Introduction to the

Clinical Setting
Physical Therapists and What
They Do
(APTAs Guide to Physical Therapist Practice)
Education and Qualifications
Physical Therapist
Is required to have the following:
Professionally educated at the college or
university level in physical therapy curricula
approved by the appropriate accreditation
body
Licensed in the state or states in which they
practice
Clinical Specialist
Is a physical therapist that has advanced
clinical practice competency with a
certificate awarded by the specialty-
regulating body of the professional
association in any of the specialty areas
Specialty Areas
Cardiovascular and Pulmonary Physical
Therapy
Clinical Electrophysiology
Geriatric Physical Therapy
Neurologic Physical Therapy
Orthopedic Physical Therapy
Pediatric Physical Therapy
Sports Physical Therapy
Practice Settings
Physical therapists practice in a broad
range of inpatient, outpatient, and
community-based settings, including
the following:
Hospitals (critical care, intensive care, acute
care, and sub-acute care)
Outpatient clinics or offices
Rehabilitation facilities
Skilled nursing, extended care, or sub-acute
facilities
Homes
Education or research centers
Schools and playgrounds (preschool,
primary, and secondary)
Hospices
Corporate or industrial health centers
Industrial, workplace, or other occupational
environments
Athletic facilities (collegiate, amateur, and
professional)
Fitness centers and sports training facilities
Patients and Clients
Patients
Individuals who are the recipients of
physical therapy examination, evaluation,
diagnosis, prognosis, and intervention
and who have a disease, disorder,
condition, impairment, functional
limitation, or disability
Clients
Individuals or organizations (e.g.
businesses, school systems, athletic
teams) who engage the services of a
physical therapist and who can benefit
from the physical therapists consultation,
interventions, professional advice,
prevention services, or services
promoting health, wellness and fitness
Generally accepted elements of
patient/client management typically
apply to both patients and clients
Scope of Practice
Physical Therapy
The care and services provided by or
under the direction and supervision of a
physical therapist
Physical Therapists (PTs)
The only professionals who provide
physical therapy
Specifically:
Provide services to patients/clients who
have impairments, functional limitations,
disabilities or changes in physical
function and health status resulting from
injury, disease, or other causes
Interact and practice in collaboration with
a variety of professionals
Address risk
Provide prevention and promote health,
wellness, and fitness
Consult, educate, engage in critical
inquiry, and administrate
Direct and supervise the physical therapy
service, including support personnel
Roles in Primary Care
Physical therapists have a major
role to play in the provision of
primary care, which has been
defined as:
The provision of integrated, accessible health
care services by clinicians who are accountable
for addressing a large majority of personal
health care needs, developing a sustained
partnership with patients, and practicing within
the context of family and community
APTA has endorsed the concepts of
primary care set forth by the
Institute of Medicines Committee
on the Future of Primary Care,
including the following:
Primary care can encompass myriad
needs that go well beyond the capabilities
and competencies of individual
caregivers and that require the
involvement and interaction of varied
practitioners
Primary care is not limited to the first
contact or point of entry into the health
care system
The primary care program is a
comprehensive one
Acute musculoskeletal and
neuromuscular conditions
Certain chronic conditions
Industrial and workplace settings
Roles in Secondary and Tertiary
Care
Secondary care settings
Patients with musculoskeletal, neuromuscular,
cardiovascular/pulmonary, or integumentary
disorders may be treated initially by another
practitioner and then referred to physical
therapists for secondary care in a wide range of
settings, including acute care and rehabilitation
hospitals, outpatient clinics, home health, and
school systems
Tertiary care settings
Physical therapists provide tertiary care in
highly specialized, complex, and technology-
based settings (e.g. heart and lung transplant
units, burn units) or in response to other health
care practitioners requests for consultation and
specialized services (e.g. for patients with
spinal cord lesions or closed-head trauma)
Roles in Prevention and in the
Promotion of Health, Wellness,
and Fitness
These initiatives decrease costs by
helping patients/clients:
Achieve and restore optimal functional
capacity
Minimize impairments, functional
limitations, and disabilities related to
congenital and acquired conditions
Maintain health (thereby preventing
further deterioration or future illness) and
Create appropriate environmental
adaptations to enhance independent
function
Physical therapists are involved in:
Prevention
Promoting health, wellness, and fitness
Performing screening activities
Prevention
Three types of prevention in which
physical therapists are involved:
Primary prevention
Secondary Prevention
Tertiary Prevention
Primary prevention
Preventing a target condition in a susceptible or potentially
susceptible population through such specific measures as
general health promotion efforts
Secondary Prevention
Decreasing duration of illness, severity of disease, and
number of sequelae through early diagnosis and prompt
prevention
Tertiary Prevention
Limiting the degree of disability and promoting
rehabilitation and restoration of function in patients with
chronic and irreversible diseases
Prevention screening
Physical therapists conduct screenings to
determine the need for:
Primary, secondary, or tertiary prevention
services
For further examination, intervention, or
consultation by a physical therapist or
Referral to another practitioner
Candidates for screening generally are
not patients/clients currently receiving
physical therapy services
Screening is based on a problem-focused,
systematic collection and analysis of data
Prevention activities and health,
wellness, and fitness promotion
activities
Exercise programs to prevent or reduce
the development of sequelae in
individuals with life-long conditions
Other Professional Roles of the
Physical Therapist
Consultation
Education
Critical Inquiry
Administration
Consultation
The rendering of professional or expert
opinion or advice by a physical therapist
Patient-related consultation & Client-
related consultation
Education
The process of imparting information or
skills and instructing by precept,
example, and experience so that
individuals acquire knowledge, master
skills, or develop competence
Critical Inquiry
The process of applying the principles of
scientific methods to read and interpret
professional literature; participate in,
plan, and conduct research; evaluate
outcomes data; and assess new concepts
and technologies
Administration
The skilled process of planning,
directing, organizing, and managing
human, technical, environmental, and
financial resources effectively and
efficiently
The Physical Therapy Service:
Direction and Supervision of
Personnel
Direction and supervision are
essential to the provision of high-
quality physical therapy
The degree of direction and
supervision necessary for ensuring
high-quality physical therapy
depends on many factors, including:
Education, experience, and
responsibilities of the parties involved
Organizational structure in which the
physical therapy is provided
Applicable state law
In any case, supervision should be
readily available to the individual
being supervised
Director of the Physical Therapist
Service
A physical therapist who has
demonstrated qualifications based on
clinical education and experience in the
field of physical therapy and who has
accepted the inherent responsibilities of
the role
Director of the Physical Therapist
Service
Responsibilities of the director of the physical
therapy service:
Establish guidelines and procedures that will
delineate the functions and responsibilities of all
levels of physical therapy personnel in the service
and the supervisory relationships inherent to the
functions of the service and the organization
Director of the Physical Therapist
Service
Ensure that the objectives of the service are
efficiently and effectively achieved within the
framework of the stated purpose of the
organization and in accordance with safe
physical therapist practice
Interpret administrative policies
Act as liaison between line staff and
administration
Foster the professional growth of the staff
Director of the Physical Therapist
Service
Also has responsibilities borne solely by
physical therapists
Physical Therapist
When the physical therapist directs
assistive personnel to perform specific
components of physical therapy
interventions, that physical therapist
remains responsible for supervision of the
plan of care
Physical Therapist
Regardless of the setting in which the
service is given, the following
responsibilities must be borne solely by a
physical therapist:
Interpretation of referrals when available
Initial examination, evaluation, diagnosis,
and prognosis
Physical Therapist
Development or modification of a plan of
care that is based on the initial examination
or the re-examination and that includes
physical therapy anticipated goals and
expected outcomes
Physical Therapist
Determination of:
When the expertise and decision-making
capability of the physical therapist requires the
physical therapist to personally render physical
therapy interventions and
When it may be appropriate to utilize the
physical therapist assistant
Physical Therapist
Provision of physical therapy interventions
Re-examination of the patient/client in light
of the anticipated goals and expected
outcomes, and revision of the plan of care
when indicated
Establishment of the discharge plan and
documentation of discharge summary/status
Oversight of all documentation for services
rendered to each patient
Assistive Personnel
Person(s) who may assist the physical
therapist either in selected components of
intervention or some other aspect of the
overall care of a patient
Physical Therapist Assistants (PTAs)
Physical Therapy Aides (PT Aides)
Other Assistive Personnel
Persons licensed or certified in another
discipline but who are employees in a
physical therapy service under the
supervision of a physical therapist
massage therapists
exercise physiologists
athletic trainers
Support Personnel
Not involved directly in patient care
Management
Clerical
Maintenance
Preferred Practice Patterns in
Physical Therapy
(APTAs Guide to Physical Therapist Practice)
Introduction
APTAs Guide to Physical Therapist
Practice
Also known as the Guide
APTA developed the Guide as a resource not
only for physical therapist clinicians, educators,
researchers, and students, but for health care
policy makers, administrators, managed care
providers, third-party payers, and other
professionals
The Guide serves the following purposes:
To describe physical therapist practice in general,
using the Disablement Model as the basis
To describe the roles of physical therapists in
primary, secondary, and tertiary care; in prevention;
and in the promotion of health, wellness, and fitness
To describe the settings in which physical therapists
practice
The Guide serves the following purposes:
To standardize terminology used in and related to
physical therapist practice
To delineate the tests and measures and the
interventions that are used in physical therapist
practice
The Guide serves the following purposes:
To delineate preferred practice patterns that will
help physical therapists:
Improve quality of care
Enhance the positive outcomes of physical therapy
services
Enhance patient/client satisfaction
Promote appropriate utilization of health care services
Increase efficiency and reduce unwarranted variation in
the provision of services, and
Diminish the economic burden of disablement through
prevention and the promotion of health, wellness, and
fitness initiatives
The Guide does not provide specific protocols
for treatments, nor are the practice patterns
contained in the Guide intended to serve as
clinical guidelines
The preferred practice patterns in the Guide
identify the breadth of physical therapist
practice
These are the boundaries within which the physical
therapist may select and implement any of a number
of clinical alternatives based on consideration of a
wide variety of factors, including:
Individual patient/client needs
The professions code of ethics and standards of practice
Patient/client age, culture, gender, roles, race, sex, sexual
orientation, and socioeconomic status
The Guide is not intended to set forth the
standard care for which a physical therapist
may be legally responsible in any specific case
Preferred Practice Patterns in
Physical Therapy
Found in APTAs Guide to Physical
Therapist Practice (all editions and
revisions)
Five Elements of Patient/Client
Management
The physical therapist integrates the five
elements of patient/client management in a
manner designed to optimize outcomes
The first four elements are all part of a process
that helps the physical therapist determine the
most appropriate intervention(s) (fifth element)
to address the outcomes that are desired by the
patient/client
Examination
Required prior to the initial intervention and is
performed for all patients/clients
Initial examination is a comprehensive screening
and specific testing process leading to diagnostic
classification or, as appropriate, to a referral to
another practitioner
Examination
Components:
History
Systems Review
Tests and Measures
Examination
Components:
History
Systematic gathering of data from both the past and
the present related to why the patient/client is
seeking the services of the physical therapist
Examination
Components:
Systems Review
A brief or limited examination of:
1. The anatomical and physiological status of the
cardiovascular/pulmonary, integumentary,
musculoskeletal, and neuromuscular systems and
2. The communication ability, affect, cognition,
language, and learning style of the patient/client
The physical therapist especially notes how these affect the ability
to initiate, sustain, and modify purposeful movement for
performance of an action, task, or activity that is pertinent to
function
Examination
Components:
Systems Review
Also assists the physical therapist in identifying
possible problems that require consultation with or
referral to another provider
Examination
Components:
Tests and Measures
The means of gathering data about the patient/client
From the history and systems review, the physical
therapist determines patient/client needs and generates
diagnostic hypotheses that may be further investigated
by selecting specific tests and measures
These are used to:
1. Rule out causes of impairment and functional
limitations
2. Establish a diagnosis, prognosis, and plan of care
3. Select interventions
Evaluation
Are clinical judgments of the physical therapist that
are based on the data gathered from the examination
that are synthesized to establish the diagnosis,
prognosis, and plan of care
Diagnosis
Diagnostic labels
May be used to describe multiple dimensions of the
patient/client, ranging from the most basic cellular level to
the highest level of functioning as a person in society
Typical physician diagnostic labels
Identification of a disease, disorder, or condition at the
level of the cell, tissue, organ, or system
Physical therapist diagnostic labels
Identification of the impact of a condition on function at
the level of the system (especially the movement system)
and at the level of the whole person
Prognosis (including the Plan of Care)
Prognosis
The determination of the predicted optimal level of
improvement in function and the amount of time needed to
reach that level
May also include a prediction of levels of improvement
that may be reached at various intervals during the course
of therapy
Prognosis (including the Plan of Care)
Plan of Care
Consists of statements that specify the anticipated goals
and expected outcomes, predicted level of optimal
improvement, specific interventions to be used, and
proposed duration and frequency of the interventions that
are required to reach the anticipated goals and expected
outcomes
Therefore describes:
Specific patient/client management
Timing for patient/client management for the episode
of physical therapy care
Intervention
The purposeful interaction of the physical therapist
and the patient/client and, when appropriate, with
other individuals involved in patient/client care,
using various physical therapy procedures and
techniques to produce changes in the condition that
are consistent with the diagnosis and prognosis
Components:
Coordination, Communication, and Documentation
Patient/Client-related Instruction
Procedural Interventions
Re-examination
The process of performing selected tests and
measures after the initial examination to
evaluate progress and to modify or redirect
interventions
May be indicated more than once during a
single episode of care
Re-examination
May also be performed over the course of a
disease, disorder, or condition, which for some
patients/clients may be over the life span
Indications for re-examination:
New clinical findings
Failure to respond to physical therapy interventions
Global Outcomes
Throughout the entire episode of care, the
physical therapist determines the anticipated
goals and expected outcomes for each
intervention
Global Outcomes
Beginning with the history, the physical
therapist identifies:
Patient/client expectations
Perceived need for physical therapy services
Personal goals and
Desired outcomes
Global Outcomes
The physical therapist then considers whether
these goals and outcomes are realistic in the
context of the examination data and the
evaluation
In establishing a diagnosis and a prognosis and
selecting interventions, the physical therapist
asks the question,
What outcome is likely, given the diagnosis?
Global Outcomes
The physical therapist may use re-examination
to determine whether predicted outcomes are
reasonable and then modify them as necessary
Global Outcomes
As the patient/client reaches the termination of
physical therapy services and the end of the
episode of care, the physical therapist measures
the global outcomes of the physical therapy
services by characterizing or quantifying the
impact of the physical therapy interventions on
the following domains:
Pathology/pathophysiology (disease, disorder,
condition)
Impairments
Functional limitations
Disabilities
Risk reduction/prevention
Health, wellness, and fitness
Societal resources
Patient/client satisfaction
Global Outcomes
The physical therapist engages in outcomes
data collection and analysis that is, the
systematic review of outcomes of care in
relation to selected variables (e.g. age, sex,
diagnosis, interventions performed) and
develops statistical reports for internal or
external use
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care
Consists of all physical therapy services that are:
Provided by a physical therapist
Provided in an unbroken sequence and
Related to the physical therapy interventions for a given
condition or problem related to a request from the
patient/client, family, or other provider
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care
A defined number or identified range of number of
visits will be established for an episode of care
A visit consists of all physical therapy services provided in
a 24-hour period
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care
May include transfer between sites within or across
settings or reclassification of the patient/client from
one preferred practice pattern to another
Reclassification may alter the expected range of number of
visits and therefore may shorten or lengthen the episode of
care
If reclassification involves a condition, problem, or request
that is not related to the initial episode of care, a new
episode of care may be initiated
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care
A single episode of care should not be confused
with multiple episodes of care that may be required
by certain individuals who are classified in
particular patterns
For these patients/clients, periodic follow-up is needed
over a lifetime to ensure optimal function and safety
following changes in physical status, caregivers, the
environment, or task demands
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Maintenance
A series of occasional clinical, educational, and
administrative services related to maintenance of
current function
No defined number or identified range of number of
visits is be established for this type of episode
Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Prevention
A series of occasional clinical, educational, and
administrative services related to prevention, to the
promotion of health, wellness, and fitness, and to the
preservation of optimal function
No defined number or identified range of number of
visits is be established for this type of episode
Criteria for Termination of Physical
Therapy Services
Discharge
The process of ending physical therapy services that
have been provided during a single episode of care,
when the anticipated goals have been achieved
Does not occur with a transfer that is when the
patient is moved from one site to another site within
the same setting or across settings during a single
episode of care
Criteria for Termination of Physical
Therapy Services
Discharge
There may be facility-specific or payer-specific
requirements for documentation regarding the
conclusion of physical therapy services as the
patient moves between sites or across settings
during the episode of care
Occurs based on the physical therapists analysis of
the achievement of anticipated goals and expected
outcomes
Criteria for Termination of Physical
Therapy Services
Discharge
For patients/clients who require multiple episodes of
care, periodic follow-up is needed over the life span
to ensure safety and effective adaptation following
changes in physical status, caregivers, environment,
or task demands
Criteria for Termination of Physical
Therapy Services
Discharge
In consultation with appropriate individuals, and in
consideration of the anticipated goals and expected
outcomes, the physical therapist plans for discharge
and provides for appropriate follow-up or referral
Criteria for Termination of Physical
Therapy Services
Discontinuation
The process of ending physical therapy services that
have been provided during a single episode of care,
when:
The patient/client, caregiver, or legal guardian declines to
continue intervention
The patient/client is unable to continue to progress toward
anticipated goals and expected outcomes because of
medical or psychosocial complications or because
financial/insurance resources have been expended
Criteria for Termination of Physical
Therapy Services
Discontinuation
The process of ending physical therapy services that
have been provided during a single episode of care,
when:
The physical therapist determines that the patient/client
can no longer benefit from physical therapy services
Criteria for Termination of Physical
Therapy Services
Discontinuation
When termination of physical therapy services occur
prior to achievement of anticipated goals and
expected outcomes, patient/client status and the
rationale for discontinuation are documented
Criteria for Termination of Physical
Therapy Services
Discontinuation
In consultation with appropriate individuals, and in
consideration of the anticipated goals and expected
outcomes, the physical therapist plans for
discontinuation and provides for appropriate follow-
up or referral