectors for pathology/pathophysiology (disease, disorder, or condition), impairments,ftmctionallimitations, or disabilities - transitions across settings - transitions to new roles

Ability to perform physical actions, tasks, or activities is improved. Awareness and use of community resources are improved. Behaviors that foster healthy habits, wellness, and prevention are acquired. Decision making is enhanced regarding patient/client health and the use of health care resources by patient/client, family, significant others, and caregivers. Disability associated with acute or chronic illnesses is reduced. 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 knowledge and awareness of tbe diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/client knowledge of personal and environmental fectors associated with the condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/client, family, significant others, and caregivers is improved. Self-management of symptoms is improved. Utilization and cost of health care services are decreased.

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Procedural Interventions Procedural interventions for this pattern may include: Therapeutic Exercise
Interventions Anticipated Goals and Expected Outcomes

Aerobic capacity/endtirance conditioning or reconditiotiing - aquatic programs - gait and locomotor training - increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agility training - developmental activities training - motor fimction (motor control and motor learning) training or retraining - neuromuscular education or reeducation - pereeptual training - posture awareness training - standardized, programmatic, complementary exercise approaches - task-specific perfonnance training Body mechanics and postural stabilization - 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, complementary exercise approaches - wheelchair training Relaxation - breathing strategies - movement strategies - relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exereises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs - standardized, programmatic, complementary exereise approaches - task-specific performance training

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 mancement, 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 reducedSafety 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] and Instrumental Activities of Daily Living [IADL]) Interventions Anticipated Goals and Expected Outcomes

ADL training - bathing - bed mobility and transfer training - developmental activities dressing - eating - grooming - toileting Devices and equipment use and training - assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and L\DL - prosthetic device or equipment training 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 children - 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

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 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, 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,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], Work Hardening, and Work Conditioning) Interventions Anticipated Gods and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL prosthetic device or equipment training during IADL Functional training programs back schools job coaching simulated environments and tasks task adaptation task training IADL training - community service training involving instruments school and play activities training including tools and instruments work training with tools Injury prevention or reduction injury prevention education during w^ork (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment - safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 Manual Therapy Techniques (Including Mobilization/Manipulation)

a
Airikipcriwd Gods and Expactod Oulnmws

Interventions

Massage connective tissue massage therapeutic massage Mobilization/manipulation soft tissue Passive range of motion

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,and significant others. - Sense of weU-being is improved. - StresKjrs are decreased.

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Procedural Interventions conHnued

Electrotherapeutic Modalities

Interventions

Anticipaled Goals and Expected Outcomes

Biofeedback Electrical stimulation electrical muscle stimulation (EMS) functional electrical stimulation (FRS) high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (TENS)

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 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. - 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 instrumental activities of daily living (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 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 continued

Physical Agents and Mechanical Modalities

Interventions

Anticipated Gods and Expected Outcomes

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)

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 instrumental activities of daily Uvit^ (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 self-care, home management, work (job/school/play), community, and leisure roles is improved. Risk reduction/prevention Complications of soft tissue and circulatory disorders are decreased. Risk 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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Reexamination
Reexamination is the process of performir^ selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinicalfindingsot feilurc to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy strvices by characterizing or quantifying the impact of the physical therapy interventions in thefoUowingdomains: 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of Me.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not otrcur with a transfer (defined as the time when a patient is moved from one site to another site ^vithin the same setting or across settings during a single episode of care). Although there may be faciUty-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated 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) the patient/cUent, caregiver, or legal guardian decUnes to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial CompUcations or becausefinancial/insuranceresources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adaptation foUowing changes in physical status, caregivers, environment, or task demiuids. In consultation with appropriate individuals, and in consideration 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 of Motion Associated With Bony or Soft Tissue Surgery
This preferred practice pattern describes the generally accepted elements of patient/dient management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/dient needs; the profession's code of ethics and standards of practice; and patient/cUent age, culture, gender roles,race,sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients w^ill be classified into this patternfor impaired joint mobiUty, motor function, muscle performance, and range of motion associated w^ith bony or soft tissue surgeryas a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/ pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabiUties or the need for health, wellness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion
The following examples of examination findings may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

Exclusion or Multiple-Pattern Classification

The following examples of examinationfindingsmay support exclusion from this pattern or classification into addition;il patterns. Depending on the level of severity or complexity of the examinationfindings,the physical therapist may determine that the patient/cUent would be more appropriately managed through (1) classification in an entiiely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Ankylosis Bone graft and lengthening procedures Cesarean section Connective tissue repair or reconstruction Fascial releases Fusions Internal debridement Internal knee derangement

Intervertebral disk disorder Laminectomies Muscle, tendon, Ugament, capsule repair or reconstruction Multisite fractures Open reduction internal fixation Osteotomies Tibial tuberosity procedures

Impairments, Functional Limitations, or Disabilities

Amputation Closed head trauma Non-union fractures Peripheral nerve lesions Total joint arthroplasties

Decreased range of motion Decreased strength and endurance due to inactivity Impaired joint mobility Limited independence in activities of daily Uving Pain Swelling

Findings That May Require Classification in Additional Patterns

Neurological sequelae Non-healing wound Vascular sequelae

Note:

Some risk fectors or consequences of pathology/ pathophysiologysuch as failed surgeriesmay be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See 'Evaluation, Diagnosis, and Prognosis," page S276.)

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ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional Umitations, and disabilitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 715 717 718 Osteoarthrosis and aUied disorders Internal derangement of knee 717.8 Other internal derangement of knee 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 Other and unspecified disorders of joint Spondylosis and allied disorders Intervertebral disk disorders 722.7 Intervertebral disk disorder with myelopathy Other disorders of cervical region Other and unspecified disorders of back 724.0 Spinal stenosis, other than cervical 724.3 Sciatica Peripheral enthesopathies and aUied syndromes 726.0 Adhesive capsuUtis of shoulder 726.1 Rotator cuff syndrome of shoulder and aUied disorders 726.2 Other affections of shoulder region, not elsewhere classified Periarthritis of shoulder Scapulohumeral fibrositis 726.9 Unspecified enthesopathy 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 Disorders of muscle, Ugament, and fascia 728.6 Contracture of palmar fescia Dupuytren's contracture Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.0 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 Other disorders of bone and cartUage 733.1 Pathologic fracture Spontaneous fracture 733.8 Malunion and nonunion of fracture 733.82 Nonunion of fracture Other acquired deformities of limbs 736.8 Acquired deformities of other parts of limbs Curvature of spine Other acquired deformity' 738.4 Acquired spondylolisthesis Other congenital musculoskeletal anomalies 756.1 Anomalies of spine Fracture of face bones Fracture of vertebral column without mention of spinal cord injury Fracture of pelvis Fracture of clavicle Fracture of scapula Fracture of humerus Fracture of radius and ulna Fracture of carpal bone(s) Fracture of metacarpal bone(s) Fracture of one or more phalanges of hand Fracture of neck of femur Fracture of other and unspecified parts of femur Fracture of pateUa Fracture of tibia and fibula Fracture of ankle Fracture of one or more tarsal and metatarsal bones Fracture of one or more phalanges of foot Dislocation of jaw Dislocation of shoulder Dislocation of elbow Dislocation of w^rist Dislocation of finger Dislocation of hip

733

719 721 722 723 724

736 737 738 756 802 805 808 810 811 812 813 814 815 816 820 821 822 823 824 825 826 830 831 832 833 834 835

726

727

728

731

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ICD-9-CM Codes continued

836 Dislocation of knee 836.0 Tear of medial cartilage or meniscus current 836.1 Tear of lateral cartilage or meniscus of knee, current 836.2 Other tear of cartilage or meniscus of knee, current 836.5 Other dislocation of knee, closed 837 Dislocation of ankle 838 Dislocation of foot 839 Other, multiple, and iU-defined dislocations 839.0 Cervical vertebra, closed 839.3 Thoracic and lumbar vertebra, open 839.8 Multiple and ill-defined, closed Arm Back Hand Multiple locations, except for fingers or toes alone 840 Sprains and strains of shoulder and upper arm 840.4 Rotator cuff (capsule) 841 Sprains and strains of elbow and forearm 842 Sprains and strains of ^vri.st and hand 843 Sprains and strains of hip and thigh 844 Sprains and strains of knee and leg 845 Sprains and strains of ankle and foot 846 Sprains and strains of sacroiUac region 847 Sprains and strains of other and unspecified parts of back 848 Other and ill-defined sprains and strains 959 Injury, other and unspecified 959.2 Shoulder and upper arm 959.9 Unspecified site

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, ^vhen appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify' impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, weUness, andfitness.Thephysical therapist synthesizes the examinationfindingsto establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components: the patient/client history, the systems review, and tests and measures.The history is a systematic gathering of past and current information (often from the patient/client) related to -why the patient/client is seeking the services of the physical therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication abiUty, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, w^ork (job/school/play), or community situation; and other relevant factors. For clinical indications in setecting tests and measures and for listings of tests and measures, 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 Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community' characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary' Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily 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 current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other cUnicalfindings(eg, nutrition and hydration)

Current Condition(s)/Chief Complaint(s)

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)

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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client,femily,significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
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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 scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (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 or qu tntify:
Aerobic Capacity and Endurance Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily living [ADL| scales, indexes, instrumental activities < f daily living [IADL] scales, observations)
Anthropometric Characteristics

Body dimensions (eg, body mass index, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Assistive and Adoptive Devices

Assistive or adaptive devices and equipment use during iiinctional activities (eg,ADL scales, functional scales, IADL .scales, intervie\vs, observations) Components, alignment, fit, and abUity to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)

I'k ctiophysiological integrity (eg, electroneuromyography) .Motor distribution of the cranial nerves (eg, dynamometry, musi It tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, nmscie tests, observations, thoracic outlet tests) Sensory distribution of the cranial nerves (eg, discrimination tests: tactile tests, including coarse and light touch, cold and lit at, pain, pressure, and vibration) Sensory tlistribution of the peripheral nerves (eg, discriminati(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, observaiioiis, ijue.stionnaires Physical space and environment (eg, compliance standards, 1 >bserYatic)ns, photographic assessments, questionnaires, structural specifications, videographic assessments)

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Tests ond Measures continued

Ergonomics and Body Mechanics Integumentary Integrity

Ergonomics Dexterity and coordination durir^ work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checkUsts, job simulations, lifting models, preemployment screenings, task analysis checkUsts, workstation checkUsts) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checkUsts, vibration assessments) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg,ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)
Gait, Locomotion, ond Balance

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 prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, risk assessment scales) Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography) 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,fineand gross motor control tests, finger dexterity tests, manipulative abiUty tests, observations)
Muscle Performonce (Including Strength, Power, and Endurance)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) w^ith or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, di2ziness inventories, dynamic posturography,feUscales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobiUty skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adajv tive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobiUty skiU profUes, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobiUty tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries, faU scales, functional assessment profiles, logs, reports)

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual musde tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, pow^er, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)
Orthotic, Protective, ond Supportive Devices

Components, aUgnment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, LADL scales, interviews, observations, profiles) Remediation of impairments, functional Umitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries,feUscales, interviews, logs, observations, reports)

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Tests and Measures continued

Pain

:O
Self-Care and Home Management (Including ADL and IADL)

Pain, soreness, and nociception (eg, analog scales, angina scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from 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)

Ability to gain access to home environments (eg, barrier identification, observations, physical jjerformance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, LADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg. diaries. faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Elec trophysiological integrity (eg,electroneuromyography)
Work (Job/School/Ploy), Community, and Leisure Integration or Reintegration (Including IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibiUty, and flexibility (eg, contracture tests, goniometry, inclinometry, Ugamentous tests, linear measurement, multisegment flexibility tests, palpation)
Reflex Integrity

Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) Superficial reflexes and reactions (eg, observations, provocation tests)

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 questionnaires, IADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

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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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of function, chronicity or severity of the problem, possibUity of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, 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 diagnostic process, 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 in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. Tbe plan of care identifies reaUstic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/cUent and appropriate others.These anticipated goals and expected outcomes should be measureable and time limited. 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 longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout tbe evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probabiUty of prolonged impairment, functional Umitation, or disability; and stabiUty of the condition.

Prognosis

Expected Range of Number of Visits Per Episode of Care 6 to 70

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode

Over the course of 1 to 8 months, patient/cUent wiU demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments. During the episode of care, patient/cUent wiU achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ cUents who are classified in this pattern.

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 70 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service deUvery.

AccessibiUty and availabiUty of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, complications, or secondary impairments Concurrent medical, surgical, and therapeutic interventions Decline in functional independence Level of impairment Level of physical function Living environment Multisite or multisystem involvement Nutritional status Overall health status Potential discharge destinations Premorbid conditions ProbabiUty of prolonged impairment, functional limitation, or disabiUty Psychological and socioeconomic factors Psychomotor abiUties Social support StabiUty of the condition

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent response and the 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 settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 Goab cmd Expected Outcomes

Addressing required functions - advance directives individuaUzed family service plans (IFSPs) or individuaUzed education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, includir^: - equipment suppliers - home care agencies payer groups schools - transportation agencies Communication across settings, including: case conferences documentation education 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, and disabilities changes in interventions elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamw^ork case conferences patient care rounds - patient/client family meetings Referrals to other professionals or resources

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, and mandatory communicaticm aiKl reporting (eg, patient advocacy and abuse iieportmg) are obtained or completed. AvailaiMe resources are maxiiaalty utUized. Care is coordii^ted with patient/client, &mily, significant others, 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 r o i ^ case conferences, 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 management and across settii^ andfollowsAPTA's Guidelinesfor Physical Therapy Documentation (Appendix 3). Iaterdiscipltary coilabotation occurs t h r o i ^ case conferences, patient care rounds, and patient/dient &mily meetings. Patient/dient, faoiUy, significant other, and caiegivar understanding of anticipated goals mud expected outcomes is increased. Placement needs are dettnined. Referrals are made to other professionals (H* resources whenever 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, disorder, or condition), impairments, functional limitations, or disabUities - transitions across settings transitions 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 is reduced. 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 knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/dient knowledge of personal and environmental fectors associated with the condition is increased. Performance levels in self<are, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/dient,femily,significant others, and caregivers 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 Gods and Exptctad Oirtconws

Aerobic capacity/endurance conditioning or reconditioning aquatic programs - gait and locomotor training - increased workload over time - waUdng and wheelchair propulsion programs Balance, coordination, and agiUty training developmental activities training motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation - perceptual training posture aw^areness training standardized, programmatic, complementary exercise approaches sensory training or retraining - task-specific performance training Body mechanics and postural stabilization - body mechanics training posture aw^areness training postural control training - postural stabilization activities FlexibUity exercises - muscle lengthening range of motion - stretching Gait and locomotion training developmental activities training gait training implement and device training perceptual training - standardized, programmatic, complementary exerci.se approaches wheelchair training Relaxation breathing strategies movement strategies - relaxation techniques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive. active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs - standardized, programmatic, complementary exercise approaches task-specific performance training

on 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^nits 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 instrumental activities of daify Uving (IADL) with or without devices and equipmott are increased. - 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-aiaii@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:alfimctionis 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] ond Instrumental Activities of Doily Living [IADL]) Interventions Anticipoted Gools ond Expected Outcomes

ADL training - bathing - bed mobiUty and transfer training developmental activities - dressing - eating grooming toileting Devices and equipment use and training - assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and LADL - prosthetic device or equipment training during ADL and IADL 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 chUdren - yard work Injury prevention or reduction - injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during self-care and home management

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 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 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 Activities of Doily Living [IADL], Woric Hordening, ond Work Conditioning] Interventions Anticipoled Gools ond Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during LADL orthotic, protective, or supportive device or equipment training during L\DL prosthetic device or equipment training during IADL Functional training programs - back schools - job coaching simulated environments and tasks - task adaptation task training IADL training community service training involving instruments - school and play activities training including tools and instruments work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 equipment are increased. - Tolerance of positions and activities is increased. Impact on disabiUties - AbiUty to assimie or resume required work (job/school/play), commtmity, 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 increa,sed. - Physical function is improved. Impact on sodetal resources Costs 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.

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Procedural Interventions conHnued Manual Therapy Techniques (Including Mabilization/Manipulation)

Interventions

Anficipated Goals and Expected Otffcomes

Manual lymphatic drainage Manual traction Massage - connective tissue massage therapeutic massage Mobilization/manipulation soft tissue peripheral joints Passive range of motion

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,and significant 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 Goob and Expscted Ouieomes

Adaptive devices - environmental controls - hospital beds raised toilet seats seating systems Assistive devices canes - crutches - long-handled reachers power devices static and dynamic splints walkers wheelchairs Orthotic devices braces - casts - shoe inserts - splints Protective devices braces cushions protective taping Supportive devices - compression garments corsets elastic wraps neck collars serial ca.sts slings supportive taping

Impact on pathol<^y/pa)lK>physk>Iogy (disease, disorder, C - condition) M - 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 iinioved. - 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. - Physicalftmctionis 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 Anticipated Goals and Expected Outcomes

Biofeedback Electrotherapeutic delivery of medications - iontophoresis Electrical stimulation - electrical muscle stimulation (EMS) - functional electrical stimulation (FES) high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS)

Impact on pathology/pathophysiology (disease, disorder, or condition) Edema, lymphedema, or effusion is reduced. - Joint swelling, inflammation, or restriction is reduced. - Nutrient delivery to tissue is increased. - Osteogenic effects are enhanced. - Pain is decreased. Soft tissue or wound healing is enhanced. - Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced. Impact on impairments - Integumentary integrity is improved. - Motor function (motor control and motor learning) is improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Quality and quantity of movement between and across body segments are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness is increased. Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tolerance of positions and activities is increased. Impact on disabilities - Ability to assume or resume required self-care, home management, work (job/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

Anticipatod Goob and Expected Outcomes

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 bandaging compression garments - taping - vasopneumatic compression devices Gravity-assisted compression devices - tilt table Mechanical motion devices - continuous passive motion (CPM)

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 Instrumental activities of daily living (LVDL) with or without devices and eqiupment are increased. - 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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/cUents may be over the life span. Indications for reexamination include new clinicalfindingsor failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of Ufe.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care ^vhen (1) the patient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial CompUcations or becausefinancial/insuranceresources have been expended; or (3) the physical therapist determines that the patient/client wiU no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adaptation foUow^ing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides fbr appropriate foUow up or refierral.

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Impaired Motor Function, Muscle Performonce, Ronge of Motion, Goit, Locomotion, ond Bolonce Associoted With Am pu to tion
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundarie.s within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles,race,sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients wiU be classified into this patternfor impaired motor ftmction, muscle performance, range of motion, gait, locomotion, and balance associated with amputationas a result of the physical therapist's evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional Umitations, or disabilities or the need for health, wellness, orfitnessprograms.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion
The foUowing examples of examination findings may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity' of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Amputation Diabetes Frostbite Peripheral vascular disease Trauma 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

Impairments, Functional Umitations, or Disabilities

Amputation with respiratory feUure

Findings That May Require Classification in Additional Patterns

Openw^ound

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as multisystem involvement and traumatic amputation of multiple partsmsLy be severe and complex; however, they do not necessarity exctude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page

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ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/cUent diagnostic classification is based on impairments, functional Umitations, and disabUitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. Diabetes meUitus 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 shoulder girdle 781 Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait 781.5 Clubbing of fingers 781.9 Other symptoms involving nervous and musculoskeletal systems 250 353 885 886 887 895 896 897 905 906 927 928 929 990 991 Traumatic amputation of thumb (complete) (partial) Traumatic amputation of other finger(s) (complete) (partial) Traumatic amputation of arm and hand (complete) (partial) Traumatic amputation of toe(s) (complete) (partial) Traumatic amputation of foot (complete) (partial) Traumatic amputation of leg(s) (complete) (partial) Late effects of musculoskeletal and connective tissue injuries 905.9 Late effect of traumatic amputation Late effects of injuries to skin and subcutaneous tissues Crushing injurj' of upper limb Crushing injury of lower Umb Crushing injury of multiple and unspecified sites Effects of radiation, unspecified Effects of reduced temperature 991.1 Frostbite of hand 991.2 Erostbite of foot Effects of other external causes 994.0 Effects of Ughtning CompUcations affecting specified body system, not elsewhere classified 997.6 Amputation stump compUcation

994 997

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for aU patients/cUents.Through the examination, the physical therapist may identify impairments, functional Umitations, disabiUties, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness.The physical therapist synthesizes the examination findings to 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 gathering of past and current information (often from the patient/client) related to why the patient/cUent is seeking the services of the physical therapist.The systems review is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromu.scular systems and (2) the communication ability, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the ty/>es of data generated try tests and measures, refer to Chapter 2. Patient/Client History The history may include:
General Demographics Social/Heahh Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metaboUc Gastrointestinal Cienitoiirinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitaUzations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary 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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptotns Patient/client, family, significant other, and earegiver expectations and goals for the therapeutic intervention Patient/cl ient,femily,sign ificari t other, and caregiver perceptions of patient's/ client's irmotional response to the current clinical situation Previous occurrence of chief complaint(.s) Prior therapeutic interventions

Current and prior fianctional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily Uving (IADL) Current and prior functional status in w^ork (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

Current Condition(s)/Chief Complaint(s)

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)

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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 scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 or quantify: Remediation of impairments, functional Umitations, or disabiliAerobic Capacity and Endurance ties with use of assistive or adaptive devices and equipment Aerobic capacity during functional activities (eg, activities of (eg, activity status indexes,ADL scales, aerobic capacity tests, daily living [ADL] scales, indexes, instrumental activities of daily functional performance inventories, health assessment quesUving [IADL] scales, observations) tionnaires, IADL scales, pain scales, play scales, videographic Aerobic capacity during standardized exercise test protocols assessments) (eg, ergometry, step tests,time/distancewalk/run tests, tread Safety during use of assistive or adaptive devices and equipmiU tests, wheelchair tests) ment (eg, diaries, fall scales, interviews, logs, observations, Cardiovascular signs and symptoms in response to increased reports) oxygen demand with exercise or activity, including pressures and flo^v; heart rate, rhythm, and sounds; and superficial vascuCirculation (Arterial, Venous, and Lymphatic) lar responses (eg, electrocardiography, exertion scales, observa Cardiovascular signs, including heart rate, rhythm, and sounds; tions, palpation, sphygmomanometry) pressures and flow; and superficial vascular responses (eg, aus Pulmonary signs and symptoms in response to increased oxycultation, claudication scales, palpation, sphygmomanometry, gen demand with exercise or activity, including breath and thermography) voice sounds; cyanosis; gas exchange; respiratory pattern, rate, Physiological responses to position change, including autonomand rhythm; ventilatory flow, force, and volume (eg, ausctiltaic responses, central and peripheral pressures, heart rate and tion, exertion scales, observations, oximetry, palpation) rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, Anthropometric Characteristics sphygmomanometry) Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Cranial and Peripheral Nerve Integrity Body dimensions (eg, body mass index, girth measurement, Electrophysiological integrity (eg, electroneuromyography) length measurement) Motor distribution of the peripheral nerves (eg, dynamometry, Edema (eg, girth measurement, palpation, scales, volume meamuscle tests, observations, thoracic outlet tests) surement) Sensory distribution of the peripheral nerves (eg, discriminaArousal, Attention, and Cognition

Motivation (eg, adaptive behavior scales)

Assistive and Adaptive Devices

tion tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations) Components, alignment,fit,and abiUty to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

Current and potential barriers (eg, checklists, interviews, observations, questionnaires) Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

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Tests and Measures continued

Ergonomics and Body Mechanics

Integumentary Integrity

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, phy.sical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checklists, job simulations, lifting models, preemployment screenings, ta.sk analysis checklists, workstation checklists) Ibols, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, 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, technology assisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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 prosthetic devices and equipment that may produce or reUeve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobiUty, naU growth, temperature, texture, and turgor (eg, observations, palpation, photographic 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 distraction, drawer, gUde, impingement, shear, and valgus/varus stress tests; arthrometry)
Motor Function (Motor Control and Motor Learning)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,Al>L scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supporiive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography,feUscales, motor impairment tests, observations, photographic assessments, postural contn)! tests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobilit}^ skill profiles, observations, video graphic assessments) Gait and locomotion with or wthout the use of assistive, adaptive, orthotic, protective, .supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, niobUity skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheek hair mobility' tests) Safet>' during gait, locomotion, and balance (eg, confidence scales, diaries, faU scales, functional assessment profiles, logs, reports)

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, finger dexterity tests, manipulative abiUty tests, observations)
Muscle Performance (Including Strength, Power, and Endurance)

Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during ftuictional activities (eg, ADL scales, ftmctional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Orthotic, Protective, and Supportive Devices

< Components, alignment, fit, and ability to care for orthotic, protct tivc, and svipportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment IIS*.' during functional activities (eg, ADL scales, functional sc;des, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabUities \v ith use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, faU scales, interviews, logs, < )bservations, reports)

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Tests and Measures continued

Pain

Self-Care and Home Management (Including ADL and IADL)

Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain draw^ings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural aUgnment and position (dynamic), including symmetry and deviation from midUne (eg, observations, technology-assisted analyses, videographic assessments) Postural aUgnment and position (static), including symmetry and deviation from midUne (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Prosthetic Requirements

AbiUty to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Components, alignment,fit,and abiUty to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) Prosthetic device use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations) Remediation of impairments, functional Umitations, or disabilities with use of the prosthetic device (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Residual limb or adjacent segment, including edema, range of motion, skin integrity, and strength (eg, goniometry, muscle tests, observations, palpation, photographic assessments, skin integrity tests, videographic assessments, volume measurement) Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports)
Range of Motion (ROM) (Including Muscle Length)

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 questionnaires, IADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, incUnometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibiUty, and flexibiUty (eg, contracture tests, goniometry, incUnometry, Ugamentous tests, linear measurement, multisegment flexibUity tests, palpation)

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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 tests and 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 function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status A diagnosis is a label encompassing a cluster of signs and symptoms, syndrome s, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s) toward w^hich the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the 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 outcomes, and discharge plans. The plan of care identifies reaUstic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.These anticipated goiils and expected outcx)mes should be measureable and time Umited. 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 longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation pnxess, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise, chronicity or severity of the current condition; Uving environment; multisite or multisystem involvement; social support; potential discharge destinations: probabiUty of prolonged impairment, functional limitation, or disabiUty; and stabUity of the condition.

Prognosis Over the course of 6 months, patient/ cUent wiU demonstrate optimal motor function; muscle performance; range of motion; and gait, locomotion, and balance; and the highest level of functioning in home, work (job/school/play), community, and leisure environments. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ cUents who are classified in this pattern.

Expected Range of Number of Visits Per Episode or Care 15 to 45 ITiis range represents the lower and upper limits of the number ot physical therapi.st visits required to achieve anticipated goals :ind expected outcomes It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goah and expected outcomes within 15 to 't 5 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service deUvery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/ Duration of Episode Accessibility and avaUability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise {Chronicity or severity of the current condition 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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Intervention
Intervention is the purposeftil interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent 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/cUents across aU settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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

Anticipated Goals and Expected Outcomes

Addressing required functions advance directives - individuaUzed famUy service plans (IFSPs) or individuaUzed education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management CoUaboration and coordination with agencies, including: - equipment suppUers - home care agencies - payer groups schools transportation agencies Communication across settings, including: case conferences documentation education 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 Umitations, and disabiUties changes in interventions elements of patient/cUent management (examination, evaluation, diagnosis, prognosis, intervention) - outcomes of intervention InterdiscipUnary teamwork case conferences patient care rounds - patient/cUent family meetings Referrals to other professionals or resources

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, and mandatory commimication and reportir^ (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximaUy utilized. Care is coorditiated with patient/cUent, family, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. CoUaboration and coordination occurs with agencies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Commimication occurs across settings through case conferences, education plans, and documentation. Data are coUected, analyzed, and reported, including outcome data, peer reviewfindings,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 management and across settings and foUows APTA's GuidelinesforPhysical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/clientfemilymeetings. Patient/cUent, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are 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 performance llealth, w^elUiess, and fitness programs plan of care risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabiUties transitions across settings transitions 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 is reduced. 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 knowledge and sviaseness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/cUent knowledge of personal and environmental factors associated with the condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, ta^cs, or activities 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 caregivers 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 include:

Therapeutic Exercise
Interventions Anticipated Goals and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning aquatic programs gait and locomotor training increased workload over time walking and wheelchair propulsion programs Balance, coordination, and agiUty training motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation perceptual training posture awareness training - standardized, programmatic, complementary exercise approaches sensory training or retraining ta.sk-specific performance training Body mechanics and postural stabilization body mechanics training - developmental activities training - posture awareness training - postural control training - postural stabilization activities FlexibiUty exercises muscle lengthening range of motion stretching Gait and locomotion training developmental activities training gait training implement and device training perceptual training standardized, programmatic, complementary exercise approaches w^heelchair training Relaxation breathing strategies movement strategies - relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training

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 instrumental activities 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/prevention Preoperative 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,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 Atonagement (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]) Interventions ADI. training bathing - bed mobiUty and transfer training - developmental activities dressing - eating gr(K)ming toileting Devices and equipment use and training assistive and adaptive device or equipment training during ADL and IADL - orthotic, protective, or supportive device or equipment training during ADL and IADL prosthetic device or equipment training during ADL and IADL Functional training programs back schools simulated environments and tasks task adaptation IADL training - caring for dependents - home maintenance household chores shopping structured play for infants and children y ard work Injury prevention or reduction - injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during seLf-care and home management Anticipated 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 eqxiiinent 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 rluced. - Risk of secondary impairments is reduced. - Safety is improved. - Self-muiagement of symptoms is improved. Impact c i health, wellness, and fitness M - 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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions

AnHdfXited &m\$ and Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL orthotic, protective, or supportive device or equipment training during IADL prosthetic device or equipment training during IADL Functional training programs - back schools - job coaching simulated environments and tasks task adaptation task training IADL training community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction - injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment - safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities and training

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 orreintegrationis 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 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/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 massage therapeutic massage Mobilization/manipulation soft 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. - Jcnt 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 electrical stUnulation (NMBS) transcutaneous electrical nerve stimulation (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 iiistnimental activities of d ^ Uving (IADL) widi or withoitt devices and equipment are increased. - 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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/cUents may be over the Ufe span. Indications for reexamination include new clinicalfindingsorfeUureto respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in each preferred 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 the physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quaUty of Ufe.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy service.s that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may befeciUty-specificor payer-specific requirements for documentation regiirding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. Discontinuation is the process of ending physical therapy services that have l)een provided during a single episode of care when (1) the patient/cUent, caregiver, or legal guardian declines to continue intervention; (21 the patient/cUent is unable to continue to progress toward outcomes because of medical or psychosoc-ial complications or becauseflnanciaL'insurance resources have been expended; or (3) the physical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminated prior 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 adaptation foUowing changes in physical status, caregivers, envin)nment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate foUow-up or referral.

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CHAPTER 5 Preferred PracHce Patterns: Neuromuscular

Preferred practice patterns describe the Hve elements of patient/client management that are provided by physical therapi.st.s: examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis (including pian of care), and intervention (with anticipated goals and expected outcomes). Each pattern also addresses reexamination, global outcomes, and criteria for termination of physical therapy services. Examples of ICD-9-CM codes are included. Pattern A: Primary Prevention/Risk Reduction for Loss of Balance and Falling Pattern B: Impaired Neuromotor Development Pattern C: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous SystemCongenital Origin or Acquired in Infancy or Childhood Pattern D: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the (Central Nervous SystemAcquired in Adolescence or Adulthood Pattern E: Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central NetT'ous System Pattern F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury Pattern G: Impaired Motor Function and Sensory Integrity Associated With Acute i )r Chronic Polyneuropathies Pattern H: Impaired Motor Function, Peripheral Nerve Integrity, and Sensory Integrity Associated With Nonprogressive Disorders of the Spinal Cord Pattern I: Impaired Arousal, Range of Motion, and Motor Control Associated With Coma, Near Coma, or Vegetative State

S307 S319

S339

S357

S375 S393 S411

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Primary Prevention/Risk Reduction for Loss of Balance and Falling

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/cUents who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and .socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified into this primary prevention/risk reduction pattern as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the need for a prevention/risk reduction program.The physical therapist integrates, synthesizes, and interprets the data to determine inclusion in this diagnostic category.

Inclusion
The following examples of examination findings may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/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 Deconditioning Difficulty negotiating in community environment Difficulty negotiating terrains Disequilibrium GeneraUzed weakness Impaired gait pattern Impaired position sense

Impairments, Functional (imitations, or Disabilities

Note:
Prevention and risk reduction are inherent in atl practice patterns. Patients/ctients inctuded in this pattern are in need of primary prevention/risk reduction onty.

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ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/cUent diagnostic classification is based on impairments, functional Umitations, and disabiUtiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 331 332 333 334 335 336 340 342 345 359 386 Other cerebral degenerations 331.0 Alzheimer's disease Parkinson's disease Other extrapyramidal disease and abnormal movement disorders SpinocerebeUar disease Anterior horn ceU disease Other diseases of spinal cord Multiple sclerosis Hemiplegia and hemiparesis EpUepsy Muscular dystrophies and other myopathies Vertiginous syndromes and other disorders of vestibular system 386.0 Meniere's disease 386.1 Other and unspecified peripheral vertigo 386.2 Vertigo of central origin 386.3 Labyrinthitis General symptoms 780.0 Alteration of consciousness 780.2 Syncope and coUapse 780.4 Dizziness and giddiness 780.7 Malaise and fatigue Symptoms involving nervous and musculoskeletal systems 781.0 Abnormal involuntary movements 781.2 AbnormaUty of gait 781.3 Lack of coordination Senility without mention of psychosis

780

781

797

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner Examination is required prior to the initial intervention and is performed for aU patients/cUents.Through the examination, the physical therapist may identify impairments, functional Umitations, disabiUties, changes in physical function or overaU health status, and needs related to restoration of health antl to prevention, wellness, and fitness.The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/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 gathering of past and current information (often from the patient/cUent) related to why the patient/cUent is seeking the services of the physical therapist.The systems revietv is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication abiUty, affect, cognition, language, and learning 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; stage of recovery (acute, subacute. chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for tistings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2. Patient/Client History The history may include:
General Demographics Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg smoking, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

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, and leisure action.s, ta.sks, or activities
Growth and Development

Developmental histor>' Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected di.scharge de.stinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metaboUc Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated condition.s Psychological Pulmonary
Current Condirion(s)/Chief Complaint(s)

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily Uving QADV) Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical lests

l.aboratory and diagnostic tests Review of avaUable records (eg, medical, education, surgical) Review of other cUnical findings (eg, nutrition and hydration)

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)

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 physical therapist C^urrent therapeutic interventions Mechanisms of injury or disease, including datf of onset and course of events Onset and pattern of symptoms Patient/cUent, family, significant other, and caregiver expectations and goals for the therapeutic intervt ntion Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
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Systems Review

The systems review may include:

Anatomical and Physiological Stotus

Cardiovascular/Pulmonary Blood pressure Edema Heart rate Respiratory rate

Integumentary Presence of scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daUy living [ADL] scales, indexes, instrumental activities of daily Uving [IADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmiU tests, wheelchair tests)
Arousal, Attention, and Cognition

Arousal and attention (eg, adaptabiUty tests, arousal and awareness scales, indexes, profiles, questionnaires) Cognition, including abUity to process commands (eg, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) Motivation (eg, adaptive behavior scales) Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) RecaU, including memory and retention (eg, assessment scales, intervie'ws, questionnaires)
Assistive and Adaptive Devices

Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations) Response to stimuU, including auditory, gustatory, olfactory, pharyngeal, vestibular, visual (eg, observations, provocation tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactUe tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outiet tests)
Environmentol, Home, and Work (Job/School/Play) Barriers

Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, LADL scales, interviews, observations) Components, aUgnment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, intervie^vs, observations, reports) Safety during use of assistive or adaptive devices and equipment (eg, faU scales, reports, interviews, observations)

Ergonomics Safety in work environments (eg, hazard identification checkUsts, job severity indexes, Ufting standards,riskassessment scales, standards for exposure limits) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, LADL scales, observations, photographic assessments, videographic assessments)

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Tests and Measures conHnued

Gait, Locomotion, and Balance Range of Motion (Including Muscle Length)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, LADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during functional activities with or withovit the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profUes, IADL scales, mobiUty skiU profiles, observations) Safety during gait, locomotion, and balance (eg, confidence scales, tall scales, functional assessment profiles, reports)
A4otor Function (Motor Control and AAotor Learning)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometrv, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibiUty, and flexibility (eg, contracture tests, flexible rulers, goniometers, inclinometers, Ugamentous tests, multisegment flexibiUty tests, palpation)
Reflex Integrity

Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) Posiund reflexes and reactions, includingrighting,equUibrium, and pr<jtective reactions (eg, observations, postural chaUenge tests, reflex profiles) Resistance to passive stretch (eg, tone scales)
Self-Core and Home Management (Including Activities of Daily Living and Instrumentol AcHvities of Daily Living)

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Initiation, modification, and control of movement patterns and voluntary postures (eg, movement assessment batteries, neuromotor tests, observations, physical perfonnance tests, postural chaUenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) Safety in self-care and home management activities and environments (eg,feUscales, interviews, observations, reports)
Sensory Integrity

Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests,technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations)
OrlhoHc, Protective, and Supportive Devices

Combined/cortical sensations (eg, stereognosis, tactile discrimination test.s) Det p .sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)
Work fJob/School/Pkiy), Community, and Leisure Integration or Reintegration (Including IADL)

Components, aUgnment,fit,and abiUty to care for orthotic, protective, and supportive devices and equipment (eg, interviews, observations, reports) Orthotic, protective, and supportive devices and equipment use duringfimctionalactivities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles) Safety during use of orthotic, protective, and supportive devices and equipment (eg,fellscales, reports, interviews, observations)
Posture

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 activities and environments (eg, faU scales, interviews, observations)

Postural aUgnment and position (dynamic), including symmetry and deviation from midUne (eg, observations, technology-assisted analyses, videographic assessments) Postural aUgnment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

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Pre/ention/Risk Reduction

Loss of Balance and Falling 3 1 9 / S 3 n

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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status. A diagnosis is a label encompassing a cluster of signs and symptoms, .syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s) toward which the therapist wiU direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/cUent and appropriate others.These anticipated goals and expected outcomes should be measureable and time Umited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/cUents based on a variety of factors tbat the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probabiUty of prolonged impairment, functional Umitation, or disability^; and stabiUty of the condition.

Prognosis

Expected Range of Number of Visits Per Episode of Care 2to 18

Factors That May Require Nev/ Episode of Care or That May Modify Frequency of Visits/Duration of Care

Patient/cUent wiU reduce the risk of falUng through therapeutic exercise, balance training, and Ufestyle modification.

This range represents the low^er and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 2 to 18 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service deUvery.

Accessibility and availabiUty of resources 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved with the patient/client, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent response and 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 settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 Anticipoted Goals and Expected Outcomes

Addressing required functions individuaUzed family service plans (IFSPs) or individuaUzed education plans (IEPs) intbrmed consent mandatory communication and reporting (eg, patient/cUent advocacy and abuse reporting) Collaboration and coordination with agencies, including: equipment suppliers - home care agencies - payer groups schools transportation agencies C'omniunication, including: education plans documentation Data coUection, analysis and reporting outcome data peer review iindings record revie\vs Documentation elements of patient/cHent management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Referrals to other professionals or resources
Patient/Client-Related Instruction

AccountabiUty for services is increased. IndividuaUzed family service plans (IFSPs) or individuaUzed education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient/cUent advocacy and abuse reporting) are obtained or completed. Available resources are maximally utiUzed. Collaboration and coordination occurs with ^encies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Ctimmunication occurs through education plans and documentation. Data are coUected, analyzed, and reported, kidudii^ outcome data, peer reviewfindings,and record reviews. Ekxision making is enhanced regarding patient/cUent health and the use of health care resotwces by patient/cUent, femily, sitjnificant others, and caregivers. Documentation occurs throughout client management and follows APIA'S Guidelines for Ptrysical Therapy Documentation (Appendix 5). Patient/client,femily,significant other, and caregiver understtnding of anticipated goals and expected outcomes is increased. Referrals are made to other professionals or resources whenever necessary and appropriate. R:sources are utiUzed in a cost-effective way.

Pdtient/cUent-related instruction may include:

Interventions Anticipated Goals ond Expected Outcomes

Instruction, education, and training of patients/cUents and caregivers regarding: enhancement of performance health, weUness, and fitness programs - plan for intervention risk factors for pathology/ patbophysiology (disease, disorder, or condition), impairments, functional Umitations, or disabiUties

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 are increased. Patient/dient knowledge of personal and envin>nmental fectors associated with the condition 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.
5/ Pre\/eniion/R!s< Reduction Loss of Balance and Palling 321/'S313

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Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise
Interventions

Anticipated Goals and Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning - aquatic programs - gait and locomotor training increased w^orkload over time w^aUcing and w^heelchair propulsion programs Balance, coordination, and agiUty training motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation perceptual training posture awareness training standardized, programmatic, complementary exercise approaches - sensory' training or retraining - task-specific performance training - vestibular training Body mechanics and postural stabilization body mechanics training posture awareness training postural control training - postural stabUization activities FlexibiUty exercises muscle lengthening range of motion stretching Gait and locomotion training gait training implement and device training - perceptual training standardized, programmatic, complementary exercise approaches wheelchair training Relaxation breathing strategies - movement strategies - relaxation techniques - standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, Umb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training

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 instrumental activities of daily Uving (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 self-care, home management, work (job/school/play), community, 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, 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] and Instrumentol Activities of Daily Living [IADL]) Interventions Anticip(rid Golds and bqected Outcomes

Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during self-care and home management Functional training programs simulated environments and tasks task adaptation

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 without 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 management 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 to patient/ctotit. - Administrative mani^ment of practice is acceptable to patient/cUent. - CUnical pioflciency of physical therapist is acceptable to patien/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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Prevention/Risk Reduction

Loss ot Bolonce and Falling

323/S315

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) Interventions Anticqaoted Goals and E}q>ected Outcomes

Injury prevention or reduction - injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Functional training programs simulated environments and tasks task adaptation - task training - travel training

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 resumereqviiredwork (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.

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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 Antkipated Gods and Ex|MCtad OutconMs

Assistive devices - canes - crutches long-handled reachers Protective devices braces helmets Orthotic devices braces - shoe inserts

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- cxitrol 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 potions 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 inqoved. 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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Prevention/Risk Reduction

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

Global Outconfies for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in each preferred 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 the physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quaUty of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defmed as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial CompUcations or becausefinancial/insuranceresources have been expended; or (3) tbe physical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adaptation foUowing changes in physical status, caregivers, environment, or task demands. In consultation w^ith appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontintiation and provides for appropriate foUow-up or referral.

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Impaired Neuromotor Development

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

Patient/Client Diagnostic Classification

Patients/clients will be classified into this pattern for impaired neuromotor development as a result of the physical therapist's evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.The physical tht rapist integrates, synthesizes, and interprets the data to determine the diagnostic classification. Inclusion The following examples of examination findings may support the inclusion of patients/clients in this pattern;
Risk Factors or Consequences of Pathology/Pothophysiology (Disease, Disorder, or Condition)

Exclusion or Mulriple-Pattern Classificarion The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Alteration in senses (auditory, visual) Birth trauma Cognitive delay Developmental coordination disorder Developmental delay Dyspraxia Fetal alcohol syndrome Genetic syndromes Prematurity' Clumsiness during play Delayed motor skills Delayed oral motor development Impaired arousal, attention, and cognition Impaired locomotion Impaired sensory integration

Spinal cord injury

Findings That May Require Classification in Additional Patterns

Impairments, Functional Limitations, or Disabilities

Arthritis Congenital heart defect

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as neoplasmmay be severe and complex; ^O!t'e?'e>; they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis,' page S326.)

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ICD-9-CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, 111: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit reqturements. 191 Malignant neoplasm of brain 192 Malignant neoplasm of other and unspecified parts of nervous system 225 Benign neoplasm of brain and other parts of nervous system 252 Disorders of parathyroid gland 252.0 Hyperparathyroidism 253 Disorders of the pituitary gland and its hypothalamic control 253.3 Pituitary dwarfism 262 Other severe, protein-calorie malnutrition 299 Psychoses with origin specific to childhood 299.0 Infantile autism 315 Specific delays in development 315.4 Coordination disorder 315.9 Unspecified delay in development 333 Other extrapyramidal disease and abnormal movement disorders 333.7 Symptomatic torsion dystonia 345 Epilepsy 345.1 Generalized 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 polyarthropathies 714.3 Juvenile chronic polyarthritis 728 Disorders of muscle, ligament, and fascia 728.3 Other specific muscle disorders Arthrogryposis 741 Spina bifida 742 Other congenital anomalies of nervous system 742.3 Congenital hydrocephalus 742.5 Other specified anomalies of spinal cord 745 Bulbus cordis anomalies and anomalies of cardiac septal closure 745.1 Transposition of great vessels 745.2 Tetralog)' of Fallot 745.4 Ventricular septal defect 745.5 Ostium secundum type atrial septal defect
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746 747 748 754

755 756

758

759 760

762

763 764 765 767

768

770

771

779 780

Other congenital anomalies of heart 746.0 Anomalies of pulmonary valve Other congenital anomalies of circulatory system 747.1 Coarctation of aorta Congenital anomalies of respiratory system Certain congenital musculoskeletal deformities 754.2 Of spine 754.3 Congenital dislocation of hip Other congenital anomalies of limbs Other congenital musculoskeletal anomalies 756.5 Osteodystrophies 756.51 Osteogenesis imperfecta Chromosomal anomalies Includes: syndromes associated with anomalies in the number and form of chromosomes Other and unspecified congenital anomalies Fetus or newborn affected by maternal conditions which may be unrelated to present pregnancy 760.7 Noxious influences affecting fetus via placenta or breast milk Fetus or newborn affected by complications of placenta, cord, and membranes 762.5 Other compression of umbilical cord Fetus or new-born affected hy other complications of labor and delivery Slow fetal growth and fetal malnutrition Disorders relating to short gestation and unspecified low birth weight Birth trauma 767.0 Subdural and cerebral hemorrhage 767.9 Birth trauma, unspecified 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 Other respirator^' conditions of fetus and newborn 770.1 Meconium aspiration syndrome 770.7 Chronic respiratory disease arising in the perinatal period Infections specific to the perinatal period 771.2 Other congenital infections Congenital toxoplasmosis Other and ill-defined conditions originating in the perinatal period General symptoms 780.3 Convulsions

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ICD-9-CM Codes continued

783 Symptoms concerning nutrition, metabolism, and development 799 Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia 800 Fracture of vault of skull 801 Fracture of base of skull 803 < )ther and unqualified skull fractures 804 Multiple fractures involving skull or face with other hones 850 (Concussion 851 (;erebral laceration and contusion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 994 Effects of other external causes 994.1 Drow^ning and nt)nfatal submersion 995 ("ertain adverse effects not elsewhere classified 995.5 Child maltreatment syndrome

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness,The physical therapist synthesizes the examinationfindingsto establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components: the patient/client history, the systems review, and tests and measures,The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist,The systetns review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovasctilar/pulmonary integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For ctinical indications in selecting tests and measures and for listings of tests and measures, 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 Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medical/Surgical History

Social History

Cultural beliefs and behaviors Family and caregiver resources Social interactions, social activities, and support systems
Employment/Work (Job/School/Play)

Current and prior work (job/school/play), community, and leisure actions, tasks, and activities
Growth and Development

Developmental history Hand dominance

Uving Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary Concerns that led patient/client to seek the services of a physical therapist Concerns or needs of patient/client who requires the services of a physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions

Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) Current and prior functional status in work (job/school/play), conimunity, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinicalfindings(eg, nutrition and hydration)

Current Condition(s)/Chief Complaint(s)

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)

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Systems Review

The systems revieiv may include:

Anatomical and Physiological Status

Cardiovascular/Pulmonary - Blood pressure - Edema Heart rate Respiratory rate

Integtimentary Presence of scar formation Skin color - Skin integrity

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

Neuromuscular - Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, 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)

Tests and Measures

Test and measures for this pattern may include those that characterize or quantify':
Aerobic Capacity and Endurance

Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Remediation of impairments, functional limitations, or disabilities witli use of assistive or adaptive devices and equipment (eg, activit) status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Circulation (Arterial, Venous, Lymphatic)

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, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) Motivation (eg, adaptive behavior scales) Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) Recall, including memory and retention (eg, assessment s<.:ales, interviews, questionnaires)
Assistive and Adaptive Devices

Cajtliovasctilar signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, ausctiltation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) Cardiovascular symptoms (eg, angina, claudication, dyspnea, and pt r< eived exertion scales) Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomiinometry)
Cranial and Peripheral Nerve Integrity

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, intervie'ws, observations) Components, alignment,fit,and abiUty to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, musck tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation test*-) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heal, pain, pressure, and vibration) Sensor)- distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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Tests and Measures continued

En^fironmental, Home, and Work (Job/School/Ploy) Barriers

Integumentary Integrity

Current and potential barriers (eg, checklists, interviews, observations, questionnaires) Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)
Ergonomics and Body Mechanics

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during w^ork actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checklists, job severity, lifting standards, risk assessment scales) Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, w^orkstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg,ADL scales, IADL scales, observations, photographic assessments, videographic assessments)
Gait, Locomotion, and Babnce

Associated skin Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales) Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve tratima to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)
Joint Integrity and Mobility

Specific body parts (eg, apprehension, compression and distraction, draw^er, glide, impingement, shear, and valgus/varus stress tests; 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 assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Balance during ftmctional activities w^ith or w^ithout the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests) Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adajv tive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, ^veight-bearing scales, wheelchair mobility tests) Safety dtiring gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endtirance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, pow^er, and endurance during functional activities (eg,ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)
Neuromotor Devebpment and Sensory Integration

Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infent and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) Oral motor function, phonation, and speech production (eg, interviews, observations) Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests)

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Tests and Measures conrinued

Orthotic, Protective, and Supportive Devices Reflex Integrity

Components, alignment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, presstire-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, ftmctional performance inventories, health assessment questiormaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Pain

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 challenge tests, reflex profiles) Primitive reflexes and reactions, including developmental (eg, reflex profiles) Resistance to passive stretch (eg, tone scales) Superficial reflexes and reactions (eg, observations, provocation tests)
Self-Care and Home Management (Including ADL and lADLJ

Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability lo perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive;, ;>r prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Satety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Prosthetic Requirements

Combined/cortical sensations (eg, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic: assessments, vibration tests)
Ventilation and Respiration/Gas Exchange

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>L scales, functional scales, IADL scales, interviews, observations) Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports)
Range of Motion (Including Muscle Length)

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analysis, observations, oximetry) Ptilmonary signs of ventilatory function, including airway protection: breath and voice sounds; respiratory rate, rhythm, and pattern: ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilator)' muscle force tests) Ptilmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, flexible rulers, goniometers, inclinometers, ligamentous tests, multisegment flexibility tests, palpation)

Ability to assume or resume work (job/school/play), community, and leisure activities w^ith or without assistive, adaptive, ortliotic, protective, supportive, or prosthetic devices and equipment (eg, .ctivit>' profiles, disability indexes, fimctional status questionnaires, IADL scales, observations, physical capacity tests) AbiUty to gain access to work (job/school/play), cotnmunit), and leisure environments (eg, barrier identification, interviews, observations, physical capacity, transportation assessments) Saleiy in work (job/school/play), commtmity, and leisure activities ;ind environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

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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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination.The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination ofthe predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals 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 outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations ofthe patient/client and appropriate others.These anticipated goals and expected outcomes should be measureable and time limited. 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 longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disabiUty; and stability of the condition.
Expected Range of Number of Visits Per Episode of Care 6 to 90 Factors That May Require New Episode of Care or That Mci/ Modify Frequency of Visits/ Duration of Episode

Prognosis

Over the course of 12 months, patient/ client will demonstrate optimal neuromotor development and the highest level of ftmctioning in home, work (job/ school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

This range represents the lower and upper limits ot the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 90 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Note:

These patients/clients may require multiple episodes of care over the Ufetime to ensure safety and effective adaptation follo^ving changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes of care include: Cognitive maturation Periods of rapid growth

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, 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

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the 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 settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 Antidpatsd Goals and Expected Oufeiomes

Addressing required functions advance directives individualized family service plans (IFSPs) or individualized education plans (IEPs) informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, including: eqtiipment suppliers home care agencies payer groups schools - transportation agencies Communication across settings, including: case conferences documentation education plans Cost-effective resource utilization Data collection, analysis, and reporting - outcome data - peer review findings record reviews Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: changes in impairments, functionat limitations, and disabilities changes in interventions - elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences - patient care rounds - patient/client family meetings Referrals to other professionals or resources

Accountability for services is increase. Admission data and dischai^e planning are completed. Advance directives, individualizedfiunityservice plans (IFSPs) or Individi^Uzed education plans (IEPs), informed consent, and mand^ory communication and reportii^ (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized, Care is coordinated with patient/client,femity,significant others, caiegivers, and other professionals. Case is mana^d throughout the episode of care. Collaboration and coordination occurs with ^encies, including equipment suppUers, home care agencies, payer groups, schools, and transportation ^oicies. Communication enhances risk reduction and prevention. Communication occurs across settings through case conferences, 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 management and across setting andfollowsAPTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboratian occurs t h r o t ^ case conferences, patient care rounds, and patient/client family meetings. Patient/client, family, significant other, and car^ver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined, Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utilized in a cost-effective way.

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Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions Anticipated Goals and Expected Outcomes

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, w^ellness, and fitness programs plan of care - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities - transitions across settings transitions to new roles

Ability to perform physical actions, tasks, or activities is improved. Awareness and use of community resources are improved. Behaviors that foster healthy habits, wellness, and prevention are acquired. Decision making is enhanced regarding patient/client health and the use of health care resourees by patient/client, family, significant others, and caregivers. Disability associated with acute or chronic illnesses is reduced. Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. Health status is improved. Intensity of care is decreased. Level of supervision required for task performance is decreased. Patient/client,femily,significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. Patient/client knowledge of personal and environmental factors associated with the condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/cUent, family, significant others, and caregivers 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 Anlic^Kited Gocris end Expected Outcomes

Aerobic capacity/endurance conditioning or reconditioning aquatic programs gait and locomotor training increased workload over time walking and w^heelchair propulsion programs Balance, coordination, and agility training - developmental activities training motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation perceptual training posture awareness training standardized, programmatic, complementary exercise approaches sensory training or retraining task-specific performance training Body mechanics and postural stabilization body mechanics training - posture awareness training - po.stural control training postural stabilization activities Neuromotor development training developmental activities training motor training - movement pattern training neuromuscular education or reeducation Flexibility exercises muscle lengthening range of motion stretching Gait and locomotion training - developmental activities training - gait training implement and device training perceptual training wheelchair training Relaxation breathing strategies movement strategies relaxation techniques Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and ptyometric) - aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training

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 C I itnpairments: M - 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 segments 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 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, 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 to patient/dient. - Administrative management of practice is acceptable to patient/cUent. - Clinical proficiency of physical therapist is acceptable to patient/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 continued

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Uving [IADL]) Interventions Anticipated Goals and Expected Outcomes

ADL training - bathing bed mobility and transfer training developmental activities dressing - eating grooming toileting Ftmctional training programs simulated environments and tasks task adaptation - travel training IADL training - home maintenance household chores shopping structured play for infants and children travel training - yard w^ork Devices and equipment use and training - assistive and adaptive device or equipment training during ADL and IADL orthotic, protective, or supportive device or equipment training during ADL and IADL - prosthetic device or equipment training during ADL and LADL Injury prevention or reduction - injury prevention education during selfcare and home management injury prevention or reduction w^ith use of devices and equipment safety awareness training during selfcare and home management

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 Activities of Daily Living [IADL], Work Hardening, and Work Conditioning) Interventions Devices and equipment use and training assistive and adaptive device or equipment training during L D AL orthotic, protective, or supportive device or equipment training during IADL prosthetic device or equipment training during L D AL Functional training programs job coaching - simulated environments and tasks task adaptation task training travel training IADL training community service training involving instruments - school and play activities training including tools and instruments w^ork training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities training Anticipated 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 impaUrments Balance 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

Antkipated Gods am) Expected Outcomes

Manual traction Massage - connective tissue massage - therapeutic massage Mobilization/manipulation Soft tissue mobilization Passive range of motion

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 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<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 fitness Physical 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 Afrikipcrind Gt>ds and &qpwltod OMcomw

Adaptive devices environmental controls hospital beds raised toilet seats seating systems Assistive devices canes - crutches long-handled reachers power devices static and dynamic splints walkers wheelchairs Orthotic devices braces casts shoe inserts splints Prosthetic devices (lower-extremity and upper-extremity) Protective devices braces cushions helmets protective taping Supportive devices compression garments corsets elastic wraps neck collars supplemental oxygen

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, orrestxk:tionis 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 management, 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 ^ t h , 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 significant others. - Sense of well-beii^ is improved. Stressors are decreased.

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Impaired Neuromotor Development 341/S333

Procedural Interventions continued

Eledrotherapeutic Modalities

Interventions

d Expc|d
Impact 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 management, 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 C * without devices and equipment are H increased. - 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. - Riskfiictorsare 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.

Biofeedback Electrical muscle stimulation - electrical muscle stimulation (EMS) - neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (TENS)

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Procedural Interventions continued Physical Agents and Mechanical Modalities Interventions

Mechanical modaUties may include: Compression therapies compression bandaging compression garments - taping - total contact casting - vasopneumatic compression devices Gravity-assisted compression devices standing frame - tilt table

Anticipated Goals and Expected Outcomes Impact on pathology/pathophysiology (disease, disorder, or condition) Edema, lymphedema, or effusion is reduced. - Joint 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 instrumental activities of daily Uving (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 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 fitness Physical 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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Reexamination
Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, wliich for some patients/clients may be over the Ufe span. Indications for reexamination include new clinicalfindingsor failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the- iinticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the Usts of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains: Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, wellness, and fitness Societal resources Patient/dient satisfection

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

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across .settings during a single episode of care). Although tliere may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes. Discontinuation is the process of ending physical therapy services that havt heen provided during a single episode of care when (1) the patient/cUent, caregiver, or legal guardian declines to continue intervention: (2j the patient/dient is unable to continue to progress toward outcomes because of medical or psychosocial complications or becau.seflnaniiaL'insurance resources have been expended; or (3) the physical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and therationalefor 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 adaptation following changes in physical status, caregivers. environment, r task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

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5B Impaired Neuromotor Development 345/S337

Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System Conaenital Origin or Acquired in Infancy or

Childhood
This preferred practice pattern describes the generally ace epted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries w ithin which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide varietj' of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients will be classified into this patternfor impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system (congenital origin or acquired in infancy or childhood)as a result of the physical therapist's evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.Tlie physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification. Inclusion The following examples of examinationfindingsmay support the inclusion of patients/clients in this pattern;
Risk Factors or Consequences of Pothology/Pathophysiology (Diseose, Disorder, or Condition)

Exclusion or Multiple-Pattern Classification The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examinationfindings,the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Anoxia or hypoxia Birth trauma Brain anomalies Cerebral palsy Encephalitis Cienetic syndromes affecting central nervous system (CNS)

Hydrocephalus Infectious disease affecting CNS Meningocele Neoplasm Prematurity Tethered cord Traumatic brain injury Impaired expressive or receptive communication Impaired motor function Loss of balance during daily activities Inability to keep up with peers Inability to perform work (job/school/play) activities

Impairments, Functional Limitotions, or Disabilities

Amputation Coma Spinal cord injury

Findings That M a y Require Classification in Additional Patterns

Difficulty negotiating terrains Difficulty planning movements Difficulty with manipulation skills Difficulty w^ith positioning Frequent falls Impaired affect Impaired arousal, attention, and cognition

Congenital Heart Defect Fracture

Nofe: Some risk factors or consequences of pathology/ pathophysiologysuch as neoplasmmay be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S345.)
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ICD-9-CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-S>-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

036 Meningococcal infection 052 055 056 072 090 225 320 321
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 nonbacterial organisms classified elsewhere* Metungitis of unspecified cause 322.9 Meningitis, unspecified Encephalitis, myelitis, and encephalomyelitis 323.4 Other encephalitis due to infection classified elsewhere* 323.5 Encephalitis following immunization procedures 323.6 Postinfectious encephalitis* 323.8 Other causes of encephalitis 323.9 Unspecified cause of encephalitis Other extrapyramidal disease and abnormal movement disorders 333.7 Symptomatic torsion dystonia Athetoid cerebral palsy [Vogt's disease]; double athetosis (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

741 742 756 758

759 765 767

768

322 323

771

780 799

333

343 345

800 801 803 804 850 851 852 853 854 984 985 994

348

Spina bifida Other congenital anomalies of nervous system 742.3 Congenital hydrocephalus Other congenital musculoskeletal anomalies 756.1 Anomalies of spine Chromosomal anomalies Includes; syndromes associated with anomalies in the number and form of chromosomes Other and unspecified congenital anomalies Disorders relating to short gestation and unspecified low birth weight Birth trauma 767.0 Subdural and cerebral hemorrhage 767.9 Birth trauma, unspecified 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 Infections specific to the perinatal period 771.2 Other congenital infections Congenital toxoplasmosis General symptoms 780.3 Convulsions Other ill-defined and unknowfn causes of morbidity, and mortality' 799.0 Asphyxia Fracture of vault of skull Fracture of base of skull Other and unqualified skull fractures Multiple fractures involving sktxO or foce with other bones Concussion Cerebral laceration and contusion Subarachnoid, subdural, and extradural hemorrhage, following injury Other and unspecified intracranial hemorrhage following injury Intracranial injtiry of other and unspecified nature Toxic effect of lead and its compounds (including fumes) Toxic effect of other metals Effects of other external causes 994.1 Drowning and nonfatal submersion

* Not a primary diagnosis

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients.Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical fiinction or overall health status, and needs related to restoration of health and to prevention, weUness, andfitness.Thephysical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process. Examination has three components; the patient/client history, the systems review, and tests and measures.The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/ctient is seeking the services of the physical therapist.The systems revieiv is a brief or Umited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integtimentary, musculoskeletal, and netiromuscular systems and (2) the communication abiUty, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabilitation (earh', intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. Ior clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated tjy testi and measures, refer to Chapter 2.
Patient/Client History

The history may include:

General Demographics Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

Familial health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental histor>' Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endcjcrine/metabolic Gastrointestinal Genitourinary' Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions Psychological Piilmonasy 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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including dale of onset and course of events Onset and pattern of symptoms Patient/client, family, significant other, and caregiver expectations and goals for the tlierapeutic intervention Patient/client, family, signiiicant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
')(',

Current and prior functional status in self-care and home management activities, including activities of daily Uving (ADL) and instrumental activities of daily living (LADL) C^urrent and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

laboratory and diagnostic tests Review of available records (eg, medical, education, sui^ical) Review of other clinicalfindings(eg, nutrition and hydration)

Current Condition(s)/Chief Complaintjs)

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)

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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 scar formation Skin color Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, 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 Assistive and Adaptive Devices

Aerobic capacity during functional activities (eg, activities of daily Uving [ADL] scales, indexes, instrumental activities of daily living [LADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Body dimensions (eg, body mass index, girth 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, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists) Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) Motivation (eg, adaptive behavior scales) Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) Recall, including memory and retention (eg, assessment scales, interview's, questionnaires)

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, LADL scales, interviews, observations) Components, alignment,fit,and ability to care for the assistive or adaptive devices and eqtiipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional limitations, or disabilities wfith use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, ftmctional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Circulation (Arterial, Venous, and Lymphatic)

Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

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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, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to stimuli, incltiding auditory, gustatory, olfactory, phar>'ngeal, vestibular, and visual (eg, observations, provocation tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

(iait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportivt, or prosthetic devices or equipment (eg,ADL scales, gait j:irofiles, IADL scales, mobility skill profiles, observations, videographic assessments) < iait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or (quipment (eg, dynamometry, electroneuromyography, footprmt analyses, gait profiles, mobility skiU profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence sciiles, diaries, faU scales, functional assessment profiles, logs, leport.s)
Integumentary Integrity

Current and potential barriers (eg, checkUsts, interviews, observations, questionnaires) Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural 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, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checkUsts, job severity indexes, Ufting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checkUsts, job simulations, lifting models, preemployment screenings, task analysis checkUsts, workstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics Body mechanics during seUk:are, home management, work, community, or leisure actions, tasks, or activities (eg,ADL scales, IADL scales, observations, photographic assessments, technolog)'-assisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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 prosihetic devices and equipment that may produce or reUeve iniuma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Vkin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)
Joint Integrity and Mobility

Specific body parts (eg, apprehension, compression and distrac1 i( in, drawer, glide, impingement, shear, and valgus/varus stress rests; 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 assessment batteries, neuromotor tests, observations, physical performance tests, postural chaUenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography,fiillscales, motor impairment tests, observations, photographic assessments, postural control tests)
Guide to Physical Therapist Practice

Electrophysiological integrity (eg, electroneuromyography) Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, technology-assisted anal) ses, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments) Muscle tension (eg, palpation)

5C

Impoirments / Nonprogressive CNS Disorders-Child 35]/'S343

Tests and Measures continued

Neuromotor Development and Sensory Integration Reflex Integrity

Acquisition and evolution of motor skiUs, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, itifant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) Oral motor function, phonation, and speech production (eg, interviews, observations) Sensorimotor integration, including posttiral, equilibritim, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skill tests)
Orthotic, Protective, and Supportive Devices

Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) Electrophysiological integrity (eg, electroneuromyography) Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles) Primitive reflexes and reactions, including developmental (eg, reflex profiles) Resistance to passive stretch (eg, tone scales) Superficial reflexes and reactions (eg, observations, provocation tests)
Self-Care and Home Management (Including ADL ond IADL)

Components, aUgnment,fit,and abiUty to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during ftmctional activities (eg,ADL scales, fimctional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, fimctional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety dtiring use of orthotic, protective, and supportive devices and equipment (eg, diaries, faU scales, interview's, logs, observations, reports)
Pain

AbiUty to gain access to home environments (eg, barrier identification, observations, physical performance tests) AbiUty to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg,electroneuromyography)
Ventilation and Respiration/Gas Exchange

Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Range of Motion (ROM) (Including Muscle Length)

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory mtiscle force tests) Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, incUnometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibiUty (eg, contracture tests, goniometry, inclinometry, Ugamentous tests, Unear measurement, multisegment flexibility tests, palpation)

AbiUty to assume or resume work (job/school/play), community, and leistire activities w^ith or w^ithout assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disabiUty indexes, functional status questionnaires, L\DL scales, observations, physical capacity tests) AbiUty to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, 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 tests and 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 function, chronicity or severity of the problem, possibiUty of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, 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 diagnostic process, 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 in function and the amount of time needed to reach that level ;md may also include a prediction of levels of improvement that may be reached 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 outcomes, and discharge plans. The plan of care identifies realistic anticipated goats and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.llicse anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver consistency or expenisc chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition. Factors That May Require New Expected Range of Number of Visits Episode of Care or That May Modify Per Episode of Care Prognosis Frequency of Visits/Duration of Care Patient/cUent wiU demonstrate optimal motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, ftmctional limitations, and disabilities. During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ cUents who are classified in this pattern. 6to90 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected oiitt omes. It is anticipated that 80% of patients/clients ivho are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 90 i'i.<iits during a single continuous episodi' of cure. Frequency ol' visits and duration of the episode of care should be dttermined by the physical therapist to maximi/e effectiveness of care and efficiency of service delivery. Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition C Cognitive status Comorbitities, compUcations, or secondary impairments Cxmcurrent medical, surgical, and therapeutic interventions Decline in functional independence Level of impairment Level of physical function Uving environment Multisite or mtiltisystem involvement Nutritional status OveraU health status Potential discharge destinations Premorbid conditions Probability' of prolonged impairment, functional Umitation, or disability Psychological and socioeconomic factors Psychomotor abilities Social support Stability of the condition

Note: These patients/clients may require multiple episodes of care over the lifetime to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Factors that may lead to these additional episodes ot care include: Cognitive maturation Periods of rapid growth

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved in patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent w^ith 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/cUent-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include; Interventions Addressing required functions - advance directives individuaUzed family service plans (IFSPs) or individuaUzed education plans (IEPs) informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination w^ith agencies, including; equipment suppUers home care agencies payer groups schools - transportation agencies Communication across settings, including; - case conferences documentation education 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, 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/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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utiUzed. Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Commtmication occurs across settings through case conferences, 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 management and across settings and follows APTA's GuidelinesforPhysical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/cUent family meetings. Patient/cUent,femily,significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources ^ 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

Aniicipaled Goak and Expeded Oulcomes

Instruction, education and training of patients/cUents and caregivers regarding: current condition (pathologj'/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities) - enhancement of performance health, weUness, and fitness programs plan of care risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities - transitions across settings transitions to new roles

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 is reduced. 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 knowledge and awareness of the di^nosis, prognosis, interventions, and iknticipated goals and expected outcomes are increased. Patient/cUent knowlec^ of personal and environmental factors associated with the condition is increased. Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. Physical function is improved. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety of patient/cUent, fiamily, significant others, and caregivers 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 include:

Therapeutic Exercise

Interventions Aerobic and endurance conditioning or reconditioning - aquatic programs - gait and locomotor training increased workload over time walking and wheelchair propulsion programs Balance, coordination, and agiUty training - motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation perceptual training posture awareness training standardized, programmatic, complementary exercise approaches - sensory training or retraining task-specific performance training - vestibular training Body mechanics and postural stabilization body mechanics training posture awareness training postural control training postural stabilization activities FlexibiUty exercises muscle lengthening range of motion stretching Gait and locomotion training developmental activities training gait training implement and device training perceptual training - standardized, programmatic, complementary exercise approaches - wheelchair training Neuromotor development developmental activities training motor training movement pattern training neuromuscular education or reeducation Relaxation breathing strategies movement strategies - relaxation techniques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, Umb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training
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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 instrumental activities of daily Uving (LADL) with or without devices and equipment are increased. - 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/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 - 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.
Physical Therapy Volume 81 Number 1 January 2001

Procedural Interventions continued Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]) Interventions ADL training - bathing bed mobiUty and transfer training developmental activities dressing eating grooming gait and locomotion training toileting Devices and equipment use and training assistive and adaptive device or ec(uipment training during ADL and IADL orthotic, protective, or supportive device or equipment training during ADL and IADL Fvmctional training programs simulated environments and tasks - task adaptation - travel training LVDL training - caring for dependents home maintenance household chores shopping - structured play for infants and children - yard work Injury prevention or reduction - injury prevention education during self-care and home management injury' prevention or reduction with use of devices and equipment safety awareness training during self-care and home management 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 selfcare iind home niiagement is improved, - Level of supervisionreqviiredfort a ^ performance is decreased. - Peifomtance of and independence in ADL and IADL with or without 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 management 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 to patient/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 to patient/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 Activities of Daily Uving [IADL] and Work Conditioning) Interventions Anticipated Goals and Expected Outcomes

Devices and equipment use and training - assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during IADL prosthetic device or equipment training during IADL Functional training programs job coaching simulated environments and tasks - task adaptation task training - travel training LADL training community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction - injury prevention education during work (job/school/play), community, and leisure integration or reintegration injury prevention or reduction with use of devices and equipment safety aw^areness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities training

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 orreintegrationis improved. Level of supervision reqtiired for task performance is decreased. I^rformance 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 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 continued

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

Manual traction Massage connective tissue massage therapeutic massage MobiUzation/manipulation soft 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 is improved. - 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 ccnmunity, 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^caltiierafristis 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 Aniicipcrted Goals and Expeded Outcomes

Adaptive devices environmental controls hospital beds raised toilet seats seating systems Assistive devices canes crutches long-handled reachers power devices - static and dynamic sphnts - walkers - wheelchairs Orthotic devices braces casts shoe inserts splints Protective devices braces cushions helmets protective taping Supportive devices - compression garments - corsets elastic wraps neck collars serial casts slings supplemental oxygen supportive taping

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 instrumental activities of daily livii^ (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/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 resources Utilization of physical therapy services is optimized. Utilization of physical therapy services results in efficient use of health care dollars. Patient/client satisfaction - Access, availability, and services provided are acceptable to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/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

AnAkipotad Goals and Expscted Outcomes

Breathing strategies active cycle of breathing or forced expiratory' techniques - assisted cough/huff techniques autogenic drainage paced breathing pursed lip breathing techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Positioning positioning to alter work of breathing - positioning to maximize ventilation and perfusion pulmonary postural drainage

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 andrespiration/gasexchange ate improved. - AJSbtk of breathing is decreased. Impact onftmctionallimitations - Abiity to perform physical actions, tasks, or activities related to setf-care, home management, 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 Anticipated Goals and Expected Outcomes

Interventions

Biofeedback Electrical stimulation - functional electrical stimulation (FES) - neuromuscular electrical stimulation (NMES) - transcutaneous electrical nerve stimulation (TENS)

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 segments are improved. Range of motion is improved. Sensory awareness is increased. Impact on functional limitations - Ability to perform physical actions, tasks, or activities related to selfcare, home management, community, woik (job/ school/ play), and leisure 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 without devices 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 to patient/client. - Administrative management of practice is acceptable to patient/client. - Clinical proficiency of physical therapist is acceptable to patient/client. - Coordination of care is acceptable to patient/client. Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. - Sense ofwell-being is improved. Stressors are decreased.

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Procedural Interventions continued

Physical Agents and Mechanical Modalities

Interventions

Anticipate Goals and Expected Oirtcomes

Mechanical modalities may include: Compression therapies compression bandaging compression garments - taping total contact casting vasopneumatic compression devices Gravity-assisted compression devices standing frame - tilt table

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 instrumental activities of daily living (IADL) with or without devices and equipment sat increased. - 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 fitness Physical function is improved. Impact on societal resources - Utilization of physical therapy services is optlimizl. 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 itient/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.

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains: Pathology/pathophysiology (disease, disorder, or condition) Impairments Functional limitations Disabilities Risk reduction/prevention Health, wellness, and fitness Societal resources Patient/client satisfaction

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

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the 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) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or becausefinancial/insuranceresources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination are documented. For patients/clients who require multiple episodes of care, periodic foUow-up is needed over the life span to ensure safety and effective adaptation foUow^ing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate fbUow-up or referral.

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Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System Acquired in Adolescence or Adulthood
This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns art' the boundaries n ithin which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety ol factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age, ciiliiire, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients wiU be classified into this patternfor impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system (acquired in adolescence or adulthood)as a result of the physical therapist's evaluation of the examination data.The finding.s from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.
Inclusion Exclusion or Multiple-Pattern Classification

The foUowing examples of examination findings may support the inclusion 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 affects the central nervous system Difficulty negotiating terrains Difficulty planning movements Difficulty w^ith manipulation skills Difficulty with positioning Frequent falls Impaired affect Impaired arousal, attention, and cognition

Intracranial neurosurgical procedures Neoplasm Seizures Traumatic brain injury-

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity ofthe examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Classification in a Different Pattern

Impairments, Functional Limitations, or Disabilities

Amputation (^
Findings That May Require Classification in Additional Patterns

Impaired expressive or receptive communication Impaired motor function Loss of balance during daily activities Inability to keep up with peers Inability' to perform work (job/school/play) activities

Fraetiire Multisystem trauma

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as traumatic brain injurymay be severe and complex; however, they do not necessarily exctude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis,' page S363 )

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ICD-9-CM Codes
The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilitiesnot on codes patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients. This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (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 manuals that contain exclusion notes and instructions regardingfifth-digitrequirements.

049 Other non-arthropod-borne viral diseases of central nervous

Unspecified non-arthropod-bome viral diseases of 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 nonbacterial organisms classified else^vhere* Meningitis of unspecified cause 322.9 Meningitis, unspecified Encephalitis, myelitis, and encephalomyelitis 323.4 Other encephalitis due to infection classified elsewhere* 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 of consciousness 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 system 049.9

386 431 433 434 435

225 320 321

322 323

436 437 442 444 447 780 781

331

342 345

799

800 801 803 804 850 851 852 853 854 994

348

Vertiginous syndromes and other disorders of vestibular system 386.5 Labyrinthine dysfunction Intracerebral hemorrhage Occlusion and stenosis of precerebral arteries Occlusion of cerebral arteries Transient cerebral ischemia 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias Acute, but ill-defined, cerebrovascular disease Other and ill-defined cerebrovascular disease Other aneurysm 442.8 Of other specified artery Arterial embolism and thrombosis 444.9 Of unspecified artery Other disorders of arteries and arterioles 447.1 Stricture of artery General symptoms 780.3 Convulsions Symptoms involving nervous and musculoskeletal systems 781.2 Abnormality of gait Gait: ataxic 781.3 Lack of coordination Ataxia, not otherwise specified Other ill-defined and unknown causes of morbidity and mortality 799.0 Asphyxia Fracture of vault of skuU Fracture of base of skull Other and unqualified skull fractures Multiple fractures involving skull or face with other bones Concussion Cerebral laceration and contusion Subarachnoid, subdural, and extradural hemorrhage, following injury Other and unspecified intracranial hemorrhage following injury Intracranial injury of other and unspecified nature Effects of other external causes 994.1 Drowning and nonfatal submersion

351

* Not a primary diagnosis

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Examination
Examination is a comprehensive screening and specific testmg process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the imtial intervention and is performed for all patients/cUents.Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness.The physical therapist synthesizes the examination findings to 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 gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist.The systetns review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonar^f, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2. Patient/Client History The histor>' may include:
General Demographics Social/Health Habits (Past and Current) Functional Status and Activity Level

Age Sex Race/etlmicity Primary language Education

Behavioral health risks (eg, smoking, drug abuse) Level of physical fitness
Family History

FamiUal liealth risks

Medical/Surgical History

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', and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metabolic Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitaUzations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonar\'
Current Condition(s)/Chief Complaint(s)

Current and prior ftmctional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily 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 current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findmgs (eg, nutrition and hydration)

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)

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 physical therapist Current therapeutic interventions Mechanisms of injury or disease, including date of onset and cours<.' of events Onset and pattern of symptoms Patient/client,family,significant other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, signiiicant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous occurrence of chltf complaint(s) Prior therapeutic interventions
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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 scar formation - Skin color - Skin integrity

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

Neuromuscular Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 or quantify:
Aerobic Capacity and Endurance

Aerobic capacity during functional activities (eg, activities of daily Uving [ADL] scales, indexes, instrumental activities of daily Uving [LADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)
Anthropometric Characteristics

Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Circulation (Arterial, Venous, and Lymphatic)

Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) Body dimensions (eg, body mass index, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Arousal, Attention, and Cognition

Arousal and attention (eg, adaptability tests, arousal and aw^areness scales, indexes, profiles, questionnaires) Cognition, including abiUty to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checkUsts) Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) Motivation (eg, adaptive behavior scales) Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) Recall, including memory and retention (eg, assessment scales, interview's, questionnaires)
Assistive and Adaptive Devices

Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, observations, palpation, sphygmomanometry, thermography) Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)
Cranial and Peripheral Nerve Integrity

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations) Components, aUgnment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to neural provocation (eg, tension tests, vertebral artery compression tests) Response to stimuU, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
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Tests and Measures cantinued

Environmental, Home, and Work (Job/School/Play) Barriers

Integumentary Integrity

Current and potential barriers (eg, checklists, interviews, observations, questionnaires) Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)
Ergonomics and Body Mechanics

Ergonomics Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dj'namometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observ ations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checkUsts. job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists) Tools, devices, equipment, and w^orkstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, lAl^L scales, observations, photographic assessments, technology-;issisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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 prosthetic devices and equipment that may produce or reUeve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Skin characteristics, including blistering, continuity of skin color, dermatitis, hair giowth, mobility, nail growth, temperatui'e, texture, and turgor (eg, observations, palpation, photograpbic assessments, thermography)
Joint Integrity and Mobility

SjKCific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry)
Motor Function (Motor Control and Motor Learning)

Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, vids'ographic assessments) Elet:trciphysiol()gical integrity (eg, electroneuromyography) H.ind (unction (eg,fineand 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 O S motor function profiles, motor scales, movement assessS ment batteries, neuromotor tests, obseir^ations, physical performance tests, postural challenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Balance during functional activities with or -without the use of assistive. adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturogi-aphy, fall scales, motor impainnent tests observations, photographic assessments, postural control tests) Gait ami locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobilit>' skill profiles, obset^ations. videograpbic assessments) Gait and kx:omotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometr>\ electroneuromyography, footprint analyses, gait profiles, mobiUty skill profiles, observations, photographic assessments, technology-assisted assessments, videogniphic assessments, w^eight-bearing scales, wheelchair mobilit)' tests) Safety during gait, locomotion, and balance (eg, confidencescales, diaries, fall scales, functional assessment profiles, logs, reports)

Elet trophysiological integrity (eg, electroneuromyography) Mu.Ncle strength, power, and endurance (eg, dynamometry, manual musck; tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Musck strength, power, and endurance during functional activiti(-s (eg,ADL scales, functional muscle tests, IADL scales, observ;ition,s, videographic assessments) Muscle tension (eg, palpation)
Neuromotor Development and Sensory Integration

Acquisition and evolution of motor skiUs, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, learning profiles, motor ftmction tests, 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, and righting reactions (eg, behavioral assessment scales, motor and processing skiU tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, \ isual perceptual skill tests)

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Tests and Measures continued

Orthotic, Protective, and Supportive Devices

Self-Care and Home-Management (Including ADL and IADL)

Components, alignment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, mterviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, LADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)
Pain

AbiUty to gain access to home environments (eg, barrier identification, observations, physical performance tests) AbiUty to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aertv bic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg,electroneuromyography)
Ventilation and Respiration/Gas Exchange

Pain, soreness, and nociception (eg, analog scales, discritrunation tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural aUgnment and position (dynamic), including symmetry and deviation from midUne (eg, observations, technology-assisted analyses, videographic assessments) Postural aUgnment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Range of Motion (ROM) (Including Muscle Length)

Pulmonary- signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) Pulmonary signs of ventilatory function, including airw^ay protection; breath and voice sounds; respiratoryrate,rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance testing, observations, palpation, pulmonary function tests, ventilatory muscle force tests) Pulmonary' symptoms (eg, dyspnea and perceived exertion indexes and scales)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, gomometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibiUty (eg, contracture tests, gomometry, inclinometry, Ugamentous tests, linear measurement, multisegment flexibiUty tests, palpation)
Reflex Integrity

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, disabiUty indexes, functional status questionnaires, LADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, faU scales, interviews, logs, observations, videographic assessments)

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 challenge tests, reflex profiles, videographic assessments) Primitive reflexes and reactions, including developmental (eg, reflex profiles, screening tests) Resistance to passive stretch (eg, tone scales) Superficial reflexes and reactions (eg, observations, provocation tests)

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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 tests and 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 funo tion, chronicit)' or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, 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 diagnostic pr(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 in function and the amount of time needed to reach that level and may also inckule a. prediction of levels of improvement that may be reached 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 outcomes, and dischai^e plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.These anticipated goals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/cUents based on a variety t)f factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes relate^d to growth and development; caregiver consistency or expertise; chronicity or sc verity of the ctirrent condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probiibility of prolonged impairment, functional Umitation, or disability; and stabiUty of the condition. Factors That May Require New Expected 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 motor function and sensory integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. During the episode of care, patient/cUent wiU achieve (1) the anticipated goals and expected outcomes of the interventions that 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 and upper Umits ofthe number of physical therapist visits required to ac hieve anticipated goals and expected outcomes, ft is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 10 to 60 "isits during a single continuous episode of care. Frequency of visits and duration nf the episode of cave should be determined by the physical therapist to maximize effectiveness of ciire and efficient y of service delivery. Accessibility and availabiUty of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, complications, or secondary impairments (A>ncurrent 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 disabiUty Psychological and socioeconomic factors Psychomotor abiUties Social support Stability of the condition

Note: 1 hese patients/clients may require multiple episodes of care over the Ufetinie to ensure .safety and effective adaptation following changes in physical si at us, caregivers, environment, or task demands Factors that may lead to these idditional episodes of c.ire include: Cognitive maturation Periods of rapid growth

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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved m patient/cUent care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/cUent response and the 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 settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions Anticipated Goals and Expected Outcomes

Addressing required functions advance directives individualized family service plans (IFSPs) or individualized education plans (IEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management CoUaboration and coordination with agencies, including: equipment suppUers home care agencies payer groups - schools - transportation agencies Communication across settings, including: case conferences documentation education plans Cost-effective resource UtiUzation Data coUection, analysis, and reporting outcome data peer review findings record reviews Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: changes in impairments, functional Umitations, and disabiUties changes in interventions elements of patient/cUent management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences patient care rounds - patient/cUent family meetings Referrals to other professionals or resources

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, and mandatory commimication and reporting (eg, patient advocacy and abuse reportii^) are obtained or completed. Available resources are maximaUy utiUzed. Care is coordinated with patient/cUent,femily,significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Communication occurs across settings through case conferences, education plans, and documentation. Data are 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 management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings. Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are 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 performance health, w^eUness, and fitness programs plan of care - risk factors fbr pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities transitions across settings transitions 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 is reduced. Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased. Health status is improved. Intensity of care is decreased. Level of supervision required for task performance is decreased. Patient/client,femily,significant other, and cai^ver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and e3q>ected outcomes are increased. Patient/client knowledge of personal and envbonmental foetors associated with the condition is increased. Perfonnance levels in selfcare, home management, work (job/school/play), community, or leisure actions, tasks, or activities 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 caregivers 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 reconditioning aquatic programs - gait and locomotor training increased w^orkload over time walldng and wheelchair propulsion programs Balance, coordination, and agiUty training developmental activities training - motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation - perceptual training posture awareness training - standardized, programmatic, complementary exercise approaches - sensory training or retraining task-specific performance training - vestibular training Body mechanics and postural stabOization body mechanics training posture aw^areness training postural control training postural stabilization activities FlexibiUty exercises muscle lengthening range of motion stretching Gait and locomotion training - developmental activities training - gait training - implement and device training perceptual training standardized, programmatic, complementary exercise approaches - w^heelchair training Neuromotor development training - developmental activities training motor training movement pattern training neuromuscular education or reeducation Relaxation breathing strategies - movement strategies relaxation techniques standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head, neck, Umb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training
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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 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 - 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 instrumental activities of daily Uving (IADL) with or without devices and equipment are 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/prevention Preoperative 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.
Physical Therapy Volume 81 Number 1 January 2001

Procedural Interventions continued Functional Training in Self-Care and Home Management (Including Activities of Daily Uving (ADL) and Instrumental Activities of Daily LJving(IADLj Interventions
AI>L training bathing bed mobiUty and transfer training - developmental activities dressing eating grooming toileting Devices and equipment use and training - assistive and adaptive device or equipment training during activities of daily living (ADL) and instrumental activities of daily living (L\DL) - orthotic, protective, or supportive device or equipment training during ADL and IADL - prosthetic device or equipment training during ADL and LVDL Functional training programs simulated environments and tasks task adaptation travel training IADL training caring for dependents home maintenance household chores shopping yard w^ork Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction with use of devices and equipment safety awareness training during self-care and home management

Anticipated 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 impairments Balance 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 Anticipated Goals and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during LADL - orthotic, protective, or supportive device or equipment training during LADL Functional training programs - back schools - job coaching simulated environments and tasks task adaptation task training travel training LVDL training community service training involving instruments - school and play activities traimng including tools and instruments - work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities training

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 orreintegrationis improved. Level of supervision required for task performance is decreased. Performance of and independence m IADL with or without devices and equipment 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/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 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 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 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 massage therapeutic massage Mobilization/manipulation soft tissue Passive range of motion Anticipated Goals and Expected Outcomes Impact on pathology/pathophysiology (disease, disorder, or condition) - Edema, lymphedema, or effusion is reduced. - Joint swelling, inflammation, or restriction is reduced. Pain is decreased. Soft tissue 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 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 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 fitness Physical 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 Anticipated Goals and Expected Outcomes

Adaptive devices - environmental controls hospital beds raised toilet seats seatmg systems Assistive devices - canes - crutches - long-handled reachers power devices static and dynamic spUnts walkers wheelchairs Orthotic devices - braces casts shoe inserts splints Protective devices braces cushions - helmets - protective taping Supportive devices compression garments corsets elastic w^raps - neck collars serial casts slings supplemental oxygen supportive taping

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 management, 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 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), 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 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 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.
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Procedural Interventions continued Airway Clearance Techniques

Interventions Breathing strategies active cycle of breathing or forced expirato ry techniques assisted cough/huff techniques autogenic drainage paced breathing pursed lip breathing techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Manual/mechanical techniques assistive devices chest percussion, vibration, and shaking chest vv^all manipulation suctioning ventilatory aids Positioning positioning to alter work of breathing positioning to maximize ventilation and perfusion pulmonary 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 is improved. - Perfonnance of axid independence in activities of daily living (ADL) and instriimental activities of daily living (IADL) with or without devices and equijMnent 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. - Riskfiwrtorsare 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

Antkipaied Goab and Expected Outcomes

Electrical stimulation electrical muscle stimulation (EMS) - functional electrical stimulation (FES) transcutaneous electrical nerve stimulation (TENS)

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 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 instnmiental activities of daily living (LADL) with or without devices and equipment are increased. - 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

Interventions

Antictpatsd Goals ond Expected Oukomes

Physical agents may include: Cryotherapy cold packs ice massage vapocoolant spray Hydrotherapy whirlpool tanks pools Sound agents phonophoresis ultrasound Thermotherapy dr\' heat hot packs paraffin baths Mechanical modalities may include: Compression therapies compression bandagmg compression garments - taping Gravity-assisted compression devices standing frame - tilt table

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 instrumental activities of daily living (IADL) with or without devices and equipment are increased. - Tblerance of positions and activities is increased. Impact on cHsabiUties - Ability to assume or resume required self<are, h(ne management, wotk qob/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.

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are deUneated m shaded boxes that accompany the Usts of interventions in each preferred 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 the physical 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 of intervention. More commonly, how^ever, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of Ufe.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site w^ithm the same setting or across settings during a single episode of care). Although there may be faciUty-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs 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) the patient/cUent, caregiver, or legal guardian declines to continue intervention; (2) the patient/cUent is unable to continue to progress toward outcomes because of medical or psychosocial complications or becausefinancial/insuranceresources have been expended; or (3) the physical therapist determines that the patient/cUent wiU no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adajv tation foUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate foUow-up or referral.

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Impaired Motor Function and Sensory integrity Associated With Progressive Disorders of the Central Nervous System
This preferred practice pattern describes the generally accepted elements of patient/cUent management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/cUent needs; the profession's code of ethics and standards of practice; and patient/cUent age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients wiU be classified into this patternfor impaired motor function and sensory integrity associated with progressive disorders of the central nervous systemas a result of the physical therapist's evaluation of the examination data.The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/ pathophysiology, impairments, functional Umitations, or disabiUties or the need for health, weUness, or fitness programs.The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.
Inclusion

Exclusion or Multiple-Pattern Classificotion The following examples of exammation fmdings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/cUent would be more ap]>ropriately managed through (1) classification m an eniirely different pattern or (2) classification in both this and another pattern.
Findings That May Require Cbssification in a Different Pattern

The foUowing examples of examination findmgs may support the inclusion of patients/clients in this pattern:
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

Acquired immune deficiency syndrome Alcoholic ataxia Alzheimer disease Amyotrophic lateral sclerosis Basal ganglia disease CcrebeUar ataxia CcrebeUar disease Huntington disease Idiopathic progressive cortical disease

Intracranial neurosurgical procedures Multiple sclerosis Neoplasm Parkinson disease Primary lateral palsy Progressive muscular atrophy Seizures

Amputation Coma
Findings That May Require Classification in Additional Patterns

Impairments, Functional Limitations, or Disabilities

Amyotrophic lateral sclerosis with pneumonia Parkinson disease with arthritis

Difficulty coordinating movement Difficulty w t h mampulation skills Difficulty negotiating terrains Frequent falls Intpaired affect Impaired arousal, attention, and cognition Impaired endurance Impaired motor function Note:

Impaired sensory integrit)' Loss of balance during daily activities Progressive loss of function Inability to keep up with peers InabiUty to negotiate community environment InabiUty to perform job/school activities Lack of safety in home environment

Some risk factors or consequences of pathology/ pathophysiologysuch as neoplasmmay be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," pageS381.)
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ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/cUent diagnostic classification is based on impairments,fianctionalUmitations, and disabiUtiesnot on codes patients/clients may be classified into the pattern even though the codes Usted w t h 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 referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 042 Human immunodeficiency virus [HTV] disease 191 Malignant neoplasm of brain 192 Malignant neoplasm of other and unspecified parts of nervous system 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 303 331 Alcohol dependence syndrome 303.9 Ataxia Other cerebral degenerations 331.0 Alzheimer's disease 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus Parldnson's disease Other extrapyramidal disease and abnormal movement disorders 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 diseases and abnormal movement disorders 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 Other diseases of spinal cord 336.0 SyringomyeUa and syringobulbia Multiple sclerosis Other demyelinating diseases of central nervous system 341.8 Other demyeUnating diseases of central nervous system Central demyelination of corpus callosum 341.9 DemyeUnating disease of central nervous system, unspecified Epilepsy 345.4 Partial epilepsy, with impairment of consciousness Epilepsy: partial: secondarily generalized 345.5 Partial epilepsy, without mention of impairment of consciousness Epilepsy: sensory-induced Other conditions of brain 348.9 Unspecified condition of brain General symptoms 780.3 Convulsions Symptoms involving nervous and musculoskeletal systems 781.2 AbnormaUty of gait Gait: ataxic 781.3 Lack of coordination Ataxia, not otherwise specified

336 340 341

332 333

345

334

348 780 781

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Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Exammation is required prior to the initial intervention and is performed for all patients/cUents.Through the examination, the physical therapist may identify impairments, functional Umitations, disabUities, changes in physical function or overaU health status, and needs related to restoration of health and to prevention, wellnt ss, and fitness.The physical therapist synthesizes the examination 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 gathering of past and current information (often from the patient/client) related to v^ hy the patient/cUent is seeking the services of the physical therapist.The systems revieiv is a brief or Umited examination t)f (1) the anatomical and physiological status ofthe cardiovascular/pulmonary, integumentary, mtistuloskeletal, and neuromuscular systems and (2) the communication abiUt)', affect, cognition, language, and learning 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; stage of recovery (acute, subacute, chronic); phase of rehabiUtation (early, intermediate, late, return to activity); home, w^ork (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by^ tests and measures, refer to Chapter 2. PoHent/Client History The history may include:
General Demographics Social/Health Habits (Past and Current) Functional Stotus and Activity Level

Agf Sex Race/ethnicity Primary language Education

Behavioral health risks (t g smoking, drug abuse) Level of physical fitness

Family History

FamiUal health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Stotus (Sel^Report, Family Report, Caregiver Report)

Cardiovascular Endocrine/metaboUc Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitaUzations, surgeries, and preexisting medical and other healthrelated conditions Psychological Pulmonary 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 physical therapist Current therapeutic intei-ventions Mechanisms of injury or disease, including date of onset and course of events Onset and pattern of symptoms Pdtient/ciient, family, significant other, and caregiver expectation^ and goals for the therapeutic intervention Patient/cUent, family, significant other, and caregiver perceptions of patient's/ client s emotional response to the current clinical situation Previous occurrence of chief complaint(s) Prior therapeutic interventions
5E

Current and prior functional status in self-care and home management activities, including activities of daily Uving (ADL) and instrumental activities of daily living (L\DL) Ctirrent and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications fbr other conditions
Other Clinical Tests

laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other clinical findings (eg, nutrition and hydration)

Current Condition(s)/Chief Complalnt(s)

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)

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Systems Review

The systems revieiv may include:

Anatomical and Physiological Stotus

Cardiovascular/Pulmonary - Blood pressure - Edema Heart rate Respiratory rate

Integumentary - Presence of scar formation Skin color Skin integrity

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

Neuromuscular - Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

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 Assistive and Adaptive Devices

Aerobic capacity during functional activities (eg, activities of daily Uving [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations) Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests) Cardiovascular signs and symptoms in response to increased oxygen demand "with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry) Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, exertion scales, observations, oximetry, palpation)
Anthropometric Characteristics

Assistive or adaptive devices and equipment use during functional activities (eg,ADL scales, functional scales, LADL scales, interviews, observations) Components, aUgnment,fit,and abiUty to care for the assistive or adaptive devices and equipment (eg, intervie^vs, logs, observations, pressure-sensing maps, reports) Remediation of impairments, functional Umitations, or disabiUties with use of assistive or adaptive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Circulation (Arterial, Venous, and Lymphatic)

Body dimensions (eg, body mass mdex, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Arousal, Attention, and Cognition

Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires) Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checkUsts) Communication (eg, functional communication profiles, interviews, inventories, observations, questionnaires) Motivation (eg, adaptive behavior scales) Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales) Recall, including memory and retention (eg, assessment scales, inter\'iews, questionnaires)
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Tests ond Meosures continued

Cranial Nerve Integrity

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) Response to neural provocation (eg, tension tests, vertebral artery compression tests) Response to stimuli, including auditory, gustatory, olfactory, phary ngeal, vestibular, and visual (eg, observations, provocation tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, coltl and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, :ind vibration; thoracic outlet tests)
Environmentol, Home, and Work (Job/School/Play) Barriers

(rait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportivt, or prosthetic devices or equipment (eg,ADL scales, gait l>r<3files, IADL scales, mobility skill profiles, observations, videographic assessments) (iait and locomotion with or without the use of assistive, adaptive, (irthotic, protective, supportive, or prosthetic devices or (quipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skiU profiles, observations, photographic assessments, technology-assisted assessments, viiieographic assessments, w^eighf-bearing scales, wheelchair mobility tests) Saliety during gait, locomotion, and balance (eg, confidence scales, iliurics, fall scales, functional assessment profiles, logs, reports)
Integumentory Integrity

Current and potential barriers (eg, checkUsts, interviews, observations, questionnaires) Physical space and enviromiient (eg, compUance standards, obsei^ations, photographic assessments, questionnaires, structural 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 ability tests) Safety in work environments (eg, hazard identification cliecklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checkUsts) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, 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, technology-assisted analyses, videographic assessments)
Gait, Locomotion, and Balance

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 prosI hctic devices and equipment that may produce or relieve trauma to the skin (eg, observations,pressure-sensing maps, risk assessment scales) Skin characteristics, including blistering, continuity of skin < olor, dermatitis, hair growth, mobiUty, nail growth, temperature, texture, and turgor (eg, observations, palpation, photoj^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, finger dexterity 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 assessment batteries, neuromotor tests, observations, physical performance tests, postural chaUenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, LADL scales, observations, videographic assessments) Balance (dynamic and static) \vith or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

Electrophysiological integrity (eg, electroneuromyography) (Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity lests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activitit s (i.-g, ADL scales, functional muscle tests, L\DL scales, obserV ations, videographic assessments) Muscle tension (eg, palpation)

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Tests ond Meosures continued

Neuromotor Development and Sensory Integration

Reflex Integrity

Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental mventories and questionnaires, infant and toddler motor assessments, learning profiles, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests, screens, videographic assessments) Oral motor function, phonation, and speech production (eg, interviews, observations) Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skiU tests, postural challenge tests, observations, reflex tests, sensory profiles, temperament questionnaires, visual perceptual skiU tests)
Orthotic, Protective, and Supportive Devices

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 chaUenge tests, reflex profiles, videographic assessments) Primitive reflexes and reactions, including developmental (eg, reflex profiles) Resistance to passive stretch (eg, tone scales) Superficial reflexes and reactions (eg, observations, provocation tests)
Self-Care and Home Management (Including ADL and IADL)

Components, aUgnment,fit,and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional Umitations, or disabiUties with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, aerobic capacity tests, functional performance mventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, faU scales, mterviews, logs, observations, reports)
Pain

Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, ldnesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg, electroneuromyography)
Ventilation and Respiration/Gas Exchange

Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial 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-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation 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)

Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry) PuUnonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary ftmction tests, ventUatory muscle force tests) Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)
Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL)

Eunctional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, mdinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibiUty, and flexibiUty (eg, contracture tests, goniometry, mdinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Ability to assume or resume work (job/school/play), commumty, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disabiUty indexes, functional status questionnaires, LADL scales, observations, physical capacity tests) AbiUty to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, 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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the cUnical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and 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 diagnostic process, 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 in function and the amount of time needed to reach that level ;mcl may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposett frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated go;ils and expected outcomes, taking into consideration the expectations ofthe patient/cUent and appropriate others These anticipated gcals and expected outcomes should be measureable and time limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode w^ith a diminislung intensity of intervention. Frequency and dtiration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as anatomical and physiological changes related to growth and development; caregiver coiisistenc7 or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discliarge destinations: ()robability of prolonged impairment, functional Umitation, or disabiUty; and stabilitv of the condition.

Prognosis
Over the course of 12 months, patient/ cUent wiU demonstrate optimal motor function and sensory integrity and the highest level of fimctioning in home, work (job/school/play), community, and leisureenvironments, within the context of the impairments, functional limitations, and disabiUties. During the episode of care, patient/cUent wiU achieve (1) the anticipated goals and expected outcomes of the interventions that 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 Visits Per Episode of Core 6 to 50

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 50 visits during a single cimtinuous episode of care. Frequency of visits and duration of the episode of care shouki be determined by the physical therapist to maximize effectiveness of care anct efficiency of service deUvery.

Foctors Thot Moy Require New Episode of Core or Thot Moy Modify Frequency of Visits/Durotion of Core
Accessibility and availabiUty of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/cUent and, when appropriate, with other individuals involved in patient/cUent care, usmg various physical therapy procedures and techmques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitormg of patient/cUent response and the 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 settings. Procedtiral interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/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 Anticipated Goals and Expected Outcomes

Addressing required functions advance directives - individuaUzed family service plans GFSPs) or individualized education plans (IEPs) - informed consent - mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management CoUaboration and coordination w^ith agencies, including: equipment suppliers home care agencies payer groups - schools transportation agencies Communication across settings, including: case conferences documentation education 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, and disabUities changes in interventions elements of patient/cUent management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention InterdiscipUnary teamwork case conferences patient care rounds patient/client family meetmgs Referrals to other professionals or resources

AccountabiUty for services is increased. Admission data and discharge planning are completed. Advance directives, individuaUzedfemilyservice plans (IFSPs) or individuaUzed education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximaUy utilized. Care is coordinated with patient/cUent, family, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occurs with agencies, including equipment suppUers, home care agencies, payer groups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Communication occurs across settings through case conferences, education plans, and documentation. Data are coUected, analyzed, and reported, induding outcome data, peer reviewfindings,and record reviews. Decision making is enhanced regarding on health, wellness, andfitnessneeds. 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 management and across settings and foUows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary CoUaboration occurs through case conferences, patient care rounds, and patient/cUent family meetings. Patient/cUent,femily,significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever necessary and appropriate. Resources are utiUzed in a cost-effective way.

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Potient/Clien^Reloted Instruction Patient/cUent-related instruction may include:

Interventions

ls and Expectod Outcomes

Instruction, education and training of patients/clients and caregivers regarding: - current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional Umitations, or disabilities) enhancement of performance - health, wellness, and fitness programs plan of care risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, fimctional limitations, or disabilities transitions across settings transitions to new roles

Ability to perform physical actions, tasks, or activities is improved. Awaiseness 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, g^nificant others, and caregivers. DisalMUty associated with acute or chronic illnesses is reduced. 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 is decreased. Patient/client,femity,s^nificant other, and caregiver knowledge and awareness ofthe diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased. I^tient/dient knowledge of personal and environmental fectors associated with the condition is increased. Perfiairmance levels in sdf-care, home management, work (joh/school/play), community, or leisure actions, tasks, or activities 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 caregivers 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 reconditioning aquatic programs gait and locomotor training increased workload over time - walking and wheelchair propulsion programs Balance, coordination, and agiUty traming developmental activities training - motor function (motor control and motor learning) training or retraining neuromuscular education or reeducation perceptual training posture awareness training - standardized, programmatic, complementary exercise approaches sensory training or retraining task-specific performance training vestibular training Body mechanics and postural stabilization - body mechanics training - posture awareness training postural control training postural stabilization activities FlexibiUty exercises muscle lengthening range of motion stretching Gait and locomotion training developmental activities training gait training implement and dev^ice training perceptual training - standardized, programmatic, complementary exercise approaches - wheelchair training Neuromotor development developmental activities training motor training movement pattern training neuromuscular education or reeducation Relaxation breathing strategies movement strategies relaxation techniques standardized, programmatic, complementary exercise approaches Strength, pow^er, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches task-specific performance training
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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 is improved. Level of supervision required for task performance is decreased. Performance of and independence m activities of daily Uving (ADL) and mstrumental activities of daily Uving (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 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 fitness Fitness is improved. Health status is improved. - Physical capacity is increased. Physical function is improved. Impact on societal resources Utilization of physical therapy seiTdces is optimized. - UtiUzation of physical therapy services results in efficient use of health care dollars. 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.
Physical Theropy Volume 81 Number 1 Jonuory 2001

Procedurol Interventions conHnued

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]) Interventions Anticipated Goals and Expectsd Outcomes

ADL training bathmg bed mobility ;ind transfer training developmental activities dressing eating grooming toileting Devices and equipment use and training - assistive and adaptive device or equipment training dtiring ADL and L\DL - orthotic, protective, or supportive device or equipment training during ADL and L\DL Functional training programs simulated environments and tasks - ta.sk adaptation travel training IADL training caring for dependents home maintenance - household chores shopping stnicttired play for infants and children yard work Injury prevention or reduction injury prevention education during self-care and home management injury prevention or reduction wth use of devices and equipment safety awareness training during self-care and home management

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 and equijMnent are increased. - Tolerance of positions and activities is increased. Impact on disabiUties - Ability to assume or resume required self-care and home management roles is improved. 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 resources Utilization 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.

Guide to Physicoi Therapist Proctice

5E

Impoirments / Progressive GNS Disorders

393/S385

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 Anticipated Goals and Expected Outcomes

Devices and equipment use and training assistive and adaptive device or equipment training during IADL - orthotic, protective, or supportive device or equipment training during LADL Functional training programs - job coaching simulated environments and tasks task adaptation - task training - travel training IADL training community service training involving instruments school and play activities training including tools and instruments work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities training

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 reintegration 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), community, 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 of health 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 to patient/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

Anticipated Goo^ and Expttded Otrtcomes

Manual traction Massage connective tissue massage therapeutic massage Mobilization/manipulation soft tissue Passive range of motion

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 mancement, 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.

Guide to Physicol Theropist Proctice

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Impairments / Progressive GNS Disorders

395/S387

Procedurol Interventions continued

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Interventions Anticipated Goals and Expected Outcomes

Adaptive devices environmental controls hospital beds - raised toilet seats seating systems Assistive devices canes - crutches long-handled reachers pow^er devices static and dynamic splints walkers wheelchairs Orthotic devices - braces casts shoe inserts splints Protective devices - braces cushions helmets protective taping Supportive devices compression garments corsets elastic wraps mechanical ventilators neck collars serial casts slings - supplemental oxygen supportive tapmg

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 are improved. - 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 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 instrumental activities of daily Uving (LADL) with or without devices and equipment are increased. - 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/prevention Pressure on txxlytissuesis 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, and significant others. - Sense of weU-b)eing is improved. Stressors are decreased.
Physical Therapy Volume 81 Number 1 January 2001

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Procedural Interventions continued Airway Clearance Techniques Interventions Aitficipaisd Goals and Expedtd Outcomes

Breattiing strategies active cycle of breathing or forced expiratory techniques - assisted cough/huff techniques autogenic drainage paced breathing pursed Up breathing techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation) Manual/mechanical techniques assistive devices - chest percussion, vibration, and shaking - chest waU manipulation - suctioning - ventilatory aids Positioning positioning to alter work of breathing positioning to maximize ventilation and perfusion - pulmonary postural drainage

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 andrespiration/gasexctiange 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 is impi'oved. - Performance of and independence in activities of daily living (ADL) and in^xumental activities of daily living (IADL) with or without devices and equipment 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 thapy 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.

Guide to Physical Therapist Practice

5E

Impoirments / Progressive GNS Disorders

397/S389

Procedurol Interventions continued Electrotherapeutic Modalities

Interventions

Anticipated Goals and Expected Outcomes

Electrotherapeutic deUvery of medications iontophoresis Electrical stimulation electrical muscle stimulation (EMS) - functional electrical stimulation (FES) neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (TENS)

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 segments 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 selfcare, home management, community, work (job/ school/play), and leisure is improved. - Level of supervision required for task performance is decreased. - Performance of and independence in activities of daily Uving (ADL) and instrumental activities of daily living (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, home management, work (job/school/play), commtmity, and leisure roles is improved. Risk reduction/prevention CompUcations 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 resources UtiUzation of physical therapy services is optimized. Utilization of physical therapy 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 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 well-being is improved. Stressors are decreased.

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Procedurol Intervenrions conrinued

Physical Agents and Mechanical Modalities

Interventions

Anticipated Goals and Expected

Physical agents may mdude: Cryotherapy cold packs ice massage vapocoolant spray Hydrotherapy whirlpool tanks pools Thermotherapy dry heat - hot packs paraffin baths Mechanical modalities may include: Compression therapies compression bandaging compression garments - taping Gravity-assisted compression devices standing frame tilt table

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 instrumental activities of daily Uving (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<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.

Gulide to Physical Theropist Proctice

5E

Impairments / Progressive GNS Disorders

399/S391

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

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are deUneated in shaded boxes that accompany the Usts of interventions in each preferred 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 the physical 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 of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quaUty of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis 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) the patient/cUent, caregiver, or legal guardian decUnes to contmue intervention; (2) the patient/cUent is unable to continue to progress toward outcomes because of medical or psychosocial CompUcations or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/cUent will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/cUent status and therationalefor 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 adaptation foUowing changes in physical status, caregivers, environment, or task demands. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for dischai^e or discontinuation and provides for appropriate foUow-up or referral.

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Impaired Peripheral Nerve Integrity and Muscle Perfarmance Associatea With Peripheral Nerve Injury
This preferred practice pattern describes the generally accepted elements of patient/cUent management that physical therapists provide for patients/cUents who are classified in this pattern. The pattern titie reflects the diagncisis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession s code of ethics and standards of practice; and patient/client age. cultnre, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Classification

Patients/clients wiU be classified into this patternfor impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injuryas a result of the physical therapist s evaluation of the examination data. The findmgs ftom 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 heaith, wellness, or fitness programs.The physical therapist integrates, synthesizes, and inti rprets the data to determine the diagnostic classification.
Inclusion Exclusion or Multiple-Pattern ClassificaHon

The following examples of examination findings may support the inclusion 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 syndrome Tarsal tunnel syndrome Peripheral vestibular disorders Labyrinthitis Paroxysmal positional vertigo Surgical nerve lesions Traumatic nerve lesions
Impairments, Functianal Limitations, or Disabilities

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appro]iriately managed through (1) classification in an entirely different pattern or (2) classification in both this and .mother pattern.
Findings That Atoy Require Classification in a Different Pattern

Impairments associated with Bell palsy Imjiairments ass(x:iated with demyeUnating disease R;iclictiiopathies
Findings That May Require Classification in Additional Patterns

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

Deciibitis ulcer Reflex sympathetic dystrophy syndrome

Note: Some risk factors or consequences of pathology/ pathophysiologysuch as peripheral vascular diseasemay be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagmisis, and Prognosis," page S399.)

Guide to Physicol Theropist Proctice

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Impairments / Peripheral Nerve Injury

401/S393

ICD-9-CM Codes
The Usting below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/cUent diagnostic classification is based on impainnents, functional limitations, and disabiUtiesnot 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 referring 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 manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 225 Benign neoplasm of brain and other parts of nervous system 225.1 Cramal nerves Trigeminal nerve disorders 350.1 Trigeminal neuralgia 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 Nerve root and plexus disorders 353.0 Brachial plexus lesions 353.1 Lumbosacral plexus lesions 353.6 Phantom limb (syndrome) Mononeuritis of upper limb and mononeuritis multiplex 354.0 Carpal tunnel syndrome 354.2 Lesion of ulnar nerve 354.3 Lesion of radial nerve Mononeuritis of lower Umb Inflammatory and toxic neuropathy 357.1 Polyneuropathy in coUagen vascular disease* 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 Birth trauma 767.6 Injury to brachial plexus Palsy or paralysis: Erb (Duchenne)

350 352

353

354

355 357 386

767

* Not a primary diagnosis

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Physical Therapy Volume 8) Number 1 January 2001

Examination
Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for aU patients/cUents.Through the examination, the physical therapist may identify impairments, functional limitations, disabiUties, changes in physical function or overall health status, and needs related to restoration of health and to prevention, weOness, and fitness.The physical therapist synthesizes the examination 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 gathering of past and current information (often from the patient/cUent) related to why the patient/client is seeking the services of the physical therapist.The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cogmtion, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chrome); phase of rehabiUtation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; atid other relevant factors. Far clinical indicati<ms in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2. Patient/Client History The history may include:
General Demographics Social/Health Habits (Past and Current) Functianal Status and Activity Level

Age Sex Race/ethnicity Primary language Education

Behavioral health risks (eg smokmg, drug abuse) Level of physical fitness
Family History

FamiUal health risks

Medical/Surgical History

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, and leisure actions, tasks, or activities
Growth and Development

Developmental history Hand dominance

Living Environment

Cardiovascular Endocrine/metaboUc Gastrointestinal Genitourinary Gynecological Integumentary Musculoskeletal Neuromuscular Obstetrical Prior hospitalizations, surgeries, and preexisting medical and other healthrelated conditions
Psychological

Ctirrent and prior functional status in self-care and home management activities, including activities of daily Uving (ADL) and instrumental activities of daily Uving (L\DL) CXirrent and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities
Medications

Medications for current condition Medications previously taken for current condition Medications for other conditions
Other Clinical Tests

Laboratory and diagnostic tests Review of available records (eg, medical, education, surgical) Review of other cUnical findings (eg, nutrition and hydration)

Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic) Living environment and community characteristics Projected discharge destinations
General Health Status (Self-Report, Family Report, Caregiver Report)

Pulmonary
Current Condition(s)/Chief Complaint(s)

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)

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 physical therapist Current therapeutic interventions Mechanisms of injury or diseast', including date of onset and course of events Onset and pattern of symptoms Patient/client, family, significiint other, and caregiver expectations and goals for the therapeutic intervention Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation Previous ot cuirence of chief complaint(s) Prior therapeutic interventions
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Systems Review
The systems review may include: Anatamical and Physiological Status

Cardiovascular/Pulmonary Blood pressure - Edema - Heart rate - Respiratory rate

Integumentary Presence of scar formation Skin color Skin integrity

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

Neuromuscular - Gross 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 characterize or quantify;
Aerobic Capacity and Endurance Cranial and Peripheral Nerve Integrity

Aerobic capacity during functional activities (eg, activities of daily Uving [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)
Anthropometric Characteristics

Body dimensions (eg, body mass mdex, girth measurement, length measurement) Edema (eg, girth measurement, palpation, scales, volume measurement)
Assistive and Adaptive Devices

Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations) Components, alignment,fit,and ability to care for the assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports) Safety during use of assistive or adaptive devices and equipment (eg, diaries, faU scales, interviews, logs, observations, reports)
Circulation (Arterial, Venous, and Lymphatic)

Electrophysiological integrity (eg, electroneuromyography) Motor distribution of the cranial nerves (eg, dynamometry, muscle 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, pharyngeal, vestibular, and visual (eg, observations, provocation tests) Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration) Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and Ught touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)
Environmental, Home, and Work (Job/School/Play) Barriers

Current and potential barriers (eg, checkUsts, interviews, observations, questionnaires)

Cardiovascular signs, induding heart rate, rhythm, and sounds; pressures and flow; and superficial vascular resp>onses (eg, auscultation, claudication scales, girth measurement, palpation, sphygmomanometry, thermography) Physiological responses to position change, includmg autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, observations, palpation, sphygmomanometry)

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Tests and Measures continued

Ergonomics and Body Mechanics Integumentary Integrity

Ergonomics Dexterity and coordmation durmg work (job/school/play) (eg, hand function tests, impairment ratmg scales, manipulative ability tests) Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses) Safety in work environments (eg, hazard identification checkUsts, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits) Specific work conditions or activities (eg, handUng checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, w^orkstation checklists) Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments) Body mechanics Body mechanics during self<are, 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

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 prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales) Skin characteristics, including bUstering, continuity of skin color, dermatitis, hair growth, mobiUty, nail growth, temperatun, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)
Joint Integrity and Mobility

Si)ecific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests: arthrometry)
Motor Function (Motor Control and Motar Learning)

Balance duhng functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, IADL scales, observations, videographic assessments) Balance (dynamic and static) with or without the use of assistive, atlaptive, orthotic, protective, supportive, or prosthetic devices 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 without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobiUty skill profiles, observations, videographic assessments) Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobiUty skiU profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests) Safety during gait, locomotion, and balance (eg, confidence scales, diaries,fiiUscales, functional assessment profiles, logs, reports)

Dexterity, coortlination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments) Hand function (eg,fineand gross motor control tests, finger dexterity tests, manipulative ability tests, observations) Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments)
Muscle Performance (Including Strength, Power, and Endurance)

Elet trophysiological integrity (eg, electroneuromyography) Mascle strength, power, and endurance (eg, dynamometry, manual musde tests, musde performance tests, physical capacity tests, technology-assisted analyses, timed activity tests) Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observatii)ns, videographic assessments) Muscle tension (eg, palpation)

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Tests and Measures conrinued

Orthotic, Protective, and Supportive Devices

Sel^Core ond Home Manogement (Including ADL and IADL)

Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, Interviews, logs, observations, pressure-sensing maps, reports) Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles) Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments) Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)
Pain

Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests) Ability to perform self-care and home management activities w^ith or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg,ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles) Safety in self-care and home management activities and environments (eg, diaries, faU scales, interviews, logs, observations, reports, videographic assessments)
Sensory Integrity

Combined/cortical sensations (eg, stereognosis, tactile discrimination tests) Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests) Electrophysiological integrity (eg,electroneuromyography)
Work (Job/School/Ploy), Community, and Leisure Integration or Reintegration (Including IADL)

Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain draw^ings and maps, provocation tests, verbal and pictorial descriptor tests,) Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)
Posture

Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments) Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments) Specific body parts (eg, angle assessments, forward-bending test, goniometry, observations, palpation, positional tests)
Ronge of Motion (ROM) (Including Muscle Length)

Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, LADL scales, observations, physical capacity tests) Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments) Safety in work (job/school/play), community, and leisxire activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Functional ROM (eg, observations, squat tests, toe touch tests) Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments) Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, Unear measurement, multisegment flexibility tests, palpation)
Reflex Integrity

Deep reflexes (eg, myotatic reflex scale, observations, reflex tests) Electrophysiological integrity (eg, electroneuromyography) Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments) Superficial reflexes and reactions (eg, observations, provocation tests)

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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 tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that inftuence the complexity of the evaluation include the clinicalfindings,extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, 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 diagnostic process, 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 in function and the amount of time needed to reach that levet and may also include a prediction of tevets of improvement that may t5e reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and dimition of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, takii^ into consideration the expectations of the patient/client and appropriate others.'rhese anticipated goiils lind expected outcomes should be measureable and time Limited. The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation proc ess, such as anatomical and physiological changes related to growth and development; caregiver consistency or expertise, chronicity or severity of the current condition; living environment; multisite or multisystem involvement; sociat support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Expected Ronge of Number of Visits Per Episode of Core

Foctors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Care

Over the course of 4 to 8 montlis, patient/client will demonstrate optimal peripheral nerve integrity and muscle performance and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities. During the episode of care, patient/client wilt achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

12to56
This range represents the low;r and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 12 to 56 t'isits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by ttie physical therapist to maximize effectiveness of care and efficient y of service delivery.

Accessibility and availability of resources Adherence to the intervention program Age Anatomical and physiological changes related to growth and development Caregiver consistency or expertise Chronicity or severity of the current condition Cognitive status Comorbitities, complications, or secondary impairments 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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Intervention
Intervention is the purposeful interaction of the physical therapist with the patient/client and, w^hen appropriate, with other individuals involved in patient/client care, using various physical therapy procedtires and techniques to produce changes in the condition consistent w^ith 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/ctient-retated instruction are provided for atl patients/cUents across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goats and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions Anticipated Goals ond Expected Outcomes

Addressing required functions advance directives - individualized family service plans (IFSPs) or individualized education plans GEPs) informed consent mandatory communication and reporting (eg, patient advocacy and abuse reporting) Admission and discharge planning Case management Collaboration and coordination with agencies, includir^: equipment supptiers - home care agencies payer groups schoots transportation agencies Communication across settings, inctuding: case conferences documentation - education plans Cost-effective resource utilization Data collection, analysis, and reporting - outcome data peer review findings record reviews Doctimentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including: - changes in impairments, functional limitations, and disabilities changes in interventions elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) outcomes of intervention Interdisciplinary teamwork case conferences patient care rounds patient/client family meetings Referrals to other professionals or resources

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, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed. Available resources are maximally utilized. Care is coordinated with patient/client, family, significant others, caregivers, and other professionals. Case is managed throughout the episode of care. Collaboration and coordination occtirs with agencies, including eqtiipment suppliers, home care agencies, payer gtoups, schools, and transportation agencies. Communication enhances risk reduction and prevention. Commtmication occurs across settings through case conferences, education plans, and doctimentation. Data are collected, analyzed, and reported, including outcome data, peer reviewfindings,and record reviews. Decision making is enhanced regarding on health, weUness, andfitnessneeds. Decision making is enhancedregardingpatient/client health and the use of health care resotirces by patient/client, family, significant others, and caregivers. Documentation occtirs throughout patient/cUent management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). Interdisciplinary collaboration occtirs through case conferences, patient care rounds, and patient/dient family meetings. Patient/cUent,femily,significant other, and caregiver tmderstanding of anticipated goals and expected outcomes is increased. Placement needs are determined. Referrals are made to other professionals or resources whenever 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, disorder, or condition), impairments, functional Umitations, or disabilities transitions across settings transitions 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 is reduced. 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 knowledige 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 factors associated with the condition is increased. Perfofmance levels in self-care, home management, work (job/jchool/play), community, or ktsuie actions, tasks, or activities 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 caregivers is Improved. Self-management of symptoms is improved. Utilization and cost of health care services are decreased.

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Impairments / Peripheral Nerve Injury

409/S401

Procedural Interventions Procedural interventions for this pattern may include: Theropeutic Exercise Interventions Aerobic and endurance conditioning or reconditioning aquatic programs - gait and tocomotor training - increased workload over time walking and w^heelchair propulsion programs Balance, coordination, and agiUty training developmental activities training - motor function (motor control and motor learning) training or retraining - neuromuscular education or reeducation perceptual training posture awareness training standardized, programmatic, complementary exercise approaches sensory training or retraining task-specific performance training vestibutar training Body mechanics and postural stabilization - body mechanics training - posture awareness training - postural control training - postural stabiUzation activities Flexibility exercises muscle lengthening range of motion - stretching Gait and locomotion training - developmental activities training gait training implement and device trainir^ - perceptual training standardized, programmatic, complementary exercise approaches - wheelchair training Strength, power, and endurance training for head, neck, limb, pelvic-ftoor, trunk, and ventilatory muscles active assistive, active, andresistiveexercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) aquatic programs standardized, programmatic, complementary exercise approaches - task-specific performance training Relaxation breathing strategies - movement strategies relaxation techniques Anticipated Goals and Expected Outcomes Imict 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 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 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] and Instrumental Activities of Daily Living [IADL]) Interventions ADL training - bathing - bed mobility and transfer training developmental activities dressing eating - grooming toileting Functional training programs simulated environments and tasks task adaptation travel training IADL training - caring for dependents - home maintenance household chores shopping structured play for infants and children yard work Injury prevention or reduction - injurj' prevention education during self-care and home management injury' prevention or reduction ^vith use of devices and equipment safety a'wareness training during setf<;are and 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 h H m management is improved. cn e - 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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Impairments / Peripheral Nerve Injury 41 1 / S 4 0 3

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 schools job coaching simulated environments and tasks task adaptation - task training - travel training IADL training community service training involving instruments school and play activities training including tools and instruments - work training with tools Injury prevention or reduction injury prevention education during work (job/school/play), community, and leisure integration or reintegration - injury prevention or reduction with use of devices and equipment safety awareness training during work (job/school/play), community, and leisure integration or reintegration Leisure and play activities training

Anticipated Goals and Expected Outcomes Impact on pathology/pathophysiology (disease, disorder, or condition) - Pain is decreased. - Physiological response to increased oxygen demand is improved. Impact on impairments - Balance is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - Motor function (motor control and motor learning) is improved. - Muscle 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. :

Guide to Physical Therapist Practice

5F

Impairments / Peripheral Nerve Injury 4 1 3 / S 4 0 5