1995-Guide To Physical Therapist Practice, Volume I-707-64

A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management PHYS THER. 1995; 75:707-764.
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A Guide to Physical Therapist Practice. Volume I: A Description of Patient Management

[A Guide to Physical Therapist Practice. Volume One: A Description of Patient Management.
Pbys Ther. 1995;75:R.1
Table of Contents
Preface ............................................................... 709 Chapter One: Management of Physical Therapy Patients .......................................................... 711 Physical Therapists ............................................ 711 Definition of Physical Therapy ........................... 711 Physical Therapist Practice ............................... 712 Practice Settings ...................... . . . . . . . . . . . . . . . . 712 Primary Care .................................................... 712 Secondary and Tertiary Care .............................. 713 Patient Management .................... . . . .............. 713 I. Examination ............................................. 714 A. The History ............................................. 714 B. Systems Review ...................................... 715 C. Tests, Measures. and Data Generated ....... 715 I1. Evaluation ............................................ 715 I11. Diagnosis ................................................. 715 IV. Prognosis ................................................. 716 v. ~ntervention ......................................... 716 A. Direct Intervention ................................. 716 B. Patient-related Instruction ........................ 716 C. Coordination. Communication. and Documentation ....................................... 716 Additional Professional Activities of the Physical Therapist ....................................................... 716 I. Prevention and Wellness (including Health Promotion) .............................................. 717 I1. Consultation ............................................. 717 1 1 1. Screening ................................................. 717 IV. Education ................................................ 718 V. Critical Inquiry .......................................... 718 VI . Administration .......................................... 718 Physical Therapy Services: Direction and Supervision of Support Personnel .................... 718 Support Personnel ............................................. 719 I. Physical Therapist Assistants ........................ 719 I1. Physical Therapy Aides .............................. 719 I11. Other Support Personnel ........................... 719 References ........................................................ 719 Chapter Two: Examinations Provided by Physical Therapists ........................................ 720 Aerobic Capacity or Endurance Examination ....... 720 Anthropometric Characteristics Examination ........ 721 Arousal, Mentation. and Cognition Examination ... 722 Assistive, Adaptive, Supportive, and Protective Devices Examination ...................................... 722
Community or Work Reintegration Examination (including Instrumental Activities of Daily Living) .......................................................... 723 Cranial Nerve Integrity Examination .................... 724 Environmental. Home. or Work Barriers Examination .................................................. 725 Ergonomics or Body Mechanics Examination ....... 725 Gait and Balance Examination ............................ 727 Integumentary Integrity Examination ................... 727 Joint Integrity and Mobility Examination .............. 728 Motor Function Examination .............................. 729 Muscle Performance Examination (including Strength. Power. and Endurance) .................... 730 Neuromotor Development and Sensory Integration Examination ................................. 731 Orthotic Requirements Examination .................... 731 Pain Examination .............................................. 732 Posture Examination .......................................... 733 Prosthetic Requirements Examination .................. 734 Range of Motion Examination (including Muscle Length) ......................................................... 734 Reflex Integrity Examination .............................. 735 Self-care and Home-Management Examination (including Activities of Daily Living and Instrumental Activities of Daily Living) ............. 736 Sensory Integrity Examination (including Proprioception and Kinesthesia) ...................... 737 Ventilation. Respiration. and Circulation Examination ................................................ 737 Chapter Three: Interventions Provided by Physical Therapists ........................................ 739 Intervention ...................................................... 739 I. Direct Intervention ...................................... 739 1 1. Patient-related Instruction ........................... 740 1 1 1. Coordination. Communication. and Documentation .......................................... 740 Therapeutic Exercise (including Aerobic Conditioning) .............................................. 741 Functional Training in Self Care and Home Management (including Activities of Daily Living and Instrumental Activities of Daily Living) .......................................................... 742 Functional Training in Community or Work Reintegration (including Instrumental Activities of Daily Living. Work Hardening. and Work Physical Therapy / Volume 75. Number 8 / August 1995
. .
Conditioning) ................................................ Manual Therapy Techniques (including Mobilization and Manipulation) ....................... Prescription. Fabrication. and Application of Assistive. Adaptive. Supportive. and Protective Devices and Equipment .................................. Airway Clearance Techniques ............................. Debridement and Wound Care ........................... Physical Agents and Mechanical Modalities ..........
742 743
744 744 745 746
Electrotherapeutic Modalities .......................... Patient-related Instruction .................................. Appendices ................................................... Appendix I . A Glossary of Operational Definitions in Physical Therapy ............................. . . . ..... Appendix I1. Code of Ethics and Guide for Professional Conduct ..................................... Appendix I11. Guidelines for Physical Therapy Documentation ...............................................
746 747 749 749 757 762
Physical Therapy / Volume 75. Number 8 /August 1995

A Guide to Physical Therapist Practice, Volume I: A Description
of Patient Management
Physical therapy is a dynamic profession with an established theoretical base and widespread clinical applications, particularly in the preservation, development, and restoration of maximum physical function. Physical therapists seek to prevent injury, impairments, functional limitations, and disability; to maintain and promote fitness, health, and quality of life; and to ensure availability, accessibility, and excellence in the delivery of physical therapy services to the patient. As essential participants in the health care delivery system, physical therapists assume leadership roles in prevention and health maintenance programs, in the provision of rehabilitation services, and in professional and community organizations. They also play important roles in developing health policy and appropriate standards for the various elements of physical therapy practice. Physical therapists help nearly a million Americans daily to restore health, alleviate pain, and prevent the onset and progression of impairments, functional limitations, and disability. The benefits of rehabilitation and physical therapy services are well documented, and services are covered in nearly all federal, state, and private insurance plans. The American Physical Therapy Association (APTA), the national organization representing the profession of physical therapy, believes it to be critically important that those outside the profession understand the role of physical therapists in the health care system and the unique services they provide. As clinicians, physical therapists examine patients, identdy potential and existing problems, perform evaluations, establish a diagnosis, set forth a prognosis, provide interventions (those practices and procedures used by the physical therapist in treating and instructing patients), evaluate the success of those interventions, and moddy treatment to effect the desired outcomes. Physical therapy includes not only those services provided by physical therapists but also those rendered under their direction and supervision. The APTA is committed to informing consumers, federal and state governments, and third-party payers of the benefits of physical therapy and, more specifically, of the relationship of the patient's health status after treatment to the services that the therapist has provided. The Association actively supports outcomes research and strongly endorses all efforts to develop appropriate systems to measure the results of physical therapy patient management.
A Guide to Physical Therapist Practice is a two-volume description of general physical therapy patient management developed by the APTA to give readers a thorough understanding of the contributions that physical therapists bring to
Physical Therapy / Volume 75, Number 8 /August 1995
health care. Volume I: A Description of Patient Management, focuses first on physical therapists as health professionals, describing their approach to patient management in Chapter One. Chapter Two details 23 examinations that physical therapists often perform and includes an overview of each examination, clinical indications that may prompt its use, a list of the general tests and measures that may be atiministered, and data that may be generated. Chapter Three details the interventions (treatments) that physical therapists frequently provide. An overview for each intervention is given, followed by a listing of the modes in which the intervention may be applied. Clinical indications for selecting the intervention are described and its expected benefits listed. Finally, three appendices are presented: a glossary, the APTA Code of Ethics and Guidefor Ptofssional Conduct, and the APTA Guidelinesfor Physical T?m-apyDocumentation. [Volume I t Preferred Practice Patterns, will be keyed to defined impairments and ICD-9 codes ancl is in the process of being developed.]
A Guide to Physical 7h;berapistPractice serves two purposes: 1) to provide a guide to the domain of accepted physical therapy practice and 2) to facilitate the development of preferred practice patterns that will reduce unwarranted variation in the provision of physical therapy treatments, improve the quality of physical therapy, enhance consumer satisfaction, promote appropriate utilization of health care services, and reduce costs. This document is intended to be used as a reference by health care policymakers, administrators, managed care providers, third-party payers, physical therapists, and other health care professionals. The material presented describes the generally accepted elements of physical therapy patient management. Decisions about the appropriateness of treatment are made by the physical therapist in light of the patient's needs and the profession's code of ethics, standards of practice, and practice patterns. The physical therapist considers the influence of culture, gender, race, age, socioeconomic status, and sexual orientation when providing services to a patient, while adhering to APTA policy on nondiscrimination.
The American Physical Therapy Association recommends that federal and state governments and other entities that provide insurance reimbursement for physical therapy services require that these services be provided only by or under the direction of a physical therapist. The use of any physical therapy examination or intervention, unless provided by a physical therapist or under the direction or supervision of a physical therapist, is not physical therapy, nor should it be represented or reimbursed as such.

Chapter One: Management of Physical Therapy Patients
This chapter introduces physical therapists, describes their qualifications, defines the field of physical therapy, details the elements of physical therapist practice, and discusses the roles of physical therapists in the provision of primary, secondary, and tertiary care. Physical therapists are professionals involved in the examination, evaluation, treatment, and prevention of neuromuscular, musculoskeletal, cardiovascular, and pulmonary disorders that produce movement impairments, disabilities, and functional limitations. As members of primary care teams or as providers of specialty care, physical therapists help patients to improve function, alleviate pain, and prevent the onset of disease or disability. Chapter One also lists the settings in which physical therapists practice and describes the professional activities in which they are involved, which include patient management (examination, evaluation, diagnosis, prognosis, and intervention), prevention and wellness (including health promotion), consultation, screening, education, critical inquiry, and administration. The chapter eoncludes with a discussion of support personnel. Pt,ysical Therapists Physical tb~rapists are professionally educated at the college or university level and are required to be licensed in the states(s) in which they practice. Graduates from 1960 to the present have successfully completed professional programs of physical therapy accredited by the APTA's Cornmission on Accreditation in Physical Therapy Education (CAPTE). Graduates from 1926 to 1959 completed physical therapy curricula approved by appropriate accreditation bodies.
Physical therapists interact and practice in collaboration with a variety of health professionals, including physicians, dentists, podiatrists, nurses, social workers, occupational therapists, speech and language pathologists, and others. As responsible health professionals, physical therapists acknowledge the need to educate and inform other health professionals, government agencies, insurers, and the consumer public about the services they offer and their effective and cost-efficient delivery. Physical therapists provide patients with services at the preventive, acute, and rehabilitative stages directed toward achieving increased functional independence and decreased functional impairment. They provide preventive care that forestalls or prevents functional decline and the need for more intense care. Through timely and appropriate intervention, they frequently reduce or eliminate the need for costlier forms of care such as surgery and may also shorten or even eliminate institutional stays. Definition of Physical Therapy The current Model Definition of Physical Therapy for State Practice Acts was adopted by the APTA Board of Directors in March 1993 and revised in March 1995:
aerobic capacity or endurance anthropometric characteristics arousal, mentation, and cognition assistive, adaptive, supportive, and protective devices community or work reintegration cranial nerve integrity environmental, home, or work barriers ergonomics or body mechanics gait and balance integumentary integrity joint integrity and mobility motor function muscle performance neuromotor development and sensory integration orthotic requirements pain posture prosthetic requirements range of motion reflex integrity self care and home management sensory integrity ventilation, respiration, and circulation 2) Alleviating impairments and functional limitations by designing, implementing, and modthing therapeutic intauentions that include, but are not limited to, the following: therapeutic exercise (including aerobic conditioning) functional training in self care and home management (including activities of daily living and instrumental activities of daily living) functional training in community or work reintegration activities (including instrumental activities of daily living, work hardening, and work conditioning)
Physical therapy, which is the care and services provided by or under the direction and supenrision of a physical therapist, includes:
1) Examining patients with impair-
ments, functional limitations, and disability or other health-related conditions in order to determine a diagnosis, prognosis, and intervention; examinations include, but are not limited to, thefollowing:
Physical Therapy /Volume 75, Number 8 /August 1995
manual therapy techniques (including mobilization and manipulation) prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment airway clearance techniques debridement and wound care physical agents and mechanical modalities electrotherapeutic modalities patient-related instruction
to engage in age- and sex-specific roles in a particular social context and physical environment. Physical function, which is a fundamental component of health status, describes the state of those sensory and motor slulls necessary for mobility, work, and recreation. Health status, which is part of well-being, describes an individual in terms of physical, mental, affective, and social function.
Practice Settings
Physical therapists practice in a broad range of inpatient, outpatient, and community settings, including, but not limited to, the following: hospitals homes physical therapy office practices rehabilitation facilities subacute care facilities skilled nursing or extended care facilities hospices schools (preschool, primary, and secondary) corporate or industrial health centers work or occupational environments athletic training facilities sports injury treatment centers fitness centers education or research centers
3) Pmazting injury, impimzents,

functional limitations, and disability, including the promotion and maintenance offitness, health, and quality of life in all age populntiorts.
4) Engaging in consultation, education, and mearch.
Physical Therapist Practice

Physical therapists are committed to offering necessary, appropriate, and highquality health services. They provide these services to patients (individuals who are sick or injured) and clients (individuals who are not necessarily sick or injured but who can benefit from physical therapy services, eg, a person with a chronic disability, a person wishing to prevent a loss of function). In addition, physical therapists offer selected services (eg, screening) to individuals, businesses, school systems, and others also termed clients. Physical therapists also provide wellness initiatives, including health promotion and education, that stimulate the public to engage in healthy behavior. Physical therapists provide services to patients with impairments, functional limitations, disability, or change in physical function and health status resulting from injury, disease, or other causes. Impaimzents are losses or abnormalities of physiological, psychological, or anatomical structure or function. Functional limitations are restrictions of the ability to perform a physical action, activity, or task in an efficient, typically expected, or competent manner. Disability is the inability
Recognition that primary care can encompass a myriad of needs that g o well beyond the capabilities and competencies of individual caregivers and that require the involvement and interaction of varied practitioners Rejection of the "gatekeeper" concept because of its pejorative connotation that the role of the primary care practitioner is to manage costs and, for the most part, to keep the "gate" closed Awareness that primary care is not limited to the "first contact" or point of entry into the health care system Emphasis on the comprehensiveness o f a primary care program Recognition of the important role of family and community in the provision of primary care, and recognition that caregivers and care-receivers function within, and are dependent on, a wide range of societal and environmental factors Physical therapists are involved in the examination, treatment, and prevention of neuromusculoskeletal disorders and are well positioned to provide those services as members of primary care teams. On a daily basis, physical therapists practicing at acute, rehabilitative, and preventive stages of care assist individuals in restoring health, alleviating pain, and preventing the onset of disease or disability. They play roles in the acute, chronic, prevention, and wellness areas. A number of studies indicate that the assumption by physical therapists of a primary care role is an efficient use of health care resources. Physical therapists provide a broad range of neuromusculoskeletal health services from entry to discharge, including screening, triage, examination, referral, intervention, coordination of care, and education and prevention. For acute neuromusculoskeletal disorders, the triage and initial examination is the appropriate responsibility of a physical therapist. The primary care team functions more efficiently with
PtSmary Cam
Physical therapists have major roles to play in the provision of primary care, recently defined as fol1ows:l Primary care is the provision of integrated, accessible health care sm'ces by clinicians who are accountable for addressing a large majority of peronal health care needs, developing a sustainedpattndip with patients, and practicing in the context of family and community. In recent years a number of organizations, including the Institute of Medicine, have examined the delivery of primary care services in the United States. The APTA endorses the concepts of primary care set forth by the Institute of Medicine's Committee on the Future of Primary Care,l which include the following:

712 / 67
physical therapists who recognize neuromusculoskeletal disorders, perform examinations, and treat or refer without delay (eg, physical therapists providing immediate pain reduction and programs for strengthening, flexibility, endurance, postural alignment, instruction in activities of daily living, and work modification for patients with low back pain). These actions result in more efficient and effective patient care and more appropriate use of other members of the primary care team. The efficiency and cost effectiveness of physical therapy in this context is well documented. With physical therapists functioning in a primary care role and delivering early intervention for work-related musculoskeletal injuries, time lost due to injuries has been dramatically reduced. For certain chronic conditions, physical therapists should be recognized as the principal providers of care within the collaborative primary care team. Physical therapists are well prepared to coordinate care related to loss of physical function. Through community-based agencies, physical therapists coordinate and integrate provision of services to individuals with chronic neuromusculoskeletal disorders, including a vast array of postural, muscular, joint, and functional problems in patients with osteoporosis of the spine or hips. The practice of physical therapists in industrial or workplace settings illustrates another key element of primary care. In these settings, physical therapists manage the care provided to employees and prevent injury by designing or redesigning the work environment. The services provided by physical therapists focus on both the individual and the environment to ensure comprehensive and appropriate intervention. These practices have been documented to be both costand clinically effective.
integumentary, or other disorders frequently are seen initially by another health practitioner and then referred to physical therapists for secondary care. Physical therapists provide secondary care in a wide range of settings, from hospitals to preschools. Physical therapists provide tertiary care services in highly specialized, complex, and technologically based settings (eg, a heart or lung transplant service, a bum unit). They are also tertiary-care practitioners when supplying specialized services (eg, to patients with a spinal cord lesion, to individuals who have suffered closedhead trauma) following referral from clinicians such as physicians, dentists, and nurse practitioners.
may be conceptualized as either patient-related (eg, satisfaction with care) or associated with service delivery (eg, efficacy and efficiency). In many cases the physical therapist offers all five elements of care before an outcome is reached, but outcomes may result from the rendering of even a single element, such as the examination, or two to four elements (eg, examination, evaluation, diagnosis, and prognosis but no intervention).
Patient Management
A schema describing the physical therapist's approach to patient management is presented below in Figure 1. As the figure demonstrates, the physical therapist integrates five elements of care in a manner designed to maximize the patient's outcome, which
Examination is the process of obtaining a patient history, performing relevant systems reviews, and selecting and administering specific tests and measures to obtain data. (Frequently, physical therapists will perform one or which are any more ~examinations, examinations that take place after the initial examination is completed. A reexamination gives the physical therapist the opportunity to evaluate the patient's progress and to mod^ or adapt the patient management process as necessary.) Evaluation is a dynamic process in which the physical therapist makes
EVALUATION DIAGNOSIS
v
PROGNOSIS INTERVENTION
,
Secondary and Tertiary Cam

Physical therapists play major roles in secondary and tertiary care as well. Patients with neuromuscular, muscule skeletal, cardiovascular, pulmonary,
Figure 1.
mal outcome.
7he elements of physical therapist patient management leading to opti-
clinical judgments based on data gathered during the examination. Diagnosis is both the process and the end result of evaluating information obtained from the patient examination, which the physical therapist then organizes into defined clusters, syndromes, or categories to help determine the most appropriate intervention strategies for each patient. Pmgnosis is the determination of the level of maximal improvement that might be attained and the time required to reach that level; it may also include predictions of improvement at various intervals during therapy. Intervention is the purposeful and skilled interaction of the physical therapist with the patient, using various methods and techniques to produce changes in the patient's condition consistent with the diagnosis and prognosis. After analyzing all relevant information that has been gathered from the history and systems reviews, the physical therapist decides what groups of tests and measures should be included in the exarnination of the patient. The physical therapist will decide to use one, more than one, or portions of several .$pec$c examinations (detailed in Chapter Two) as part of the examination. As the examination progresses, the physical therapist may determine that there are additional problems present that were not uncovered by the history and systems review and conclude that other specfic examinations (in Chapter Two) or portions of specific examinations will need to be performed to obtain sufficient data to make an evaluation, render a diagnosis, fomi a prognosis, and choose interventions. In addition, as described below, the physical therapist may reexamine at any stage of the patient management process. Because physical therapy is most often an ongoing process delivered over a period of weeks rather than at a single visit, physical therapists rely on reexaminations to modify or redirect the patient management process and to evaluate outcomes that have been predicted. In actuality, the reexamination has an important quality assurance component, as it allows the Physical Therapy /Volume 75, Number
physical therapist to focus on both the elements of physical therapy management and the outcomes of care.
At each step of the management pro-
selecting and administering specific tests and measures The examination is a required element prior to any intervention and is performed for all patients. The physical therapist selects components of specific examinations described in Chapter Two based on the purpose of the patient's visit to the physical therapist, the complexity of the patient's condition(~), and the evolving impression formed by the physical therapist during the examination. The examination may therefore be as brief or lengthy as necessary. For example, the physical therapist may conclude from the patient history and systems review that further testing and management by the physical therapist is not required a n d o r that the patient should be referred to another health care practitioner. Conversely, the physical therapist may decide that a full examination is necessary and then select appropriate tests and measures to be administered. The range of tests and measures may include those selected from any or all of the specific examinations listed in Chapter Two, depending on the complexity of the patient's problems and the directions taken by the physical therapist in the clinical decision-making process. It should be noted that at some point after completing the initial examination, the physical therapist may conclude that a second examination (re-examination) is indicated (because of new clinical indications, failure of the patient to respond to interventions, etc) and proceed to perform it as described above.
cess the physical therapist considers the possible patient outcomes. Outcome is the result of physical therapy management and is expressed in five areas: prevention and management of symptom madestation, consequences of disease (impairment, disability, andor role limitation), cost-benefit analysis, health-related quality of life, and patient satisfaction. Because the physical therapist projects an outcome that reflects the needs of the patient, a successful outcome includes improved or maintained physical function when possible, a slowing of functional decline where the status quo cannot be maintained, andor an expression by the patient that the outcome is desirable. During the initial history taking, the physical therapist identifies the patient's expectations for therapeutic interventions, perceptions about the clinical situation, and goals and desired outcomes. The physical therapist considers whether these are realistic in the context of the examination findings. In setting forth a diagnosis, making a prognosis, and choosing interventions, the physical therapist also considers potential patient outcomes; eg, what outcome is likely given this patient's diagnosis?The physical therapist may use a re-examination to see whether predicted outcomes are reasonable and then m o d e them as necessary. Ideally, the physical therapist also engages in outcomes analysis; ie, he or she systematically examines the outcomes of care in relation to selected patient variables (eg, age, sex, diagnosis, interventions performed) and develops statistical reports for internal or external use.
I. Examination. The exarnination, which is an investigation, is the first step in the management process. It has three components:
obtaining a patient history performing relevant systems reviews
A. The History. The patient history is an account of past and present health status. It includes the identification of complaints and provides the initial source of information about the patient; it also suggests the patient's ability to benefit from physical therapy services. The patient history provides information that enables the therapist to identlfy health-risk factors, health restoration and prevention needs, and co-existing health problems that have implications for physical therapy intervention. It is commonly conducted by gathering data from the patient, family,
signhcant others, caregivers, and other interested persons; by consulting with other members of the health care team; and by reviewing the medical record. In conducting the history, the physical therapist encourages patients to express their expected outcomes, which may be used in the process of establishing goals and intended outcomes. The process of taking a history to identlfy specific information about the patient may include, but is not limited to, the following: interviewing administering a questionnaire consulting with other health professionals reviewing available records Data generated from a history may include, but are not limited to, the following: needs or concerns that led an individual to seek the services of a physical therapist the patient's expectations for therapeutic interventions and perceptions about his/her clinical situation prior functional status in selfcare and home-management activities (activities of daily living and instrumental activities of daily living) current community or work activities prior hospitalizations, surgeries, and pre-existing medical and other health-related conditions medications level of fitness health risks (eg, family history, diet, alcohol consumption, smoking, stress) incontinence, bowel and bladder problems obstetric history developmental history social interactions, activities, and support systems nutrition and hydration sleep patterns skin integrity family and caregiver resources living environment and community characteristics
70 / 715
projected discharge designation
8 . Systems Review. The systems

review is a brief or limited exarnination to provide additional information about the patient's general health that will help the physical therapist to formulate a diagnosis and select an intervention program. The systems review also assists the physical therapist in ident~fying possible health problems that require consultation with or referral to another health care provider. Data generated from a systems review that may affect subsequent examination(~)and intervention(s) include the following: physiologic and anatomic status cardiopulmonary response during rest and activity neuromusculoskeletal physiologic responses during rest and activity somatosensory integrity newly identified or recently emerging signs or symptoms communication skills and cognitive status emotional status
judgments) based on the data gathered from the examination. Factors that influence the complexity of the examination and the evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's overall physical function and health status. Thus, the physical therapist's evaluation reflects the severity of the current problem, the stability of the patient's condition, the presence of pre-existing conditions, and the possibility of multiple sites or systems involvement. Physical therapists also consider the l&l of the patient's impairment(s) and the possibility of prolonged impairment, functional limitations, and disability, as well as the patient's social supports, living environment, and potential discharge destination. Frequently, the physical therapist's evaluation will indicate that a second examination (reexamination) is necessary, which would then be conducted as detailed in the section entitled "I. Examination" above. 111. Diagnosis. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the decision reached as a result of the diagnostic process, which includes evaluating the information obtained during the patient examination and organizing it into clusters, syndromes, or categories. The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient. In the event that the diagnostic process does not yield an identifiable cluster, syndrome, or category, intervention may be guided by the alleviation of symptoms and remediation of deficits. Alternatively, the physical therapist may determine that a re-examination is in order and proceed accordingly. The diagnostic process includes the following: " obtaining relevant history performing systems review selecting and administering specific tests and measures interpreting all data organizing the data
C. Tests, Measures, and Data Generated. Tests and measures are procedures or sets of procedures used to obtain data. After concluding the systems review, the physical therapist examines the patient more closely and selects tests and measures from one or more specific examinations to elicit additional information. Before, during, and after administering the tests and measures, physical therapists will frequently apply their hands to the patient to gauge responses, to assess physical status, and to obtain a more specific understanding of the patient's condition and diagnostic and therapeutic requirements.
Tests and measures commonly performed by physical therapists and the resulting data generated are discussed in the specific examinations presented in Chapter Two. 11. Evaluation. Physical therapists perform evaluations (make clinical

In carrying out the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals. In addition, as the diagnostic process continues, physical therapists may identlfy findings that should be shared with other health professionals, including referral sources, to ensure optimal patient care. If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist should then refer the patient to an appropriate practitioner.
direct intervention patient-related instruction coordination, communication, and documentation
IV. Prognosis. Prognosis is the determination of the level of maximal improvement that might be attained by the patient and the amount of time needed to reach that level; it may also include a prediction of the levels of improvement that may be reached at various intervals during the course of therapy. The physical therapist makes prognoses for recovery from impairment, functional limitation, and disability; for return to role fulfillment; and for other outcomes, including prevention and management of symptom manifestations. When the physical therapist determines that physical therapy intervention would be likely to produce desirable outcomes, the appropriate intervention is implemented. When the physical therapist considers physical therapy intervention unlikely to be beneficial, the physical therapist discusses those findings and conclusions with the individuals concerned, and there is no further physical therapy intervention. V. Intervention. Intenention is the purposeful and skilled interaction of the physical therapist with the patient and, if appropriate, other individuals involved in the patient's care, using various methods and techniques to produce changes in the patient's condition consistent with the diagnosis and prognosis. Decisions about intervention are contingent on the timely monitoriilg of the patient's response and the progress made toward achieving outcomes. There are three intervention components:
A. Direct Intervention. Physical therapists select, apply, or modlfy one or more interventions based on the data gathered from the initial examination. Based on the results of the intervention(~), the physical therapist may decide that a re-examination is necessary, a decision that may lead to the use of ddferent interventions or, alternatively, the discontinuation of treatment. Chapter Three details several interventions commonly selected by the physical therapist:
therapeutic exercise (including aerobic conditioning) functional training in self care and home management activities (including activities of daily living and instrumental activities of daily living) functional training in community or work reintegration (including instrumental activities of daily living, work hardening, and work conditioning) manual therapy techniques (including mobilization and manipulation) prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment airway clearance techniques debridement and wound care physical agents and mechanical modalities electrotherapeutic modalities patient-related instruction Factors that influence the complexity of the intervention and the decisionrnalung process may include the following: severity of the current problem stability of the patient's condition pre-existing conditions level(s) of impairment(s1 probability of prolonged impairment, functional limitations, and disability social supports and living environment
multiple sites or systems involvement overall physical function and health status cognitive status potential discharge destination
B. Patient-related Instmction. The physical therapist uses patient-related instruction to educate not only the patient but also families and other caregivers about the patient's current condition, treatment plan, and future transition to home, work, or community roles. The physical therapist may include information and training in maintenance activities as well as primary and secondary prevention in the instruction program. C. Coordination, Communication, and Documentation. These processes ensure that the patient receives appropriate, coordinated, comprehensive, and cost-effective services between admission and discharge. The services include, but are not limited to, the following:
patient care conferences communications (telephone, fax, etc) documentation of all elements of patient management coordination of care with patients, significant others, family members, and other health professionals record reviews discharge planning Documentation should follow the APTA Guidelinesfor Physical Theram Documentation (Appendix 111).
Additional Professional Activitks of the Physical Therapist

Physical therapists also participate actively in the following activities: prevention and wellness (including health promotion) consultation screening education critical inquiry administration

I. Prevention and Wellness (Including Health Promotion). Physical therapists have successfully integrated prevention, wellness, and the promotion of positive health behavior into physical therapy practice to reduce injury, impairment, and disability among their patients. These initiatives have decreased costs by achieving and restoring functional capacity, minimizing limitations due to congenital and acquired diseases, maintaining health (because sustaining a level of function may prevent further deterioration or future illness), and providing appropriate environmental adaptations to enhance independent function.
For example, physical therapists are heavily involved in preventing and treating low back pain, a disorder that afflicts d l i o n s of Americans and is the most common disability for those under 45 years of age. The majority of such injuries are work related. The annual cost of this disability exceeds $10 billion, but cost savings realized through physical therapy programs aimed at preventing injury in the work site, which may include back schools, workplace redesign, strengthening, stretching, endurance exercise, and postural training, have been sigtxficant.2-5 Older adults are prime candidates for preventive interventions by physical therapists: Laboratory and clinical studies have shown that bone mass increases in response to mechanical strain and exercise, and that exercise can reduce the incidence of wrist and hip fractures from falls, for which older women are particularly at ljsk.6-13 Cardiac and pulmonary rehabilitation, which are offered to the elderly as well as to younger patients, have also proven to be of great value. Short, contained exercise and education programs decrease hospital costs, health care visits, and related expenses. Individuals with chronic obstructive pulmonary disease can decrease their hospital costs by 50% per year through pulmonary rehabilitation.14-16
Physical therapists initiate numerous other prevention and wellness programs aimed at both individual patients and the community to curtail tobacco, alcohol, and other drug use, prevent head injury (through the use of helmets), and reduce domestic violence (by reporting suspected abusive behavior). Prevention of strains and sprains has generated considerable cost savings.17-'9 In industry, physical therapists help to prevent job-related disabilities, including repetitive motion injuries. Finally, physical therapists participate in obstetrical care, where cardiovascular conditioning and instruction in posture for women both before and after childbirth have been shown to decrease infant morbidity and maternal disability and dysfunction.20,21
11. Consultation. Consultation is a service provided by a physical therapist to render a professional or expert opinion or advice. Consultants apply highly specialized knowledge and skills to identlfy problems, recommend solutions, or produce some specified outcome or product in a given amount of time on behalf of a patient or client. Patient-related consultation is a service provided by a physical therapist at the request of a patient, health care practitioner, or health care organization either to evaluate the quality of physical therapy services being provided or to recommend physical therapy services that are needed; it does not involve actual treatment. Client-related consultation is a sewice provided by a physical therapist at the request of an individual, business, school, government agency, or other organization.
Examples of consultation activities in which physical therapists engage include: responding to a request for a second opinion advising a referring practitioner about the indications for intervention
advising employers about the requirements of the Americans with Disabilities Act (ADA) instructing employers about preplacement in accordance with provisions of the ADA educating other health practitioners (eg, in injury prevention) performing environmental assessments to minimize the risk of falls conducting a program to determine the suitability of employees for specific job assignments examining school environments and recommending changes to improve accessibility for students with disabilities developing programs that evaluate the effectiveness of an intervention plan in reducing workrelated injuries working with employees, labor unions, and government agencies to develop injury reduction and safety programs participating at the local, state, and federal levels in policymaking for physical therapy services providing expert legal opinion
111. Scrreening. Screening is the brief process of determining the need for further examination or consultation by a physical therapist or for referral to another health care practitioner. Screening is based on a problemfocused, systematic collection and analysis of data to: 1) iden* individuals at risk in order to provide primary prevention, 2) identlfy those in need of physical therapy intervention or other rehabilitative services, and 3) ascertain the presence of positive findings that require attention by another health care practitioner in order to provide secondary or tertiary prevention. Generally, candidates for screening are not patients currently receiving physical therapy sewices. Examples of screening activities in which physical therapists engage include:
identifying children who may need an examination for idiopathic scoliosis identifying risk factors in the workplace
Physical Therapy / Volume 75, Number 8 / August 1995
pre-performance testing of individuals active in sports identifying an individual's lifestyle factors (eg, exercise, stress, weight) that may lead to increased risk for serious health problems identifying elderly individuals in a community center or nursing home who are at high risk for slipping, tripping, or falling
VI. Administration. Administration is the skilled process of planning, directing, organizing, and managing human, technical, environmental, and financial resources effectively and efficiently, including the management by individual physical therapists of resources for their patients' care as well as the managing of organizational resources.
Examples of administration activities in which physical therapists engage include: supervising physical therapist assistants, physical therapy aides, and other support personnel managing staff resources, including the acquisition and development of clinical expertise and leadership abilities monitoring quality of care and clinical productivity budgeting for physical therapy services developing, implementing, and reviewing strategic plans and marketing programs
organization; 2) ensures that the objectives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization and in accordance with safe physical therapy practice; and 3) interprets administrative policies, acts as a liaison between line staff and administration, and fosters the professional growth of the staff. Written practice and performance criteria are available for all levels o f physical therapy personnel in a physical therapy service. Regularly scheduled performance appraisals are conducted by the supervising physical therapist based on these standards of practice and performance criteria. Delegated responsibilities are commensurate with the qualifications, including experience, education, and training, of the individuals to whom the responsibilities are being assigned and must be in accordance with applicable state law. When the physical therapist delegates patient care responsibilities to physical therapist assistants or other support personnel, that physical therapist is responsible for supervising the physical therapy program. Regardless of the setting in which the service is given, the following responsibilities are borne solely by the physical therapist: interpretation of referrals when available initial examination, problem identification, and diagnosis for physical therapy development or modification of a plan of care that is based on the initial examination and that includes the physical therapy treatment goals determination of which tasks require the expertise and decision-making capacity of the physical therapist and must be personally rendered by the physical therapist, and which tasks may be delegated delegation and instruction of the services to be rendered by the physical therapist assistant or other support personnel, including, but not limited to, specific
IV. Education. Education is the process of imparting information or skills and instructing by precept, example, and experience so that individuals acquire knowledge, master skills, or develop competence. In addition to instructing patients as an element of intervention, examples of educational activities in which physical therapists engage include:
planning and conducting programs for the public to increase its awareness of issues in which physical therapists have expertise planning and conducting programs for local, state, and federal health agencies planning and conducting academic and continuing clinical education programs for physical therapists, other health care providers, and students V. Critical Inquiry. Critical inquiry is the process of applying the principles of scientific methods to read and interpret professional literature; participate in, plan, and conduct research; and analyze patient care outcomes, new concepts, and findings. Examples of critical inquiry activities in which physical therapists engage include: analyzing and applying research findings to patient management and. client programs evaluating the efficacy of both new and established technologies participating in, planning, and conducting clinical, basic, or applied research disseminating the results of research
Physical Therapy Sewiees: Direction and Supervision of Support Pemonnel

Direction and supervision are essential to the provision of quality physical therapy services. The degree of direction and supervision necessary for ensuring quality physical therapy services depends on many factors, including the education, experience, and responsibilities of the personnel involved, the organizational structure in which the physical therapy services are provided, and applicable state law. The physical therapist who directs a physical therapy service has qualifications based on education a n d experience in the field of physical therapy and has accepted the responsibilities inherent in being a supervisor. The director of a physical therapy service: 1) establishes guidelines and procedures that delineate the functions and responsibilities of all levels of physical therapy personnel in the service and the supervisory relationships inherent in the functions of the service and the

treatment program, precautions, special problems, and contraindicated procedures timely review of treatment documentation, re-examination of the patient and the patient's treatment goals, and revision of the plan of care when indicated establishment of the discharge plan and documentation of discharge summary or status
therapist or, in accordance with the law, by a physical therapist assistant. The physical therapist is directly responsible for the actions of the physical therapy aide. The physical therapy aide provides support services in the physical therapy service, both patientrelated and non-patient-related duties. When providing direct physical therapy services to patients, the physical therapy aide functions only with the continuous on-site supervision of the physical therapist or, where allowable by law andlor regulation, the physical therapist assistant. The requirement for continuous on-site supervision mandates the presence of the physical therapist or physical therapist assistant in the immediate area and their involvement in appropriate aspects of each treatment session in which a component of treatment is delegated to a physical therapy aide.
Support Personnel
I. Physical Therapist Assistants. The physical therapist assistant is an educated health care provider who assists the physical therapist in providing physical therapy. The physical therapist assistant is a graduate of a physical therapist assistant associate degree program accredited by an agency recognized by the Secretary of the United States Department of Education or the Council on Postsecondary Accreditation.
The supervising physical therapist is directly responsible for the actions of the physical therapist assistant. The physical therapist assistant performs physical therapy procedures and related tasks that have been selected and delegated by the supervising physical therapist. Where permitted by law, the physical therapist assistant also carries out routine operational functions, including supervising the physical therapy aide and documenting treatment progress. The ability of the physical therapist assistant to perform the selected and delegated tasks is assessed on an ongoing basis by the supervising physical therapist. The physical therapist assistant may m o d e a specific treatment procedure in accordance with changes in patient status within the scope of the established treatment plan.
111. Other Support Personnel. When other personnel (eg, exercise physiologists, athletic trainers, massage therapists) work within the supervision of a physical therapy service they should be employed under their appropriate titles. Any involvement in patient care activities should be within the limits of their education, in accord with applicable laws and regulations, and at the discretion of the physical therapist. However, if they function as an extension of the physical therapist's license, their title and all provided services must be in accordance with state and federal laws and regulations. (In all situations in which the physical therapist delegates activities to other support personnel, physical therapists must recognize their legal responsibility and liability for such delegation.)
References
1. Donaldson M, Yordy K, Vanselow N. Defrning Primary Care: An Interim Repott. Washington, DC: National Academy Press; 1994. 2, Hazard RG, Fenwick JW, Kalisch SM, et al, Functional restoration with behavioral support: a one-year prospective study of patien's: with chronic low back pain. Spine. 1989;14:157-161. 3. Kellet KM, Kellett DA, Nordholm LA. Effects of an exercise program on sick leave due to back pain. Phys Iher. 1991;71:285293.
11. Physical Therapy Aides. The physical therapy aide is a nonlicensed worker who is specifically trained under the direction a physical pist. The physical therapy aide performsdesignated routine tasks related
4. Klaber Moffett JA, Chase SM, Portek I, Ennis JR. A controlled, prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain. Spine. 1986;11:120-122. 5. Bigos SJ, Battie MC. Acute care to prevent back disability. Clin Orthop. 1987;221: 121-130. 6. Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Phys Iher. 1993;73:254-265. 7. Rutherford OM. The role of exercise in the prevention of osteoporosis. Physiotherapy. 1990;76:522-526. 8. Nelson ME, Fisher EC, Dilmanian FA, et al. A one-year walking program and increased dietary calcium in post-menopausal women: effects on bone. Am J Clin Nutr. 1991;53:1304-1311. 9. Osteoporosis: Cause, Treatment, Prevention U S Dept of Health and Human Services Publication No. (NIH) 86-2226. Bethesda, MD: National Institute of Arthritis and Musculoskeletal and Skin Diseases; 1986. 10. Whedon GC. Interrelation of physical activity and nutrition on bone mass. In: White PL, Mondeika T, eds. Diet and Erercise: Syn1 1 : ergism in Health Maintenance. Chicago, 1 American Medical Association; 1982:99. 11. Jacobsen PC, Beaver W, Grubb SA, et al. Bone density in women: college athletes and older athletic women. J Orthop Res. 1984;2:328-332. 12. Nilsson BE, Westlin NE. Bone density in athletes. Clin Orthop. 1971;77:179-182. 13. Chow RK, Harrison JE, Brown CF, et al. Physical fitness effect on bone mass in postmenopausal women. Arch Phys Med Rehabil. 1986;67:231-234. 14. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J. 1992;123:195-200. 15. Busch AJ, McClements JD. Effects of a supervised home exercise program on patients with severe chronic obstructive pulmonary disease. Phys Iher. 1988;68:469-474. 16. Hudson LD, Tyler ML, Petty T. Hospitalization needs during an outpatient rehabilitation program for severe chronic airway obstruction. Chest. 1976;70:606-610. 17. Dinchin M, Woolf 0,Kaplan L, Floman Y. Secondary prevention of low-back pain: a clinical trial. Spine. 1990;15:1317-1319. 18. Ryden LA, Molgaard CA, Bobbitr SL. Benefits of a back care and lighr duty health promotion program in a hospital setting. J Community Health. 1988;13:222-230. 19. Wood PJ. Design and evaluation of a back injury prevention program within a geriatric hospital. Spine. 1987;12:77-81. 20. Clapp JF. The course of labor after endurance exercise during pregnancy. Am J Obstet Gynecol. 1990;163:1799-1805. 21. Lokey EA, Tran ZV, Wells CL, et al. Effects of physical exercise On pregnancy outcomes: a meta-analytic review. Med Sci Sports &WC. 19'91;23:1234-1239.
the a therapy service delegated by the physical 74 / 719

Chapter Two: Examinations Provided by Physical Therapists
The physical therapist's patient management process of examination, evaluation, diagnosis, prognosis, and intervention has been described in Chapter One. Twenty-three examinations that the physical therapist may select are detailed in Chapter Two; other examinations not described in h s chapter may also be used in patient management. Depending on the data generated during the history and systems review, the physical therapist may use one or more of these examinations, in whole or in part. For example, in examining a patient with impairments and disabilities resulting from a brain injury, the physical therapist may decide to peiform part or all of several examinations, based on the pattern of involvement in the individual patient. Thus, the physical therapist should individualize the selection of examinations rather than choose them solely on the patient's presenting diagnosis (eg, brain injury). For each of the examinations, four areas are discussed: Overview-Provides an introduction to the examination. Clinical Indications-Lists examples of the functional limitations, impairments, disabilities, or special requirements that may prompt the physical therapist to conduct the examination. Tests and Measures-Lists general methods and techniques used in conducting the examination. Data Generated-Describes the information collected from the tests and measures. Other information that may be required for the examination includes, but is not limited to, clinical findings of other health professionals; results of diagnostic imaging, clinical laboratory,
and electrophysiologic studies; federal, state, and local work surveillance and safety reports and announcements; and observations of family members, significant others, caregivers, and other interested persons. A physical therapy examination or intervention, unless performed by a physical therapist, is not physical therapy nor should it be represented or reimbursed as such. Aerobic Capacity or Endurance Examination
tion will lead to an evaluation, a diagnosis, a prognosis, and the selection of appropriate interventions. Clinical Indications. An aerobic capacity or endurance examination is appropriate in the presence of: Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that speclfy minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: weakness shortness of breath dizziness palpitation tightness of the chest wall lack of mobility lack of endurance abnormalities in movement, flexibility, or strength edema of the lower extremities referred pain (angina) indicative of cardiac ischemia ischemic pain in the extremities (claudication) inability to perform specific movement tasks abnormalities of heart rate, blood pressure, respiratory rate or pattern of breathing, and/or heart muscle function
Overview. Ambic capacity, p o w , and endurance are all measures of the ability to perform work or participate in activity over time using the body's oxygen uptake, delivery, and energy release mechanisms. During activity, the physical therapist employs tests ranging from simple determinations of heart rate, blood pressure, and respiratory rate to complex calculations of oxygen consumption and carbon dioxide production to determine the appropriateness of an individual's response to increased oxygen demand. Monitoring responses at rest and during activity can indicate the degree and severity of impairment, iden* cardiopulmonary deficits that produce functional limitations, and indicate that other tests and specific therapeutic interventions are needed.
The aerobic capacity or e n d u m c e examination produces information used to identlfy the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examina-

Tests and Measures. Tests and measures for performing an aerobic capacity or endurance examination include, but are not limited to:
obtainment of standard vital signs (blood pressure, heart and respiratory rate) at rest, during activity, and during recovery auscultation of heart sounds auscultation of the lungs auscultation of major vessels for bruits palpation of pulses performance of an electrocardiogram performance of pulse oximetry performance of tests of pulmonary function and ventilatory mechanics performance of gas analysis or oxygen consumption studies observation of chest movements and breathing patterns with activity performance of claudication time tests assessment of patient's performance during established exercise protocols (eg, treadmill, ergometer, 6-minute walk test, 3-minute step test) monitoring of the patient by telemetry during activity assessment of perceived exertion or dyspnea during activity using a visual analog scale
after activity (including comparison of actual to predicted) maximum oxygen consumption (including comparison of actual to predicted) oxygen consumption for particular activity (including comparison of actual to predicted) respiratory quotient anaerobic threshold description of chest movement and breathing patterns with activity report of any arrhythmias at rest and during activity report of symptoms limiting activity
Anthropometric Characteristics Examination Overview.Anthropometric character&ticsdescribe human body measurements such as height, weight, girth, and body fat composition. The physical therapist uses the anthropometric characteristics examination to test for muscle atrophy, gauge the extent of edema, and establish a baseline to allow patients to be compared to national norms on such variables as weight and body-fat composition. An anthropometric characteristics examination may lead to a recommendation that other examinations be performed, such as an aerobic capacity or endurance examination.
The anthropometric characteristics examination produces information to idenhfy the possible or actual cause($ of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Suspected or identified pathology, injury, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication inability to perform specific movement tasks effusion or edema (including edema during pregnancy) muscle atrophy suspected onset of lymphedema
Data Generated. Data generated may include, but are not limited to:
description of peripheral vascular integrity report of vital signs (blood pressure, heart and respiration rate) at rest, during, and after activity list of activities that aggravate or relieve symptoms physical exertion scale grading and/or dyspnea assessment with activity report of oxygen saturation with activity report of ventilatory volumes and flow at rest and after activity (including comparison of actual to predicted) report of inspiratory and expiratory muscle force before and
Tests and Measums. Tests and measures for performing an anthropometric characteristics examination include, but are not limited to:
measurement of height, weight, and girth measurement of body-fat composition, using calipers, underwater weighing tanks, or electrical impedance classification of edema through volumetrics and girth
Clinical Indications. An anthropometric characteristics examination is appropriate in the presence of:

observation and palpation of an extremity or part at rest and during activity assessment of activities and postures that aggravate or relieve edema assessment of edema (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)
findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to a n evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
change in baseline status of arousal, mentation, cognition
Tests and Measures. Tests and measures for performing an arousal, mentation, and cognition examination include, but are not limited to:
determination of patient's level of consciousness determination of patient's level of recall determination of patient's orientation to time, person, and place cognitive screening (eg, to determine ability to process commands, to measure safety awareness) screening for gross expressive and receptive deficits assessment of arousal, mentation, and cognition using standardized instruments
Clinical Indications. An arousal, mentation, and cognition examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance motor deficits (eg, weakness; paralysis; uncoordination; abnormal spatial or temporal patterns of movement; tone; spasticity; flaccidity; and pathological reflexes) somatosensory deficit gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks inadequate circulation, recurrent ischemia, or claudication
height in feet and inches or centimeters weight in pounds or kilograms girths of extremities and chest and lengths of extremities in inches or centimeters body fat (as a percentage of mass or in inches or centimeters) volumetric displacement in liters a list of activities and postures that aggravate or relieve edema integrity of lymphatic system
level of arousal, mentation, or cognition deficits difference between predicted and actual performance variation over time of arousal, mentation, or cognition deficits scores on standardized instruments for measuring arousal, mentation, and cognition
Arousal, Mentation, and Cognition Examination Ovwiew. Amusal is the stimulation to action or to physiologic readiness for activity. Mentation is a mechanism of thought or mental activity. Cognition is the act or process of knowing, including both awareness and judgment. Tht: physical therapist uses the arousal, mentation, and cognition examination to assess the patient's responsiveness; orientation to time, person, and place; and ability to follow directions. The examination guides the physical therapist in selecting interventions by indicating whether the patient has the cognitive ability to participate in the care process.
The arousal, mentation, and cognition examination produces information used in identifying the possible or actual cause($ of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the
Assistive, Adaptive, Supportive, and Protective Devices Examination Overview. Assistive, adaptive, supportive, and protective devices are a variety of implements or equipment used to aid individuals in performing tasks or movements. Rssirstive deuices, which include crutches and canes, involve rather simple technologies; adaptive devices, which include such technologies as a wheelchair and the longhanded reacher, are generally more complex. Supportive devices include taping, compression garments, corsets, and neck collars, while protective devices include braces and helmets. The physical therapist uses the assistive, adaptive, supportive, and protective devices examination to determine whether an individual might benefit from such a device or, where one is

already in use, to determine how well the patient performs with it. The assistive, adaptive, supportive, and protective devices examination produces information used in identifying the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures wiU depend on the findings of the patient history and systems review. The exarnination may require testing while the patient performs specfic activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
inability to perform specific movement tasks impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication integumentary deficits incontinence, bowel, and bladder difficulty lymphedema
ability to use the device and understanding of its appropriate use level of compliance with use of the device
Community or Wo& Reintegration Examination (Including lnstnrmental Activities of Daily Living)

r k reinteOverview. Community or m gration is the process of resuming one's role(s) in the community or at work. The physical therapist uses the community or work reintegration examination to make an informed judgment as to whether an individual is currently prepared to resume community or work roles or to determine when and how such reintegration might occur. The physical therapist also uses this examination to determine whether an individual is a candidate for a work hardening or work conditioning program. The community or work reintegration examination produces information used in identdjmg the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures wiU depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Tests and Measures. Tests or measures for performing an assistive, adaptive, supportive, and protective devices examination include, but are not limited to:
analysis of the potential to remediate impairments, functional limitations, or disabilities using an assistive, adaptive, supportive, or protective device observation of the individual using the device for intended effects and benefits and ability to use the device review of reports provided by the patient, significant others, family, and caregivers analysis of alignment and fit of the device and inspection of related changes in skin condition assessment of appropriate components of the device assessment of safety while using the device videotape analysis of the patient or client using the device computer-assisted analysis of motion
Clinical Indications. An assistive, adaptive, supportive, and protective devices examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents the normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbance(s) abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling
deviations and malfunctions that can be corrected or alleviated by an assistive, adaptive, supportive, or protective device alignment of anatomical parts with the device safety and effectiveness of the device in providing protection, promoting stability, or improving performance of tasks and activities expressions of comfort, cosmesis, and effectiveness using the device
Clinical Indications. A community or work reintegration examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including community or work reintegration or leisure tasks and movements Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program
Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform community or work reintegration or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficitGI and disturbances postural deficits abnormalities in movements, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication incontinence, bowel and bladder difficulty
application of functional rating scales measurement of functional capacity assessment of appropriateness of assistive, adaptive, supportive, and protective devices analysis of environment and job tasks analysis of mentation and cognition analysis of adaptive skills
formance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specfic activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
levels of strength, flexibility, and endurance effort in specific movement tasks aerobic capacity or endurance gross and fine motor function difference between predicted and actual performance physical, functional, behavioral, and vocational status work-related systemic neuromusculoskeletal restoration needs vital signs and physiologic response during community or work reintegration and leisure activities presence or absence of mentation and cognition deficits level of adaptive skills
Clinical Indications. A cranial nerve integrity examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility motor deficits (eg, weakness; paralysis; uncoordination; abnormal spatial and temporal patterns of movement; tone; spasticity; flaccidity; and pathological reflexes) somatosensory deficit abnormalities in movement, flexibility, or strength impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks
Tests and Measures. General tests and measures for performing a community or work reintegration examination include, but are not limited to:
observation of the individual performing work tasks and community and leisure activities review of reports provided by the individual, family members, significant other, or caregiver administering questionnaires and conducting interviews with the patient and other interested persons application of instrumental activities of daily living measurement scales and performance batteries for community, work, and leisure activities measurement of physiologic responses during community, work, and leisure activities review of daily activities logs measurement of static and dynamic strength analysis of aerobic capacity or endurance during community, work, and leisure activities assessment of dexterity and coordination
Cranial Nerve Integrity Examination Overview. A cranial n e m is one of twelve paired nerves (eg, olfactory, optic) that emerge from or enter the brain. The cranial nerve integrity examination has somatic, visceral, afferent, and efferent components. The physical therapist uses the cranial nerve integrity examination to localize a dysfunction in the brain stem and to iden* cranial nerves that merit an in-depth examination. The physical therapist uses a number of cranial nerve tests to assess the patient's sensory and motor functions, such as taste, smell, and facial expression.
The cranial nerve integrity examination produces information used to identlfy the possible or actual cause(s) of difficulties during the patient's per-
Tests and Measures. Tests and measures for performing a cranial nerve integrity examination include, but are not limited to:

performance of tests of: touch pain temperature vision vestibular sensibility auditory sensibility taste smell assessment of muscles innervated by the cranial nerves
difference between predicted and actual performance description of eye movements amount of constriction and dilation of pupils visual deficits pain, touch, temperature localization gross auditory acuity equilibrium responses characteristics of swallowing integrity o f gag reflexes degree of loss of taste degree of loss of function in muscles innervated by the cranial nerves
The environmental, home, or work barriers examination produces information used in iden*ing the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specfic tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Tests and Measures. Tests and measures for performing an environmental, home, or work barriers exarnination include, but are not limited to:
assessment of present and potential barriers physical inspection of the environment conducting interviews and administering questionnaires off-site analysis of physical space using photography or videotape measureihent of physical space ergonomic analysis of an individual's home, workplace, or other customary environment
Clinical Indications. An environmental, home, or work barriers examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s1 and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation incontinence, bowel, and bladder difficulty inability to perform specific movement tasks
a list of space limitations and other barriers, including their dimensions, that limit an individual's ability to perform specific movement tasks during home, work, and leisure activities degree of compliance with standards set forth in the Americans with Disabilities Act recommendations for elimination of environmental barriers a list of adaptations, additions, or modifications that would enhance patient safety
11
Envimnmental, Home, or Work Bammets Examination Overview. Environmental, home, and work barrim are the physical impediments that keep individuals from functioning optimally in their surroundings. The physical therapist uses the environmental, home, or work barriers examination to iden@ any of a variety of possible impediments, including safety hazards (eg, throw rugs, slippery surfaces), access problems (eg, narrow doors, high steps), and home or office design (eg, excessive distances to negotiate, multiple-story environment). The physical therapist uses this examination, often in conjunction with elements of the ergonomics or body mechanics examination, to suggest modifications to the environment (eg, grab bars in the shower, ramps, raised toilet seats, increased lighting) that will permit the patient or client to improve functioning in the home, workplace, or other settings.
Ergonomics or Body Mechanics Examination Overview. E?gonomics is the study of the relationships between people, work, and the work environment, using scienthc and engineering principles to improve those relationships. Body mechanics describes the interrelationships of the muscles and joints as they maintain or adjust posture in response to environmental forces. The physical therapist uses the ergonomics or body mechanics examination to examine the work environment on behalf of patients or clients to determine the potential for trauma to result from inappropriate workplace design. The ergonomics or body mechanics examination may be conducted after a work injury or as a preventive measure, particularly when an individual is
Physical Therapiy / Volume 75, Number 8 / August 1995

returning to the work environment after an extended absence. The ergonomics or body mechanics examination produces information used in identlfylng the possible or acmal cause(s) of dificulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
impaired motor function and learning impaired sensation abnormal body alignment and movement patterns inadequate circulation, recurrent ischemia, or claudication frequent injury
computer-assisted motion analysis of the patient or client at work Tests and measures for performing a body mechanics examination include, but are not limited to: measurement of height, weight, and girth observation of the individual performing selected movements or activities determination of dynamic capabilities and limitations during specific work activities videotape analysis of the patient or client performing selected movements or activities computer-assisted motion analysis of the patient or client performing selected movements or activities
Tests and Measures. Tests and measures for performing an ergonomics examination include, but are not limited to:
ergonomic analysis of job tasks or activities to assess the following: essential functions of the job task or activity work postures required to perform the job task or activity joint range of motion used to perform the job task or activity strength required in the work postures necessary to perform the job task or activity repetition/work/rest cycling during the job task or activity sources of potential trauma vibration tools, devices, or equipment used endurance required to perform aerobic endurance activities assessment of work hardening or work conditioning, including identification of needs related to physical, functional, behavioral, and vocational status administration of batteries of work performance review of safety and accident reports assessment of dexterity and coordination observation of the individual performing selected movements or activities determination of dynamic capabilities and limitations during specific work activities video analysis of the patient or client at work
Clinical Indications. An ergonomics or body mechanics examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure tasks and movements Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits ab~lormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations inability to perform specific mclvement tasks impaired balance or frequent falling
height in feet and inches or meters and centimeters weight in pounds or kilograms girths of extremities and chest amount of dficulty experienced or pain expressed during the performance of specific job tasks or activities a list of potential and actual ergonomic stressors body alignment, timing, and sequencing of component movements during specific job tasks or activities levels of strength, flexibility, and endurance level of effort in specific movement tasks aerobic capacity or endurance levels of gross and fine motor function difference between predicted and actual performance safety records and accident reports physical, functional, behavioral, and vocational status level of work performance work-related systemic neuromusculoskeletal restoration needs

temporal and spatial characteristics of movements during job tasks or activities
Gait and Balance Examination Overview. Gait is the manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed. Balance is the ability to maintain the body in equilibrium with gravity both statically (eg, while stationary) and dynamically (eg, while walking). The physical therapist uses the gait and balance examination to investigate disturbances in gait and balance because they frequently lead to decreased mobility, a decline in functional independence, and an increased risk of falls. Gait and balance problems often involve dficulty in integrating sensory, motor, and neural processes. The physical therapist also uses the gait and balance examination to determine whether the patient is a candidate for an assistive, adaptive, supportive, or protective device.
The gait and balance examination used in identifyproduces ~nformation ing the possible or actual cause(s) of dficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to ~ e r f o r m self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficitcs) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication incontinence, bowel, and bladder difficulty inability to participate in athletics
analysis of gait on various terrains, in different physical environments, and in water administration of functional ambulation profiles videotape analysis of patient's movement to assess gait or balance EMG analysis of patient's movement to assess gait or balance computer-assisted analysis of patient's movement application of gait analysis rating scales assessment of safety awareness ergonomic analysis of gait application of mechanical and electrical weight-bearing scales and force plates
qualitative and quantitative descriptions of gait and balance gait cycle, gait deviations, and the safety and quality of gait over time in different environments and on a variety of surfaces safety and quality of gait and the gait cycle over time using assistive, adaptive, supportive, or protective devices a list of surfaces and elevations patient is able to negotiate number ratings from standardized gait testing instruments charts and videos that reflect gait pattern changes over time a list of patient activities that aggravate or diminish difficulties with gait patient's perception of gait problems level of safety awareness weight-bearing ability, including standardized measures of weight-bearing in pounds or kilograms
Tests and Measums. Tests and measures for performing a gait and balance examination include, but are not limited to:
identification of gait characteristics identification and quantification of static and dynamic balance characteristics analysis of biomechanical, arthrokinematic, and other spatial and temporal characteristics of gait and balance with and without the use of assistive, adaptive, supportive, or protective devices analysis of spatial and temporal characteristics of gait and balance using - kinematic, kinetic, and electromyographic (EMG)
f ~ ^ + ^
Clinical Indications. A gait and balance examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance
Integumentary Integrffy Examination Overview. Integumentary integrity is the health of the skin, including its ability to serve as a barrier to environmental threats (eg, bacteria, parasites). The physical therapist uses an integu-
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application of balance and gait analysis rating scales

mentary integrity examination to assess the effects of a wide variety of problems that result in skin and subcutaneous changes, including pressure and vascular insufficiency ulcers, burns and other traumas, as well as a numtxr of diseases (eg, connective tissue disorders). The integumentary integrity examination is also used to obtain more information about circulation through inspection of the skin or the nail beds. The integumentary integrity examination produces information used in identlfying the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
gait deficit(s1 and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication incontinence, bowel and bladder difficulty loss of integumentary integrity inability to perform specific movement tasks
skin condition characterization of a wound (eg, inflamed, macerated, necrotic) characterization of wound drainage (eg, serous, serosanguineous, pus, slough) skin temperature in degrees degree of soft tissue and scar mobility wound dimensions in square or cubic inches or centimeters description of wound contraction and scar tissue (cicatrix) grid photograph of wound minimal erythema1 dose reactions in seconds a list of activities and postures that aggravate or relieve pain or other disturbed sensations
Tests and Measures. Tests and measures for performing an integumentary integrity examination include, but are not limited to:
determination of the sensory and temperature sensitivity of the skin observation and palpation of part or all of an extremity at rest and during activity observation of burn, skin condition, wound, or wound drainage administration of skin temperature tests, including thermistors and thermography palpation of tissue or scar mobility, turgor, and texture measurement of wound depth and size, using grid photography or other techniques observation of wound contraction and scar tissue (cicatrix) observation of nail beds administration of photosensitivity tests assessment of activities and postures that aggravate or relieve pain or other disturbed sensations
Joint lnteg~i@ and Mobility Examination 0verview.Joint integrity is the conformance of joints to expected anatomic, biomechanical, and kinematic norms. Joint mobility is the capacity of a joint to be moved passively in certain ways that take into account the structure and shape of the joint surface as well as characteristics of the tissue surrounding the joint. The assessment of joint mobility involves the performance of accessory joint movements by the physical therapist because these movements are not under the voluntary control of the patient. The physical therapist uses the joint integrity and mobility examination to determine whether there is excessive or lirmted motion of the joint. Excessive joint motion necessitates a program of protection, while limited joint motion calls for interventions to increase mobility and enhance functional capability.
The joint integrity and mobility examination produces information used in identlfying the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The exarnina-
Clinical Indications. An integumentary integrity examination is appropriate in the presence of:

Suspected or identified pathology, injury, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify specific minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance
girths in inches or centimeters or volumetric displacement in milliliters characterization of the extremity in terms of color and temperature (in degrees or words)
Physical Therapy /Volume 75, Number
tion will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Clinical Indications. A joint integrity and mobility examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, leisure, and sports or fitness training Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks edema or effusion soft-tissue limitation
observation of the nature and quality of movement of the joint or body part during the performance of specific movement tasks palpation and observation of specific joint mobility in response to manual provocation of the joint assessment of joint hyper- and hypomobility assessment of sprain measurement of connective tissue laxity
patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Clinical Indications. A motor function examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance motor deficits (eg, weakness; paralysis; uncoordination; abnormal spatial and temporal patterns of movement; tone; spasticity; flaccidity; and pathological reflexes) gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation impaired performance of specific movement tasks soft tissue limitations inadequate circulation, recurrent ischemia, or claudication somatosensory deficit
quantity and quality of joint movement grades and classification systems of joint mobility classification and grade of sprain clinical signs or pain in response to a specific test of provocation
Motor Function hamination Overview. Motor function is the ability to learn or demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns. The physical therapist uses the motor function examination in the diagnosis of underlying pathology. Deficits in motor function reflect the type, location, and extent of the pathology, which may be a neurologic disease or other disorder. Weakness and paralysis are common manifestations of most neurologic disease; however, abnormal movement patterns and timing, uncoordination, clumsiness, involuntary movements, or abnormal postures may also indicate neurologic disease or other disorders.
The motor function examination produces information used in idennfying the possible or actual causecs) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the
Tests and Measures. Tests and measures for performing a joint integrity and mobility examination include, but are not limited to:
assessment of pain and soreness quantification of pain using standard pain scales

altered level of consciousness and comprehension
Tests and Measures. Tests and measures for performing a motor function examination include, but are not limited. to:
administration of motor assessment scales analysis of head, trunk, and limb movement analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, hopping, skipping, running, jumping) administration of physical performance scales assessment of sensorimotor integration assessment of motor control and motor learning assessment of dexterity, coordination, and agility analysis of gait performance of electrophysiologic tests (eg, diagnostic and kinesiologic electromyography [EMG], motor nerve conduction testing) analysis of stereotyped movements
normal electrical potentials in muscles description of synergies, athetotic movements, etc
Muscle Performance Examination (Including Strength, h w e r , and Endurance) Overview. Muscle p@onnance is the capacity of a muscle to do work (force X distance). The performance of an individual muscle depends on its characteristics of length, tension, and velocity. Integrated muscle performance over time is mediated by neurologic stimulation, fuel storage, and fuel delivery, as well as balance, timing, and sequencing of contraction. The physical therapist uses the muscle performance examination to determine the patient's ability to produce movements that are prerequisite to functional activity.
The muscle performance examination produces information used in identifying the possible or actual cause(s) of difficulties during the patient's perforrnance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient and Systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s1 and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication inability to perform specific movement tasks abnormal power weakness of the pelvic floor muscle
difference between predicted and actual performance degree that maturation is coordinated with stages of development descriptions of skill and efficiency of motor function, including - the ability to initiate, contrc~l, and terminate movement timing, accuracy, sequencing, and number of repetitions of specific movement patterns and postures scores and comparisons to standardized age and sex norms for motor performance characteristics of muscle activity during movement conduction velocity along peripheral motor nerves amplitude, duration, waveform, and frequency of normal or ab-
Tests and Measures. Tests and measures for conducting a muscle performance examination include, but are not limited to:
administration of manual muscle tests administration of functional muscle testing administration of computerassisted electromechanical muscle tests performance of dynamometry performance of electrophysiologic tests (eg, EMG, nerve conduction velocity) assessment of muscle flaccidity and spasticity quantification of pain and soreness assessment of perineal integrity
Clinical Indications, A muscle performance examination is appropriate in the ~resence of:

1
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, leisure, and sports or fitness training Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program
numbers, percentages, or letter grades from standardized grad-

ing systems for manual and functional muscle testing force, velocity, torque, work, and power of muscle performance changes in muscle performance over time consistency of effort and performance amplitude, duration, waveform, and frequency of EMG signals descriptions of the muscle contractions (eg, maximal, painful, smooth, coordinated, cogwheel) expressions of pain, soreness, or other symptoms produced by provocation of muscle contractions description of the strength of the pelvic floor Neummotor Development and Sensow Integration Examination Overview. Neumrnotor development is the acquisition and evolution of movement slulls throughout the lifespan. Sensoy integration is the ability to integrate information from the environment in order to produce normal movement outputs. The physical therapist uses the neuromotor development and sensory integration exarnination to assess motor capabilities in both children and adults. The examination may be used to assess mobility, achievement of motor milestones and normal responses, postural control, and volitional and nonvolitional movement. The physical therapist will also employ the examination to test balance, righting and equilibrium reactions, eye-hand coordination, and other motor capabilities. The neuromotor develo~ment and sensory integration examination produces information used to identlfy the possible or actual cause(s) of diaculEies during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specdic activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the 86 / 731
determination of appropriate interventions. Clinical Indications. A neuromotor development and sensory integration examination is appropriate in the presence of: Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance motor deficits (eg, weakness; paralysis; uncoordination; abnormal spatial and temporal patterns of movement; tone; spasticity; flaccidity; and pathological reflexes) gait deficit(s) and disturbances postural deficits abnormalities of flexibility and strength biomechanical and arthrokinematic limitations im~aired balance or freauent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks somatosensory deficit
administration of a battery of tests of sensory integration administration of a battery of tests of motor development assessment of gross and fine motor skills evaluation of language development assessment of equilibrium and righting reactions administration of tests of motor development assessment of function screening for age- and sexappropriate development analysis of gait and posture analysis of reflex and movement patterns assessment of alertness assessment of behavioral response assessment of dexterity, agility, and coordination Data Generated. Data generated may include, but are not limited to: normal and abnormal motor patterns difference between predicted and actual performance gross and fine motor developmental age presence or absence of primitive reflexes qualitative description of the organization and processing of information description of postural alignment description of movement asymmetries description of characteristics of normal, age-appropriate movement patterns, postures, and sequences Orthotic Requirements Examination Ovenriew. An orthosis is a device (eg, a splint, a brace, a shoe insert) to support weak or ineffective joints or muscles and may serve to enhance performance. The physical therapist uses the orthotic requirements examination to determine the need for an orthotic device in individuals not currently using one and to evaluate the
Tests and Measures. Tests and measures for performing a neuromotor development and sensory integration examination include, but are not limited to:

appropriateness and fit of those orthotic devices already in use. The physical therapist correlates the patient's problems with available orthoses to make a choice that best serves the patient. For example, the physical therapist may have to choose between an orthosis that provides maximum control of motion and one that permits considerable movement. The orthotic requirements examination produces information used in identifying the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs spechc activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventior~s.
biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks inadequate circulation, recurrent ischemia. or claudication
ing stability, or improving performance of tasks and activities levels of comfort, cosmesis, and effectiveness using an orthotic device ability to put on and remove an orthotic device and to understand its use and application level of compliance with use of an orthotic device
Pain Examination Tests and Measures. Tests and measures for performing an orthotic requirements examination include, but are not limited to:
analysis of the potential to remediate impairments, functional limitations, or disabilities with an orthotic device assessment of appropriate components of an orthotic device analysis of alignment and fit of an orthotic device and inspection of related changes in skin condition observation of the individual wearing an orthotic device for intended effects and benefits (including energy conservation and expenditure) assessment of the individual's ability to put on and remove an orthotic device and to understand its use and application videotaped analysis of the patient's or client's movement while wearing an orthotic device computer-assisted analysis of the patient's or client's movement while wearing a device review of reports provided by the patient, family, significant other, and caregivers
Overview. Pain is a disturbed sensation causing suffering or distress. The physical therapist uses the pain exarnination to determine the intensity, quality, and temporal and physical characteristics of any pain that is sigrdicant to the patient. The physical therapist may hypothesize a cause or mechanism for the pain(s) through this examination. The examination may also be used to determine whether a referral to a physician or mental health professional is appropriate.
The pain examination produces information used in identifying the possible or actual cause(s1 of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Clinical Indications. An orthotic requirements examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developrnental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength
Clinical Indications. A pain examination is appropriate in the presence of:

Suspected or identified pathology, injury, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program
energy expenditure requirements deviations and dysfunctions that can be corrected or alleviated by an orthotic device alignment of anatomical parts with an orthotic device effectiveness of orthotic device in providing protection, promot-
Physical Tlierapy / Volume 75, Number 8 /August 1995

Change in daily activities or lifestyle Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication
expressions of pain in response to tests of provocation and during specific movement tasks consistency of patient's responses to pain behavior or painful reaction(s) observed during particular movement tasks number ratings from standardized rating instruments charts that reflect changes in pain reaction(s) over time charts that reflect the somatic distribution of pain expressions of sensory and temporal qualities of pain list of activities that aggravate or relieve pain response to noxious stimuli
Posture Gramination Ovewiew. Posture is the alignment and positioning of the body in relation to gravity, center of mass, and basis of support. The physical therapist uses the posture examination to assess structural abnormalities as well as the ability to right oneself with gravity. Good posture is a state of muscular and skeletal balance that protects the supporting structures of the body against injury or progressive deformity. Findings from the posture examination may lead the physical therapist to perform additional examinations (eg, joint integrity and mobility, respiration and circulation).
The posture examination produces information used in identifying the possible or actual cause(s) of dficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Pregnancy Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s1 and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation
Tests and Measums. Tests and measures for performing a pain examination include, but are not limited to:
observation of pain behavior and reactiods) during specific movements administration of pain questionnaires administration of visual analog scales administration of graphic rating scales determination of muscle soreness by classification and grade interview of the patient to elicit perceived sensations (eg, phantom pain) and verbal descriptors of discomfort, tenderness, or soreness administration of pressure algometry and dolorimetry administration of symptom magnification scales or indices
Tests and Measures. Tests and measures for performing a posture examination include, but are not limited to:
visual estimation of posture alignment observation of posture using a posture grid or plumb line computer-assisted analysis of the patient's posture during movement still photography of the patient observation of resting posture assumed in any position
Clinical Indications. A posture examination is appropriate in the presence of:
Physical Therapy / Volume 75, Number 8 /August 1 9 5

postural alignment while standing, sitting, lying, or during movement alignment and symmetry of body landmarks within segmental planes while at rest or in motion deviations from anticipated postural alignments within lines or grid marks in various views
A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s1 and disturbances biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks inadequate circulation, recurrent ischemia, or claudication in residual limb and/or adjacent segment loss of part or all of a limb
Prosthetic Requirements Examination Overview. A pmthesis is an artificial device, often mechanical or electrical, used to replace a missing part of the body. Physical therapists use the prosthetic req~~irements examination for patients wearing a prosthesis and also for those who might benefit from one. The physical therapist chooses a prosthesis that will permit the patient maximum freedom of movement and functional capability with a minimum of discomfort and inconvenience.
The prosthetic requirements examination produces information used in identifying the possible or actual cause(s) d difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work task:s. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
while wearing a prosthetic device computer-assisted analysis of the patient's or client's movement while wearing a prosthetic device review of reports provided by the patient, family, significant other, and caregivers assessment of residual limb and/or adjacent segment for range of motion, strength, skin integrity, and edema
energy expenditure requirements deviations and dysfunctions that can be corrected or alleviated by a prosthetic device practicality and ease of use of a proposed prosthetic device alignment of anatomical parts with a prosthetic device effectiveness of a prosthetic device in providing protection, promoting stability, or improving performance of tasks and activities and enhancing function at home and in community expressions of comfort, cosmesis, and effectiveness using a prosthetic device ability to put on and remove a prosthetic device level of compliance with use of a device range of motion, strength, skin integrity, and edema in residual limb and/or adjacent segment
Tests and Measures. Tests and measures for performing a prosthetic requirements examination include, but are not limited to:
analysis of the potential to remediate impairments, functional limitations, or disabilities with a prosthetic device analysis of the practicality and ease of use of a prosthetic device assessment of appropriate components of a prosthetic device analysis of alignment and fit of a device and inspection of related changes in skin condition observation of the individual wearing a prosthetic device for intended effects and benefits (including energy conservation and expenditure) assessment of the individual's ability to put on and remove a prosthetic device videotaped analysis of the patient's or client's movement
Clinical Indications. A prosthetic requirements examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance
Range of Motion Examination (Including Muscle Length) Overview. Range of motion describes the space, distance, or angle through which a patient can move a joint or series of joints. Muscle length is measured during various stages of tension (from resting at full extension through the contractile range); muscle length, in conjunction with joint integrity and connective tissue extensibility, determines flexibility. The physical therapist uses the range of motion examination to determine the function and biomechanics of a joint, which include its
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Physical 'Therapy / Volume 75, Number 8 / August 1995

flexibility and movement characteristics. Adequate range of motion is valuable for injury prevention because it allows the tissues to adjust to irnposed stresses. The range of motion examination produces information used in identifying the possible or actual cause(s) of dficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findmgs of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
impaired balance or frequent falling impaired motor function and learning impaired sensation inability to perform specific movement tasks soft tissue limitations inadequate circulation, recurrent ischemia, or claudication
Tests and Measures. Tests and measures for performing a range of motion examination include, but are not limited to:
quantification of pain and soreness of soft tissue observation and palpation of muscles, tendons, and associated soft tissue during multisegment motion determination of range using a tape measure, flexible ruler, or electronic device determination of muscle soreness by classification and grades performance of goniometry digitized analysis of motion performance of posturography palpation of muscles, joints, or soft tissue
The reflex integrity examination produces information used in identifying the possible or actual cause(s) of d f i culties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specfic tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Clinical Indications. A reflex integrity examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility motor deficits (eg, weakness, paralysis, uncoordination, abnormal spatial and temporal patterns of movement, tone, spasticity, flaccidity) gait deficit(s) and disturbances postural deficits abnormalities in flexibility or strength impaired balance or frequent falling impaired motor function and learning impaired sensation
Clinical Indications. A range of motion examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance gait deficit(s) and disturbances postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations
expressions of pain or tenderness in muscle(s), joint(s), and soft tissue during movements or activities that require elongation of muscle(s) range of joint motion in degrees findings of passive tension during multi-segment movement that requires elongation of muscle deviations from planes in degrees or inches or centimeters excursion distances in inches or centimeters
Reflex Integrity Examination Overview. A refex is a stereotyped reaction to any of a variety of sensory stimuli. The physical therapist uses the reflex integrity examination to determine the excitability of the nervous system and the integrity of the neuromuscular system.

inability to perform specific movement tasks somatosensory deficit altered state of consciousness Tests and Measums. Tests and measures for performing a reflex integrity examination include, but are not limited to: determination of the presence, absence, or exaggeration of developmentally appropriate reflexes assessment of normal reflexes (eg, deep tendon reflex) assessment of pathologic reflexes (eg, Babinski) performance of electrophysiologic testing (eg, H-reflex) elicitation of postural, equilibrium, and righting reactions Data Generated. Data generated may include, but are not limited to: presence, absence, or exaggeration of normal and/or pathologic reflexes difference between predicted and actual performance variation in reflex activity over time or with positioning time of conduction over reflex pathway Self-Cane and HomeManagement Examination (Including Activities of Daily Living and lnstmmental Activities of Daily Living) Overview. Self care is the set of activities comprising daily living, eg, rising from bed, dressing, bathing, eating, and toileting. Home management is a set of more complex activities that comprise maintaining a home, eg, shopping, cooking, housekeeping, managing money, and driving a car or using public transportation. The physical therapist uses the self care or home management examination to determine whether an individual can perform the tasks necessary for independent daily living. In addition, the physical therapist uses the self care or home management examination to determine whether the patient is a candidate for an orthosis or an assis-
tive, adaptive, supportive, or protective device. Finally, the physical therapist uses this examination to determine whether the patient is a candidate for body mechanics training or an organized hnctional training program. In every case the physical therapist integrates the patient's perceptions and expectations into the examination process. The self care and home management examination produces information used in identlfylng the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions. Clinical Indications. A self care and home management examination is appropriate in the presence of: Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care or home management tasks and movements Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care or home management tasks and movements: pain weakness lack of mobility lack of endurance lack of flexibility gait deficit(s1 and disturbances postural deficits
biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation inadequate circulation, recurrent ischemia, or claudication incontinence, bowel and bladder diaculty inability to perform specific movement tasks Tests and Measunes. Tests and measures for performing a self-care and home-management examination include, but are not limited to: administration of the activities of daily living scale administration of the instrumental activities of daily living scale performance of functional range of motion and muscle tests assessment of physiologic responses during self-care and home-management activities review of daily activity logs observation of the individual performing self-care and homemanagement activities review of reports provided by the individual, family member, significant other, or caregiver administration of questionnaires and conduct of interviews with the individual and others as appropriate Data Generated. Data generated may include, but are not limited to: level of performance of self-care and home-management activities and dependence on human and mechanical assistance spatial and temporal requirements for performing specific tasks related to self care and care of the household vital signs and physiologic response during self-care and home-management activities numerical scores on standardized rating scales movement patterns during performance of self-care and homemanagement activities patient's daily activity level

Sensory Integtfty Examination (Including Pmprioception and Kinesthesb) Overview. A s m oy integrity examination is the assessment of peripheral sensory processing (eg, sensitivity to touch) and cortical sensory processing (eg, two-point and sharp/dull discrimination). Proprioception includes position sense, the awareness o f the joints at rest, and kinesthesia, the awareness of movement. The physical therapist uses the sensory integrity examination to determine the integrity of the somatosensory system. Somatosensory abnormalities are frequent indicators of pathology.
The sensory integrity examination produces information used in identifying the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specdic tests and measures will depend on the findings of the patient history and systems review. The examination may require testing while the patient performs specific activities. The examination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
weakness lack of mobility lack of endurance motor deficits (eg, weakness, paralysis, uncoordination, abnormal spatial and temporal patterns of movement, tone, spasticity, flaccidity, and pathological reflexes) disturbances in balance somatosensory deficit altered state of consciousness disturbance in gait, particularly when selectively present in conditions of low vision postural deficits abnormalities in movement, flexibility, or strength biomechanical and arthrokinematic limitations impaired balance or frequent falling impaired motor function and learning impaired sensation sympathetic disturbances inability to perform specific movement tasks soft tissue limitations inadequate circulation, recurrent ischemia, or claudication
difference between predicted and actual performance visual or auditory acuity verbalization skills presence, absence, or distortion of superficial sensory capacities presence, absence, or distortion of perception of movement by extremities presence, absence, or distortion of joint position sense accuracy of cortical perceptions (eg, tactile recognition of objects, recognition of symbols drawn on the skin, ability to localize touch sensations) conduction times and velocities along peripheral and/or central musculoskeletal sensory pathways presence of skin breakdown or injury that may cause decreased sensation
Ventilation, Respiration, and Circulation Bramination Overview. Ventilation is the movement of a volume of gas into and out of the lungs. Respi'ration refers primarly to the exchange of oxygen and carbon dioxide across a membrane into and out of the lungs as well as the cells. Circulation is the passage of blood through the heart, blood vessels, organs, and tissues; it also describes the oxygen delivery system. The physical therapist uses the ventilation, respiration, and circulation examination to determine whether the patient has an adequate ventilatory pump, oxygen uptake, and oxygen delivery system to perform activities of daily living, ambulation, and aerobic exercise.
The ventilation, respiration, and circulation examination produces information used in identdjmg the possible or actual cause(s) of difficulties during the patient's performance of essential everyday activities, leisure pursuits, and work tasks. Selection of specific tests and measures will depend on the findings of the patient h t o r y and systems review. The examination may
Clinical Indications. A sensory integr i t y examination is appropriate in the presence of:

Physical disability, impaired sensorimotor function, pain, or developmental delay that prevents normal performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain
Tests and Measures. Tests and measures for performing a sensory integrity examination include, but are not limited to:
assessment o f gross receptive (eg, vision, hearing) or expressive (eg, verbalization) deficits assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense) assessment of combined (cortical) sensations (eg, stereognosis, tactile localization, two-point discrimination, vibration, texture recognition) performance of electrophysiologic testing (eg, sensory nerve conduction testing) assessment of skin integrity in cases of decreased sensation

require testing while the patient performs specfic activities. The exarnination will lead to an evaluation, a diagnosis, a prognosis, and the determination of appropriate interventions.
Clinical Indications. A ventilation, respiration, and circulation examination is appropriate in the presence of:
Physical disability, impaired sensorimotor function, pain, or developnlental delay that prevents normal. performance of daily activities, including self care, home management, community or work reintegration, and leisure Requirements of employment that specify minimum capacity for performance A need to initiate or change a prevention or wellness program Expectations or indications of one or more of the following impairments or functional limitations experienced when attempting to perform self care, home management, community or work reintegration, or leisure tasks and movements: pain weakness lack of mobility lack of endurance postural deficits abnormalities in movement, flexibility, or strength inadequate circulation, recurrent ischemia, or claudication abnormal breathing patterns or abnormal blood gases dyspnea at rest or o n exertion impaired ventilation abnormal cough or airway protection responses sympathetic disturbances chest congestion
inability to perform specific movement tasks edema, including edema of pregnancy dizziness or palpitations effects of thoracic or abdominal surgery
performance of pulmonary function tests and measures of ventilatory mechanics performance of pulse oximetry performance of arterial blood gas analysis
Tests and Measures. Tests and measures for performing a ventilation, respiration, and circulation exarnination include, but are not limited to:
obtainment of standard vital signs (blood pressure, heart, and respiratory rate) observation of chest movements and breathing patterns at rest and during exercise calculation of respiratory rate at rest and during exercise observation for cyanosis auscultation and percussion of the heart and lungs auscultation of major vessels for bruits palpation of pulses (eg, for integrity of the vascular system) palpation of the chest wall (eg, for diaphragmatic excursion; for chest wall expansion, mobility, or pain; for fremitus) application of perceived exertion scales and dyspnea scales assessment of cough and sputum assessment of phonation classfication of edema through volumetrics and girths gas analysis to measure oxygen consumption assessment of activities that aggravate or relieve edema, pain, or other disturbed sensations assessment of ability to perform activities of daily living and instrumental activities of daily living
report of vital signs and blood gases characteristics of normal and abnormal heart and lung sounds peripheral circulation integrity mobility of chest wall, rib integrity, and presence of spinal curves that could affect chest expansion characteristics of the pulse description of perceived exertion grading and dyspnea at rest and during activity characteristics of cough, sputum, phonation, and skin grading of edema using standardized number scales girths in inches or centimeters or volumetric displacement in milliliters a list of activities that aggravate or relieve edema, pain, or other disturbed sensations description of chest movements and breathing patterns at rest and during activity description of ventilatory muscle integrity, strength, and endurance description of the work of breathing and ventilatory reserve capacity ability to perform activities of daily living and instrumental activities of daily living oxygen saturation

Chapter Three: Interventions Provided by Physical Therapists
This chapter describes the fifth element of physical therapist patient management, ie, intervention. Figure 2, the schema describing the physical therapist's approach to patient management that was presented in Chap ter One, is shown below with intervention highlighted.
The APTA believes that policy decisions about the use of physical therapy personnel and resources to manage patients with impairments, functional limitations, and disabilities should be based on knowledge of the elements of physical therapy patient management. The Association notes that, while all health services incur costs, failing to intervene appropriately and prevent illness and neglecting to rehabilitate individuals with impairments, Functional limitations, and disability leads to greater costs at personal and societal levels. This document is a first step in providing policymakers with the information needed to make decisions about the costeffectiveness of physical therapy services. Physical therapy interventions include ongoing examination and modification of the treatment plan for each patient when necessary. The interventions selected are based on the complexity of the patient's clinical problems. Treatment plans include discharge planning that begins early and is based on the actual and expected treatment outcomes that are determined by periodic reexamination. As soon as clinically appropriate, patients are Informed of their prognoses and begin, with the assistance of the therapist, long-range planning for managing any residual impairment, functional limitation, or disability. Through appropriate education, patients are also encouraged to develop health habits to maintain or improve their function,
prevent recurrence of clinical problems, and promote wellness. Any physical therapy intervention includes four critical components: 1) development of a patient management program that encourages independence; 2) patient-related instruction; 3) development of the capacity of patients, family members, significant others, and caregivers to participate effectively; and 4) promotion of proactive, wellnessariented lifestyles.
sis, and prognosis. Decisions determining intervention are contingent upon the timely monitoring of the patient's response and the progress made toward achieving outcomes. There are three intervention components: direct intervention patient-related instruction coordination, communication, and documentation
Intervention
Flgum 2.
mal outcome.
Intervention is the purposeful and skilled interaction of the physical therapist with the patient, using various methods and techniques to produce changes in the patient's condition consistent with the evaluation, diagno-
b Dimct Intervention. This process includes the selection, application, and modification of one or more therapeutic interventions. Three interventions therapeutic exercise, functional training in self care and home management, and functional training in community or work reintegration activitie-form the core elements in most physical therapy plans of care. These
EXAMINATION EVALUATION
m e elements of physical therapist patient management leading to opti-
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plans of care frequently include the use of other interventions to augment functional training and therapeutic exercise. The selection of any physical therapy intervention should be supported by the following: examination (including history and systems review), evaluation, and diagnosis that support physical therapist intervention plan of care designed to improve function using interventions of appropriate intensity, frequency, and duration to achieve specific goals efficiently with available resources prognosis that is associated with improved or maintained health status through the remediation of impairments, functional limitations, or disabilities The intenrentions available to the physical therapist in developing a treatment program include, but are not limited to, the following: therapeutic exercise (including aerobic conditioning) functional training in self care and home management (including activities of daily living and instrumental activities of daily living) functional training in community or work reintegration (including instrumental activities of daily living, work hardening, and work conditioning) manual therapy techniques (including mobilization and manipulation) prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment airway clearance techniques debridement and wound care physical agents and mechanical modalities electrcjtherapeutic modalities patient-related instruction Physical therapists select interventions based on the data gathered from the examination process. Factors that influence the complexity of the inter-
vention and the evaluation process include, but are not limited to, the following:
severity of current problem stability of the patient's condition pre-existing conditions level of impairment(s) probability of prolonged impairment, functional limitations, and disability social supports and living environment multiple sites or systems involvement overall physical function and health status potential discharge destination
status (change in level of pain, sensation, reflexes, strength, endurance, range, and quality of joint movement) changes since previous intervention and any alteration(s) in technique or intervention plan Changes in functional limitations and disability, especially as they relate to meaningful, practical, and sustained change in the patient's life. If pain reduction is a goal, the outcome should be documented in terms of reduction in level of pain as it relates to a change in functional performance. Documentation should follow the
APIA Guidelinesfor Physical i%erapy
11. Patient-related Instruction. This process includes instruction of the patient, groups of patients, families, and other caregivers regarding the patient's current condition, treatment, and transition to his or her role at home, at work, or in the community. In addition to imparting information, instruction may also include training in maintenance activities and primary and secondary prevention. 111. Coordination, CommunicationJ and Documentation. These processes ensure that the patient receives appropriate, coordinated, comprehensive, and cost-effective services between admission and discharge. The services include, but are not limited to, the following:
patient care conferences communications (telephone, fax, etc) documentation of all elements of patient management coordination of care with patients, significant others, family members, caregivers, and other health professionals record reviews discharge planning Clinical documentation states: the specific mode(s) of interventions selected and the parameters of their application the direct effects of each intervention in terms of impairment
Documentation (Appendix 111).

For all physical therapy interventions: Initiation of a specific procedure is based on a clinical plan with expected outcomes. Routine monitoring determines the need for any alteration(s1 in an intervention or the plan of care. The physical therapist assesses the patient's (significant other's, family's, or caregiver's) ability to perform the intervention independently. When it is appropriate, any individual who can perform an intervention independently should be instructed in its safe and efficacious application. Discontinuance of a procedure may be indicated because of lack of progress, lack of patient tolerance, lack of patient motivation, attainment of maximum improvement, the achievement of expected outcomes, or the determination of a more effective alternative The interventions used, including their frequency and duration, are consistent with the patient's needs and physiologic and cognitive status, the goals of treatment, and resource constraints For each intervention, four areas are discussed:

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Overview-Provides an introduction to the intervention. Modes of Intervention-Lists the possible methods, procedures, or techniques of the intervention. CMcal Indications-Describes general criteria for appropriate use of the intervention. Benefits-Addresses expected positive results from the intervention. The use of any physical therapy intervention, unless performed by a physical therapist or under the direction or supervision of a physical therapist, is not physical therapy nor should it be represented or reimbursed as such.
nity. It also incorporates activities to allow well clients to improve or maintain their health or performance status (for work, recreational, or sports purposes) and prevent or minimize future potential health problems.
Therapeutic exercise is performed actively, passively, or against resistance. When the patient cannot participate actively due to weakness or other problems, passive exercise may be necessary. Resistance may be provided manually, by gravity, through use of a weighted apparatus, or by mechanical or electromechanical devices. Aquatic physical the physical and properties water facilitate patient performance.
those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for therapeutic exercise are individuals restricted from completing necessary job, task, or activity demands by performance deficits in the following body systems: neuromusculoskeletal cardioDulmonarv perip(eral vasc;lar integumentary lymphatic endocrine or metabolic genitourinary Candidates for therapeutic exercise also include, but are not limited to, individuals who are: at risk of developing cardiovascular, neuromusculoskeletal, or pulmonary impairments severely deconditioned pre- or post-surgical intervention pre- or post-partum diabetic or osteoporotic or at risk of developing diabetes or osteoporosis engaged in recreational, organized amateur, or professional athletics
Therapeutic Execise (Including Aerobic Conditioning)
Modes of Intervention. Therapeutic exercise includes, but is not limited to:

stretching strengthening active assistive active resistive, using manual resistance, pulleys, weights, hydraulics, elastics, robotics, and mechanical or electromechanical devices neuromuscular relaxation, inhibition, and facilitation neuromuscular re-education motor training or retraining developmental activities breathing exercises, ventilatory muscle training aerobic endurance activities, using cycles, treadmills, steppers, pools, manual resistance, pulleys, weights, hydraulics, elastics, robotics, and mechanical or electromechanical devices aquatic exercises conditioning and reconditioning ambulation and elevation training balance and coordination training body mechanics and ergonomics training posture awareness training play or leisure activities
OvefView. Therapeutic exercise consists of a broad group of activities intended to improve a patient's strength, muscle length, range of motion, endurance, breathing, balance, coordination, posture, motor function, motor development, or confidence when any of a range of problems constrains the patient's ability to perform a functional activity. Therapeutic exercise is a part of fitness and wellness programs designed to promote overall well-being or, in general, to prevent complications related to inactivity or overuse. This intervention may be used during pregnancy and the post-partum period to improve function and reduce stress. It may also be used (with proper guidance) in patients with hematologic and o n c e logic disorders to combat fatigue and systemic breakdowns. Therapeutic exercise may also prevent further complications and decrease use of health care resources during and after surgery or hospitalization.
Therapeutic exercise includes activities to improve physical function and health status (or reduce or prevent disability) resulting from impairment(s) by identdying specific performance goals that will allow patients to achieve a higher functional level in the home, school, workplace, or commu-
Benefits. All benefits of therapeutic exercise are measured in terms of remediation or prevention of impairments, functional limitations, and &ability. Specific benefits related to therapeutic exercise include, but are not limited to:
improved physical function and health status improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and inflammation improved quality and quantity of movement between and across body segments improved weight-bearing status improved ambulation and elevation abilities reduction in secondary impairments increased mobility increased tolerance to positions and activities
Clinical Indications. Before applying therapeutic exercise, a thorough examination is performed to identdy
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increased capacity to execute physical tasks increased endurance reduced risk of system impairment decreased disability from acute or chronic illnesses decreased service utilization, cost, and risk of recurrence increased independence decreased level of supervision or care improved self-management reduced risk factors increased sense of well-being and decreased stress reduced pre- and post-operative complications decreased pain improved ability to perform activities of daily living
Modes of Intervention. Functional training activities include, but are not limited to:
activities of daily living training, eg, bed mobility transfer training ambulation training wheelchair mobility developmental activity play or leisure activity instrumental activities of daily living training, eg, shopping cooking housekeeping house chores money management assistive, adaptive, supportive, or protective devices training orthotic training prosthetic training body mechanics training organized functional training programs, eg, back schools
home management include, but are not limited to: improved safety increased mobility increased tolerance to positions and activities increased capacity to execute essential life tasks improved performance of activities of daily living and instrumental activities of daily living (including increased strength, endurance, and efficiency and safety of movement) appropriate use of prosthetic or orthotic devices appropriate use of assistive, adaptive, supportive, and protective devices decreased disability from illness or injury increased independence decreased level of supervision of care decreased service utilization, cost, and risk of recurrence
Functional Training in Self Can? and Home Management (Including Activities of Daily Living and lnstmmental Activities of Daily Living) Overview. Functional training in self care and home management includes a broad group of performance activities designed to improve a patient's neuromusculoskeletal, cardiovascular, and pulmonary capacities. Functional training is used to improve the physical function and health status of individuals with physical disability, impaired sensorimotor function, pain, injury, or disease; it is also used for well individuals. It is frequently based on activities associated with growth and development.
The physical therapist targets the patient's problems with performing a movement or task and specifically directs the functional training to alleviate impairments, functional limitations, and disabilities. In applying functional training, the physical therapist may choose from a number of options, including training in activities of daily living, instrumental activities of daily living, body mechanics, and usage of therapeutic appliances, orthoses, and prostheses. Organized functional training programs such as back schools may also be selected.
Clinical Indications. Before applying functional training in self care and home management, a thorough examination is performed to identlfy those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for functional training are individuals constrained in their ability to complete necessary job, task, or activity demands by performance deficits in the following body systems:
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic genitourinary endocrine or metabolic Candidates for functional training also include patients with functional deficits of a risk of developing them.
Functional Training in Community or Work Reintegration (Including lnstmmental Activities of Daily Living, Work Hardening, and Work Conditioning) Overview. Functional training in community or work reintegration includes a broad group of activities designed to return the patient to the community and/or to work as quickly and efficiently as possible. It involves improving a patient's physiologic capacities in order to facilitate the fulfillment of community- and work-related roles. Functional training is used to imprave the physical function and health status of individuals with physical disability, impaired sensorimotor function, pain, injury, or disease; it is also used for well individuals. It is frequently based on activities associated with growth and development.
The physical therapist targets the patient's problems in performing a movement, community activity, or job task and specilically directs the functional training to enable the patient to return to the community or work
Benefits. All benefits of functional training are measured in terms of remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to functional training in self care and

environment. A variety of approaches may be taken, depending on the patient's needs. For example, the physical therapist may provide training in the instrumental activities of daily living to patients who need to live more independently, or body mechanics and posture awareness training if a patient is deficient in these areas. Work hardening and work conditioning are specialized functional training programs aimed at reducing the disability and functional limitations resulting from impairment(s) associated with job-related injuries.
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic endocrine or metabolic genitourinary Candidates for functional training in community or work reintegration also include, but are not limited to, individuals with: a job-related disability or functional limitation a known work-injury-related impairment
and noncontractile tissue extensibility, andlor improve pulmonary function. These interventions employ a variety of techniques, such as the application of graded forces. Physical therapists use manual therapy techniques to improve physical function and health status (or reduce or prevent disability) resulting from impairment(~)by identlfylng specific performance goals that will allow patients to achieve a higher functional level in the home, school, workplace, or community. They also use these techniques, including therapeutic massage and soft tissue mobilization and manipulation, for well clients to give them a greater sense of wellbeing, to induce relaxation, and to improve physical function.
I
I
Modes of Intervention. Functional training activities include, but are not limited to:
instrumental activities of daily living, eg, shopping, cooking, housekeeping, money management use of assistive, adaptive, supportive, or protective devices use of orthotic devices use of prosthetic devices posture awareness training body mechanics training organized functional training programs, eg, back schools conditioning or reconditioning environmental or job task adaptation dexterity and coordination training injury prevention or reduction ergonomic stressor reduction job coaching job simulation
Benefits. A l l benefits of functional training community or work reintegration activities are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to community or work reintegration include, but are not limited to:
improved safety when performing community and job tasks increased mobility increased tolerance to positions and activities increased ca~acitv , to execute physical tasks minimized costs of job-related injuries reduced disability associated with acute or chronic problems acquisition of behaviors that foster healthy habits, wellness, and prevention decreased service utilization, cost, and risk of recurrence increased independence reduced secondary impairments increased awareness and usage of community resources
Modes of Intervention. Manual therapy techniques include, but are not limited to:
passive range of motion joint mobilization and manipulation manual traction connective tissue massage soft tissue mobilization and manipulation therapeutic massage
Clinical Indications. Before a program of functional training in community or work reintegration is initiated, a thorough examination is performed to identlfy those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for functional training in community or work reintegration (including instrumental activities of daily living, work hardening, and work conditioning) are individuals constrained in their ability to complete necessary job, task, or activity demands by performance deficits in the following body systems:
Clinical Indications. Before applying manual therapy techniques, a thorough examination is performed to identlfy those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for manual therapy techniques are individuals constrained in their ability to complete necessary job, task, or activity demands by performance deficits in the following body systems:
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic genitourinary Candidates for manual therapy techniques also include, but are not limited to, individuals who have: limited range of motion
Manual Therapy Techniques (Including Mobilization and Manipulation) Overview. Manual therapy consists of a broad group of passive interventions in which physical therapists use their hands to administer skilled movements designed to modulate pain, increase joint range of motion, reduce or eliminate soft tissue inflammation, induce relaxation, improve contractile

soft tissue swelling pain scar tissue or contracted tissue spasm joint hypomobility
of the patient's social and cultural environment. The physical therapist targets the patient's problems with movement tasks and selects (or fabricates) the most appropriate equipment or device, then fits it and trains the patient in its use and application. The goal is for the patient to function at a higher level and to decrease the effects of impairment. Assistive, adaptive, supportive, and protective devices and equipment include, but are not limited to, splints, casts, prostheses, corsets, orthoses, ambulation devices, wheelchairs or other mobility aids, activities-fdaily living and employment-related assistive devices, and corrective and protective taping.
activity demands by performance deficits in the following body systems: neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic endocrine or metabolic genitourinary
Benefits. AU benefits of manual therapy techniques are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to manual therapy techniques include, but are not limited to:
improved physical function and health status improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and inflammation improved mobility increased tolerance to positions and activities increased capacity to perform movement tasks improved quality and quantity of movement between and across body segments reduced secondary impairments increased capacity to execute physical tasks decreased disability from acute or chronic illnesses decreased service utilization, cost, and risk of recurrence
Benefits. All benefits of these therapeutic devices and equipment are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to the prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment include, but are not limited to:
improved safety improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and inflammation improved mobility increased tolerance to positions and activities increased capacity to execute physical tasks requiring independent movement improved joint stability improved tissue healing prevention of deformity reduced complications decreased disability associated with acute or chronic illness decreased service utilization, cost, and risk of recurrence increased independence and self-esteem decreased level of supervision of care reduced secondary impairments improved weight-bearing status decreased loading on a body Pa* improved physical function and health status
Airway Clearance Techniques
Modes of Intervention. The selection of these therapeutic devices and equipment includes, but is not limited to, the prescription, fabrication, and application of:
orthoses (eg, braces, shoe inserts) prostheses (eg, artificial limbs and joints) assistive devices (eg, crutches, canes, walkers, casts) adaptive devices (eg, longhandled reachers, raised toilet seats, wheelchairs and other mobility devices) supportive devices (eg, supportive taping, elastic wrap, compression garments, corsets, neck collars, splints, casts) protective devices (eg, braces, protective taping, helmets, splints)
PrescriptionI Fabrication, and Application of Assistive, Adaptive, SupportiveI and Pnotective Devices and Equipment Overview. The prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment includes the use of a broad group of therapeutic appliances to reduce the level of physical disability, impaired sensorimotor function, and pain caused by musculoskeletal, neuromuscular, integumentary, peripheral vascular, lymphatic, and/or cardiopulmonary pathology, injury, developmental delay, or inherited conditions. These procedures are often used in conjunction with functional training, work conditioning and work hardening, and other interventions, and should be selected in the context
Physical Therapy / Volume 75, Number
Clinical Indications. Before prescribing, fabricating, or applying these devices and equipment, a thorough examination is performed to identlfy those conditions that would prevent the use of these devices and equipment or indicate that they should be applied with caution. Candidates for assistive, adaptive, supportive, and protective devices and equipment are individuals constrained in their ability to complete necessary job, task, or
Overview. Airway clearance techniques include a broad group of activities used to manage or prevent consequences of acute and chronic lung diseases and impairments, including
those associated with surgery. Airway clearance techniques may be used with therapeutic exercise, manual therapy techniques, or mechanical modalities to improve pulmonary function. The physical therapist performs airway clearance techniques to improve physical function and health status (or reduce or prevent disability) resulting from impairment(s) by identifying specific performance goals that will allow the patient to achieve a higher functional level in the home, school, workplace, or community.
impaired ventilatory pump altered breathing patterns risk of complications from anesthesia or surgery exacerbation and progression of chronic disease
components of the early part of a treatment plan to augment other active or functionally oriented procedures. These interventions are subsequently discontinued as treatment progresses and wound healing occurs. Debridement and wound care are used directly by the physical therapist, who determines the appropriate technique based on the functional needs of the patient and direct physiological effects desired.
Benefits. All benefits of airway clearance techniques are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to airway clearance techniques include, but are not limited to:
improved lung function improved quality of breathing improved exercise tolerance improved cough increased airway clearance, including patients on mechanical ventilation resolution of acute atelectasis reduced complications during hospitalization decreased disability associated with acute or chronic illness decreased service utilization, cost, and risk of recurrence decreased level of supervision of care decreased secondary complications increased physical functioning increased independence in self care for airway clearance techniques .. improved health status and socia1 interaction
Modes of Intervention. Methods of debridement and wound care include, but are not limited to:
sharp debridement debridement with other agents dry dressings wet dressings topical agents (eg, enzymes) hydrotherapy
Modes of Intervention. Airway clearance techniques include, but are not limited to:
postural drainage and positioning chest percussion, vibration, and shaking active cycles of breathing autogenic drainage forced expiratory pressure techniques to maximize ventilation assistive cough techniques suctioning
Clinical Indications. Candidates for debridement include, but are not limited to, patients with wounds that:
have nonviable tissue show signs of inflammation a have full- or partial-thickness skin lesions are exuding or undergoing reepithelialization and/or connective tissue replacement
Clinical Indications. Before applying airway clearance techniques, a thorough examination is performed to identify those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for airway clearance techniques are individuals with inadequate ventilation and limited ability to clear lung secretions because of performance deficits in the following body systems:
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic genitourinary Candidates for airway clearance techniques also include, but are not limited to, patients with: acute or chronic lung conditions impaired airway protection impaired airway clearance
Debridement and Wound Care Overview. Debridement is a therapeutic procedure involving removal of nonviable tissue from a wound bed, most often by the use of instruments or enzymes. Wound care includes procedures used to achieve a clean wound bed, to promote a moist wound environment or facilitate autolytic debridement, and to absorb excessive exudation from a wound complex.
The desired effects of debridement and wound care can be achieved in a variety of ways. The physical therapist almost always uses debridement and wound care as supportive, short-term
Benefits. All benefits of debridement and wound care are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to debridement and wound care include, but are not limited to:
reduced complications improved wound and soft tissue status reduced wound size reduced secondary impairments improved physical function and health status reduced risk factors from infection enhanced wound healing

Physical Agents and Mechanical Modalities Overview. Physical agents use heat, sound, or light energy to increase connective tissue extensibility, modulate pain, reduce or eliminate soft tissue inflammation and swelling caused by musculoskeletal injury or circulatory dysfunction, increase the healing rate of open wounds and soft tissue, remodel scar tissue, or treat skin conditions.
Mechanical modalities include a broad group of procedures (eg, traction, continuous passive motion) to modulate pain, stabilize an area that requires temporary support, increase range of motion, or apply distraction, approximation, or compression. Both physical agents and mechanical modalities are typically used in conjunction with or in preparation for other physical therapy interventions such as therapeutic exercise and functional training. The physical therapist uses physical agents and mechanical modalities to improve physical function and health status (or reduce or prevent disability) resulting from impairment(s) by identifying specific performance goals that wdl allow patients to achieve a higher functional level in the home, school, workplace, or community.
traction (sustained, intermittent, or positional) continuous passive motion (CPM) tilt table or standing table mechanical percussion compression therapies (eg, vasopneumatic compression devices, compression bandaging, compressive garments, taping)
prevention of impairments, functional limitations, and disability. Specific benefits related to physical agents include, but are not limited to: improved physical function and health status improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and pain improved skin and wound status enhanced healing of tissues reduced sequelae of soft tissue and circulatory disorders improved cosmesis reduced complications increased mobility increased tolerance to positions and activities increased capacity to perform movement tasks debridement of nonviable tissue without surgical intervention decreased secondary impairments Specific benefits related to mechanical modalities include, but are not limited to: improved physical function and health status improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and inflammation improved neurologic status improved hemodynamic response to change in position decreased pain improved healing of bony segments decreased mobility restrictions increased tolerance to positions and activities increased capacity to perform movement tasks decreased secondary impairments
Clinical Indications Before using either physical agents or mechanical modalities, a thorough examination is performed to identlfy those conditions that would prevent the use of these interventions or indicate that they are to be applied with caution. Candidates for physical agents or mechanical modalities are individuals who are constrained in their ability to complete necessary job, task, or activity demands by performance deficits in the following body systems:
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic endocrine or metabolic genitourinary Candidates for physical agents also include, but are not limited to, patients with: observable soft tissue inflammation and swelling pain disorder open wounds circulatory compromise integumentary deformities skin conditions Candidates for mechanical modalities also include, but are not limited to, patients with: pain disorders disk disorders nerve injury sprains or strains joint disorders that limit motion assisted weight-bearing or upright activity needs
Modes of Intervention. Physical agents include, but are not limited to:
deep thermal modalities (eg, ultrasound) athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) superficial thermotherapy (eg, heat, paraffin baths, hot packs, fluidotherapy) and cryotherapy modalities (eg, cold packs, ice massage) hydrotherapy (eg, whirlpool, tanks, contrast baths) phototherapies (eg, ultraviolet) Mechanical modalities include, but are not limited to:
Electmtherapeutic Modalities Overview. Electrotherapeutic modalities include a broad group of physical agents that use electricity to modulate or decrease pain; reduce or eliminate
Benefits. All benefits of physical agents and mechanical modalities are measured in terms of a remediation or

soft tissue inflammation caused by musculoskeletal, neuromuscular, peripheral vascular, or integumentary injury, disease, developmental delay, or surgery; maintain strength after injury or surgery; decrease unwanted muscular activity; assist muscle contraction in gait or other functional training; or increase the rate of healing of open wounds. Electrotherapeutic modalities are generally components of a treatment plan used to augment other active or functionally oriented procedures.
pain disorders open wounds functions that will improve by using functional electrical stimulation motor function that can be enhanced by biofeedback impaired muscle contraction that could be improved with electrical stimulation prolonged or permanent paralysis
and potential complications of the interventions instruction and assistance in making appropriate decisions on the management of the patient instruction and assistance in implementing interventions under the direction of the physical therapist
Modes of lntewention Electrotherapeutic modalities include, but are not limited to:
alternating, direct, and pulsed current (eg, high-voltage galvanic stimulation, interferential current) neuromuscular electrical stimulation (NMES) functional electrical stimulation (FES) for improving posture or movement transcutaneous electrical nerve stimulation (TENS) iontophoresis electrical muscle stimulation biofeedback
Benefits. A l benefits of electrotherapeutic procedures are measured in terms of a remediation or prevention of impairments, functional limitations, and disability. Specific benefits related to electrotherapeutic modalities include, but are not limited to:
improved physical function improved health status improved quality and quantity of joint movement reduced signs and symptoms of joint and soft tissue swelling and inflammation improved skin and wound status increased mobility increased tolerances to positions and activities increased capacity to execute physical tasks reduced complications reduced secondary impairments decreased pain
Modes of Intervention. The activities that should be included in the development of a patient-related instruction program include, but are not limited to:
verbal instruction written or pictorial instruction computer-guided instruction actual practice by the patient or caregiver use of audio and visual aids for both teaching and home reference return demonstration periodic re-examination
Clinical Indications. Before applying electrotherapeutic modalities, a thorough examination is performed to identlfy those conditions that would prevent the use of this intervention or indicate that it is to be applied with caution. Candidates for electrotherapeutic modalities are individuals constrained in their ability to complete necessary job, task, or activity demands by performance deficits in the following body systems:
neuromusculoskeletal cardiopulmonary peripheral vascular integumentary lymphatic genitourinary Candidates for electrotherapeutic modalities also include, but are not limited to, patients with: observable soft tissue inflammation
Clinical Indications. A patient-related instruction program should be developed for all patients for whom physical therapy is indicated. A thorough examination must be performed to determine whether the patient's cognitive, physical, or resource status would allow the patient to perform a home management program independently or only with the assistance of famdy, significant others, or other caregivers.
Family memben, sigmficant others, and other caregiven, including home health aides, are instruction candidates when required to assist the patient in a management plan.
Patient-mlated Instruction Overview. Patient-related instruction is the process of imparting information and developing slulls to promote independence and to allow care to continue after discharge. Instruction should focus on the patient as well as the family, significant others, and other caregiven to ensure short- and longterm compliance with the physical therapy interventions and the prevention of future disability. The development of an ihtruction program is consistent with the goals of the plan of care. Patient-related instruction may include:
information about the cause of the patient's impairment, functional limitation, or disability; the prognosis; and the purposes
Benefits All benefits of patientrelated instruction programs are measured in terms of remediation or prevention of impairment, functional limitation, and disability. Specfic benefits related to patient-related instruction programs include, but are not limited to:
improved physical function and health status improved safety for the patient, significant others, family, and caregivers

enhanced progress by extending direct care increased patient, significant other, family, and caregiver knowledge and awareness of the patient's condition, prognosis, and management enhanced decision-making about the health of the patient and use of health care resources
by the patient, family, or caregivers acquisition of behaviors that foster healthy habits, wellness, and prevention improved levels of performance in employment, recreational, and sports activities reduced disability associated with acute or chronic illnesses
decreased service utilization, cost, and risk of recurrence increased independence decreased level of supervision or care reduced secondary impairments increased capacity to execute physical tasks Appendixes follow.
Appendix I. A Glossay of Operational Definitions in Physical Therapy
Activities of Daily Living: The self-care, communication, and mobility skills (eg, rising from bed, using the toilet, dressing, and eating meals) required for independence in everyday living. Aerobic Activity/Conditioning: The performance of exercise (eg, running, swimming, cycling) to increase endurance. Aerobic Capacity: A measure of the ability to perform work or participate in activity over time using the body's oxygen uptake, delivery, and energy release mechanisms. Affective: Relating to the expression of emotion; eg, affective disorder. Afferent: Proceeding from the peripheral to the central nervous system. Airway Clearance Techniques: A broad group of activities used to manage or prevent consequences of acute and chronic lung diseases and impairments, including those associated with surgery. Algometer (Pressure> An instrument for measuring the degree of sensitivity to a painful stimulus. Ambulation: Walking, with or without the use of assistive devices. Americans With Disabilities Act: The 1990 federal statute that prohibits discrimination against disabled individuals in employment, public accommodations, etc. Amplitude: The maximum difference between an alternating current's peak and average values. Anaerobic Threshold: The point during exercise at whiCh a person cannot supply enough oxygen to meet the demands of the body. Anthropometric Characteristics: Human body measurements such as height, weight, girth, and body fat composition. Approx&nation: Bringing together two joint surfaces. Arousal: The stimulation to action or to physiologic readiness for activity. Arrhythmia: An irregular or abnormal heart rhythm. Arthrokinematic: Describing the motion of a joint without regard to the forces producing that motion or resulting from it; describing the structure and shape of joint surfaces. Assistive, Adaptive, Supportive, and Protective Devices: A variety of implements or equipment used to aid individuals in performing tasks or movements. Assistive devices, which include crutches and canes, involve rather simple technologies; adaptive devices, which include such technologies as a wheelchair and the long-handed reacher, are
generally more complex. Supportive devices include taping, compression garments, corsets, and neck collars, while protective devices include braces and helmets. Atelectasis: Airlessness of the lungs due to failure of expansion or resorption of air from the alveoli. Athermal: Not using heat, describing, for example, a modality such as pulsed ultrasound. Athetotic: Describing an impaired movement often marked by slow, writhing movements of the hands. Auditoly: Related to the ability to hear. Auscultation: The act of listening to internal body sounds (eg, the heartbeat). Autogenic Drainage: Airway clearance through the patient's own efforts (coughing, etc). Back School: A structured educational program about low back problems, usually offered to a group of patients. Balance: The ability of an individual to maintain the body in equilibrium with gravity both statically (eg, while stationary) and dynamically (eg, while walking). Biofeedback: A training technique that enables an individual to gain some element of voluntary control over muscular or autonomic nervous system functions using a device that produces auditory or visual stimuli. BiomechanicaL. Describing the action of forces on the body, especially as they affect the musculoskeletal system. Body Mechanics: The interrelationships of the muscles and joints as they maintain or adjust posture in response to environmental forces. Bruit: An auscultatory (internal body) sound, especially an abnormal one (eg, a blowing murmur heard over an aneurysm). Caregiver: One who provides care, often used to describe a person other than a health professional. Case Management: The coordination of patient care or client activities. Cicatrix: Scar; the fibrous tissue replacing the normal tissues destroyed by injury or disease. Circulation: The passage of blood through the heart, blood vessels, organs, and tissues; it also describes the oxygen delivery system. Claudication: A complex of symptoms associated with absence of lower limb pain at rest but increasing discomfort and pain with walking, causing the patient to limp. Physical Therapy / Volume 75, Number 8 / August 1995
Client: An individual(s1, business(es), agency(ies1, or other organizational entity receiving consultative services; a client would not typically be described as a patient. Clinical Indications: The patient factors (symptoms, impairments, deficits, etc) that suggest that a particular kind of care (examination, intervention) would be appropriate. Cluster: A set of observations, data, etc, that frequently occur as a group in a single patient. Cognition: The act or process of knowing, including both awareness and judgment. Cogwheel: A type of spasticity characterized by stiff, restricted movements. Community or Work Reintegration: The process of resuming one's role(s) in the community or at work. Compression Therapy: Treatment using devices or techniques that decrease the density of a part of the body through the application of pressure. Conduction: Transmission of electrical energy. Conduction velocity: The speed at which electrical energy is transmitted. Consultation: The provision by a physical therapist of a professional, expert opinion or of advice. Consumer: One who acquires, uses or purchases goods or service; any actual or potential recipient of health care. Continuous Passive Motion (CPM): The use of a device that allows a joint (eg, the knee) to be exercised without the involvement of the patient, often in the early postoperative period. Contrast Bath: Immersing the patient sequentially in cold and hot water. Cortical: Involving the cerebral cortex; referring to tracts in the spinal cord that mediate information to and from the cerebral cortex. Cosmesis: A concern in therapeutics, especially in surgical operations, for the appearance of the patient. Cranial Nerve: One of twelve paired nerves (eg, olfactory, optic) that emerge from or enter the brain. Critical Inquiry: The process of applying the principles of scientific methods to read and interpret professional literature, participate in research activities, and analyze patient care outcomes, new concepts, and findings. Cryotherapy: Therapeutic application of cold (eg, ice). Cyanosis: A bluish or purplish discoloration of the skin due to a severe oxygen deficiency. Debridement: Excision of contused and necrotic tissue from the surface of a wound. Autolytic: Selfdebridement, ie, removal of contused or necrotic tissue through the action of enzymes in the tissue. Sharp: Debridement using a sharp instrument. Deficit: .4 shortfall in amount or quality. Developmental: Difference between expected and actual (lower) performance in an aspect of development (eg, motor, communication, social). Expressive: A shortfall Physical Therapy / Volume 75, Number 8 /August 1995
in expression (eg, in speech). Receptive: A shortfall in the skills involving reception (eg, in vision, in hearing). Developmental Delay: The failure to reach expected age-specific performance in one or more areas of development (eg, motor, sensory-perceptual). Diagnosis: A label encompassing a cluster of signs and symptoms, syndromes, or categories. It is also the decision reached as a result of the diagnostic process, which is the evaluation of information obtained from the patient examination organized into clusters, syndromes, or categories. Disability: The inability to engage in age- and sexspecific roles in a particular social context and physical environment. Dislocation: A disturbance or disarrangement of the usual relationship of bones as they enter into the formation of a joint. Distraction: The act of pulling apart the surfaces of a joint. Dolorimeter: A device to measure pain. Dressing: A material (eg, topical agent, gauze) applied to a lesion. Dynamometry: Measuring the degree of muscular power. Dyspnea: Shortness of breath; subjective difficulty or distress in breathing frequently manifested by rapid, shallow breaths; usually associated with serious disease of the heart or lungs. Edema: An accumulation of fluid, often occurring as part of the inflammatory process after trauma. Education: Knowledge or skill obtained or developed by a learning process; a process designed to change behavior by formal instruction and/or supervised practice, which includes teaching, training, information sharing, and specific instructions. Efferent: Sending information away from the central nervous system. Effusion: The escape of fluid into a body part or tissue. Electrical Device: An instrument or modality that applies electrical current to biologic tissue for pain control, tissue healing, or muscle dysfunction; an instrument that records electrical activity from excitable tissues of the body for purposes of neuromuscular diagnosis, education, or relaxation. Electrical Impedance: A method of analyzing body composition (eg, percentage of body fat) by sending an electrical current through the body and measuring resistance. Electrical Potential: The amount of electrical energy residing in specific tissues. Electrical Stimulation: Treatment through the application of electricity. Functional: The application of electrical stimulation to particular peripheral nerves to allow paretic and paralyzed muscles to make functional and purposeful movements. Electrogoniometry: The measurement of the movement of a joint using an electrical potentiometer.
Electromechanical Equipment: Mechanical devices or systems electrically activated, as by a solenoid. Electrophysiologic Concerned with the electrical activity of various body tissues or systems. Electrophysiologic Testing: The process of examining the relationships of body functions to electrical phenomena, such as the effects of electrical stimulation on the tissues, the production of electrical currents by organs and tissues, and the therapeutic use of electrical current. Electrotherapeutic Modalities: A broad group of therapeutic physical agents (eg, neuromuscular electrical stimulation, iontophoresis). E M & Electromyography; the recording of the electrical activity of a muscle. Endocrine: The body system concerned with glands and other structures that make substances such as hormones and other substances that influence metabolism and other body functions; the pituitary gland, thyroid gland, etc, have endocrine functions. Endurance: The ability to perform work over time. Environmental, Home, and Work Barriers: The physical impediments that keep individuals from functioning optimally in their surroundings, including safety hazards (eg, throw rugs, slippery surfaces), access problems (eg, narrow doors, high steps), and home or office design (eg, excessive distance to negotiate, multiple-story environment). Ergonoidcs: The study of work, including the application of the life sciences to well-being and work performance, which relates human factors (height, weight, etc) to work requirements; the study of the relationships between people, work, and the work environment, using scientific and engineering principles to improve those relationships. Erythemal: Describing an abnormal redness of the skin. Evaluation: A dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination. Evoked Potentials: The electrical signals recorded from a sensory receptor, nerve, muscle, etc of the central nervous system that has been stimulated, most often by electricity (eg, auditory evoked potentials). Examination: The process of obtaining a patient history, performing relevant systems reviews, and selecting and administering specific tests and measures. Excursion: Movement within the body, with return to the original site implied (eg, excursion of the diaphragm). Exudation: The process of expressing material through a wound, usually characterized as oozing. Fluidotherapy "Dry whirlpool"; the application of dry heat through a fluidotherapy machine. Force Plate: A plate embedded in the floor used to measure the force that a person exerts when walking.
Fremitus: A sensation felt when placing a hand on a part of the body (eg, the chest) that vibrates during speech. Function: The special, normal, or proper action of any part or organ; those activities identified by an individual as essential to support physical and psychological well-being as well as create a personal sense of meaningful living; the action specifically for which a person or thing is fitted or employed; an act, process, or series of processes that serve a purpose; to perform an activity or to work properly or normally. Functional LLmitation: A restriction of the ability to perform a physical action, activity, or task in a typically expected, efficient, or competent manner. Gait: The manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed. Gas Analysis: Laboratory testing of a gas, as in blood gas analysis, in which oxygen and carbon dioxide concentrations are measured and the pH determined. Goal: The long-term statement(s) that define the patient's expected level of performance at the end of the rehabilitation process; the functional outcomes of therapy, indicating the amount of independence, supervision, or assistance required and the equipment or environmental adaptation necessary to ensure adequate performance. Desired outcomes may be stated as long-term or short-term as determined by the needs of the patient and the setting. Goniometxy Manual: The measurement of the movement of a joint by manual methods. Electrical: See electrogoniometry. Graded Forces: A term used in manual therapy to denote the application by the physical therapist of varying amounts of pressure on the patient's body. Graphic Rating Scale: A tool that permits a patient to express the location of pain by pointing to an illustration (eg, of the human body) and the integrity of pain by using various symbols (eg, X = sharp, 0 = dull). Grid Marks: Background lines used to assess posture (curvature, etc) during an examination. Health Care Provider: A person or organization offering health services directly to patients or clients. Health Promotion: Activity designed to develop healthy behaviors in such areas as diet, avoidance of drug abuse, etc. Health Status: The level of an individual's physical, mental, affective, and social function; health status is an element of well-being. Hemianopsia: Loss of vision for one-half of the visual field of one or both eyes. Hemostat: Anything that arrests, chemically or mechanically, the flow of blood from an open vessel. Herniated Disk: The protrusion of one of the spinal disks into an opening in the spinal cord, thereby compressing the nerve root.
History: An account of past and present health status that includes the identification of complaints and provides the initial source of information about the patient. The history also suggests the patient's ability to benefit from physical therapy services. Home, Environmental, or Architectural Barriers: The physical impediments (eg, stairs, slippery surfaces, kitchen layout) that restrain or obstruct a person's ability to function in the home or other usual environment. Hubbard Tank: A shallow tank made of stainless steel, Plexiglas, or tile, for administering hydrotherapy. Hydrodynamic: Concerned with the flow of liquids. Hydrotherapy: Treatment with external water. Hypomobility/Hypermobility: Abnormally low or high movement or ability to move (eg, of a joint). Immunodeficiency Inadequate functioning of the immune system, seen in AIDS and some other disorders. Impairment: A loss or abnormality of physiological, psychological, or anatomical structure or function. Infrared Heat: A therapy using thermal radiation with a wavelength greater than the red end of the visible spectrum. Innervation: The supply of nerve fibers to a part of the body, such as an organ. Instrumental Activities of Daily Living: Activities such as shopping, cooking, housekeeping, managing money, etc, that are important components of maintaining an independent lifestyle. Integrity: The characteristic of being whole or fully functional; see integumentary integrity and joint integrity below. Integumentary Integrity The health of the skin, including its ability to serve as a barrier to environmental threats (eg, bacteria, parasites). Intervention: The purposeful and skilled interaction of the physical therapist with the patient, using various methods and techniques to produce changes in the patient's condition. Iontophoresis: Introduction of the ions of a medication under the tissues by means of electric current. Ischemh Local anemia due to mechanical obstruction (mainly arterial narrowing) of the blood supply. Joint Integrity: The conformance of the joints to expected anatomic, biomechanic, and kinematic norms. Joint Mobility: The ability to move a joint; takes into account the structure and shape of the joint surface as well as characteristics of tissue surrounding the joint. Kinematic: Having to d o with the possible motions of a part or all of the human body. Kinesthesia: The awareness of the body's or a body part's movement. Laxity: Looseness, eg, laxity of a joint.
Loading: The force placed on a body part (eg, a foot, the feet); used often in describing the employment of an assistive device. Lymphatic: Concerned with the lymph nodes and vessels, which comprise a system for collecting fluid from the tissues and adding it to the venous blood system. Manipulation: A therapeutic movement, usually of small amplitude, accomplished at the end of the available range of motion but within the anatomical range at a speed over which the client has no control. Manual Therapy: A broad group of skilled hand movements used by the physical therapist to mobilize soft tissues and joints for the purpose of modulating pain, increasing range of motion, etc. Maceration: Softening by the action of a liquid. Magnetic Fields Energy, Pulsed: A therapy using the intermittent application of energy produced by magnetic fields. Mastication: Chewing. Mechanical: Caused by or derived from machinery; habitual, routine, automatic; related to, controlled or affected by physical forces (eg, traction device). Biomechanical: the physical structure, forces, and movements in the human body. Mentation: A mechanism of thought or mental activity. Metabolic: Concerned with metabolism, the sum of all physical and chemical changes that take place within an organism; all energy and material transformations that take place within living cells. Microvolt: One millionth of a volt. Mobilization: A therapeutic movement accomplished within the available range of motion at a speed that the patient cannot control. ModaUty(ies): Physical agent(s), including, but not limited to, thermal, acoustic, light, mechanical, or electrical energy, applied to produce therapeutic changes in biologic tissue. Motor Function: The ability to learn or demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns. Fine: Refers to relatively delicate movements such as using a fork, tying a shoelace, etc. Gross: Refers to larger-scale movements such as assuming an upright position, carrying a bag, etc. Mucous: Covered with or as if in mucus; a secretion produced by the mucous membranes. Multi-segment Motion: Simultaneous movement of several parts of the body. Muscle Length: The length of the muscle during various stages of tension (from resting at full extension through the contractile range); in conjunction with joint integrity and connective tissue extensibility, muscle length determines flexibility. Muscle Performance: The capacity of a muscle to d o work (force X distance).
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Necrotic: Dead, as in necrotic tissue. Nerve: A band of tissue that conducts impulses and connects parts of the nervous system with other organs. Nerve Root Compression: A squeezing of one of two bundles of nerve fiber emerging from the spine; frequently caused by a herniated disk. Nervous System: The brain, spinal cord, nerves, and ganglia. Central nervous system: The brain and spinal cord. Peripheral nervous system: The system of nerves in the extremities. Neural: Having to do with a nerve or nerves. Neuromotor Development: The acquisition and evolution of movement skills throughout the lifespan. Nonvolitional: Involuntary, not controllable. Objective: A measurable behavioral statement of an expected response or outcome; something worked toward or striven for; a statement of direction or desired achievement that guides actions and activities. Orthosis: A device (eg, a shoe insert, splint, brace) that supports weak or ineffective joints or muscles. Osteoporotic: Pertaining to or characterized by a porous condition of the bones; refers to a reduction in the quantity of bone or atrophying of skeletal tissue. Oxygen Consumption:The amount of oxygen inspired minus the amount of oxygen exhaled. Oxygen Saturation: The degree to which oxygen is present in a particular substance. Outcome: The result of physical therapy management expressed in five areas: prevention and management of symptom manifestation, consequences of disease (impairment, disability, and/or role limitation), cost-benefit analysis, health-related quality of life, and patient satisfaction. A successful outcome includes improved or maintained physical function when possible, slows functional decline where the status quo cannot be maintained, and/or is considered meaningful by the patient. Outcomes Analysis: A systematic examination of patient outcomes in relation to selected patient variables (eg, age, sex, diagnosis, interventions performed); outcomes analysis may be used in quality assessment, economic analysis of practice, etc. Pain: A dsturbed sensation causing suffering or distress. Palpation: Examination using the hands (eg, palpation of the spleen). PamEm Bath: A superficial heat treatment using paraffin wax and mineral oil. Pathomechanical: Describing a disturbance in function not resulting from a disease. Pathophysiological: Describing the functional changes that accompany a particular disease or syndrome. Pathway A conduction route for nerve impulses. Sensorypathway: A conduction route for nerve impulses from the sense organs. Patient: One who is being treated for an illness or injury; an individual receiving health care.
Percussion (Mechanical): A diagnostic procedure in which the clinician taps a body part with a finger or a rubber-headed hammer to estimate its density. Performance Battery: A set of tests designed to measure a patient's or client's ability to function in a particular area(s1. Peripheral Circulation: The movement of blood through the extremities. Peripheral Vascular: Concerned with the blood vessels of the extremities. Phonation: Character of speech. Photosensitivity: Sensitivity of the skin to light, usually due to the action of certain drugs (or plants, or other substances). Phototherapy Treatment using the application of light. Ultraviolet: Light therapy using rays with wavelengths beyond the violet end of the visible spectrum. Physical Agent: A form of mechanical, radiant, thermal, acoustic, or electrical energy that is applied to biological tissues in a systematic manner to achieve a therapeutic effect; a therapeutic modality used to treat physical problems. Physical Function: The measurement of physiological, biomechanical, social, and psychological performance in practical or goal-oriented terms. Physical Therapist: A licensed health professional who offers services designed to preserve, develop, and restore maximum physical function. Physical Therapist Assistant: An educated health care provider who performs physical therapy procedures and related tasks that have been selected and delegated by the supervising physical therapist. Physical Therapy Aide: A non-licensed worker, trained under the direction of a physical therapist, who performs designated routine physical therapy tasks. Planes (midline and segmental): Imaginary flat surfaces drawn through the body; the midline plane bisects the body vertically, while segmental planes are drawn at various angles. Plumb Line: A simple mechanism to measure verticality (eg, of posture) consisting of a suspended cord or similar device with a weight on one end. Postural Drainage: Placing the body in a position that causes fluid to drain from the lungs. Postural Reactions: The adjustments of the body to gravity required for normal performance; the ability to alter the position of the head, trunk, and extremities to balance one's body with gravity. Posture: The alignment and positioning of the body in relation to gravity, center of mass, and basis of support. Posture Grid: A large, lined chart placed on a wall that permits an evaluation of the postural alignment or deviation from alignment of a person standing in front of it.
Postmgraphy: Procedures to test standing posture, balance, and equilibrium sense. Power: Work produced per unit of time. Presenting Problem: The specific dysfunction that causes an individual to seek attention or intervention (ie, chief complaint). Prevention: Activities concerned with slowing or stopping the occurrence of both mental and physical illness and disease; minimizing the effects of a disease or impairment on disability; reducing the severity or duration of an illness. Primary: Preventing the development of disease in a susceptible or potentially susceptible population through specific measures such as immunization and through general health promotion efforts. Secondaty: Seeking to shorten the duration of illness, reduce severity of' diseases, decrease the possibility of contagion, and limit sequelae through early diagnosis and prompt therapy. Tertiaty: Attempting to limit the degree of disability and promoting rehabilitation and restoration of patients with chronic and irreversible diseases. Primary Care: The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (From the Institute of Medicine, 1994.) Proactive: Seizing the initiative; responding actively rather than passively; performing an action with the idea of influencing events. Prognosis: The determination of the level of maximal improvement that might be attained by the patient and the amount of time needed to reach that level. Proprioception: The reception of stimuli from within the body (eg, from muscles, from tendons); includes position sense (the awareness of the joints at rest) and kinesthesia (the awareness of movement). Prosthesis: An artificial device, often mechanical or electrical, used to replace a missing part of the body. Pulse Oximetry: Measurement of the oxygen saturation of hemoglobin in a finger through a small device that is attached to that finger. Pulses: The dilations of arteries (occasionally veins or vascular organs) that correspond to the beating of the heart. Range of Motion: Describes the space, distance, or angle through which a patient can move a joint or series of joints. Re-epitheliallzation: Skin growth to replace skin loss due to a wound or other injury. Reflex: A stereotyped reaction to a variety of sensory stimuli. Referral: A recommendation that a patient seek service from another health care provider or resource.
Rehabilitative: Concerned with restoration of a patient to full or at least improved function. Remediation: The act or process of providing some degree of relief for a patient's clinical problem(s). Respiration: A term that refers primarily to the exchange of oxygen and carbon dioxide across a membrane into and out of both the lungs and cells. Respiratory Quotient: The ratio of the carbon dioxide that the body tissues give off to the amount of oxygen that they absorb. Righting: Adjusting or restoring the body to a desired position. Role: A behavior pattern that defines a person's social obligations and relationships with others (eg, father, husband, son). Screening: Determining the need for further examination or consultation by a physical therapist or for referral to another health professional. Cognitive screening: Briefly assessing a patient's thinking process (eg, ability to process commands). Secondary Care: The management of patients seen initially by another practitioner and then referred to physical therapy; secondary care is provided in a wide range of settings, from hospitals to preschools. Self Care:The set of activities that comprise daily living, eg, rising from bed, dressing, bathing. Self-Limited (disease): A disease or condition that runs a definite course within a limited time with or without treatment. Sensory: Having to d o with sensations or the senses; includes peripheral sensory processing (eg, sensitivity to touch) and cortical sensory processing (eg, two-point and sharp/dull discrimination). Sensory Integration: The ability to integrate information from the environment in order to produce normal movement outputs. Sequential Casting: A process in which the patient is recasted several times, with each cast less restrictive than the previous one. Serous: Like serum, watery. Serosanguineous: Containing both serum and blood. Sequelae: Aftereffects of a disease or injury. SignLficant Other: A person who fulfills some or all of the roles of a spouse for another to whom he/she is not married; sometimes called a life partner. Slough: Necrotic tissue separated from living tissue. Somatic: Concerned with the body. Somatosensory: Having to d o with the sensations received in the skin and deep tissues. Somatosensoty deficit: A shortfall in the reception of sensations in the skin and deep tissues. Spinal Curve: An abnormal curvature of the spinal column (eg, S-curve, kyphosis). Splinting, Dynamic: Functional splinting that aids in the movements initiated by the patient and/or controls the plane and range of motion.
Physical Therapy / Volume 75, Number 8 1August 1995

Sprain: A joint injury without dislocation or fracture involving possible ligament or tendon rupture. Sputum: Expectorated matter, especially mucus, expelled during diseases of the air passages. Stereognosis: Comprehending the form of an object by touching it. Strain: Injury from overuse or improper use. Strengthening, Active Assistive: A form of strengthbuilding exercise in which the physical therapist applies resistance through the range of motion of the patient's active movement. Strengthening, Resistive: Any form of active exercise in which a dynamic or static muscular contraction is resisted by an outside force. The external force may be applied manually or mechanically. Stressor: A stimulus that causes a stress. Sympathetic Disturbance: A malfunction in the sympathetic part of the autonomic nervous system, which governs smooth muscle and the contraction of blood vessels. Symptom Magnification Scale: An examination tool used to elicit descriptions of levels of pain. Syndrome: The aggregate of signs and symptoms associated with any morbid process that together constitute the picture of a known disease. Synergy: The capability of properly grouping movements in order to perform acts that require special adjustments. Systems Review'. A brief or limited examination that provides additional information about the patient's general health to help the physical therapist formulate a diagnosis and select an intervention program. Telemetry: The science of measuring a quantity, transmitting the results to a distant station, and there interpreting, indicating, and recording the results. TENS (Transcutaneous Electrical Nerve Stimulation): The use of electrical energy to stimulate cutaneous and peripheral nerves via electrodes on the skin's surface. Tertiary Care: Highly specialized care, usually including a referral. Tertiary care may be defined by the setting (eg, an organ transplant unit) or by the sophistication of the service. Tests and Measures: General methods and techniques used to conduct an examination. Therapeutic Exercise: A wide range of activities (eg, biking, walking, weightlifting) designed to increase strength, improve cardiovascular fitness, increase flexibility, enlarge range of motion, or otherwise increase a person's functional capacity. Thermal: Using heat, as in a thermal agent, for its therapeutic effects. Thermistor: A device for determining temperature; may be extremely small and may also be used to establish and maintain temperature. Thermography: A process of measuring temperature by means of a registering thermometer, one form of
which records every temperature variation and registers its rise and fall on a circular temperature chart turned by clockwork. Thermotherapy: Treatment through the application of heat, causing vasodilation and thus speeding up the healing process. Tilt Table/Standing Table: Two kinds of tables used to bring patients from a supine to a vertical position in a deliberate manner. Tissue: Collection of similar cells and the intercellular substances that surround them. Contractile:Drawn together, as in scar tissue. Topical Agent: An ointment, medication, etc, applied to the skin for its therapeutic effect. Torque: A force that produces rotation or twisting of a part upon its axis. Traction: The therapeutic use of tension created by a pulling force. Mechanical: The use of tractive forces to produce a combination of distraction and gliding to relieve discomfort and increase tissue flexibility; also called passive mobilization. Transfer Training: Practical instruction in getting into or out of bed, moving from a wheelchair to a chair, etc. Treatment: One or more interventions used to cure or ameliorate a disease or pathological condition or otherwise produce changes in the patient's health status; the sum of the therapies offered to a patient during a complete episode of care. Triage: An initial review of a patient or prospective patient to determine the need for further treatment. Turgor: Fullness, swelling. Ulcer: A break in the skin surface or in a mucous membrane with loss of tissue, usually accompanied by inflammation. Decubitus: Bedsore. Vascular insufJiciency ulcers: Lesions caused by occlusion of a blood vessel or other vascular disorder. Ultrasound: A diagnostic or therapeutic technique using high-frequency sound waves. Used therapeutically, ultrasound produces heat. Pulsed ultrasound:The application of therapeutic ultrasound at frequent predetermined levels. Vasopneumatic Compression Device: A device intended to decrease swelling by "milking fluid" away from an area, eg, an inflatable sleeve strapped around a patient's swollen extremity. Ventilation: The movement of a volume of gas into and out of the lungs. Vestibular: Describing the sense of balance located in the inner ear. Visceral: Related to the internal organs. Visual Analog Scale: A tool that permits someone to express a perception or judgment (eg, of pain) by pointing to a location on a visual scale. Vital Signs: Heart rate, blood pressure, temperature, and respiration rate. Volitional: Intentional, as in controlled movement.
Volumeters, Graduated: Containers for holding fluid marked by a series of lines indicating volume. Volumetric Displacement: The amount of a fluid that leaves a container (of any size) following the introduction of part or all of the human body. Wellness: A concept that embraces a proactive, positive approach to good health. Wellness advocates seek to increase a person's level of health as a preventive measure to guard against future disease. Work Conditioning: An intensive, work-related, goaloriented treatment program designed specifically to restore an individual's systemic neuromusculoskeletal functions (strength, endurance, movement, flexibility, and motor control), and cardiopulmonary functions. The objective of the work condi-
tioning program is to restore the client's physical capacity and function to enable the client to return to work. Work Hardening: Highly structured, goal-oriented, individualized treatment program designed to return to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. Work hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors. Wound Care: Procedures used to achieve a clean wound bed, promote a moist environment or facilitate autolytic debridement, or absorb excessive exudation from a wound complex.

Appendix I I . Code of Ethics and Guidefor Professional ConducP

American Physical Therapy Association
Guide for Professional Conduct

Purpose
all physical therapists who are Association members. These guidelines are subject to changes as the dynamics of the profession change and as new patterns of health care delivery are developed and accepted by the professional community and the public. This Guide is subject to monitoring and timely revision by the Judicial Committee of the Association.
Interpreting Ethical Principles
This Guide for Professional Conduct (Guide) is intended to serve physical therapists who are members of the American Physical Therapy Association
(Association) in interpreting the Code of Ethics (Code) and matters of professional conduct. The Guide provides guidelines by which physical therapists may determine the propriety of their conduct. The Code and the Guide apply to
Code of Ethics
Preamble This Code of Ethics sets forth ethical principles for the physical therapy profession. Members of this profession are responsible for maintaining and promoting ethical practice. This Code of Ethics, adopted by the American Physical Therapy Association, shall be binding on physical therapists who are members of the Association. Principle 1 Physical therapists respect the rights and dignity of all individuals. Principle 2 Physical therapists comply with the laws and regulations governing the practice of physical therapy. Principle 3 Physical therapists accept responsibility for the exercise of sound judgment. Principle 4 Physical therapists maintain and promote high standards for physical therapy practice, education, and research. Principle 5 Physical therapists seek remuneration for their services that is deserved and reasonable. Principle 6 Physical therapists provide accurate information to the consumer about the profession and about those services they provide. Principle 7 Physical therapists accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Principle 8 Physical therapists participate in efforts to address the health needs of the public.
Adopted by the House of Delegates June 1981 Amended June 1987 Amended June 1991 American Physical Therapy Association
The interpretations expressed in this Guide are not to be considered all inclusive of situations that could evolve under a specific principle of the Code, but reflect the opinions, decisions, and advice of the Judicial Committee. While the statements of ethical principles apply universally, specific circumstances determine their appropriate application. Input related to current interpretations or situations requiring interpretation is encouraged from Association members.
Principle 1
Physical therapists respect the rights and dignity of all individuals.

1 . 1 Attitudes of Physical Therapists
A. Physical therapists shall recognize that each individual is different from all other individuals and shall respect and be responsive to those differences.
B. Physical therapists are to be guided at all times by concern for the physical, psychological, and socioeconomic welfare of those individuals entrusted to their care.
C. Physical therapists shall not engage in conduct that constitutes harassment or abuse of, or discrimination against, colleagues, associates, or others.
1.2 Confidential lnformation
A. lnformation relating to the physical therapist-patient relationship is confidential and may not be communicated to a third party not involved in that patient's care without the prior written consent of the patient, subject to applicable law.
B. lnformation derived from component-sponsored peer review shall be held confidential by the reviewer unless written permission to release the information is obtained from the physical therapist who was reviewed.
C. lnformation derived from the working relationships of physical therapists shall be held confidential by all parties. D. lnformation may be disclosed to appropriateauthorities when it is necessary to protect the welfare of an individual or the community. Such disclosure shall be in accordance with applicable law.
112 1757
Physical Therapy /Volume 75, Number 8 / August 1995

4. Develop plan of care, including Short- and goals. Physical therapists shall not engage in any sexual relationship or activity, 5. Select and delegate appropriate s u ~of I, whether consensual or ~ o ~ c o ~ s ~ ~ tasks ~ l a of n care. with any patient while a physical thera6. Assess competence of supportive pisvpatient relationship exists. personnel to perform assigned tasks.
1.4 Informed Consent
1.3 Patient Relations
the ethical principles of the Association. Principle 4 Physical therapists maintain and promote high standards for physical therapy practice, education, and research.
4.1 Continued Education
Physical therapists shall obtain patient informed consent before treatment. Principle 2 Physical therapists comply with the laws and regulations governing the practice of physical therapy.
2 1 Professional Practice
7. Direct and su~ervise supportive ~er.. sonnel in delegated tasks. 8. Identify and document precautions, special problems, contraindications, goals, anticipated progress, and plans for reevaluation. 9. Reevaluate, adjust plan of care when necessary, perform final evaluation, and establish follow-up plan.
3.3 Provision of Services
Physical therapists shall provide consultation, evaluation, treatment, and preventive care, in accordance with the laws and regulationsof the jurisdiction(s) in which they practice. Principle 3 Physical therapists accept responsibility for the exercise of sound judgment.
3.1 Acceptance of Responsibility
A. Physical therapists shall participate in educational activities that enhance their basic knowledge and provide new knowledge. B. Whenever physical therapists provide continuing education, they shall ensure that course content, objectives, and responsibilities of the instructional faculty are accurately reflected in the promotion of the course.
4.2
A. Upon accepting an individual for provision of physical therapy services, physical therapists shall assume the responsibility for evaluating that individual; planning, implementing, and supervising the therapeutic program; reevaluating and changing that program; and maintaining adequate records of the case, including progress reports. B. When the individual's needs are beyond the scope of the physical therapist's expertise, or when additional services are indicated, the individual shall be so informed and assisted in identifying a qualified provider. C. Regardless of practice setting, physical therapists shall maintain the ability to make independent judgments.
3.2 Delegation of Responsibility
A. Physical therapists shall recognize the individual's freedom of choice in selection of physical therapy services. B. Physical therapists' professional practices and their adherence to ethical principles of the Association shall take preference over business practices. Provisions of services for personal financial gain rather than for the need of the individual receiving the services are unethical. C. When physical therapists judge that an individual will no longer benefit from their services, they shall so inform the individual receiving the services. Physical therapists shall avoid overutilization of their services. D. In the event of elective termination of a physical therapisvpatient relationship by the physical therapist, the therapist should take steps to transfer the care of the patient, as appropriate, to another provider.
3.4 Referral Relationships
Review and Self Assessment A. Physical therapists shall provide for utilization review of their services. B. Physical therapists shall demonstrate their commitment to quality assurance by peer review and self assessment. Research
4.3
A. Physical therapists shall support research activities that contribute knowledge for improved patient care. B. Physical therapists engaged in research shall ensure: 1. the consent of subjects; 2. confidentiality of the data on individual subjects and the personal identities of the subjects; 3. well-being of all subjects in compliance with facility regulations and laws of the jurisdiction in which the research is conducted; 4. the absence of fraud and plagiarism; 5. full disclosure of support received;
6. appropriate acknowledgment of individuals making a contribution to the research; 7. that animal subjects used in research are treated humanely and in compliance with facility regulations and laws of the jurisdiction in which the research experimentation is conducted. C. Physical therapists shall report to appropriate authorities any acts in the conduct or presentation of research that appear unethical or illegal.
A. Physical therapists shall not delegate to a less qualified person any activity which requires the unique skill, knowledge, and judgment of the physical therapist. B. The primary responsibility for physical therapy care rendered by supportive personnel rests with the supervising physical therapist. Adequate supervision requires, at a minimum, that a supervising physical therapist perform the following activities: 1. Designate or establish channels of written and oral communication. 2. Interpret available information concerning the individual under care.
3. Provide initial evaluation.
In a referral situation where the referring practitioner prescribes a treatment program, alteration of that program or extension of physical therapy services beyond that program should be undertaken in consultation with the referring practitioner.
3.5
Practice Arrangements
A. Participation in a business, partnership, corporation, or other entity does not exempt the physical therapist, whether employer, partner, or stockholder, either, individually or collectively, from the obligation of promoting and maintaining the ethical principles of the Association. B. Physical therapists shall advise their employer(s) of any employer practice that causes a physical therapist to be in conflict with the ethical principles of the Association. Physical therapist employees shall attempt to rectify aspects of their employment that are in conflict with
Education A. Physical therapists shall support quality education in academic and clinical settings. B. Physical therapists functioning in the educational role are responsible to the students, the academic institutions and the clinical settings for promoting
4.4

ethical conduct in educational activities. Whenever possible, the educator shall ensure: 1. the rights of students in the academic and clinical setting;
vide physical therapy services if such agreements do not violate the ethical principles of the Association. Endorsement of Equipment or Services A. Physical therapists shall not use influence upon individuals under their care or their families for utilization of equipment or services based upon the direct or indirect financial interest of the physical therapist in such equipment or services. Realizing that these individuals will normally rely on the physical therapists' advice, their best interest must always be maintained as well as their right of free choice relating to the use of any equipment or service. While it cannot be considered unethical for physical therapists to own or have a financial interest in equipment companies, or services, they must act in accordance with law and make full disclosure of their interest whenever such companies or services become the source of equipment or services for individuals under their care. B. Physical therapists may be remunerated for endorsement or advertisement of equipment or services to the lay public, physical therapists, or other health professionals provided they disclose any financial interest in the production, sale, or distribution of said equipment or services.
5.3
6.2 Information about Services
2, appropriate confidentiality of personal information;

3. professional conduct toward the student during the academic and clinical educational processes; 4, assignment to clinical settings prepared to give the student a learning experience. C. Clinical educators are responsible for reporting to the academic program student conduct that appears to be unethical or illegal.
Principle 5 Physical therapists seek remuneration for their services that is deserved and reasonable.
5.1 Fiscally Sound Remuneration
A. lnformation given to the public shall emphasize that individual problems cannot be treated without individualized evaluation and plansfprograms of care. B. Physical therapists may advertise their services to the public. C. Physical therapists shall not use, or participate in the use of, any form of communication containing a false, plagiarized, fraudulent, misleading, deceptive, unfair, or sensational statement or claim. D. A paid advertisement shall be identified as such unless it is apparent from the context that it is a paid advertisement. Principle 7 Physical therapists accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts.
7.1 Consumer Protection
A. Physical therapists shall never place their own financial interest above the welfare of individuals under their care. B. Fees for physical therapy services should be reasonable for the service performed, considering the setting in which it is provided, practice costs in the geographic area, judgment of other organizations and other relevant factors. C. Physical therapists should attempt to ensure that providers, agencies, or other employers adopt physical therapy fee schedules that are reasonable and that encourage access to necessary services.
5.2 Business PracticesIFee Arrangements
C. In endorsing or advertising equipment or services, physical therapists shall use sound professional judgment and shall not give the appearance of Association endorsement.
5.4 Gifts and Other Considerations
A. Physical therapists shall report any conduct that appears to be unethical, incompetent, or illegal. B. Physical therapists may not participate in any arrangements in which patients are exploited due to the referring sources enhancing their personal incomes as a result of referring for, prescribing, or recommending physical therapy.
7.2 Disclosure
A. Physical therapists shall not: 1. directly or indirectly request, receive, or participate in the dividing, transferring, assigning, or rebating of an unearned fee. 2. profit by means of a credit or other valuable consideration, such as an unearned commission, discount, or gratuity in connection with furnishing of physical therapy services. B. Unless laws impose restrictions to the contrary, physical therapists who provide physical therapy services in a business entity may pool fees and moneys received. Physical therapists may divide or apportion these fees and moneys in accordance with the business agreement. C. Physical therapists may enter into agreements with organizations to pro-
A. Physical therapists shall not accept nor offer gifts or other considerations with obligatory conditions attached. B. Physical therapists shall not accept nor offer gifts or other considerations that affect or give an objective appearance of affecting their professional judgment. Principle 6 Physical therapists provide accurate information to the consumer about the profession and about those services they provide.
6.1
The physical therapist shall disclose to the patient if the referring practitioner derives compensationfrom the provision of physical therapy. The physical therapist shall ensure that the individual has freedom of choice in selecting a provider of physical therapy. Principle 8 Physical therapists participate in efforts to address the health needs of the public.
8.1 Pro Bono Service
Information about the Profession
Physical therapists should render pro bono publico (reduced or no fee) services to patients lacking the ability to pay for services, as each physical therapist's practice permits. Issued by Judicial Committee American Physical Therapy Association October 1981 Last Amended January 1995
Physical therapists shall endeavor to educate the public to an awareness of the physical therapy profession through such means as publication of articles and participation in seminars, lectures, and civic programs.

Guide for Conduct of the Affiliate Member

Purpose
This Guide is intended to serve physical therapist assistants who are affiliate membersof the ~~~~i~~~ physical ~ h ~ s ~ in the ~interpretation ~ i of~ the Standards of Ethical Conduct for the Physical Therapist Assistant, providing guidelines by which they may determine the propriety of their conduct. These guidelines are subject to change as new
patterns of health care delivery are developed and accepted b~ the ~ r o f e s sional community and the public. This Guide to monitoringand timely ~ ~ is subject revision ~ i by the ~ Judicial ~ Committee of the Association.
Interpreting Standards
sive of situations that could evolve under a specific standard of the Standards of Ethical Conduct for the Physical Therapist Assistant but reflect the opinions, decisions, and advice of the Judicial Committee. While the statements of ethical standards apply universally, specific circumstances determine their appropriate application. Input related to current interpretations or situations requiring interpretation is encouraged from APTA members.
Standard 1
The interpretations expressed in this Guide are not to be considered all inclu-
Physical therapist assistants provide services under the supervision of a physical therapist.
1.1 Supervisory Relationships
Standards of Ethical Conduct for the Physical Therapist Assistant

Preamble Physical therapist assistants are responsible for maintaining and promoting high standards of conduct. These Standards of Ethical Conduct for the Physical Therapist Assistant shall be binding on physical therapist assistants who are affiliate members of the Association. Standard 1 Physical therapist assistants provide services under the supervision of a physical therapist. Standard 2 Physical therapist assistants respect the rights and dignity of all individuals. Standard 3 Physical therapist assistants maintain and promote high standards in the provision of services, giving the welfare of the patients their highest regard. Standard 4 Physical therapist assistants provide services within the limits of the law. Standard 5 Physical therapist assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. Standard 6 Physical therapist assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts.
Adopted by the House of Delegates June 1982 Amended June 1991
Physical therapist assistants shall work under the supervision and direction of a physical therapist who is properly credentialed in the jurisdiction in which the physical therapist assistant practices.
1.2 Performance of Service
A. Physical therapist assistants may not initiate or alter a treatment program without prior evaluation by and approval of the supervising physical therapist. B. Physical therapist assistants may modify a specific treatment procedure in accordance with changes in patient status. C. Physical therapist assistants may not interpret data beyond the scope of their physical therapist assistant education. D. Physical therapist assistants may respond to inquiries regarding patient status to appropriate parties within the protocol established by a supervising physical therapist. E. Physical therapist assistants shall refer inquiries regarding patient prognosis to a supervising physical therapist.
Standard 2
Physical therapist assistants respect the rights and dignity of all individuals.
2.1 Attitudes of Physical Therapist Assistants
A. Physical therapist assistants shall recognize that each individual is different from all other individuals and respect and be responsive to those differences. B. Physical therapist assistants shall be guided at all times by concern for the dignity and welfare of those patients entrusted to their care. C. Physical therapist assistants shall not engage in conduct that constitutes harassment or abuse of, or discrimination against, colleagues, associates, or others.

2.2 Request for Release of Information
Physical therapist assistants shall refer all requests for release of confidential information to the supervising physical therapist.
2.3
on patients or families to purchase or lease equipment except as directed by a physical therapist acting in accord with the in paragraph 5.3.A. of the Guide for Professional Conduct.
3.4
5.1
Patient Treatment
Physical therapist assistants shall report all untoward patient responses to a supervising physical therapist.
5.2 Patient Safety
Protection of Privacy
Financial Considerations
Physical therapist assistants must treat as confidential all information relating to the personal conditions and affairs of the persons whom they serve.
2.4
Physical therapist assistants shall never place their own financial interest above the welfare of their patients.
3.5 Exploitation of Patients
Physical therapist assistants may refuse to carry out treatment procedures that they believe to be not in the best interest of the patient.
5.3
Qualifications
Patient Relations
Physical therapist assistants shall not engage in any sexual relationship or activity, whether consensual or nonconsensual, with any patient while a physical therapist assistanvpatient relationship exists.
Standard 3
Physical therapist assistants shall not participate in any arrangements in which patients are exploited. Such arrangements include situations where referring sources enhance their personal incomes as a result of referring for, delegating, prescribing, or recommending physical therapy services.
Standard 4
Physical therapist assistants may not carry out any procedure that they are not qualified to provide.
5.4
Discontinuance of Treatment Program
Physical therapist assistants shall discontinue immediately any treatment procedures that in their judgment appear to be harmful to the patient.
5.5 Continued Education
Physical therapist assistants maintain and promote high standards in the provision of setvices, giving the welfare of patients their highest regard.
3.1
Physicaltherapist assistants provide services within the limits of the law.

4.1
Supervisory Relationships
lnformation About Services
A. Physical therapist assistants may provide consumers with information regarding provision of services within the protocol established by a supervising physical therapist. B. Physical therapist assistants may not use, or participate in the use of, any form of communication containing a false, fraudulent, misleading, deceptive, unfair. or sensational statement or claim.
3.2 Organizational Employment
Physical therapist assistants shall comply with all aspects of law. Regardless of the content of any law, physical therapist assistants shall provide services only under the supervision and direction of a physical therapist who is properly credentialed in the jurisdiction in which the physical therapist assistant practices.
4.2
Physical therapist assistants shall continue participation in various types of educational activities that enhance their skills and knowledge and provide new skills and knowledge.
Standard 6
Physical therapist assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts.
6.1 Consumer Protection
Representation
'
%f;s'; ~
therapists.
Standard 5
Physical ~ therapist ~ assistants ~ shall ~ report ~ any conduct that appears to be unethical or illegal. Issued by Judicial Committee American Physical Therapy Association October 1981 Last Amended January 1995
Physical therapist assistants shall advise their employer(s) of any employer practice that causes them to be in conflict with the Standards of Ethical Conduct for the Physical Therapist Assistant.
3.3 Endorsement of Equipment
Physical therapist assistants make those judgments that are with their qualifications as physical therapist assistants.
Physical therapist assistants may not endorse equipment or exercise influence
'Reprinted with permission of the American Physical Therapy Association.

Appendix III. Guidelines for Physical Therapy Documentationa
These guidelines were developed by a subgroup of APTA's Advisory Panel o n Documentation a n d were adopted by APTA's Board of Directors in 1993. APTA thanks Karl Gibson, MS, PT; Stephen Haley, PhD, PT; a n d Robert Babbs, MPA, PT, for their work in researching a n d preparing these guidelines.
Guidelines for Physical Therapy Documentation B O D 03-9523-61 [Amended BOD 11-94-33-107;

06 -9,+09-13; Adopted BOD 03-93-21-551
BOD
01995 by the American Physical Therapy Association. All rights reserved. For more information about this and other APTA publications, contact the American Physical Therapy Association, 1111 North Fairfax Street, Alexandria, VA 22314-1 488. [Publication No. P-1131
Introduction
The American Physical Therapy Association (APTA) is committed to meeting the physical therapy needs of society, to meeting the needs and interests of its members, and to developing and improving the art and science of physical therapy, including practice, education, and research. To help meet these responsibilities, the APTA Board of Directors has approved the following guidelines for physical therapy documentation. It is recognized that these guidelines do not reflect all of the unique documentation requirements associated with the many specialty areas within the physical therapy profession. These guidelines are intended to be used as a foundation for the development of more specific documentation guidelines in specialty areas, while at the same time providing guidance for the physical therapy profession across all practice settings.
Operational Definitions
Guidehes: APTA defines "guidelines" as approved, nonbinding statements of advice. Documentation: Any entry into the client record, such as: consultation report, initial examination report, progress note, flowsheet/ checklist that identifies the carehervice provided, reexamination report, or summation of care.
I. General Guidelines
A.
AU documentation must comply with the applicable j~ictionaVregulatoryrequirements. 1 . AU handwritten entries should be made in ink
2. Informed consent shall be obtained a s required by the AFTA Standards of Practice. 2.1 The physical therapist has sole responsibility for providing information to the patient and for obtaining the patient's
informed consent in accordance with jurisdictional law before initiating physical therapy. 2.2 Those deemed competent to give consent are competent adults. When the adult is not competent, and in the case of minors, a parent or legal guardian consents as the surrogate decision maker. 2.3 The information provided to the patient should include the following: (a) a clear description of the treatment ordered or recommended, (b) material (decisional) risks associated with the proposed treatment. (c) expected benefits of treatment, (d) comparison of the benefits and risks possible with and without treatment, and (e) reasonable alternatives to the recommended treatment. The physical therapist should solicit questions from the patient and provide answers. The patient should be asked to acknowledge understanding and consent before treatment proceeds. Examples of ways in which to accomplish this documentation: 2.3.1 Signature of patient/guardian on long or short consent form, 2.3.2 Notatiodentry of what was explained by the physical therapist or the physical therapist assistant in the official record, and 2.3.3 Filing of a completed consent checklist signed by the patient. 3. Charting errors should be corrected by drawing a single h e through the error and initlallng and dating the
chart. 4. Identification:
Include patient's full name'and identification number, if applicable, on all official documents. All entries must be dated and signed with the provider's full name and appropriate designation (eg, PT, PTA). Documentation by students (SPT/SPTA) shall be countersigned by a licensed physical therapist. Documentation by graduates (GPT/GPTA) or others pending receipt of an unrestricted license shall be countersigned by a licensed physical therapist. 5. Documentation should include the manner in which physical therapy services are initiated. Examples include: 5.1 Self-referravdirect access, 5.2 Attachment of the referral/consultation request by a qualified practitioner, and
4.1 4.2 4.3 4.4

5.3 File copy of correspondence to referral source as acknowledgment of the referral.
1 1 . Initial Exadnation and Evaluation/Consultation

A. Documentation is requjred at the onset of each episode of physkal therapy care. B. Elements include: 1. Obtalnlng a history and identifying r i s k factors: 1.1 History of the presenting problem, current complaints, and precautions (including onset date). 1.2 Pertinent diagnoses and medical history. 1.3 Demographic characteristics, including pertinent psychological, social, and environmental factors. 1.4 Prior or concurrent services related to the current episode of physical therapy care. 1.5 Comorbidities that may affect goals and treatment plan. 1.6 Statement of patient's knowledge of problem. 1.7 Goals of patient (and family members and significant others, if appropriate). 2. Selecting and administering tests and measures to determine patient status in a number of areas. The
following is a partial list of these areas, with illustrative tests and measures: 2.1 Arousal, mentation, and cognition. Examples include objective findings related, but not limited, to the following areas: 2.1.1 Level of consciousness, 2.1.2 Ability to process commands, 2.1.3 Alertness, and 2.1.4 Gross expressive and receptive deficits. 2.2 Neuromotor development and sensory integration. Examples include objective findings related, but not limited, to the following areas: 2.2.1 Gross and fine motor skills, 2.2.2 Reflex and movement patterns, and 2.2.3 Dexterity, agility, and coordination. 2.3 Range of motion. Examples include objective findings related: but not limited, to the following areas: 2.3.1 Extent of joint motion, 2.3.1 Pain and soreness of surrounding soft tissue, and 2.3.2 Muscle length and flexibility. 2.4 Muscle performance. Examples include objective findings related, but not limited, to the following areas: 2.4.1 Strength, 2.4.2 Power, and 2.4.3 Endurance. 2.5 Ventilation, respiration, and circulation. Examples include objective findings related, but not limited, to the following areas: 2.5.1 Vital signs, 2.5.2 Breathing patterns, and 2.5.3 Heart sounds. 2.6 Posture. Examples include objective findings related, but not limited, to the following areas: 2.6.1 Static posture, and 2.6.2 Dynamic posture. 2.7 Gait and balance. Examples include objective findings related, but not limited, to the following areas: 2.7.1 Characteristics of gait, 2.7.2 Functional ambulation, and 2.7.3 Characteristics of balance. 2.8 Self-care or home-management status. Examples include objective findings related, but not limited, to the following areas: 2.8.1 Activities of daily living, 2.8.2 Functional capacity, and 2.8.3 Static and dynamic strength. 2.9 Community or work reintegration. Examples include objective findings related, but not limited, to the following areas: 2.9.1 Instrumental activities of daily living, 2.9.3 Functional capacity, and 2.9.3 Adaptive skills. 2.10 Other characteristics of patient performance (eg, integumentary integrity, aerobic capacity, or endurance). 3. Evaluation (a dynamic process in which the physical therapist makes clnical judgments based on data gathered during the examhation). 4. Diagnosis (a label encompassing a cluster of signs and symptoms, syndromes, or categories that reflects the information obtained from the examination). 5. Goals: 5.1 Patient (and family members and significant others, if appropriate) is involved in establishing goals. 5.2 All goals are stated in measurable terms.
118 / 763 Physical Therapy / Volume 75, Number 8 /August 1995
5.3 Goals are linked to problems identified in the examination. 5.4 Short- and long-term goals are established when applicable. (May include potential for achieving goals.) 6. htervention plan or recommendation requirements: 6.1 Shall be related to realistic goals and expected functional outcomes. 6.2 Should include frequency (eg, two times per week) and duration (eg, 3 weeks) to achieve the stated goals. 6.3 Should include patient and family/caregiver educational goals. 6.4 Should involve appropriate collaboration and coordination of care with other professionals/services. 7. Signature and appropriate designation of physical therapist.
I I I . Documentation of the Continuum of Care

k Intervention or service provided. 1 . Documentation is required for each patient visidencounter. Examples include: 1.1 Checklist, 1.2 Flow sheet, 1.3 Graph, and 1.4 Narrative. 2. Elements include: 2.1 Identification of specific interventions provided, 2.2 Equipment provided, and 2.3 Signature and appropriate designation, or initials, of: 2.3.1 The physical therapist, physical therapist assistant, or other personnel providing the service under the supervision of a physical therapist; or 2.3.2 The physical therapist who supervised the provision of service. B. Patient status, progress, or regression. 1 . Documentation is required weekly for patients seen at intervals of 1 week or less. If the patient is seen less frequently, documentation is required for every visidencounter. 2. Elements include: 2.1 Subjective status of patient. 2.2 Changes in objective and measurable findings as they relate to existing goals. 2.3 Adverse reaction to treatment. 2.4 Progressiodregression of existing therapeutic regimen, including patient education and compliance. 2.5 Communication/consultation with providers/patient/family/significantother. 2.6 Signature and appropriate designation of either a physical therapist or a physical therapist assistant. C . Reexamhation and reevaluation. 1 . Documentation is required monthly for patients seen at intervals of 1month or less. If the patient is seen less frequently, documentation is required for every visitkncounter. 2. Elements include: 2.1 Documentation of elements as identified in III.B.2.1 through III.B.2.5 to update patient's status. 2.2 Interpretation of findings and, when indicated, revision of goals. 2.3 When indicated, revision of treatment plan, as directly correlated with documented goals. 2.4 Signature and appropriate designation of physical therapist.
IV. Summation of Care

k Documentation is required following conclusion of the current episode in the physical therapy care sequence. B. Elements include: 1. Reason for discontinuation of seivice. Examples include: 1.1 Satisfactory goal achievement. 1.2 Patient declines to continue care. 1.3 Patient is unable to continue to work toward goals because of medical or psychosocial complications. 1.4 Physical therapist determines that the patient will no longer benefit from physical therapy services. 2. Current physicaVfunctiona1status. 3. Degree of goal achievement and reasons for goals not being achieved. 4. Discharge plan that includes written and verbal communication related to the patient's continuing care. Examples include: 4.1 Home program, 4.2 Referrals for additional services, 4.3 Recommendations for follow-up physical therapy care, 4.4 Family and caregiver training, and 4.5 Equipment provided. 5. Signature and appropriate designation of physical therapist.
"Reprinted with permission of the American Physical Therapy Association.

A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management PHYS THER. 1995; 75:707-764.
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A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management PHYS THER. 1995; 75:707-764.

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A Guide to Physical Therapist Practice. Volume I: A Description of Patient Management

Pbys Ther. 1995;75:R.1

744 744 745 746

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Physical Therapy / Volume 75. Number 8 /August 1995

A Guide to Physical Therapist Practice, Volume I: A Description

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Physical Therapy / Volume 75, Number 8 /August 1995

Physical Therapy / Volume 75, Number 8 /August 1995

Chapter One: Management of Physical Therapy Patients

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Physical Therapy /Volume 75, Number 8 /August 1995

3) Pmazting injury, impimzents,

4) Engaging in consultation, education, and mearch.

Physical Therapist Practice

Physical Therapy /Volume 75, Number 8 /August 1995

Secondary and Tertiary Cam

7he elements of physical therapist patient management leading to opti-

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Physical Therapy / Volume 75, Number 8 /August 1995

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projected discharge designation

8 . Systems Review. The systems

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direct intervention patient-related instruction coordination, communication, and documentation

Additional Professional Activitks of the Physical Therapist

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Physical Therapy / Volume 75, Number 8 / August 1995

Physical Therapy Sewiees: Direction and Supervision of Support Pemonnel

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the a therapy service delegated by the physical 74 / 719

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Chapter Two: Examinations Provided by Physical Therapists

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Clinical Indications. An anthropometric characteristics examination is appropriate in the presence of:

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change in baseline status of arousal, mentation, cognition

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Community or Wo& Reintegration Examination (Including lnstnrmental Activities of Daily Living)

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Physical Therapy /Volume 75, Number 8 /August 1995

Physical Therapy /Volume 75, Number 8 /August 1995

Physical Therapiy / Volume 75, Number 8 / August 1995

Physical Therapy / Volume 75, Number 8 /August 1995

temporal and spatial characteristics of movements during job tasks or activities

application of balance and gait analysis rating scales

Physical Therapy / Volume 75, Number 8 /August 1995

Clinical Indications. An integumentary integrity examination is appropriate in the presence of:

Physical Therapy /Volume 75, Number

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Clinical Indications. A motor function examination is appropriate in the presence of:

Physical Therapy / Volume 75, Number 8 / August 1995

altered level of consciousness and comprehension

normal electrical potentials in muscles description of synergies, athetotic movements, etc

Clinical Indications, A muscle performance examination is appropriate in the ~resence of:

Physical Therapy / Volume 75, Number 8 / August 1995

Physical Therapy / Volume 75, Number 8 /August 1995

Clinical Indications. An orthotic requirements examination is appropriate in the presence of:

Clinical Indications. A pain examination is appropriate in the presence of:

Physical Tlierapy / Volume 75, Number 8 /August 1995