III STEP Series

An Integrated Framework for

Decision Making in Neurologic
Physical Therapist Practice

Decision-making frameworks are used by clinicians to guide patient manage-

ment, communicate with other health care providers, and educate patients
and their families. A number of frameworks have been applied to guide
clinical practice, but none are comprehensive in terms of patient manage-
ment. This article proposes a unifying framework for application to decision
making in the management of individuals who have neurologic dysfunction.
The framework integrates both enablement and disablement perspectives.
The framework has the following attributes: (1) it is patient-centered, (2) it is
anchored by the patient/client management model from the Guide for Physical
Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for
Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to
task analysis for interpretation of movement dysfunction. This framework
provides a mechanism for making clinical decisions, developing clinical
hypotheses, and formulating a plan of care. Application of the framework is
illustrated with a case example of an individual with neurologic dysfunction.
[Schenkman M, Deutsch JE, Gill-Body KM. An integrated framework for
decision making in neurologic physical therapist practice. Phys Ther. 2006;86:
16811702.]

Key Words: Clinical decision making, Models, Neurologic dysfunction.

Margaret Schenkman, Judith E Deutsch, Kathleen M Gill-Body

Physical
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 The proposed framework is intended
to guide physical therapist practice

D
ecision-making frameworks are instrumental
in guiding clinicians through a comprehen-
sive process of patient management, commu-
nicating with other health care providers, and
facilitating the educational process. A number of frame-
works have been applied to clinical practice over the past
2 decades for guiding clinical decision making.17 Early
frameworks were based on disablement models.8 10 Sub-
sequently, other frameworks were described based on
enablement perspectives.11,12 Most recently, the Interna-
tional Classification of Functioning, Disability and Health
(ICF)13 was developed, integrating both enablement and
disablement perspectives.14 These various frameworks
were intended to organize aspects of the patients health
condition for research, policy, and related decisions.
However, for clinical care within physical therapy, no one
framework provides enough detail for decision making.
For this purpose, it is important to separate out specific
components of enablement and disablement and to ana-
lyze their implications for patient management.
The framework proposed in this article is designed to
link the larger concepts of health (enablement and
disablement) to the scope of physical therapist practice.
The framework is intended to guide physical therapist
practice and to provide a structure for teaching clinical
decision making to future clinicians. Specifically, this
article accomplishes the following:
(1) It presents a unifying framework for making clinical
decisions by integrating and applying a variety of
conceptual models and analyses at different points
within the management process.
and to provide a structure for teaching
clinical decision making to future
clinicians.
(2) It proposes a systematic approach to task analysis for
summarizing the movement problem.
(3) It illustrates how the generation of clinical hypoth-
eses and their progressive refinement drives man-
agement choices.
(4) It uses a case example to illustrate application of the
unifying framework and systematic task analysis.
Overview of the Framework
The decision-making process we describe is patient
centered,1518 which means that the whole process is
focused around the patient as depicted in Figure 1. This
patient-centered approach contrasts with a pathology-
driven approach in which the process is initiated with
disease and culminates in disablement. The patient-
centered approach that we propose emphasizes roles
and functions of which the individual is capable and at
the same time identifies limitations in the individuals
abilities, with the goal of minimizing barriers to full
participation within society or the environment.
The framework that we describe has 4 distinct character-
istics. First, it is anchored by the structure of the patient/

M Schenkman, PT, PhD, is Professor and Director, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of
Colorado at Denver and Health Sciences Center, Denver, CO 80262 (USA). Address all correspondence to Dr Schenkman at:
margaret.schenkman@uchsc.edu.

JE Deutsch, PT, PhD, is Professor and Director of the Rivers Lab, Graduate Programs in Physical Therapy Program, Department of Developmental
and Rehabilitation Sciences, University of Medicine and Dentistry of New Jersey, Newark, NJ.

KM Gill-Body, PT, DPT, NCS, is Adjunct Clinical Associate Professor, Graduate Programs in Physical Therapy, MGH Institute of Health Professions,
Boston, Mass.

All authors contributed to each part of the manuscript, including conceptualization, writing, and editing. The authors thank Jody Cormack, PT,
DPT, for her insight and suggestions in the final drafts of the manuscript. They acknowledge substantive discussions with a number of colleagues
at the III STEP symposium and in particular thank James Gordon, PT, EdD, Lois Hedman, PT, MS, Lori Quinn, PT, EdD, and Anne
Shumway-Cook, PT, PhD. They also thank Jeffrey Lewis, who assisted with preparation of the figures.

This work was supported by National Institutes of Health grants #5 R01 HD 43770-03 and #M01 RR00051-44 and the University of Medicine and
Dentistry of New Jersey Master Educator Guild.

This article is based on a presentation at the III STEP Symposium on Translating Evidence Into Practice: Linking Movement Science and
Intervention; July 1521, 2005; Salt Lake City, Utah.

This article was received August 18, 2005, and was accepted July 14, 2006.

DOI: 10.2522/ptj.20050260

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Figure 1.
Overview of the unifying framework demonstrating the steps in the clinical decision-making process. This framework is patient centered, integrates
both enablement and disablement perspectives, and incorporates a variety of existing conceptual models and analyses at various points in the patient
management process. HOACHypothesis-Oriented Algorithm for Clinicians.
client management model, described in the Guide to
Physical Therapist Practice,19 and organizes patient man-
agement from the initial encounter through the devel-
opment and implementation of the plan of care and
outcomes measurement. Second, at each step of the
patient management process, clinical hypotheses are
generated using the Hypothesis-Oriented Algorithm for
Clinicians (HOAC)1,20 to guide decision making. The
HOAC, which has been described elsewhere,1,20 is
patient centered, hypothesis driven, and iterative. Third,
task analysis is used to examine and analyze problems
with performance of functional movement and then to
systematically summarize the movement problem.
Finally, enablement and disablement models are applied
throughout the management process, with particular
emphasis on application of the enablement perspective,
which we believe has been less well described in the
literature.
This framework was developed to provide a comprehen-
sive approach to physical therapy, which can be used to
guide clinical decisions and can be used to structure the
education of future clinicians. In the following sections
of this article, we elaborate on application of the frame-
work for the management of individuals who have
neurologic disorders. Although this article focuses on
people with neurologic dysfunction, the framework also
should be applicable across the life span to people who
have other conditions.
Physical
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History and Interview
The purpose of the history and interview is to gain an
understanding of the patient as an individual, determine
why the individual seeks physical therapy, identify what
he or she hopes to achieve through physical therapy, and
begin to formulate the examination strategy. The inter-
view and history process initiates the collaborative rela-
tionship between the patient and the physical therapist.
The interview begins by exploring questions such as the
following: What is the persons role in society, and how
is that affected by the current condition? Specifically,
what does the person do vocationally and for recreation?
What are the patients goals and identified problems?
What is it that the patient wants to be able to do that he
or she currently cannot do; in the patients view, what is
needed to overcome these functional limitations? What
assistance does the patient expect from the clinician?
What assistance does the patient need from the family or
caregivers? What assistance do the family or caregivers
need from the clinician? The patient is the primary
source for this information, but caregivers also contrib-
ute; their perspective may be different from the patients
perspective and also is important to include.21 This
process begins during the interview and is further devel-
oped during the examination.
In the proposed framework, the interview process draws
on enablement and disablement perspectives as well as
Schenkman et al . 1683
 the HOAC. To understand the proposed framework, it is
necessary to highlight salient features from these
approaches.
Application of the Enablement Perspective
The enablement model, as described by Quinn and
Gordon,7 guides the clinician to identify the individuals
participation and roles, including self-care, social, occu-
pational, and recreational activities. The enablement
model also explores the skills and resources that are
required for fulfilling roles within different environmen-
tal contexts (eg, the ability to achieve meaningful goals
with efficiency, flexibility, and consistency). Quinn and
Gordon defined resources as physical and cognitive
mechanisms, including musculoskeletal linkages, con-
trol of basic movement types and the ability to plan.7(p7)
In applying Quinn and Gordons enablement concepts
to our integrated framework, we broaden the concept of
resources to also include the social, emotional, and
societal resources at the patients disposal.
Application of the Disablement Perspective
The disablement models begin the analysis from the
underlying disease or pathology.8,9 Relevant information
is revealed during the patients report of past medical
history, and review of the medical record guides specific
questions during the interview. Specific questions also
are derived from knowledge about pathology and typical
or predicted signs, symptoms, and impairments associ-
ated with these conditions. The clinicians questions
elicit information from the patient regarding the pres-
ence and severity of these signs, symptoms, and impair-
ments. This information guides the systems review and
selection of examination procedures. Patients may iden-
tify underlying impairments that they perceive as limit-
ing (eg, weakness, stiffness, loss of feeling, pain). The
clinician may identify possible impairments through
observation and communication (eg, faulty movement
patterns, cognitive impairments).
Application of the HOAC
The HOAC1,20 is an algorithm that allows the clinician to
explore the patients concerns, referred to as the
patient-identified problems (PIPs). The clinician also
explores problems not identified by the patient but
rather by the clinician and caregivers. These problems
are referred to as nonpatient-identified problems
(N-PIPs). The clinicians perspective can be particularly
important in identifying potential future problems (pre-
vention) and in identifying functional limitations and
underlying impairments that have not risen to the level
of the patients awareness, but may become progressively
limiting. The HOAC also prompts the clinician to begin
to develop hypotheses surrounding identified problems
throughout the interview process. These hypotheses
shape the plan for further patient examination.
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Integration of Perspectives From Enablement,
Disablement, and HOAC
To illustrate how the models are integrated, we describe
the following scenario where questions from each per-
spective are asked. First, the physical therapist asks the
patient to identify his or her societal roles and any
problems he or she has in fulfilling them (eg, problems,
goals of treatment [enablement and HOAC]). The
physical therapist also solicits input from family mem-
bers and caregivers (HOAC). The physical therapist
then explores the specific abilities and skills that the
patient needs to fulfill the identified goals and ascertains
those areas in which the patient experiences difficulty
(enablement). This initial process is accomplished with-
out consideration of the primary diagnosis or past med-
ical history. When the physical therapist has completed
this portion of the history and interview, it should be
possible to answer the following questions:
What are the patients needs in terms of participa-
tion and activity?
Why is the patient here (problem and goals)?
What can the family offer?
What are the perceived needs of the family?
What is the patients social, emotional, and physical
context?
The clinician should be able to answer the above ques-
tions prior to analyzing the patients condition from a
disablement perspective. From the disablement perspec-
tive, the physical therapist explores underlying impair-
ments that could contribute to the patients functional
difficulties, based on knowledge of the pathology and its
sequelae. For example, the physical therapist proceeds
with specific questions aimed at detecting the patients
signs, symptoms, and impairments relevant to the disor-
der. All of this information, taken together, informs the
examination strategy.
Transition From Interview to Systems Review
During the history and interview, the clinician begins to
formulate hypotheses that guide the transition into the
systems review and examination (HOAC). For example,
the clinician may observe cognitive or perceptual limita-
tions that indicate the need for a detailed examination
of these systems. The clinician may observe that a patient
transitions to and from a seated position and walks with
a gait pattern typical of someone with intact sensory and
motor systems, suggesting that these systems need not be
examined in detail at the present time. Conversely, the
clinician might observe that another individual always
transitions to a standing position by pushing up from
arm rests and does not take weight symmetrically
through both lower extremities. Depending on the
patients diagnosis and premorbid and comorbid condi-
tions, the patients task performance could suggest pain,
Physical Therapy . Volume 86 . Number 12 . December 2006

loss of lower-extremity range of motion, weakness,
impaired sensory perception, or impaired motor organi-
zation. These observations, along with knowledge of the
disorder, guide the clinician to specific choices of tests,
measures, or activities to be included in the systems
review.
Systems Review
The purpose of the systems review is to rule out those
body systems with which the physical therapist need not
be concerned, identify systems that are resources for the
patient, guide choices regarding which aspects of the
remaining systems to examine in detail, and determine
whether the physical therapist should proceed or should
refer the patient to other health care providers. The
systems review can be conducted at the level of tasks or
the level of impairments, as is illustrated below.
The patient/client management model19 is used to
organize the overall systems review. Included is a review
of arousal, attention, and cognition, as well as a mini-
mum data set (eg, height, weight, heart rate after some
specific activity such as push-ups for an individual with
spinal cord injury). Four major body systems are
reviewed, related to the physical therapist practice pat-
terns, including neurologic, musculoskeletal, cardio-
pulmonary, and integumentary.
The systems review can be carried out at the level of tasks
or level of impairments, or some combination of these 2
levels. Reviewing of body systems at the level of tasks has
the advantage of emphasizing the patient-centered focus.
For this reason, we begin by describing that process.
Systems Review at the Level of Tasks
When beginning the systems review by examining tasks,
the clinician analyzes the patients overall performance
on specific relevant tasks to develop hypotheses about
which impairments should be examined in detail. If the
patients performance of a task is outside the typical
performance range for the age and sex of the patient,
the clinician proceeds to examine those specific under-
lying impairments associated with problems with perfor-
mance of the task (eg, strength [force-generating capac-
ity of a muscle], range of motion, postural control). In
the systems review, screening is conducted in a variety of
ways, including the use of measurable tasks as well as
observational analyses.
With regard to quantitative approaches to screening
tasks, performance on a number of tasks has well-
defined implications. For example, the Timed Up &
Go Test, Functional Reach Test, and Berg Balance Test
all can predict falls.2224 If the patient has difficulty with
performance on these tasks, the clinician is alerted to
perform a detailed examination of sensory and motor
Physical
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organization. However, if performance is within the
normal range on any of these measures, it may not be
necessary to assess specific elements of postural control
(or balance) such as sensory organization. Similarly, the
Six-Minute Walk Test25 can be used to identify potential
problems with cardiovascular or musculoskeletal endur-
ance that need to be further examined.
Observational task analysis also can be used in the
systems review. For example, requirements for the sit-to-
stand task include force generation of specific muscle
groups, range of motion at specific joints, and balance
and postural control.26 28 The clinician might ask a
patient to stand from a low seat in order to quickly
obtain an assessment of lower-extremity strength and
balance control. If the patient has difficulty performing
the task, the clinician could be guided to include a
detailed assessment of strength and postural control in
the examination. Alternatively, if the patient is able to
rise to a standing position successfully and smoothly, the
clinician may logically conclude that lower-extremity
strength is, at a minimum, in the fair range and that
postural control is adequate for this task. The clinician
then may chose to defer detailed examination of these
areas.
Systems Review at the Level of Impairments
The clinician also can choose to begin the systems review
by examining specific impairments. Examination of
impairments can draw on a variety of standard tests and
measures (eg, reflexes, range of motion, muscle perfor-
mance, sensory integrity), many of which are well artic-
ulated in the Guide to Physical Therapist Practice.19 Impair-
ments also can be measured using standardized tests
such as the Orpington test,29 which measures 4 areas:
motor deficit of the arm, proprioception, balance, and
cognition. The scores can be summarized to identify
disease severity. Additionally, looking at test scores in
each of the domains of the test may guide the clinician
to perform a more detailed examination.
Models That Inform the Systems Review
In contrast to the interview, where the enablement
perspective leads off the process, the systems review is
more heavily focused on a disablement perspective. This
is because a major purpose of the systems review is to
identify those systems that are impaired.
A number of disablement models provide guidance
regarding systems that are likely to be compromised with
specific diseases, injuries, or disorders. These disable-
ment models include, but are not limited to, the World
Health Organization (WHO) model8 and the Nagi mod-
el.9 The work of Verbrugge and Jette10 draws attention to
factors that should be reviewed as a result of previous
medical history (comorbid conditions). For example,
Schenkman et al . 1685
 when an individual is admitted with a stroke and a
previous history of diabetes mellitus, it is particularly
important to screen for impairments associated with
diabetes (eg, sensory and integumentary integrity of the
distal extremities). When an individual has worked in
the mines throughout his adult life, it is particularly
important to carefully review the respiratory system.
Schenkman and Butler2 further elaborated on the dis-
ablement models to make them applicable to clinical
decision making for neurologic physical therapist prac-
tice. To this end, the models of Schenkman and col-
leagues2,3,5 draw attention to systems that may be
impaired as sequelae of the injury or disorder for which
the patient seeks treatment. For example, an individual
who sustained a stroke some years ago and was sedentary
thereafter is likely to have secondary cardiovascular
deconditioning.30 An individual with Parkinson disease
(PD) is likely to have lost substantial range of motion in
the axial structures.31,32 Schenkman and colleagues have
applied this model to patients with PD, and the model
has been tested in several experimental studies, demon-
strating relationships between range of motion and both
functional and kinematic measures of standing reach as
well as improvement of functional reach following use of
exercises to improve axial range of motion.3133
In contrast, the enablement model draws attention to
physiologic reserves that may be resources to the patient.
For example, compared with more sedentary individu-
als, the distance runner may have substantial cardio-
vascular reserve and the practitioner of yoga may have
enhanced flexibility. Hypotheses regarding the presence
and extent of physiological reserves can be tested in the
systems review or during the examination.
On completion of the initial systems review, the physical
therapist should be able to accomplish the following
specific tasks associated with disablement:
Arousal, attention, and cognition:
Determine the appropriate style of interaction
with this patient and the need to modify further
examination or intervention procedures.
Identify the need for further examination
(eg, Mini-Mental State Exam).
The primary disorder:
Rule out potential problems and issues that
could occur with patients primary disorder but
do not exist for this particular patient.
Identify those body systems that are impaired and
need further examination to determine the
severity of involvement.
Determine which specific impairments will be
examined.
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Impairments associated with comorbid conditions
(pathology or disease)10:
Determine which specific impairments will be
examined in-depth, based on factors such as age,
recreational activities, and work history.
Secondary impairments2:
Identify which impairments are present among
those that typically occur as sequelae to the
primary disorder in systems other than the one
for which the patient sought physical therapy
care.
With respect to the enablement model, the clinician
should be able to accomplish the following tasks:
Communication
Determine the patients preferred style of com-
munication and learning.
Resources
Identify those systems that are particularly well
developed for the patient and can be or are used
to facilitate functional ability.
Transition From Systems Review to Examination
As information is gathered during the systems review,
the clinician integrates findings with those obtained
during the history and continues to develop clinical
hypotheses. These hypotheses may explain relationships
among existing impairments and functional abilities;
hypotheses also may identify key issues that should be
examined related to the patients environment. For
example, the clinician may make decisions about which
tasks to examine further and how to manipulate the
environment during further examination. Additionally,
the clinician often develops initial hypotheses about
prognosis.
Examination
The specific purposes of the examination may vary and
depend on the reason for which it is carried out. The
level of examination is adjusted to reflect patient-
identified problems and goals and can be drawn from
elements of the continuum of the ICF model. For
example, the examination takes into account relevant
resources (enablement), activities, participation, and
quality of life, as well as underlying impairments (dis-
ablement). For the purposes of this discussion, a distinc-
tion is made between the initial examination and subse-
quent re-examination, although examination takes place
throughout the patient management process.1,20
The initial examination provides data that can be used to
accomplish some or all of the following purposes:
(1) perform triage (eg, to determine whether referral to
Physical Therapy . Volume 86 . Number 12 . December 2006

another health care professional is needed), (2)
describe the movement problem for key tasks that are
meaningful to the patient within a relevant environmen-
tal context (eg, walking in the dark; crawling across the
carpet), (3) identify patients resources and impair-
ments, (4) test hypotheses from the history and systems
review, and (5) formulate prognoses (eg, expected
degree of recovery following a stroke, expected develop-
mental problems following premature birth). In addi-
tion, the examination leads to the ability to provide a
basis from which to determine the approach to the plan
of care and to determine potential outcome measures.
Subsequent re-examination includes the following purpos-
es: (1) test existing hypotheses, (2) develop and test new
clinical hypotheses when the initial hypotheses are not
supported by the patients response to intervention, and
(3) obtain specific outcome measurements.
As the clinician proceeds through the examination
process, there is an ongoing synthesis and analysis, as
outlined by the HOAC.1 Information from one set of
tests provides guidance regarding the next logical
choices of tests and measures. This ongoing analysis
complements, but does not replace, the overall synthesis
of findings that occurs in the evaluation.
The strategy and depth of the examination may vary,
depending on the purposes. Relevant issues to consider
include the patients level of function, the purposes of
the examination (eg, prognosis, plan of care), and the
clinicians preferred style. The purposes of the examina-
tion also set specific limits regarding what information
will be obtained. For example, if the sole purpose is for
formulation of a prognosis, the clinician may select a
specific focused examination approach (eg, the Fugl-
Meyer examination to predict recovery from stroke,34
the Gross Motor Function Classification to predict func-
tion in children with cerebral palsy,35 Glasgow Coma
Scale to predict outcome after traumatic brain injury36).
If the purpose is to develop a plan of care and measure
outcomes, the clinician might chose measures such as
the Unified Parkinsons Disease Rating Scale (UPDRS)37
or functional measures for children such as the Pediatric
Evaluation of Disability Inventory (PEDI) or the Gross
Motor Function Measure (GMFM),34,38 41 all of which
are sensitive to change.
For purposes of developing a plan of care, the following
information should be obtained:
Level of independence or dependence for func-
tional activities of greatest importance to the
patient, including level of assistance needed, use of
external devices, or environmental modifications;
Physical
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Analysis of task performance for a variety of func-
tional activities under various environmental condi-
tions; and
Possible reasons underlying the difficulty or inabil-
ity to perform the task, including relevant impair-
ments and environmental barriers.
The examination begins by observation of functional
activities (eg, walking, getting up from a bed or a chair).
The clinician decides the order in which the examina-
tion data will be obtained. For example, the clinician
might begin with a detailed task analysis of specific
functional activities and work backward toward under-
lying resources and impairments. Using this approach,
the clinician performs the detailed task analysis, devel-
ops hypotheses related to likely underlying impairments,
and proceeds with the specific tests and measures that
are most likely to identify the presence and severity of
existing impairments. This detailed task analysis is more
specific and systematic than the task analysis used during
the systems review, as is illustrated below.
The use of task analysis to make judgments during the
examination requires knowledge of the literature link-
ing performance and impairments and clinical experi-
ence to recognize patterns of performance and their
implications regarding underlying impairments. There-
fore, this strategy may be difficult for the novice
clinician.
Alternatively, the clinician might begin by examining
those impairments identified during the systems review
as well as those known to occur with the specific under-
lying disorder and its sequelae, as well as comorbid
conditions. The clinician might proceed next to a
detailed analysis of task performance. Using this route
into the examination process, the clinician works for-
ward from impairments to ability to perform functional
tasks.
Whatever examination approach is used, the clinician is
judicious in determining what should be examined so
that the maximum information can be obtained from
the fewest possible tests and measures. To make judg-
ments, the clinician draws from the patients problems
and goals, the clinicians knowledge of the disorder, and
premorbid and comorbid conditions. In reality, exami-
nation often proceeds as a combination of these 2
approaches. For clarity, however, these 2 approaches are
discussed as distinct processes beginning with task
analysis.
Examination at the Level of Task Analysis
Task analysis is a detailed observational analysis of the
patients total body movement patterns during task
performance.42 Task analysis helps clinicians to deter-
Schenkman et al . 1687

Figure 2.
The elements of task analysis. The environment and temporal sequence
are 2 elements of the task analysis that are applicable to all tasks.
Strategies and phases of movement, elements that are task specific, may
add useful information to the systematic task analysis.
mine whether the patients movement performance is
within a range of typical performance and to determine
where within the performance specific problems occur.
The results of the task analysis shape the plan of care,
which typically is focused around improvement of
function.
As movement specialists,43,44 it is incumbent upon phys-
ical therapists to analyze movement. Task analysis
(Fig. 2) is the route through which the physical therapist
carries out this central aspect of physical therapist prac-
tice. Indeed, task analysis is one of the skills that defines
the physical therapist, and therefore synthesizes many
of the skills taught throughout the physical therapy
curriculum.
In our framework, we propose a systematic approach to
task analysis, based on work of Gentile45 and of Hedman
and colleagues.46,47 These 2 approaches to task analysis
were chosen because they are global in that they are
applicable to any task and because they give a compre-
hensive description of task performance that is sufficient
for designing the plan of care. For specific tasks, this
information can be augmented by drawing from the
growing body of available literature focused on move-
ment analysis of particular tasks (see Shumway-Cook and
Woollacott48 for examples). Specific application of the
proposed task analysis is outlined below.
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Task and environment. Performance of a task can vary
substantially, depending on the conditions under which
it is performed.49 For this reason, it is important to
examine tasks under conditions comparable to those in which
the individual typically functions. Tasks can be described or
categorized in many ways. In the proposed model, the
task and environment are categorized as follows, based
on 4 conditions adapted and simplified from the work of
Gentile.45 Two variables are manipulated: the individual
and the environment. The 4 task and environment
categories that we suggest using are:
(1) Stationary individual in a stationary environment
(eg, sitting quietly on a treatment mat in a quiet
treatment area).
(2) Moving individual in a stationary environment
(eg, walking in a quiet treatment area).
(3) Stationary individual in a moving environment
(eg, standing still in a busy clinic environment).
(4) Moving individual in a moving environment
(eg, walking in a busy clinic environment).
We suggest that the first step in task analysis, then, is to
categorize the tasks included in the examination into 1
of these 4 categories.
Other terms describing task attributes also may be useful
to consider as the clinician performs the systematic task
analysis. For example, tasks can be categorized as dis-
crete with a recognizable beginning and end (eg, com-
ing from a standing position to a sitting position),
continuous with no discernable beginning or end
(eg, walking), or serial with discrete movements per-
formed sequentially (eg, coming from sitting in an
armchair to standing, walking, turning, and sitting at the
kitchen table).48(p5)
To categorize tasks using this simplified version of
Gentiles taxonomy,45 we consider all of the relevant
attributes of the task and the environment that go into
the completion of the task. Included are considerations
such as the support surface (eg, height, compliance),
base of support, lighting, use of arms, and assistive
devices. For example, walking on the beach with a cane
is very different in terms of environment and task
performance than walking in the physical therapy gym;
the relevant sensory, motor, perceptual, and cognitive
issues must be taken into account.
Categorization of the task and environment as we pro-
pose provides critical information regarding the types of
tasks and environmental conditions under which a
patient may be experiencing difficulty with functional
Physical Therapy . Volume 86 . Number 12 . December 2006

Figure 3.
The temporal sequence identifies 5 stages of task performance that can be considered during task analysis and the specific features of importance
for each stage. Reprinted with permission of the publisher from: Hedman LD, Rogers MW, Hanke TA. Neurologic professional education: lining the
foundation science of motor control with physical therapy interventions for movement dysfunction. Journal of Neurologic Physical Therapy.
1996;20:9 13.
abilities during daily activities. However, clinicians also
need to identify where within performance of the task the
difficulty occurs. For this purpose, we propose the use of
a temporal sequence to analyze the movements that
comprise the task as outlined by Hedman and col-
leagues.46,47 It is important to note that, as with the work
of Gentile,45 we are highlighting selective aspects of their
work.
Temporal sequence. Hedman and colleagues46,47 pro-
posed that task analysis can be conducted by considering
the temporal sequence of movements that comprise the
task. Use of this approach directs clinical decision mak-
ing. Applying their concepts to our model, we ask the
following questions:
What is the problem with completing the task?
Where along the movement continuum does the
problem interfere with function?
What are the underlying determinants of the
problem?
How do we intervene?
From concepts of Hedman and colleagues,46,47 perfor-
mance of any task can be differentiated into the follow-
ing 5 stages of movement: initial conditions, prepara-
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tion, initiation, execution, and termination (Fig. 3).
Features that influence performance of the tasks are
described at these specific points in the temporal
sequence (including timing, direction, amplitude, and
smoothness of movement). This observational analysis
guides the clinician to specifically target the stages
within the temporal sequence of the task where the
movement is compromised (eg, initial conditions versus
termination) and to generate ideas for intervention.
Additionally, this observational analysis guides the clini-
cian to identify the nature of the problem with move-
ment (eg, direction, amplitude) at each stage in the
temporal sequence, further refining decisions regarding
the optimal approach to intervention.
Underlying causes. Identification of the stages of move-
ment where problems occur does not, in isolation,
provide enough information for treatment planning. In
addition, at the specific stages within the temporal
sequence where problems are observed, the clinician
next identifies possible underlying causes for the task
difficulty. Hedman et al46 referred to these causes as
determinants or clinical components of movement; we
refer to them as impairments. These determinants fall
under 3 categories: neurologic (structures and pathways
that participate in control of the movement), biome-
Schenkman et al . 1689
 chanical (referring to structure and properties of mus-
cles, joints, and soft tissue), and behavioral (referring to
cognitive, motivational, perceptual, and emotional
aspects). These authors acknowledged that not all deter-
minants can be identified by observing the patients task
performance. However, 2 aspects of the determinants
can be considered as the patient is observed: (1) the
possible underlying sensory, motor, and musculoskeletal
impairments and (2) the synergistic coordination of
groups of muscles during performance of tasks. These 2
aspects are discussed below.
Determinants (impairments) are considered at each
stage in the temporal sequence of the task to guide
decisions regarding which impairments to examine in
detail. Identification of the contributing impairments
eventually helps the clinician to determine optimal
interventions. For example, if force production is one of
the main causes of difficulty with the execution stage
during the sitting-to-standing activity, it may be necessary
to include interventions that improve force production.
Analysis of individual impairments in isolation may only
partially explain difficulty with task performance. For
example, just because a muscle can fire, does not mean
that it will fire in the appropriate synergistic combina-
tion during performance of a task. Appropriate synergis-
tic firing of muscles can be problematic for any patient
and can be of particular concern for those with under-
lying neurologic dysfunction. For this reason, it can be
important to examine synergistic coordination of muscle
groups.
The coordination of synergistic groups of muscles has
some overlap with Hedman and colleagues concept of
determinants of movement,46,47 but goes beyond those
concepts. From a kinesiological perspective, purposeful,
functional movement is accomplished by coordination
of muscle groups throughout the body. Included are
prime movers, secondary movers, synergists (helping
and stabilizing), and whole-body stabilizers.50 With neu-
rologic injury, appropriate coordination of these various
muscle groups is frequently disrupted. At times, individ-
uals have the ability to produce adequate force when
muscles are examined in isolation, but they are unable to
produce force in appropriate synergistic combinations
during functional activities. Conversely, it may be possi-
ble to produce force in a muscle group only during
whole-body movements (or in combination with other
muscle groups) but not during isolated limb or joint
movements. Thus, examination of force production in
isolation may not be adequate to fully identify the
underlying causes of movement dysfunction. When pat-
terns of movement appear inappropriate or inefficient
for the task, the clinician can use observational and
manual skills to determine which muscles within a
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synergistic combination are likely participating and
which are not. This important part of the analysis of
movement has not received much attention in recent
literature and, as a consequence, may be overlooked.
The coordination of synergistic activity can be analyzed
in a systematic fashion, drawing from principles of
biomechanics and kinesiology, beginning with the ability
to stabilize against gravity, move while in relatively
supported positions (eg, recumbent, sitting), and move
while in relatively unsupported positions (eg, standing),
and progressing to the coordination of complex transi-
tional movements (eg, walking, reading). Results of the
analysis of synergistic coordination can guide the clini-
cian in making decisions about which aspects of the
coordination of synergistic activity to emphasize within
the intervention (ie, the ability to stabilize, shift weight
while remaining stable, shift weight while in less stable
positions, or coordinate complex transitional move-
ments). The clinician determines whether problems
with synergistic coordination are observed at only one or
at several of the following points in the temporal
sequence: initiation, execution, and termination of the
movement.
In summary, on completion of this systematic task anal-
ysis as we propose, the clinician can identify the task and
environmental conditions under which the patient has
difficulty, identify the stages in the temporal sequence of
movement where the difficulty is most evident, and
hypothesize about the underlying determinants of the
difficulty. The underlying determinants may include
impairments (eg, force production, coordination) as
well as coordination of synergistic groups of muscles.
This proposed approach to task analysis is generic in that
it can be used with any patient for analyzing perfor-
mance of any task.
The clinician can augment this generic analysis of task
performance by drawing from the extensive body of
literature that is task specific. This task-specific literature
focuses around strategies of task performance. The term
strategies refers to those motor patterns that are used
to accomplish the task, including how a person organizes
sensory and perceptual information.48(p123) Strategies
provide an overall description of the way the task is
performed. Strategies have been described for a number
of important activities under a variety of environmental
and task conditions. For some of these tasks, strategies
are broken down into component parts or phases
(eg, sit to stand,51 reach and grasp52) or into neuro-
physiological descriptions.53 The following examples are
provided to illustrate this point, but are by no means
comprehensive.
Physical Therapy . Volume 86 . Number 12 . December 2006

Phases have been described by a number of authors for
whole-body activities (eg, gait,54 56 sit to stand51) and for
upper-extremity reaching tasks.52 Strategies that are used
by healthy individuals of various ages have been
described as typical for getting up from the floor or
bed.5759 These and other approaches to stages and
strategies can be used to focus the clinicians observation
and analysis of these specific tasks. As another example,
when working with individuals who have balance dys-
function associated with vestibular damage, identifica-
tion of sensory organization strategies may be critical for
designing effective interventions.60 62 When working
with an individual after a cerebrovascular accident, it
may be helpful to determine whether the individual
transitions from a sitting position to a standing position
at a fast speed, utilizing momentum (momentum strat-
egy), or moves at a slow speed, relying primarily on
lower-extremity force (stabilization strategy).63
Examination at the Level of Impairments
Whether the clinician begins with task analysis or with
impairment testing, at some point in the examination,
the clinician may need to test specific impairments. As
with the systems review, examination of impairments can
draw on a variety of standard tests and measures
(eg, reflexes, range of motion, muscle performance,
sensory integrity), many of which are well articulated in
the Guide to Physical Therapist Practice.19 Additionally,
many resources are available to direct the clinician to
examine specific impairments.64,65
Summary
To summarize, task analysis and impairment testing are
used by clinicians to perform the patient examination.
Although the clinician can chose either entry point into
the examination, task analysis, in our opinion, is an
essential component of the process. Task analysis
informs the general approach to intervention as well as
those specific elements that will be incorporated into the
plan of care. This process is further elaborated on in the
next section on evaluation.
Evaluation
The evaluation consists of an interpretation of findings
in order to develop a realistic plan of care. The plan of
care is based on a synthesis of the information from all of
the previous steps, including the patients goals and
expectations, task performance, the patients resources
and impairments, and the medical diagnosis and prog-
nosis for the condition. This synthesis results in the
following: (1) identification of the most important prob-
lems for the patient (including both PIPs and N-PIPs),1
(2) evaluation from both enablement and disablement
perspectives, and (3) summary of the movement prob-
lem. This information leads to the clinicians ability to:
(1) develop a diagnosis and prognosis, (2) develop
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realistic goals and selection of appropriate outcomes
measures, and (3) determine the overall approach to
intervention as well as selection of the specific elements
for the plan of care. Each of these elements is discussed
below.
One of the first steps to the evaluation is for the clinician
to determine whether the patients goals are realistic and
appropriate. If they are inappropriate, it is necessary for
the patient and clinician to negotiate goals that are
meaningful to the patient as well as realistic.
Next, the clinician synthesizes all available information
in relation to the patients main concerns, aspirations,
and life circumstances. Included is an evaluation of
relationships among all findings. This evaluation weighs
the patients resources and impairments and analyzes
relationships among direct and indirect effects of the
disorder.
The plan of care is patient centered and often is focused
around task performance. Therefore, an important step
in the evaluation process is the analysis and summary of
the movement problem. This information allows the
clinician to design an overall approach to intervention
and to determine how to implement the intervention.
Specifically, the analysis of the task and environment
relationship allows the clinician to determine whether
the patient has difficulty with all tasks in all environ-
ments (eg, cannot even sit unsupported on a stationary
mat), has difficulty with only more demanding tasks and
environments (eg, moving in a moving environment), or
has some combination of these difficulties. This analysis
guides the clinicians choice of the environment in
which to work. The nature of the task (eg, discrete versus
serial) with which the patient has problems further
informs the clinicians decisions regarding the specific
plan of care. Identification of where the problem is
within the temporal sequence assists in the determination of
whether to focus the intervention on initial conditions,
initiation, execution, or termination of the task (or some
combination thereof). Finally, the clinicians choices
regarding how best to focus the intervention are guided
by identifying the underlying impairments influencing
task performance.
This overall approach to evaluation flows directly from
the task analysis and should be fairly consistent across
physical therapists. For example, if the movement prob-
lem for a patient occurs when the patient moves in
stationary environments, is most apparent during initia-
tion and execution of a specified task, and relates to
problems with postural control, then the overall
approach to intervention should address each of these
issues. The specific treatment techniques that the indi-
Schenkman et al . 1691
 vidual clinicians choose may vary, but the focus must be
on the issues identified (ie, execution of tasks within a
stationary environment, difficulty with postural control).
In summary, at the end of the evaluation of relevant tasks
and impairments, the clinician should be able to answer
the following questions:
(1) In what environmental contexts does this individual
have difficulty performing the task(s)?45
(2) Within the environmental context, what other issues
are of importance (eg, height of the chair seat, base
of support, lighting, compliance of the support
surfaces)?
(3) How does the movement problem manifest itself
with regard to the temporal sequence of movements
that comprise the task?46,47
(4) Which key underlying impairments likely affect spe-
cific or multiple stages within the temporal
sequence of task performance?
(5) Does the patient have difficulty coordinating syner-
gistic groups of muscles and under what conditions?
Using these elements of the task analysis, the clinician
develops a summary of the movement problem. Two
examples that illustrate this process follow.
Task Analysis for an Individual Who Sus-
tained a Cerebrovascular Accident (CVA)
A patient with a chronic CVA with residual loss of
upper-extremity control seeks physical therapy to
be able to increase the use of the affected upper
extremity under a variety of environmental condi-
tions. One difficulty that the therapist identifies is
difficulty with the grasp and manipulation phases
of the task of taking a tissue out of box. (This
difficulty was environment neutral). The therapist
observes that the initial conditions of the move-
ment may not be biomechanically optimal because
the persons trunk alignment may subsequently
produce abnormal scapular movements. The exe-
cution of the task is most affected because the
person does not seem to generate the force pro-
duction or the precision of finger movements to
remove the tissue. The compensatory trunk move-
ments have created a pattern of distal upper-
extremity control that interferes with achieving the
task. The therapist identifies initial conditions and
execution as the 2 phases to work on.
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Task Analysis for an Individual Who Has
Unilateral Vestibular Disorder
A patient 6 weeks after the onset of labrynthitis
seeks physical therapy to improve his balance and
be able to resume commuting to work on the bus.
The patient appears unstable when walking and
climbing stairs, often holding on to a rail or
touching the wall to maintain balance. Task anal-
ysis reveals that the patients primary difficulties
are with execution and termination of movement
in standing and walking in all environments, with
the most difficulty when he is moving in a busy
environment. He is malaligned in standing, which
may contribute to difficulties with balance. The
patient appears to have difficulty stabilizing body
segments, moving within and between postures,
and coordinating between postures and move-
ments to accomplish functional activities. Impair-
ments in flexibility, sensory organization, and
motor control also are likely contributing to his
overall balance problem. He is visually reliant with
very limited use of vestibular inputs for postural
control. The therapist identifies execution and
termination as the 2 phases to concentrate on.
Diagnosis and Prognosis
The diagnosis and prognosis are critical to shaping the
final plan of care. For example, a patient with a neuro-
degenerative disorder may have signs and symptoms
quite similar to those of a patient with a nonprogressive
neurologic injury. However, the course of the 2 disor-
ders can be quite different, which has a great effect on
appropriate goal setting and the overall plan of care.
Diagnosis, as performed by a physical therapist, refers to
the cluster of signs and symptoms, syndromes, or cate-
gories and is used to guide the physical therapist in
determining the most appropriate intervention strategy
for each patient.19 The physical therapy profession has
grappled for some time with the best means by which to
summarize diagnosis but has not yet reached a consen-
sus for individuals with neurologic dysfunction. This has
been a source of discussion across the profession and in
neurologic physical therapist practice in particular.66 68
As a first approach to diagnosis, the clinician can identify
the practice patterns under which this condition falls,
using the Guide to Physical Therapist Practice.19 The pre-
ferred practice patterns describe the elements of the
management process for patients with specific medical
diagnoses as well as strategies for primary prevention
and reduction of risk factors. Identification of the prac-
tice pattern, however, is not sufficient. As an evolving
approach to the diagnosis made by the physical thera-
pist, one of the important elements is diagnosis of the
movement problem.44 Ultimately, given the role of phys-
ical therapists as movement specialists, task analysis
Physical Therapy . Volume 86 . Number 12 . December 2006

should form the basis of the diagnosis. It is our hope that
this framework will stimulate further discussion and
eventual application of task analysis for diagnostic
purposes.

Prognosis for physical therapist practice refers to the

predicted optimal level of functional improvement that
can be expected and the amount of time required for
the patient to reach that level.19 The preferred practice
patterns in the Guide to Physical Therapist Practice19 pro-
vide a range of the number of visits required to manage
this condition.19 The clinician can narrow this range
through analysis of literature specifically related to prog-
nosis for the condition.

Prognosis represents a synthesis, based on an under-

standing of the pathology, foundational knowledge,
theory, evidence, experience, and examination findings
and takes into account the patients social, emotional,
and motivational status. Included in the synthesis are the
following: prognosis for this disorder (eg, a patient with
amyotrophic lateral sclerosis is likely to live 35 years),69
prognosis for neurologic recovery (eg, following stroke,
initial change scores on the Fugl-Meyer examination
predict eventual neurologic recovery),70 and prognosis
for functional change (eg, even years after an incomplete
spinal cord injury or stroke, some patients can make
substantial and meaningful functional recovery.)71,72
The patients aspirations and PIPs determine the focus
of the goals. Priorities are based on patient-identified
priorities for participation, functional ability, and task
performance. Non-PIPs also are considered by the clini-
cian, who should weigh the relative importance of
problems that he or she identifies, as well as those
identified by family members and caregivers. Taking all
of this information into account, the clinician and
patient come to an agreement regarding the most
important problems around which care should be
focused and together establish relevant goals. Goals
must be realistic and able to be achieved within the
constraints of the health care system.
Outcome measures reflect the patients goals. Outcome
can be measured in terms of qualitative changes directly
related to the patients goals (eg, patients goal is to feel
satisfied with his or her level of physical independence)
and quantitative changes related to task performance or
functional abilities that are interpreted as being essential
to meet the patients goals.
In summary, the evaluation draws on information from a
variety of frameworks and models. The HOAC1,20 is used
to understand the patients perceived problems and
related goals. The enablement perspective7,11 draws
attention to the patients resources, desires, and skills.
Figure 4.
Plan of care. The 3 distinct approaches to intervention are identified as
well as the elements important to address within any intervention
approach (environment, learning variables, dose).
The disablement perspective2,8 10 is used to interpret
underlying causes of dysfunction and prognosis, and task
analysis provides a summary of specific movement prob-
lems. By synthesizing all of this information, the clinician
and patient together arrive at goals that are meaningful
to the patient and a plan of care that is appropriate to
the goals. This synthesis guides the clinicians decisions
regarding when to use rehabilitative approaches, when
to teach compensatory strategies, and when to use
preventive approaches. The HOAC1,20 guides the physi-
cal therapist to continuously test and modify hypotheses
used to drive intervention choices as the plan of care
evolves.
Plan of Care
The plan of care is organized around the patients goals.
Goal-directed therapy has been identified as improving
motor function and promoting cortical reorganiza-
tion.7375 The goals are the outcome of the evaluation
process and consider both the PIPs and N-PIPs and the
task analysis. The approach toward the plan of care in
informed by the Guide to Physical Therapist Practice19 as
well as by principles of motor learning, and evidence of
task-specific training and other interventions in the
neuroscience and rehabilitation literature.76 79 The
physical therapist plan of care consists of consultation,
education, and intervention (Fig. 4). Physical therapists
may play all or some of these roles in a given episode of
care.

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 To elaborate on how these roles are performed, inter-
vention is organized into 3 categories: (1) remediation,
(2) compensation or adaptation, and (3) prevention.
The terms remediation, compensation or adapta-
tion, and prevention have been used by other
authors.48(p125) Remediation consists of enhancing skills
and resources or reversing impairments. A remediation
approach assumes that potential for change exists in the
system and the person (eg, neurologic plasticity, ability
of muscles to become stronger or to lengthen). Use of
body weightsupported treadmill training for a person
with a stroke80 is an example of remediation. Compensa-
tion or adaptation refers to the alteration of the environ-
ment or the task. This intervention approach is taken
when it is determined that remediation is not possible.
Examples include the use of a walker to widen the base
of support for a patient with balance problems, avoiding
multitask activities for patients with motor planning
problems, and the use of prism lenses for patients with
visual deficits. Prevention refers to the management of
anticipated problems (or N-PIPs in the HOAC model).
An example of a preventive intervention related to the
integumentary system in a person with spinal cord injury
is the use of a combined educational program regarding
the need for frequent skin inspection with direct inter-
vention for training in ischial weight relief to prevent
skin breakdown.
Interventions are rendered based on manipulation of
the environment and principles of exercise and motor
learning. The specific components of the intervention
are directly related to the results of the task analysis, in
which tasks, environments, and movement problems
were identified. The therapist uses the task analysis
findings to consider the environmental context under
which the person should practice the task in order to
acquire and generalize the skill. Task-specific training
has been advocated as the unit of therapy.48,81,82 Learn-
ing variables serve as an outline for the specific treat-
ment. Therapists select the appropriate schedule of
practice and type of feedback given the goal and the
state of the learner. The final consideration is dose,
which includes frequency, intensity, and duration. Dose
is an important variable of therapy and is included in
the framework based on the knowledge that intensive
practice (goal-directed) is an important factor is rehabil-
itation.83
A case example is provided to illustrate the process by
which these models and frameworks are integrated for
patient care. This case example is not intended to be
comprehensive, but rather is used to illustrate certain
features of the decision-making process, up through the
development of the initial plan of care.
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Case Example
History and Interview
Mr C was an 88-year-old man who sought physical
therapy following a diagnosis of PD. He lived in a life
care community with his wife of 60 years. He was the
president of a company and drove himself to the office
every day, although his son effectively ran the company.
Mr C reported that he was diagnosed with PD approxi-
mately a year previously and that since that time every-
thing has become more difficult for him, takes time, and
is just plain slow. He traversed the length of his office
(36.6 m [120 ft]) several times daily, and this was a slow
process. He had severe osteoarthritis, especially of the
knees and lumbar spine. Getting up from the seated
position could be quite painful, and the crepitus was
loud enough to hear from several feet away. Getting in
and out of cars was difficult (a contortionist activity).
When he returned from the office, he ate dinner and
went to bed by 7:30 pm.
On probing by the clinician, Mr C reported that he has
difficulty with balance control on uneven surfaces and
that, when walking from his apartment to the elevator,
he uses the walls for support. He reported frequent near
falls, which he indicated tended to occur in the morn-
ing. He also reported difficulty getting out of the bed in
the morning. Mr Cs goal in seeking treatment was to be
able to function more easily, including the ability to
complete his daily activities more efficiently, with less
painful knees, and with greater stability.
At present, Mr Cs medical management included
carbidopa-levodopa for the PD. He reported that his
symptoms did not vary according to time of dosage;
therefore, it would not be necessary to plan the inter-
vention around his medication schedule. He also had
ongoing treatment for the osteoarthritis, including ibu-
profen daily and injections of hyaline G-F 20 every 4
months.
The clinician summarized Mr Cs history and interview
from both enablement and disablement perspectives
(Fig. 5). From the enablement perspective, it was impor-
tant to assess his roles, the skills that he needs to fulfill
these roles, and his resources. From the disablement
perspective, it was important to assess those factors that
limited his ability to fulfill his roles and to identify
potential contributing impairments.
Systems Review
Based on the history and interview, as well as knowledge
of PD, the clinician determined choices and the ratio-
nale for the systems review. Two tasks were included: bed
mobility and sit to stand. These tasks were chosen both
Physical Therapy . Volume 86 . Number 12 . December 2006

Figure 5.
The enablement and disablement perspective for Mr C. PDParkinson disease, ROMrange of motion.
because they were problematic for Mr C and because
they could be used to assess trunk range of motion and
lower-extremity strength and for motor planning. The
Activities-specific Balance Confidence (ABC) Scale84 was
used to quantify confidence, given his report of instabil-
ity, and to identify other areas that would be important
to examine. The Mini-Mental State Exam85 was used to
quantify the cognitive/behavioral system, and the
Hoehn and Yahr Scale86 was used to quantify response to
posterior pull. Rationale for choices and results of the
systems review are provided in Table 1.
Examination
The examination strategy was based on Mr Cs goals as
well as the findings from the systems review. He reported
functional problems due to difficulty with bed mobility,
coming from a sitting position to a standing position,
and walking. Therefore, the examination strategy
focused on understanding the causes for difficulty with
these functional activities. The clinician chose to begin
the examination using task analysis. The 3 tasks were
analyzed in detail and under a variety of environmental
and task conditions, which were made progressively
more difficult to elicit Mr Cs underlying difficulty with
functional movement. Findings are presented in Table 2.
The task of walking is used to illustrate the application of
the models and frameworks. Walking first was examined
in a quiet clinic area (stationary environment). The task
then was made more challenging by asking Mr C to walk
in context of a serial task. He was asked to stand up from
a seated position and walk to a black mat. Walking also
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was made more challenging by asking Mr C to walk in an
environment in which the surface was moving. This was
accomplished by having Mr C walk across a black mat
that covered large stones and foam (the support surface
shifted under his weight). Finally, Mr C walked in a busy
area with people passing by quickly and unexpectedly
(moving environment). The patients typical perfor-
mance is described below.
Initial conditions revealed that he was consistently in
excessive thoracolumbar flexion, with some asymmetry
(lateral flexion to the right). Initiation was typically in the
sagittal plane only, without appropriate movement in
coronal plane to initiate gait. Notably, preparation
appeared normal, and initiation was not delayed
(ie, there was no evidence of akinesia). Execution
revealed the following: amplitude was low (eg, small
steps, small base of support), direction typically was in
the sagittal plane without shifting of weight from the
pelvis and without transverse-plane movement of the
thorax relative to the pelvis, and speed was slow. Termi-
nation was stable in less-demanding situations, but he was
unstable in moving environments and when tasks were
performed serially. Findings from the task analysis for
walking are summarized in Table 2.
The clinician next examined several impairments based
on hypotheses formed during the task analysis and
measured performance based on functions of impor-
tance for Mr C (Tab. 3). The visual analog scale87 was
used to assess knee pain, and the Modified Clinical Test
for Sensory Interaction of Balance (CTSIB)88 was used to
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 Table 1.
Systems Review of Mr Ca

Nature of System
Information Reviewed/Specific
Obtained Tests Rationale Result/Comment

Observation/query Cognitive/behavioral Patient expressed some concern Mini-Mental State Exam85 score29
regarding slowing of thought
process; important to begin to
establish ability for independent
exercise program
Confidence Patient expressed concerns about his Activities-specific Balance Confidence
stability Scale84 score45/90
Cardiovascular Determine whether system is an asset Patient self-report that he recently completed
or liability an exercise test and is safe to exercise to
75% of maximum HR
Vital signs
HR Determine cardiac response to HR:
exercise Resting: sitting55 bpm, standing61
bpm
5-min post-exercise test73 bpm
BP Determine cardiac response to BP:
exercise Resting: sitting174/70,
standing136/70
5-min post-exercise test154/70
Integumentary Determine whether system is an asset Intact
or liability
Direct examination Neurologic
Somatosensory Problems with tandem stance Proprioception: intact
Vibratory sense: impaired
Response to History of PD; difficulty with balance 5 steps; would fall if not caught (Hoehn
posterior pull control and Yahr Scale86 score2.5)
Romberg test Report of instability in the home and Romberg test: stable with eyes open and
office; determine whether problems eyes closed
with sensorimotor integration exist Sharpened Romberg test: unable to perform
with eyes open, falls to left
Task analysis Neurologic/
musculoskeletal
Bed mobility Typically, this is a difficult task for Performed slowly and with difficulty; utilizes
people with PD all available ROM, and lack of ROM
Mr C reports difficulty with this task at appears to be the major contributing
home problem
Use this task to assess axial ROM, Supine to stand: 11.5 s
organization of motor tasks, and Stand to supine: 7.4 s
bradykinesia
Sit to stand Mr C reports difficulty with this task at With hands: slow and laborious; hands on
all times mat to push up, then hands on knees
Use this task to assess pain, balance Without hands: able to complete the task
control, and lower-extremity slowly, indicating lower-extremity strength
strength, which may be limited of at least F
secondary to PD and osteoarthritis Findings suggest further examination of
pain and balance is indicated
a
HRheart rate, BPblood pressure, PDParkinson disease, ROMrange of motion.

evaluate balance control. Additionally, the UPDRS and
the Modified Hoehn and Yahr Scale37 were used to
quantify signs and symptoms specifically associated with
PD. Finally, performance-based measures were used to
quantify balance, including turning in standing,33 the
Timed Up & Go Test,23 and the Six-Minute Walk Test25
(Tab. 3). The rationale is provided for inclusion of each
measure. Additionally, the clinician obtained radio-
graphs of Mr Cs knees, which demonstrated appropri-
ate contact between the femur and tibia, but bone-on-
bone contact between the right patella and femur.
Evaluation
From the enablement perspective, it was evident that
work was very important for Mr C and that he greatly
valued his independence. The plan of care should be
focused around helping him to retain his independence
(to the extent possible) and his ability to continue to go

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Table 2. Based on the task analysis, Mr Cs move-
Examination Findings for Mr C: Task Analysis
ment problem was summarized as fol-
lows: in stationary environments, Mr C
Task and Temporal moved slowly but was relatively stable;
Environment Sequence Related Impairments
as the task and environmental condi-
Walking in a stationary Initial conditions Lack of mobility throughout spine, tions were made more challenging, he
environmenta Posture resulting in excessive had increasing difficulty with perfor-
thoracolumbar flexion, forward mance and stability. Based on the tempo-
head, left lateral flexion
Lack of mobility with hips, knees
ral sequence, the clinician observed con-
in flexion sistent problems with initial conditions
Initiation Lack of mobility throughout spine, and execution of tasks. Under more
Direction resulting in inability to shift challenging circumstances, problems
Smoothness weight from pelvis also emerged with initiation and ter-
appropriately
Painful right knee
mination. For example, his problems
Execution Lack of mobility throughout spine were more evident with serial tasks
Amplitude Painful right knee than with discrete tasks and with mov-
Direction Bradykinesia ing environments compared with sta-
Speed tionary environments.
Smoothness
Standing up from a Initiation Difficulty with sequencing multiple Based on analysis of possible determi-
seated position and Timing tasks
walking as a Execution Sensorimotor organization
nants, the clinician hypothesized that
continuous action in Stability limited mobility of the spine and result-
a stationary Termination Sensorimotor organization ing altered alignment were a source of
environment (walking Stability problems with initial conditions. Lim-
performed within a ited spinal mobility, coupled with the
serial task)b
painful right knee, interfered with
Walking in a moving Preparation Fear/anxiety direction and smoothness of execution.
environment (surface Appears impaired
moves beneath feet)c Initiation Fear/anxiety
These impairments, coupled with brady-
Timing Painful right knee kinesia resulted in limited amplitude.
Sensorimotor organization Together, these impairments affected
Postural alignment stability throughout all phases of the
Execution Sensorimotor organization task. Under more challenging condi-
Stability Painful right knee
Fear/anxiety
tions, fatigue, problems with sensori-
Postural alignment motor organization, and fear and anx-
Termination Sensorimotor organization iety related to the challenging
Unstable Postural alignment circumstances further affected perfor-
a
Only significant findings are noted. mance, explaining the slow and ineffec-
b
All issues remain that were observed for walking in a stationary environment; only additional issues are tive initiation and the instability during
noted. termination of walking.
c
All issues remain that were observed standing up from seated position and walking; only additional
issues are noted.
Diagnosis and Prognosis
Based on the Guide to Physical Therapist
to his office daily. At the same time, the fact that he was Practice,19 the clinician determined that this patients
driving himself to work was of some concern, both main complaint of PD falls under Practice Pattern 5E:
because of his limited mobility and because of his own Impaired Motor Function and Sensory Integrity Associated With
report that his thought processes seemed slower. There- Progressive Disorders of the Central Nervous System. However,
fore, it might be important to discuss driving with Mr C the osteoarthritis was of sufficient severity to warrant
and with his children as appropriate. identification of a second practice patternPractice Pat-
tern 4E: Impaired Joint Mobility, Motor Function, Muscle
From the disablement perspective, Mr C identified his Performance, and Range of Motion Associated With Localized
main problems as knee pain when getting up from a Inflammation.
seated position, slowness during all functional activities,
and instability. The physical therapist identified further Prognosis for this disorder. Parkinson disease is a
underlying problems, including substantially impaired progressive disorder with variable rates of progression.89
axial range of motion and sensorimotor organization. Pharmacological interventions have not been found to
slow the course of neurologic decline. Osteoarthritis,

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 Table 3.
Examination Findings for Mr C: Impairments and Outcome Measuresa
Measures
Impairment
Pain (visual analog scale, 010)85
Functional axial rotation33
Modified CTSIB88
Summary measure
Unified Parkinsons Disease Rating Scale37
Performance-based measures
Functional Reach Test22
360 turn33
Six-Minute Walk Test25
Timed Up & Go Test (with hands)23
a
CTSIBModified Clinical Test for Sensory Interaction of Balance, PDParkinson disease, ADLactivities of daily living.
likewise, is progressive in nature. Interventions such as
injections of hyaline G-F 20 can be beneficial in reducing
the pain associated with the condition. Total knee
replacement most likely is not indicated for this man due
to his age and to the PD. Clinical experience suggests
that patients with PD frequently experience severe
increases in symptoms following surgery.
Prognosis for functional change. Some studies90,91 sug-
gest that functional change is possible. Evidence suggests
that trunk range of motion specifically is limiting to
balance control and can improve.31,33 Mr Cs age, the
length of time that musculoskeletal changes have
existed, and his questionable commitment and ability to
carry out a home program all may limit the extent of
functional improvement. Evidence also indicates that
changes can occur with interventions directed toward
sensorimotor organization.92 Finally, improved biome-
chanics of transitioning from a sitting position to a
standing position can diminish the pain that Mr C
experiences and can slow down further degenerative
processes.
A number of investigations have been conducted, spe-
cifically examining exercise and PD. Findings of these
investigations, most of which had small sample sizes,
suggest that balance, gait, and overall function can
improve with a variety of interventions.90,91 The evalua-
tion above indicated to the physical therapist that range
of motion and altered alignment had a major effect on
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Rationale Findings
Knee pain may be limiting function, provides baseline Knee pain during sit-to-stand
data for future comparison task4
Loss of axial mobility may be limiting function, Right: X82.5, SD3.5
provides baseline data for future comparison Left: X87.5, SD3.5
Allows for further evaluation of problems with On foam, eyes open20 s
balance control, findings will inform approach to On foam, eyes closedunable
intervention
Reviews impairments and functional limitations Overall score44.5/124
associated with PD (combination of direct ADL subscale score17/52
examination and self-report), 0no problems Motor subscale score27/56
Mentation0/16
Outcome measure for standing balance control 15.2 cm (6 in)
Outcome measure chosen due to difficulty associated Right: 14 steps, 6.4 s
with PD in making turns while standing Left: 14 steps, 6.5 s
Outcome measure will be interpreted based on 175.6 m (576 ft)
endurance, pain, bradykinesia
Outcome measure will be interpreted in context of 31.6 s
bradykinesia, stability, and knee pain; assesses fall
risk
this patients performance. Therefore, interventions
are specifically indicated that focus directly on these
problems.
Finally, some studies93,94 provide guidance regarding
intervention directly focused toward osteoarthritis of the
knees. These studies demonstrated the effectiveness of
interventions including fitness walking, aerobic exercise,
and strength training as well as mobilization and manip-
ulation of the lumbar spine, knee, and ankle.
Goals and Outcome Measures
The following were determined to be meaningful
changes for Mr C: ability to conduct daily functional
activities with less painful knees, greater stability, and less
fatigue. Goals were set that were focused around these
identified changes. These goals were deemed to be
realistic and achievable within the constraints of the
health care system (Tab. 4).
Outcome measures were identified that reflected his
goals and also that reflected the hypothesized steps to
achieve those goals. Proposed outcome measures for Mr
C are shown in Table 4. The first column synthesizes his
goals and the qualitative indicators of success. The
middle column summarizes the analysis of necessary
changes to reach these goals and gives insight into the
necessary intervention. The last column lists the quanti-
tative indicators of success, which are more specific
measures that are related to his goals.
Physical Therapy . Volume 86 . Number 12 . December 2006

Table 4.
Proposed Outcome Measures for Mr C

Patient-Desired Outcome Hypothesized Necessary Changes Indicators

Sit to stand with less pain, greater speed
and stability
Stable and safe for all tasks
Overall physical improvement
Improved stability and speed
Less pain
Improved axial mobility and mechanics
Improved balance control
Improved sensory processing
Compensation for loss of vibratory sense,
sensory processing
Adopt and adhere to appropriate
exercise program
Timed Up & Go Test, change 10 s
Visual analog scale for knee pain,
change 3
Functional axial rotation change, 7
Anterior excursion of lumbar spine/pelvis
No reported loss of balance in morning
Increased capacity for balance control
Functional Reach Test, change,
1.27 cm (0.5 in)
Stable on foam, eyes closed 20 s
Appropriate use of cane
Use of electric tri-cart for distances
Self-report of improved well-being
Self-report of increased exercise habits

Implications for Treatment Planning and the
Initial Plan of Care
Taking all of this information into account, it was
deemed important to work with Mr C in progressively
more demanding environments (moving support sur-
faces and people moving around him). It also would
be important to use tasks of increasing complexity
(eg, serial versus discrete tasks). The focus of these tasks
should be on improving range of motion and posture in
order to improve the initial conditions, execution, and
termination of task performance.
Based on a full analysis of Mr Cs problems, their underly-
ing causes, and overall prognosis, a combined intervention
approach was recommended that includes remediation,
compensation, and prevention. To provide adequate phys-
iological support for function, it would be important to
improve trunk range of motion to the extent possible
(remediation) and to assist Mr C to use more biome-
chanically favorable strategies for the sitting-to-standing
task (remediation), thereby lessening the demand on his
knees and decreasing the pain. Clinical experience
suggests that exercises for trunk range of motion should
be practiced in stationary environments to allow Mr C to
focus on range of motion. Improved transitioning from
a sitting position to a standing position should be practiced
from higher chair seats with a firm surface initially to work
on the organization of the task and moving to progressively
lower seats and less firm surfaces.
Improved sensorimotor organization also was needed to
provide Mr C with greater stability while moving in
standing positions (remediation). Sensorimotor organi-
zation should be practiced in progressively more
demanding environments (eg, standing on foam with
eyes open, then eyes closed; walking across a moving
surface) and with progressively more demanding tasks
(eg, walking in the context of serial tasks).
Compensatory strategies also were indicated to assist Mr
C with his endurance and to protect his knees. For
example, he should be encouraged to use a cane while
walking and to obtain an electric tri-cart for locomotion
over longer distances (eg, from his apartment to his
parking space). He should be encouraged to have a
driver take him to and from his office.
Finally, preventive strategies were important both in
light of the PD and the osteoarthritis. With PD (as well as
increasing age), Mr C was at risk for further loss of range
of motion. An exercise program was indicated to retard
these further losses. Prevention of further damage to the
knees and back is needed (eg, the use of the tri-cart or a
cane), and general conditioning is important to retain
overall health and wellness.95
Summary of the Framework and
Its Application
A framework is proposed to guide physical therapist
practice and to provide a structure for teaching clinical
decision making to future clinicians. The framework
integrates enablement and disablement perspectives and
hypothesis generation and refinement at each step of
patient care, and it incorporates systematic task analysis
for examination, evaluation, and intervention. The pro-
cess is cyclical and iterative. The framework is illustrated
using a case example.
It is important to note that this framework is not meant
to be prescriptive in nature. That is, the order and
emphasis of application of the elements of the frame-
work depend on factors such as the clinicians level of skill,

Physical
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 experience, and preferred choices. However, the elements
that are included are meant to be comprehensive.
Many of the elements of this framework are familiar and
used with increasing frequency in both clinical and
educational settings (eg, Guide to Physical Therapist Prac-
tice,19 disablement models8,9). This framework differs
from prior work in that we propose that other critical
elements also be included (eg, task analysis, a patient-
centered enablement approach, algorithms for making
decisions). In particular, we propose that task analysis
integrates the entire framework and is critical for effec-
tive decision making in the clinic. Such a systematic
approach as we describe should be emphasized in the
process of educating physical therapists.
It also is important to note that this framework is
proposed as a working document. The framework will
continue to evolve as the scientific basis for movement
analysis and rehabilitation evolves. Additionally, the
framework should be evaluated and refined by applying
it to clinical decision making across a wide variety of
diagnostic conditions and populations, including those
with non-neurologic disorders. For example, focus
groups can be used to examine the utility of this approach
for structuring neurologic physical therapist education,
and case analyses can be used to test the clarity and utility
of the approach for patient management.
The complete framework, depicted in Figure 1, is a
representation of actual clinical practice for many expe-
rienced clinicians. By building from simple principles to
the entire framework, experienced clinicians and educa-
tors can use this framework to assist students and novice
clinicians to better understand and incorporate all aspects
of decision making necessary for effective care of patients.
This framework also provides the experienced clinician
with a structure for articulating intuitive decisions.
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