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

Physical therapy is a dynamic profession with an established theoretical base

and widespread clinical applications, particularly in the preservation, develop-
ment, and restoration of maximum physical function. Physical therapists seek to
prevent injury, impairments, functional limitations, and disability; to maintain
and promote fitness, health, and quality of life; and to ensure availability, acces-
sibility, and excellence in the delivery of physical therapy services to the patient.
As essential participants in the health care delivery system, physical therapists
assume leadership roles in prevention and health maintenance programs, in the
provision of rehabilitation services, and in professional and community organiza-
tions. They also play important roles in developing health policy and appropri-
ate standards for the various elements of physical therapy practice. Physical
therapists help nearly a million Americans daily to restore health, alleviate pain,
and prevent the onset and progression of impairments, functional limitations,
and disability. The benefits of rehabilitation and physical therapy services are
well documented, and services are covered in nearly all federal, state, and pri-
vate insurance plans.

The American Physical Therapy Association (APTA), the national organization

representing the profession of physical therapy, believes it to be critically impor-
tant that those outside the profession understand the role of physical therapists
in the health care system and the unique services they provide. As clinicians,
physical therapists examine patients, identdy potential and existing problems,
perform evaluations, establish a diagnosis, set forth a prognosis, provide inter-
ventions (those practices and procedures used by the physical therapist in treat-
ing and instructing patients), evaluate the success of those interventions, and
moddy treatment to effect the desired outcomes. Physical therapy includes not
only those services provided by physical therapists but also those rendered
under their direction and supervision.

The APTA is committed to informing consumers, federal and state governments,

and third-party payers of the benefits of physical therapy and, more specifically,
of the relationship of the patient's health status after treatment to the services
that the therapist has provided. The Association actively supports outcomes
research and strongly endorses all efforts to develop appropriate systems to
measure the results of physical therapy patient management.

A Guide to Physical Therapist Practice is a two-volume description of general

physical therapy patient management developed by the APTA to give readers a
thorough understanding of the contributions that physical therapists bring to

Physical Therapy / Volume 75, Number 8 /August 1995

health care. Volume I: A Description of Patient Management, focuses first on
physical therapists as health professionals, describing their approach to patient
management in Chapter One. Chapter Two details 23 examinations that physical
therapists often perform and includes an overview of each examination, clinical
indications that may prompt its use, a list of the general tests and measures that
may be atiministered, and data that may be generated. Chapter Three details the
interventions (treatments) that physical therapists frequently provide. An over-
view for each intervention is given, followed by a listing of the modes in which
the intervention may be applied. Clinical indications for selecting the interven-
tion are described and its expected benefits listed. Finally, three appendices are
presented: a glossary, the APTA Code of Ethics and Guidefor Ptofssional Con-
duct, and the APTA Guidelinesfor Physical T?m-apyDocumentation. [Volume
I t Preferred Practice Patterns, will be keyed to defined impairments and ICD-9
codes ancl is in the process of being developed.]

A Guide to Physical 7h;berapistPractice serves two purposes: 1) to provide a

guide to the domain of accepted physical therapy practice and 2) to facilitate the
development of preferred practice patterns that will reduce unwarranted varia-
tion in the provision of physical therapy treatments, improve the quality of phys-
ical therapy, enhance consumer satisfaction, promote appropriate utilization of
health care services, and reduce costs. This document is intended to be used as
a reference by health care policymakers, administrators, managed care provid-
ers, third-party payers, physical therapists, and other health care professionals.
The material presented describes the generally accepted elements of physical
therapy patient management. Decisions about the appropriateness of treatment
are made by the physical therapist in light of the patient's needs and the profes-
sion's code of ethics, standards of practice, and practice patterns. The physical
therapist considers the influence of culture, gender, race, age, socioeconomic
status, and sexual orientation when providing services to a patient, while adher-
ing to APTA policy on nondiscrimination.

The American Physical Therapy Association recommends that federal and state
governments and other entities that provide insurance reimbursement for physi-
cal therapy services require that these services be provided only by or under the
direction of a physical therapist. The use of any physical therapy examination or
intervention, unless provided by a physical therapist or under the direction or
supervision of a physical therapist, is not physical therapy, nor should it be
represented or reimbursed as such.

Physical Therapy / Volume 75, Number 8 /August 1995

Chapter One:
Management of Physical Therapy Patients
This chapter introduces physical thera-
pists, describes their qualifications,
defines the field of physical therapy,
details the elements of physical thera-
pist practice, and discusses the roles of
physical therapists in the provision of
primary, secondary, and tertiary care.
Physical therapists are professionals
involved in the examination, evalua-
tion, treatment, and prevention of
neuromuscular, musculoskeletal, car-
diovascular, and pulmonary disorders
that produce movement impairments,
disabilities, and functional limitations.
As members of primary care teams or
as providers of specialty care, physical
therapists help patients to improve
function, alleviate pain, and prevent
the onset of disease or disability.
Chapter One also lists the settings in
which physical therapists practice and
describes the professional activities in
which they are involved, which in-
clude patient management (examina-
tion, evaluation, diagnosis, prognosis,
and intervention), prevention and
wellness (including health promotion),
consultation, screening, education,
critical inquiry, and administration.
The chapter eoncludes with a discus-
sion of support personnel.
Pt,ysical Therapists
Physical tb~rapistsare professionally
educated at the college or university
level and are required to be licensed
in the states(s) in which they practice.
Graduates from 1960 to the present
have successfully completed profes-
sional programs of physical therapy
accredited by the APTA's Cornmission
on Accreditation in Physical Therapy
Education (CAPTE). Graduates from
1926 to 1959 completed physical ther-
apy curricula approved by appropriate
accreditation bodies.
Physical therapists interact and prac-
tice in collaboration with a variety of
health professionals, including physi-
cians, dentists, podiatrists, nurses,
social workers, occupational thera-
pists, speech and language patholo-
gists, and others. As responsible health
professionals, physical therapists ac-
knowledge the need to educate and
inform other health professionals,
government agencies, insurers, and
the consumer public about the ser-
vices they offer and their effective and
cost-efficient delivery.
Physical therapists provide patients
with services at the preventive, acute,
and rehabilitative stages directed to-
ward achieving increased functional
independence and decreased func-
tional impairment. They provide pre-
ventive care that forestalls or prevents
functional decline and the need for
more intense care. Through timely and
appropriate intervention, they fre-
quently reduce or eliminate the need
for costlier forms of care such as sur-
gery and may also shorten or even
eliminate institutional stays.
Definition of Physical Therapy
The current Model Definition of Physi-
cal Therapy for State Practice Acts was
adopted by the APTA Board of Direc-
tors in March 1993 and revised in
March 1995:
Physical therapy, which is the care
and services provided by or under the
direction and supenrision of a physical
therapist, includes:
1) Examining patients with impair-
ments, functional limitations, and
disability or other health-related
conditions in order to determine a
diagnosis, prognosis, and interven-
tion; examinations include, but are
not limited to, thefollowing:
Physical Therapy /Volume 75, Number 8 /August 1995
aerobic capacity or endurance
anthropometric characteristics
arousal, mentation, and
cognition
assistive, adaptive, supportive,
and protective devices
community or work
reintegration
cranial nerve integrity
environmental, home, or work
barriers
ergonomics or body mechanics
gait and balance
integumentary integrity
joint integrity and mobility
motor function
muscle performance
neuromotor development and
sensory integration
orthotic requirements
pain
posture
prosthetic requirements
range of motion
reflex integrity
self care and home management
sensory integrity
ventilation, respiration, and
circulation
2) Alleviating impairments and func-
tional limitations by designing,
implementing, and modthing
therapeutic intauentions that in-
clude, but are not limited to, the
following:
therapeutic exercise (including
aerobic conditioning)
functional training in self care
and home management (includ-
ing activities of daily living and
instrumental activities of daily
living)
functional training in community
or work reintegration activities
(including instrumental activities
of daily living, work hardening,
and work conditioning)
 manual therapy techniques (in-
cluding mobilization and
manipulation)
prescription, fabrication, and
application of assistive, adap-
tive, supportive, and protective
devices and equipment
airway clearance techniques
debridement and wound care
physical agents and mechanical
modalities
electrotherapeutic modalities
patient-related instruction
3) Pmazting injury, impimzents,
functional limitations, and disabil-
ity, including the promotion and
maintenance offitness, health,
and quality of life in all age
populntiorts.
4) Engaging in consultation, educa-
tion, and mearch.
Physical Therapist Practice
Physical therapists are committed to
offering necessary, appropriate, and
highquality health services. They
provide these services to patients
(individuals who are sick or injured)
and clients (individuals who are not
necessarily sick or injured but who
can benefit from physical therapy
services, eg, a person with a chronic
disability, a person wishing to prevent
a loss of function). In addition, physi-
cal therapists offer selected services
(eg, screening) to individuals, busi-
nesses, school systems, and others
also termed clients. Physical therapists
also provide wellness initiatives, in-
cluding health promotion and educa-
tion, that stimulate the public to en-
gage in healthy behavior.
Physical therapists provide services to
patients with impairments, functional
limitations, disability, or change in
physical function and health status
resulting from injury, disease, or other
causes. Impaimzents are losses or
abnormalities of physiological, psycho-
logical, or anatomical structure or
function. Functional limitations are
restrictions of the ability to perform a
physical action, activity, or task in an
efficient, typically expected, or compe-
tent manner. Disability is the inability
Physical Therapy /Volume 75, Number 8 /August 1995
to engage in age- and sex-specific
roles in a particular social context and
physical environment. Physical func-
tion, which is a fundamental compo-
nent of health status, describes the
state of those sensory and motor slulls
necessary for mobility, work, and
recreation. Health status, which is part
of well-being, describes an individual
in terms of physical, mental, affective,
and social function.
Practice Settings
Physical therapists practice in a broad
range of inpatient, outpatient, and
community settings, including, but not
limited to, the following:
hospitals
homes
physical therapy office practices
rehabilitation facilities
subacute care facilities
skilled nursing or extended care
facilities
hospices
schools (preschool, primary, and
secondary)
corporate or industrial health
centers
work or occupational
environments
athletic training facilities
sports injury treatment centers
fitness centers
education or research centers
PtSmary Cam
Physical therapists have major roles to
play in the provision of primary care,
recently defined as fol1ows:l
Primary care is the provision of inte-
grated, accessible health care sm'ces
by clinicians who are accountable for
addressing a large majority of peronal
health care needs, developing a sus-
tainedpattndip with patients, and
practicing in the context of family and
community.
In recent years a number of organiza-
tions, including the Institute of Medi-
cine, have examined the delivery of
primary care services in the United
States. The APTA endorses the con-
cepts of primary care set forth by the
Institute of Medicine's Committee on
the Future of Primary Care,l which
include the following:
Recognition that primary care
can encompass a myriad of
needs that g o well beyond the
capabilities and competencies
of individual caregivers and
that require the involvement
and interaction of varied
practitioners
Rejection of the "gatekeeper"
concept because of its pejorative
connotation that the role of the
primary care practitioner is to
manage costs and, for the most
part, to keep the "gate" closed
Awareness that primary care is
not limited to the "first contact"
or point of entry into the health
care system
Emphasis on the comprehen-
siveness of a primary care
program
Recognition of the important
role of family and community in
the provision of primary care,
and recognition that caregivers
and care-receivers function
within, and are dependent on, a
wide range of societal and envi-
ronmental factors
Physical therapists are involved in the
examination, treatment, and preven-
tion of neuromusculoskeletal disorders
and are well positioned to provide
those services as members of primary
care teams. On a daily basis, physical
therapists practicing at acute, rehabili-
tative, and preventive stages of care
assist individuals in restoring health,
alleviating pain, and preventing the
onset of disease or disability. They
play roles in the acute, chronic, pre-
vention, and wellness areas. A number
of studies indicate that the assumption
by physical therapists of a primary
care role is an efficient use of health
care resources.
Physical therapists provide a broad
range of neuromusculoskeletal health
services from entry to discharge, in-
cluding screening, triage, examination,
referral, intervention, coordination of
care, and education and prevention.
For acute neuromusculoskeletal disor-
ders, the triage and initial examination
is the appropriate responsibility of a
physical therapist. The primary care
team functions more efficiently with
712 / 67
physical therapists who recognize
neuromusculoskeletal disorders, per-
form examinations, and treat or refer
without delay (eg, physical therapists
providing immediate pain reduction
and programs for strengthening, flexi-
bility, endurance, postural alignment,
instruction in activities of daily living,
and work modification for patients
with low back pain). These actions
result in more efficient and effective
patient care and more appropriate use
of other members of the primary care
team. The efficiency and cost effective-
ness of physical therapy in this context
is well documented. With physical
therapists functioning in a primary
care role and delivering early interven-
tion for work-related musculoskeletal
injuries, time lost due to injuries has
been dramatically reduced.
For certain chronic conditions, physi-
cal therapists should be recognized as
the principal providers of care within
the collaborative primary care team.
Physical therapists are well prepared
to coordinate care related to loss of
physical function. Through
community-based agencies, physical
therapists coordinate and integrate
provision of services to individuals
with chronic neuromusculoskeletal
disorders, including a vast array of
postural, muscular, joint, and func-
tional problems in patients with osteo-
porosis of the spine or hips.
The practice of physical therapists in
industrial or workplace settings illus-
trates another key element of primary
care. In these settings, physical thera-
pists manage the care provided to
employees and prevent injury by
designing or redesigning the work
environment. The services provided
by physical therapists focus on both
the individual and the environment to
ensure comprehensive and appropri-
ate intervention. These practices have
been documented to be both cost-
and clinically effective.
Secondary and Tertiary Cam
Physical therapists play major roles in
secondary and tertiary care as well.
Patients with neuromuscular, muscule
skeletal, cardiovascular, pulmonary,
integumentary, or other disorders
frequently are seen initially by another
health practitioner and then referred to
physical therapists for secondary care.
Physical therapists provide secondary
care in a wide range of settings, from
hospitals to preschools.
Physical therapists provide tertiary care
services in highly specialized, com-
plex, and technologically based set-
tings (eg, a heart or lung transplant
service, a bum unit). They are also
tertiary-care practitioners when sup-
plying specialized services (eg, to
patients with a spinal cord lesion, to
individuals who have suffered closed-
head trauma) following referral from
clinicians such as physicians, dentists,
and nurse practitioners.
Patient Management
A schema describing the physical
therapist's approach to patient man-
agement is presented below in Figure
1. As the figure demonstrates, the
physical therapist integrates five ele-
ments of care in a manner designed to
maximize the patient's outcome, which
EVALUATION
DIAGNOSIS
v
PROGNOSIS
INTERVENTION -
,
Figure 1. 7he elements of physical therapist patient management leading to opti-
mal outcome.
Physical Therapy / Volume 75, Number 8 /August 1995
may be conceptualized as either
patient-related (eg, satisfaction with
care) or associated with service deliv-
ery (eg, efficacy and efficiency). In
many cases the physical therapist
offers all five elements of care before
an outcome is reached, but outcomes
may result from the rendering of even
a single element, such as the examina-
tion, or two to four elements (eg,
examination, evaluation, diagnosis,
and prognosis but no intervention).
Examination is the process of obtain-
ing a patient history, performing rele-
vant systems reviews, and selecting
and administering specific tests and
measures to obtain data. (Frequently,
physical therapists will perform one or
more ~examinations,which are any
examinations that take place after the
initial examination is completed. A
reexamination gives the physical
therapist the opportunity to evaluate
the patient's progress and to mod^ or
adapt the patient management process
as necessary.)
Evaluation is a dynamic process in
which the physical therapist makes
!
clinical judgments based on data gath-
ered during the examination. Diagno-
sis is both the process and the end
result of evaluating information ob-
tained from the patient examination,
which the physical therapist then
organizes into defined clusters, syn-
dromes, or categories to help deter-
mine the most appropriate interven-
tion strategies for each patient.
Pmgnosis is the determination of the
level of maximal improvement that
might be attained and the time re-
quired to reach that level; it may also
include predictions of improvement at
various intervals during therapy. Inter-
vention is the purposeful and skilled
interaction of the physical therapist
with the patient, using various meth-
ods and techniques to produce
changes in the patient's condition
consistent with the diagnosis and
prognosis.
After analyzing all relevant information
that has been gathered from the his-
tory and systems reviews, the physical
therapist decides what groups of tests
and measures should be included in
the exarnination of the patient. The
physical therapist will decide to use
one, more than one, or portions of
several .$pec$c examinations (detailed
in Chapter Two) as part of the exami-
nation. As the examination progresses,
the physical therapist may determine
that there are additional problems
present that were not uncovered by
the history and systems review and
conclude that other specfic examina-
tions (in Chapter Two) or portions of
specific examinations will need to be
performed to obtain sufficient data to
make an evaluation, render a diagno-
sis, fomi a prognosis, and choose
interventions. In addition, as described
below, the physical therapist may
reexamine at any stage of the patient
management process. Because physi-
cal therapy is most often an ongoing
process delivered over a period of
weeks rather than at a single visit,
physical therapists rely on re-
examinations to modify or redirect the
patient management process and to
evaluate outcomes that have been
predicted. In actuality, the re-
examination has an important quality
assurance component, as it allows the
Physical Therapy /Volume 75, Number
physical therapist to focus on both the
elements of physical therapy manage-
ment and the outcomes of care.
At each step of the management pro-
cess the physical therapist considers
the possible patient outcomes. Out-
come is the result of physical therapy
management and is expressed in five
areas: prevention and management of
symptom madestation, consequences
of disease (impairment, disability,
andor role limitation), cost-benefit
analysis, health-related quality of life,
and patient satisfaction. Because the
physical therapist projects an outcome
that reflects the needs of the patient, a
successful outcome includes improved
or maintained physical function when
possible, a slowing of functional de-
cline where the status quo cannot be
maintained, andor an expression by
the patient that the outcome is
desirable.
During the initial history taking, the
physical therapist identifies the pa-
tient's expectations for therapeutic
interventions, perceptions about the
clinical situation, and goals and de-
sired outcomes. The physical therapist
considers whether these are realistic in
the context of the examination find-
ings. In setting forth a diagnosis, mak-
ing a prognosis, and choosing inter-
ventions, the physical therapist also
considers potential patient outcomes;
eg, what outcome is likely given this
patient's diagnosis?The physical thera-
pist may use a re-examination to see
whether predicted outcomes are rea-
sonable and then m o d e them as
necessary. Ideally, the physical thera-
pist also engages in outcomes analysis;
ie, he or she systematically examines
the outcomes of care in relation to
selected patient variables (eg, age, sex,
diagnosis, interventions performed)
and develops statistical reports for
internal or external use.
I. Examination. The exarnination,
which is an investigation, is the first
step in the management process. It
has three components:
obtaining a patient history
performing relevant systems
reviews
selecting and administering spe-
cific tests and measures
The examination is a required element
prior to any intervention and is per-
formed for all patients. The physical
therapist selects components of spe-
cific examinations described in Chap-
ter Two based on the purpose of the
patient's visit to the physical therapist,
the complexity of the patient's condi-
tion(~),and the evolving impression
formed by the physical therapist dur-
ing the examination. The examination
may therefore be as brief or lengthy as
necessary. For example, the physical
therapist may conclude from the pa-
tient history and systems review that
further testing and management by the
physical therapist is not required
a n d o r that the patient should be
referred to another health care practi-
tioner. Conversely, the physical thera-
pist may decide that a full examination
is necessary and then select appropri-
ate tests and measures to be adminis-
tered. The range of tests and measures
may include those selected from any
or all of the specific examinations
listed in Chapter Two, depending on
the complexity of the patient's prob-
lems and the directions taken by the
physical therapist in the clinical
decision-making process. It should be
noted that at some point after com-
pleting the initial examination, the
physical therapist may conclude that a
second examination (re-examination)
is indicated (because of new clinical
indications, failure of the patient to
respond to interventions, etc) and
proceed to perform it as described
above.
A. The History. The patient history is
an account of past and present health
status. It includes the identification of
complaints and provides the initial
source of information about the pa-
tient; it also suggests the patient's
ability to benefit from physical therapy
services. The patient history provides
information that enables the therapist
to identlfy health-risk factors, health
restoration and prevention needs, and
co-existing health problems that have
implications for physical therapy inter-
vention. It is commonly conducted by
gathering data from the patient, family,
signhcant others, caregivers, and
other interested persons; by consulting
with other members of the health care
team; and by reviewing the medical
record. In conducting the history, the
physical therapist encourages patients
to express their expected outcomes,
which may be used in the process of
establishing goals and intended
outcomes.
The process of taking a history to
identlfy specific information about the
patient may include, but is not limited
to, the following:
interviewing
administering a questionnaire
consulting with other health
professionals
reviewing available records
Data generated from a history may
include, but are not limited to, the
following:
needs or concerns that led an
individual to seek the services
of a physical therapist
the patient's expectations for
therapeutic interventions and
perceptions about his/her clini-
cal situation
prior functional status in self-
care and home-management
activities (activities of daily liv-
ing and instrumental activities of
daily living)
current community or work
activities
prior hospitalizations, surgeries,
and pre-existing medical and
other health-related conditions
medications
level of fitness
health risks (eg, family history,
diet, alcohol consumption,
smoking, stress)
incontinence, bowel and blad-
der problems
obstetric history
developmental history
social interactions, activities, and
support systems
nutrition and hydration
sleep patterns
skin integrity
family and caregiver resources
living environment and commu-
nity characteristics
70 / 715
projected discharge designation
8.Systems Review. The systems
review is a brief or limited exarnina-
tion to provide additional information
about the patient's general health that
will help the physical therapist to
formulate a diagnosis and select an
intervention program. The systems
review also assists the physical thera-
pist in ident~fyingpossible health
problems that require consultation
with or referral to another health care
provider.
Data generated from a systems review
that may affect subsequent examina-
tion(~)and intervention(s) include the
following:
physiologic and anatomic status
cardiopulmonary response dur-
ing rest and activity
neuromusculoskeletal physio-
logic responses during rest and
activity
somatosensory integrity
newly identified or recently
emerging signs or symptoms
communication skills and cogni-
tive status
emotional status
C. Tests, Measures, and Data
Generated. Tests and measures are
procedures or sets of procedures used
to obtain data. After concluding the
systems review, the physical therapist
examines the patient more closely and
selects tests and measures from one or
more specific examinations to elicit
additional information. Before, during,
and after administering the tests and
measures, physical therapists will
frequently apply their hands to the
patient to gauge responses, to assess
physical status, and to obtain a more
specific understanding of the patient's
condition and diagnostic and thera-
peutic requirements.
Tests and measures commonly per-
formed by physical therapists and the
resulting data generated are discussed
in the specific examinations presented
in Chapter Two.
11. Evaluation. Physical therapists
perform evaluations (make clinical
Physical Therapy / Volume 75, Number 8 /August 1995
judgments) based on the data gath-
ered from the examination. Factors
that influence the complexity of the
examination and the evaluation pro-
cess include the clinical findings, ex-
tent of loss of function, social consid-
erations, and the patient's overall
physical function and health status.
Thus, the physical therapist's evalua-
tion reflects the severity of the current
problem, the stability of the patient's
condition, the presence of pre-existing
conditions, and the possibility of mul-
tiple sites or systems involvement.
Physical therapists also consider the
l&l of the patient's impairment(s)
and the possibility of prolonged im-
pairment, functional limitations, and
disability, as well as the patient's social
supports, living environment, and
potential discharge destination. Fre-
quently, the physical therapist's evalu-
ation will indicate that a second exam-
ination (reexamination) is necessary,
which would then be conducted as
detailed in the section entitled "I.
Examination" above.
111. Diagnosis. A diagnosis is a label
encompassing a cluster of signs and
symptoms, syndromes, or categories. It
is the decision reached as a result of
the diagnostic process, which includes
evaluating the information obtained
during the patient examination and
organizing it into clusters, syndromes,
or categories. The purpose of the
diagnosis is to guide the physical
therapist in determining the most
appropriate intervention strategy for
each patient. In the event that the
diagnostic process does not yield an
identifiable cluster, syndrome, or cate-
gory, intervention may be guided by
the alleviation of symptoms and reme-
diation of deficits. Alternatively, the
physical therapist may determine that
a re-examination is in order and pro-
ceed accordingly. The diagnostic pro-
cess includes the following:"
obtaining relevant history
performing systems review
selecting and administering spe-
cific tests and measures
interpreting all data
organizing the data
In carrying out the diagnostic process,
physical therapists may need to obtain
additional information (including diag-
nostic labels) from other health profes-
sionals. In addition, as the diagnostic
process continues, physical therapists
may identlfy findings that should be
shared with other health professionals,
including referral sources, to ensure
optimal patient care. If the diagnostic
process reveals findings that are out-
side the scope of the physical thera-
pist's knowledge, experience, or ex-
pertise, the physical therapist should
then refer the patient to an appropri-
ate practitioner.
IV. Prognosis. Prognosis is the deter-
mination of the level of maximal im-
provement that might be attained by
the patient and the amount of time
needed to reach that level; it may also
include a prediction of the levels of
improvement that may be reached at
various intervals during the course of
therapy. The physical therapist makes
prognoses for recovery from impair-
ment, functional limitation, and dis-
ability; for return to role fulfillment;
and for other outcomes, including
prevention and management of symp-
tom manifestations. When the physical
therapist determines that physical
therapy intervention would be likely
to produce desirable outcomes, the
appropriate intervention is imple-
mented. When the physical therapist
considers physical therapy intervention
unlikely to be beneficial, the physical
therapist discusses those findings and
conclusions with the individuals con-
cerned, and there is no further physi-
cal therapy intervention.
V. Intervention. Intenention is the
purposeful and skilled interaction of
the physical therapist with the patient
and, if appropriate, other individuals
involved in the patient's care, using
various methods and techniques to
produce changes in the patient's con-
dition consistent with the diagnosis
and prognosis. Decisions about inter-
vention are contingent on the timely
monitoriilg of the patient's response
and the progress made toward achiev-
ing outcomes. There are three inter-
vention components:
Physical Therapy / Volume 75, Number 8 /August 1995
direct intervention
patient-related instruction
coordination, communication,
and documentation
A. Direct Intervention. Physical thera-
pists select, apply, or modlfy one or
more interventions based on the data
gathered from the initial examination.
Based on the results of the interven-
tion(~),the physical therapist may
decide that a re-examination is neces-
sary, a decision that may lead to the
use of ddferent interventions or, alter-
natively, the discontinuation of treat-
ment. Chapter Three details several
interventions commonly selected by
the physical therapist:
therapeutic exercise (including
aerobic conditioning)
functional training in self care
and home management activities
(including activities of daily liv-
ing and instrumental activities of
daily living)
functional training in community
or work reintegration (including
instrumental activities of daily
living, work hardening, and
work conditioning)
manual therapy techniques (in-
cluding mobilization and
manipulation)
prescription, fabrication, and
application of assistive, adap-
tive, supportive, and protective
devices and equipment
airway clearance techniques
debridement and wound care
physical agents and mechanical
modalities
electrotherapeutic modalities
patient-related instruction
Factors that influence the complexity
of the intervention and the decision-
rnalung process may include the
following:
severity of the current problem
stability of the patient's
condition
pre-existing conditions
level(s) of impairment(s1
probability of prolonged impair-
ment, functional limitations, and
disability
social supports and living
environment
multiple sites or systems
involvement
overall physical function and
health status
cognitive status
potential discharge destination
B. Patient-related Instmction. The
physical therapist uses patient-related
instruction to educate not only the
patient but also families and other
caregivers about the patient's current
condition, treatment plan, and future
transition to home, work, or commu-
nity roles. The physical therapist may
include information and training in
maintenance activities as well as pri-
mary and secondary prevention in the
instruction program.
C. Coordination, Communication,
and Documentation. These processes
ensure that the patient receives appro-
priate, coordinated, comprehensive,
and cost-effective services between
admission and discharge. The services
include, but are not limited to, the
following:
patient care conferences
communications (telephone, fax,
etc)
documentation of all elements
of patient management
coordination of care with pa-
tients, significant others, family
members, and other health
professionals
record reviews
discharge planning
Documentation should follow the
APTA Guidelinesfor Physical Theram
Documentation (Appendix 111).
Additional Professional Activitks
of the Physical Therapist
Physical therapists also participate
actively in the following activities:
prevention and wellness (includ-
ing health promotion)
consultation
screening
education
critical inquiry
administration
I. Prevention and Wellness (Includ-
ing Health Promotion). Physical
therapists have successfully integrated
prevention, wellness, and the promo-
tion of positive health behavior into
physical therapy practice to reduce
injury, impairment, and disability
among their patients. These initiatives
have decreased costs by achieving and
restoring functional capacity, minimiz-
ing limitations due to congenital and
acquired diseases, maintaining health
(because sustaining a level of function
may prevent further deterioration or
future illness), and providing appropri-
ate environmental adaptations to en-
hance independent function.
For example, physical therapists are
heavily involved in preventing and
treating low back pain, a disorder that
afflicts d l i o n s of Americans and is the
most common disability for those
under 45 years of age. The majority of
such injuries are work related. The
annual cost of this disability exceeds
$10 billion, but cost savings realized
through physical therapy programs
aimed at preventing injury in the work
site, which may include back schools,
workplace redesign, strengthening,
stretching, endurance exercise, and
postural training, have been
sigtxficant.2-5
Older adults are prime candidates for
preventive interventions by physical
therapists: Laboratory and clinical
studies have shown that bone mass
increases in response to mechanical
strain and exercise, and that exercise
can reduce the incidence of wrist and
hip fractures from falls, for which
older women are particularly at
ljsk.6-13
Cardiac and pulmonary rehabilitation,
which are offered to the elderly as
well as to younger patients, have also
proven to be of great value. Short,
contained exercise and education
programs decrease hospital costs,
health care visits, and related ex-
penses. Individuals with chronic ob-
structive pulmonary disease can de-
crease their hospital costs by 50%
per year through pulmonary
rehabilitation.14-16
Physical therapists initiate numerous
other prevention and wellness pro-
grams aimed at both individual pa-
tients and the community to curtail
tobacco, alcohol, and other drug use,
prevent head injury (through the use
of helmets), and reduce domestic
violence (by reporting suspected abu-
sive behavior). Prevention of strains
and sprains has generated consider-
able cost savings.17-'9 In industry,
physical therapists help to prevent
job-related disabilities, including repet-
itive motion injuries. Finally, physical
therapists participate in obstetrical
care, where cardiovascular condition-
ing and instruction in posture for
women both before and after child-
birth have been shown to decrease
infant morbidity and maternal disabil-
ity and dysfunction.20,21
11. Consultation. Consultation is a
service provided by a physical thera-
pist to render a professional or expert
opinion or advice. Consultants apply
highly specialized knowledge and
skills to identlfy problems, recommend
solutions, or produce some specified
outcome or product in a given amount
of time on behalf of a patient or client.
Patient-related consultation is a ser-
vice provided by a physical therapist
at the request of a patient, health care
practitioner, or health care organiza-
tion either to evaluate the quality of
physical therapy services being pro-
vided or to recommend physical ther-
apy services that are needed; it does
not involve actual treatment.
Client-related consultation is a sewice
provided by a physical therapist at the
request of an individual, business,
school, government agency, or other
organization.
Examples of consultation activities in
which physical therapists engage
include:
responding to a request for a
second opinion
advising a referring practitioner
about the indications for
intervention
Physical Therapy / Volume 75, Number 8 / August 1995
advising employers about the
requirements of the Americans
with Disabilities Act (ADA)
instructing employers about pre-
placement in accordance with
provisions of the ADA
educating other health practitio-
ners (eg, in injury prevention)
performing environmental as-
sessments to minimize the risk
of falls
conducting a program to deter-
mine the suitability of employ-
ees for specific job assignments
examining school environments
and recommending changes to
improve accessibility for stu-
dents with disabilities
developing programs that evalu-
ate the effectiveness of an inter-
vention plan in reducing work-
related injuries
working with employees, labor
unions, and government agen-
cies to develop injury reduction
and safety programs
participating at the local, state,
and federal levels in policymak-
ing for physical therapy services
providing expert legal opinion
111. Scrreening. Screening is the brief
process of determining the need for
further examination or consultation by
a physical therapist or for referral to
another health care practitioner.
Screening is based on a problem-
focused, systematic collection and
analysis of data to: 1) iden* individ-
uals at risk in order to provide primary
prevention, 2) identlfy those in need
of physical therapy intervention or
other rehabilitative services, and 3)
ascertain the presence of positive
findings that require attention by an-
other health care practitioner in order
to provide secondary or tertiary pre-
vention. Generally, candidates for
screening are not patients currently
receiving physical therapy sewices.
Examples of screening activities in
which physical therapists engage
include:
identifying children who may
need an examination for idio-
pathic scoliosis
identifying risk factors in the
workplace
 pre-performance testing of indi-
viduals active in sports
identifying an individual's life-
style factors (eg, exercise, stress,
weight) that may lead to in-
creased risk for serious health
problems
identifying elderly individuals in
a community center or nursing
home who are at high risk for
slipping, tripping, or falling
IV. Education. Education is the pro-
cess of imparting information or skills
and instructing by precept, example,
and experience so that individuals
acquire knowledge, master skills, or
develop competence. In addition to
instructing patients as an element of
intervention, examples of educational
activities in which physical therapists
engage include:
planning and conducting pro-
grams for the public to increase
its awareness of issues in which
physical therapists have
expertise
planning and conducting pro-
grams for local, state, and fed-
eral health agencies
planning and conducting aca-
demic and continuing clinical
education programs for physical
therapists, other health care pro-
viders, and students
V. Critical Inquiry. Critical inquiry is
the process of applying the principles
of scientific methods to read and inter-
pret professional literature; participate
in, plan, and conduct research; and
analyze patient care outcomes, new
concepts, and findings.
Examples of critical inquiry activities in
which physical therapists engage
include:
analyzing and applying research
findings to patient management
and. client programs
evaluating the efficacy of both
new and established
technologies
participating in, planning, and
conducting clinical, basic, or
applied research
disseminating the results of
research
Physical Therapy / Volume 75, Number 8 /August 1995
VI. Administration. Administration is
the skilled process of planning, direct-
ing, organizing, and managing human,
technical, environmental, and financial
resources effectively and efficiently,
including the management by individ-
ual physical therapists of resources for
their patients' care as well as the man-
aging of organizational resources.
Examples of administration activities in
which physical therapists engage
include:
supervising physical therapist
assistants, physical therapy
aides, and other support
personnel
managing staff resources, includ-
ing the acquisition and develop-
ment of clinical expertise and
leadership abilities
monitoring quality of care and
clinical productivity
budgeting for physical therapy
services
developing, implementing, and
reviewing strategic plans and
marketing programs
Physical Therapy Sewiees:
Direction and Supervision of
Support Pemonnel
Direction and supervision are essential
to the provision of quality physical
therapy services. The degree of direc-
tion and supervision necessary for
ensuring quality physical therapy ser-
vices depends on many factors, in-
cluding the education, experience, and
responsibilities of the personnel in-
volved, the organizational structure in
which the physical therapy services
are provided, and applicable state law.
The physical therapist who directs a
physical therapy service has qualifica-
tions based on education a n d experi-
ence in the field of physical therapy
and has accepted the responsibilities
inherent in being a supervisor. The
director of a physical therapy service:
1) establishes guidelines and proce-
dures that delineate the functions and
responsibilities of all levels of physical
therapy personnel in the service and
the supervisory relationships inherent
in the functions of the service and the
organization; 2) ensures that the objec-
tives of the service are efficiently and
effectively achieved within the frame-
work of the stated purpose of the
organization and in accordance with
safe physical therapy practice; and 3)
interprets administrative policies, acts
as a liaison between line staff and
administration, and fosters the profes-
sional growth of the staff.
Written practice and performance
criteria are available for all levels of
physical therapy personnel in a physi-
cal therapy service. Regularly sched-
uled performance appraisals are con-
ducted by the supervising physical
therapist based on these standards of
practice and performance criteria.
Delegated responsibilities are com-
mensurate with the qualifications,
including experience, education, and
training, of the individuals to whom
the responsibilities are being assigned
and must be in accordance with appli-
cable state law. When the physical
therapist delegates patient care re-
sponsibilities to physical therapist
assistants or other support personnel,
that physical therapist is responsible
for supervising the physical therapy
program. Regardless of the setting in
which the service is given, the follow-
ing responsibilities are borne solely by
the physical therapist:
interpretation of referrals when
available
initial examination, problem
identification, and diagnosis for
physical therapy
development or modification of
a plan of care that is based on
the initial examination and that
includes the physical therapy
treatment goals
determination of which tasks
require the expertise and
decision-making capacity of the
physical therapist and must be
personally rendered by the
physical therapist, and which
tasks may be delegated
delegation and instruction of the
services to be rendered by the
physical therapist assistant or
other support personnel, includ-
ing, but not limited to, specific
 treatment program, precautions,
special problems, and contra-
indicated procedures
timely review of treatment docu-
mentation, re-examination of the
patient and the patient's treat-
ment goals, and revision of the
plan of care when indicated
establishment of the discharge
plan and documentation of dis-
charge summary or status
Support Personnel
I. Physical Therapist Assistants.
The physical therapist assistant is an
educated health care provider who
assists the physical therapist in provid-
ing physical therapy. The physical
therapist assistant is a graduate of a
physical therapist assistant associate
degree program accredited by an
agency recognized by the Secretary of
the United States Department of Edu-
cation or the Council on Postsecond-
ary Accreditation.
The supervising physical therapist is
directly responsible for the actions of
the physical therapist assistant. The
physical therapist assistant performs
physical therapy procedures and re-
lated tasks that have been selected
and delegated by the supervising
physical therapist. Where permitted by
law, the physical therapist assistant
also carries out routine operational
functions, including supervising the
physical therapy aide and document-
ing treatment progress. The ability of
the physical therapist assistant to per-
form the selected and delegated tasks
is assessed on an ongoing basis by the
supervising physical therapist. The
physical therapist assistant may m o d e
a specific treatment procedure in ac-
cordance with changes in patient
status within the scope of the estab-
lished treatment plan.
11. Physical Therapy Aides. The
physical therapy aide is a nonlicensed
worker who is specifically trained
under the direction a physical
pist. The physical therapy aide per-
formsdesignated routine tasks related
the a therapy
service delegated by the physical
74 / 719
therapist or, in accordance with the
law, by a physical therapist assistant.
The physical therapist is directly re-
sponsible for the actions of the physi-
cal therapy aide. The physical therapy
aide provides support services in the
physical therapy service, both patient-
related and non-patient-related duties.
When providing direct physical ther-
apy services to patients, the physical
therapy aide functions only with the
continuous on-site supervision of the
physical therapist or, where allowable
by law andlor regulation, the physical
therapist assistant. The requirement for
continuous on-site supervision man-
dates the presence of the physical
therapist or physical therapist assistant
in the immediate area and their in-
volvement in appropriate aspects of
each treatment session in which a
component of treatment is delegated
to a physical therapy aide.
111. Other Support Personnel. When
other personnel (eg, exercise physiol-
ogists, athletic trainers, massage thera-
pists) work within the supervision of a
physical therapy service they should
be employed under their appropriate
titles. Any involvement in patient care
activities should be within the limits of
their education, in accord with appli-
cable laws and regulations, and at the
discretion of the physical therapist.
However, if they function as an exten-
sion of the physical therapist's license,
their title and all provided services
must be in accordance with state and
federal laws and regulations. (In all
situations in which the physical thera-
pist delegates activities to other sup-
port personnel, physical therapists
must recognize their legal responsibil-
ity and liability for such delegation.)
References
1. Donaldson M, Yordy K, Vanselow N.
Defrning Primary Care: An Interim Repott.
Washington, DC: National Academy Press;
1994.
2, Hazard RG, Fenwick JW, Kalisch SM, et al,
Functional restoration with behavioral
support: a one-year prospective study of pa-
tien's: with chronic low back pain. Spine.
1989;14:157-161.
3. Kellet KM, Kellett DA, Nordholm LA. Ef-
fects of an exercise program on sick leave
due to back pain. Phys Iher. 1991;71:285293.
Physical Therapy / Volume 75, Number 8 / August 1995
4. Klaber Moffett JA, Chase SM, Portek I, En-
nis JR. A controlled, prospective study to eval-
uate the effectiveness of a back school in the
relief of chronic low back pain. Spine.
1986;11:120-122.
5. Bigos SJ, Battie MC. Acute care to prevent
back disability. Clin Orthop. 1987;221:
121-130.
6. Judge JO, Lindsey C, Underwood M, Win-
semius D. Balance improvements in older
women: effects of exercise training. Phys Iher.
1993;73:254-265.
7. Rutherford OM. The role of exercise in the
prevention of osteoporosis. Physiotherapy.
1990;76:522-526.
8. Nelson ME, Fisher EC, Dilmanian FA, et al.
A one-year walking program and increased
dietary calcium in post-menopausal women:
effects on bone. Am J Clin Nutr.
1991;53:1304-1311.
9. Osteoporosis: Cause, Treatment, Prevention
US Dept of Health and Human Services Publi-
cation No. (NIH) 86-2226. Bethesda, MD: Na-
tional Institute of Arthritis and Musculoskeletal
and Skin Diseases; 1986.
10. Whedon GC. Interrelation of physical ac-
tivity and nutrition on bone mass. In: White
PL, Mondeika T, eds. Diet and Erercise: Syn-
ergism in Health Maintenance. Chicago, 111:
American Medical Association; 1982:99.
11. Jacobsen PC, Beaver W, Grubb SA, et al.
Bone density in women: college athletes and
older athletic women. J Orthop Res.
1984;2:328-332.
12. Nilsson BE, Westlin NE. Bone density in
athletes. Clin Orthop. 1971;77:179-182.
13. Chow RK, Harrison JE, Brown CF, et al.
Physical fitness effect on bone mass in post-
menopausal women. Arch Phys Med Rehabil.
1986;67:231-234.
14. Ades PA, Huang D, Weaver SO. Cardiac
rehabilitation participation predicts lower re-
hospitalization costs. Am Heart J.
1992;123:195-200.
15. Busch AJ, McClements JD. Effects of a su-
pervised home exercise program on patients
with severe chronic obstructive pulmonary
disease. Phys Iher. 1988;68:469-474.
16. Hudson LD, Tyler ML, Petty T. Hospital-
ization needs during an outpatient rehabilita-
tion program for severe chronic airway ob-
struction. Chest. 1976;70:606-610.
17. Dinchin M, Woolf 0,Kaplan L, Floman Y.
Secondary prevention of low-back pain: a
clinical trial. Spine. 1990;15:1317-1319.
18. Ryden LA, Molgaard CA, Bobbitr SL. Ben-
efits of a back care and lighr duty health pro-
motion program in a hospital setting. J Com-
munity Health. 1988;13:222-230.
19. Wood PJ. Design and evaluation of a
back injury prevention program within a geri-
atric hospital. Spine. 1987;12:77-81.
20. Clapp JF. The course of labor after endur-
ance exercise during pregnancy. Am J Obstet
Gynecol. 1990;163:1799-1805.
21. Lokey EA, Tran ZV, Wells CL, et al. Effects
of physical exercise On pregnancy outcomes:
a meta-analytic review. Med Sci Sports &WC.
19'91;23:1234-1239.
Chapter Two:
Examinations Provided by Physical Therapists
The physical therapist's patient man-
agement process of examination, eval-
uation, diagnosis, prognosis, and inter-
vention has been described in Chapter
One. Twenty-three examinations that
the physical therapist may select are
detailed in Chapter Two; other exami-
nations not described in h s chapter
may also be used in patient manage-
ment. Depending on the data gener-
ated during the history and systems
review, the physical therapist may use
one or more of these examinations, in
whole or in part. For example, in
examining a patient with impairments
and disabilities resulting from a brain
injury, the physical therapist may de-
cide to peiform part or all of several
examinations, based on the pattern of
involvement in the individual patient.
Thus, the physical therapist should
individualize the selection of examina-
tions rather than choose them solely
on the patient's presenting diagnosis
(eg, brain injury).
For each of the examinations, four
areas are discussed:
Overview-Provides an intro-
duction to the examination.
Clinical Indications-Lists ex-
amples of the functional limita-
tions, impairments, disabilities,
or special requirements that may
prompt the physical therapist to
conduct the examination.
Tests and Measures-Lists
general methods and techniques
used in conducting the
examination.
Data Generated-Describes the
information collected from the
tests and measures.
Other information that may be re-
quired for the examination includes,
but is not limited to, clinical findings
of other health professionals; results of
diagnostic imaging, clinical laboratory,
Physical Therapy / Volume 75, Number 8 /August 1995
and electrophysiologic studies; federal,
state, and local work surveillance and
safety reports and announcements;
and observations of family members,
significant others, caregivers, and
other interested persons.
A physical therapy examination or
intervention, unless performed by a
physical therapist, is not physical ther-
apy nor should it be represented or
reimbursed as such.
Aerobic Capacity or Endurance
Examination
Overview. Ambic capacity, p o w ,
and endurance are all measures of the
ability to perform work or participate
in activity over time using the body's
oxygen uptake, delivery, and energy
release mechanisms. During activity,
the physical therapist employs tests
ranging from simple determinations of
heart rate, blood pressure, and respira-
tory rate to complex calculations of
oxygen consumption and carbon
dioxide production to determine the
appropriateness of an individual's
response to increased oxygen de-
mand. Monitoring responses at rest
and during activity can indicate the
degree and severity of impairment,
iden* cardiopulmonary deficits that
produce functional limitations, and
indicate that other tests and specific
therapeutic interventions are needed.
The aerobic capacity or e n d u m c e
examination produces information
used to identlfy the possible or actual
cause(s) of difficulties during the pa-
tient's performance of essential every-
day activities, leisure pursuits, and
work tasks. Selection of specific tests
and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a diag-
nosis, a prognosis, and the selection of
appropriate interventions.
Clinical Indications. An aerobic
capacity or endurance examination is
appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that speclfy minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
weakness
shortness of breath
dizziness
palpitation
tightness of the chest wall
lack of mobility
lack of endurance
abnormalities in movement,
flexibility, or strength
edema of the lower
extremities
referred pain (angina) indica-
tive of cardiac ischemia
ischemic pain in the extremi-
ties (claudication)
inability to perform specific
movement tasks
abnormalities of heart rate,
blood pressure, respiratory
rate or pattern of breathing,
and/or heart muscle function
Tests and Measures. Tests and
measures for performing an aerobic
capacity or endurance examination
include, but are not limited to:
obtainment of standard vital
signs (blood pressure, heart and
respiratory rate) at rest, during
activity, and during recovery
auscultation of heart sounds
auscultation of the lungs
auscultation of major vessels for
bruits
palpation of pulses
performance of an
electrocardiogram
performance of pulse oximetry
performance of tests of pulmo-
nary function and ventilatory
mechanics
performance of gas analysis or
oxygen consumption studies
observation of chest movements
and breathing patterns with
activity
performance of claudication
time tests
assessment of patient's perfor-
mance during established exer-
cise protocols (eg, treadmill,
ergometer, 6-minute walk test,
3-minute step test)
monitoring of the patient by
telemetry during activity
assessment of perceived exer-
tion or dyspnea during activity
using a visual analog scale
Data Generated. Data generated
may include, but are not limited to:
description of peripheral vascu-
lar integrity
report of vital signs (blood pres-
sure, heart and respiration rate)
at rest, during, and after activity
list of activities that aggravate or
relieve symptoms
physical exertion scale grading
and/or dyspnea assessment with
activity
report of oxygen saturation with
activity
report of ventilatory volumes
and flow at rest and after activ-
ity (including comparison of
actual to predicted)
report of inspiratory and expira-
tory muscle force before and
after activity (including compari-
son of actual to predicted)
maximum oxygen consumption
(including comparison of actual
to predicted)
oxygen consumption for particu-
lar activity (including compari-
son of actual to predicted)
respiratory quotient
anaerobic threshold
description of chest movement
and breathing patterns with
activity
report of any arrhythmias at rest
and during activity
report of symptoms limiting
activity
Anthropometric Characteristics
Examination
Overview.Anthropometric character-
&ticsdescribe human body measure-
ments such as height, weight, girth,
and body fat composition. The physi-
cal therapist uses the anthropometric
characteristics examination to test for
muscle atrophy, gauge the extent of
edema, and establish a baseline to
allow patients to be compared to
national norms on such variables as
weight and body-fat composition. An
anthropometric characteristics exami-
nation may lead to a recommendation
that other examinations be performed,
such as an aerobic capacity or endur-
ance examination.
The anthropometric characteristics
examination produces information to
idenhfy the possible or actual cause($
of difficulties during the patient's per-
formance of essential everyday activi-
ties, leisure pursuits, and work tasks.
Selection of specific tests and mea-
Tests and Measums. Tests and
sures will depend on the findings of
measures for performing an anthropo-
the patient history and systems review.
metric characteristics examination
The examination may require testing
include, but are not limited to:
while the patient performs specific
activities. The examination will lead to
an evaluation, a diagnosis, a progno-
sis, and the determination of appropri-
ate interventions.
Clinical Indications. An anthropo-
metric characteristics examination is
appropriate in the presence of:
Physical Therapy / Volume 75, Number 8 /August 1995
Suspected or identified pathol-
ogy, injury, or developmental
delay that prevents normal per-
formance of daily activities, in-
cluding self care, home manage-
ment, community or work
reintegration, and leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
inability to perform specific
movement tasks
effusion or edema (including
edema during pregnancy)
muscle atrophy
suspected onset of
lymphedema
measurement of height, weight,
and girth
measurement of body-fat com-
position, using calipers, under-
water weighing tanks, or electri-
cal impedance
classification of edema through
volumetrics and girth
 observation and palpation of an
extremity or part at rest and dur-
ing activity
assessment of activities and pos-
tures that aggravate or relieve
edema
assessment of edema (eg, during
pregnancy, in determining the
effects of other medical or
health-related conditions, during
surgical procedures, after drug
therapy)
Data Generated. Data generated
may include, but are not limited to:
height in feet and inches or
centimeters
weight in pounds or kilograms
girths of extremities and chest
and lengths of extremities in
inches or centimeters
body fat (as a percentage of
mass or in inches or
centimeters)
volumetric displacement in liters
a list of activities and postures
that aggravate or relieve edema
integrity of lymphatic system
Arousal, Mentation, and
Cognition Examination
Ovwiew. Amusal is the stimulation
to action or to physiologic readiness
for activity. Mentation is a mechanism
of thought or mental activity. Cogni-
tion is the act or process of knowing,
including both awareness and judg-
ment. Tht: physical therapist uses the
arousal, mentation, and cognition
examination to assess the patient's
responsiveness; orientation to time,
person, and place; and ability to fol-
low directions. The examination
guides the physical therapist in select-
ing interventions by indicating
whether the patient has the cognitive
ability to participate in the care
process.
The arousal, mentation, and cognition
examination produces information
used in identifying the possible or
actual cause($ of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
Physical Therapy / Volume 75, Number 8 /August 1995
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to a n evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. An arousal,
mentation, and cognition examination
is appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial or temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
somatosensory deficit
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
inadequate circulation, recur-
rent ischemia, or claudication
change in baseline status of
arousal, mentation, cognition
Tests and Measures. Tests and
measures for performing an arousal,
mentation, and cognition examination
include, but are not limited to:
determination of patient's level
of consciousness
determination of patient's level
of recall
determination of patient's orien-
tation to time, person, and place
cognitive screening (eg, to de-
termine ability to process com-
mands, to measure safety
awareness)
screening for gross expressive
and receptive deficits
assessment of arousal, menta-
tion, and cognition using stan-
dardized instruments
Data Generated. Data generated
may include, but are not limited to:
level of arousal, mentation, or
cognition deficits
difference between predicted
and actual performance
variation over time of arousal,
mentation, or cognition deficits
scores on standardized instru-
ments for measuring arousal,
mentation, and cognition
Assistive, Adaptive, Supportive,
and Protective Devices
Examination
Overview. Assistive, adaptive, support-
ive, and protective devices are a variety
of implements or equipment used to
aid individuals in performing tasks or
movements. Rssirstive deuices, which
include crutches and canes, involve
rather simple technologies; adaptive
devices, which include such technolo-
gies as a wheelchair and the long-
handed reacher, are generally more
complex. Supportive devices include
taping, compression garments, corsets,
and neck collars, while protective
devices include braces and helmets.
The physical therapist uses the assis-
tive, adaptive, supportive, and protec-
tive devices examination to determine
whether an individual might benefit
from such a device or, where one is
already in use, to determine how well
the patient performs with it.
The assistive, adaptive, supportive,
and protective devices examination
produces information used in identify-
ing the possible or actual cause(s) of
difficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures wiU
depend on the findings of the patient
history and systems review. The exarn-
ination may require testing while the
patient performs specfic activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the de-
termination of appropriate
interventions.
Clinical Indications. An assistive,
adaptive, supportive, and protective
devices examination is appropriate in
the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
the normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbance(s)
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
inability to perform specific
movement tasks
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
integumentary deficits
incontinence, bowel, and
bladder difficulty
lymphedema
Tests and Measures. Tests or mea-
sures for performing an assistive,
adaptive, supportive, and protective
devices examination include, but are
not limited to:
analysis of the potential to re-
mediate impairments, functional
limitations, or disabilities using
an assistive, adaptive, support-
ive, or protective device
observation of the individual
using the device for intended
effects and benefits and ability
to use the device
review of reports provided by
the patient, significant others,
family, and caregivers
analysis of alignment and fit of
the device and inspection of
related changes in skin
condition
assessment of appropriate com-
ponents of the device
assessment of safety while using
the device
videotape analysis of the patient
or client using the device
computer-assisted analysis of
motion
Data Generated. Data generated
may include, but are not limited to:
deviations and malfunctions that
can be corrected or alleviated
by an assistive, adaptive, sup-
portive, or protective device
alignment of anatomical parts
with the device
safety and effectiveness of the
device in providing protection,
promoting stability, or improv-
ing performance of tasks and
activities
expressions of comfort, cosme-
sis, and effectiveness using the
device
Physical Therapy /Volume 75, Number 8 /August 1995
ability to use the device and
understanding of its appropriate
use
level of compliance with use of
the device
Community or Wo&
Reintegration Examination
(Including lnstnrmental Activities
of Daily Living)
Overview. Community or mrk reinte-
gration is the process of resuming
one's role(s) in the community or at
work. The physical therapist uses the
community or work reintegration
examination to make an informed
judgment as to whether an individual
is currently prepared to resume com-
munity or work roles or to determine
when and how such reintegration
might occur. The physical therapist
also uses this examination to deter-
mine whether an individual is a candi-
date for a work hardening or work
conditioning program.
The community or work reintegration
examination produces information
used in identdjmg the possible or
actual cause(s) of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures wiU depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. A community or
work reintegration examination is
appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including community
or work reintegration or leisure
tasks and movements
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
 Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform community
or work reintegration or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficitGI and
disturbances
postural deficits
abnormalities in movements,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
incontinence, bowel and
bladder difficulty
Tests and Measures. General tests
and measures for performing a com-
munity or work reintegration examina-
tion include, but are not limited to:
observation of the individual
performing work tasks and com-
munity and leisure activities
review of reports provided by
the individual, family members,
significant other, or caregiver
administering questionnaires
and conducting interviews with
the patient and other interested
persons
application of instrumental activ-
ities of daily living measurement
scales and performance batteries
for community, work, and lei-
sure activities
measurement of physiologic re-
sponses during community,
work, and leisure activities
review of daily activities logs
measurement of static and dy-
namic strength
analysis of aerobic capacity or
endurance during community,
work, and leisure activities
assessment of dexterity and
coordination
Physical Therapy /Volume 75, Number 8 /August 1995
application of functional rating
scales
measurement of functional
capacity
assessment of appropriateness
of assistive, adaptive, support-
ive, and protective devices
analysis of environment and job
tasks
analysis of mentation and
cognition
analysis of adaptive skills
Data Generated. Data generated
may include, but are not limited to:
levels of strength, flexibility, and
endurance
effort in specific movement tasks
aerobic capacity or endurance
gross and fine motor function
difference between predicted
and actual performance
physical, functional, behavioral,
and vocational status
work-related systemic neuro-
musculoskeletal restoration
needs
vital signs and physiologic re-
sponse during community or
work reintegration and leisure
activities
presence or absence of menta-
tion and cognition deficits
level of adaptive skills
Cranial Nerve Integrity
Examination
Overview. A cranial n e m is one of
twelve paired nerves (eg, olfactory,
optic) that emerge from or enter the
brain. The cranial nerve integrity ex-
amination has somatic, visceral, affer-
ent, and efferent components. The
physical therapist uses the cranial
nerve integrity examination to localize
a dysfunction in the brain stem and to
iden* cranial nerves that merit an
in-depth examination. The physical
therapist uses a number of cranial
nerve tests to assess the patient's sen-
sory and motor functions, such as
taste, smell, and facial expression.
The cranial nerve integrity examina-
tion produces information used to
identlfy the possible or actual cause(s)
of difficulties during the patient's per-
formance of essential everyday activi-
ties, leisure pursuits, and work tasks.
Selection of specific tests and mea-
sures will depend on the findings of
the patient history and systems review.
The examination may require testing
while the patient performs specfic
activities. The examination will lead to
an evaluation, a diagnosis, a progno-
sis, and the determination of appropri-
ate interventions.
Clinical Indications. A cranial nerve
integrity examination is appropriate in
the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial and temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
somatosensory deficit
abnormalities in movement,
flexibility, or strength
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
Tests and Measures. Tests and
measures for performing a cranial
nerve integrity examination include,
but are not limited to:
 performance of tests of:
touch
pain
temperature
vision
vestibular sensibility
auditory sensibility
taste
smell
assessment of muscles inner-
vated by the cranial nerves
Data Generated. Data generated
may include, but are not limited to:
difference between predicted
and actual performance
description of eye movements
amount of constriction and dila-
tion of pupils
visual deficits
pain, touch, temperature
localization
gross auditory acuity
equilibrium responses
characteristics of swallowing
integrity of gag reflexes
degree of loss of taste
degree of loss of function in
muscles innervated by the cra-
nial nerves
Envimnmental, Home, or Work
BammetsExamination
Overview. Environmental, home, and
work barrim are the physical impedi-
ments that keep individuals from func-
tioning optimally in their surround-
ings. The physical therapist uses the
environmental, home, or work barriers
examination to iden@ any of a vari-
ety of possible impediments, including
safety hazards (eg, throw rugs, slip-
pery surfaces), access problems (eg,
narrow doors, high steps), and home
or office design (eg, excessive dis-
tances to negotiate, multiple-story
environment). The physical therapist
uses this examination, often in con-
junction with elements of the ergo-
nomics or body mechanics examina-
tion, to suggest modifications to the
environment (eg, grab bars in the
shower, ramps, raised toilet seats,
increased lighting) that will permit the
patient or client to improve function-
ing in the home, workplace, or other
settings.
The environmental, home, or work
barriers examination produces infor-
mation used in iden*ing the possible
or actual cause(s) of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specfic
tests and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. An environmen-
tal, home, or work barriers examina-
tion is appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s1 and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
incontinence, bowel, and
bladder difficulty
inability to perform specific
movement tasks
Physical Therapiy / Volume 75, Number 8 / August 1995
Tests and Measures. Tests and
measures for performing an environ-
mental, home, or work barriers exarni-
nation include, but are not limited to:
assessment of present and po-
tential barriers
physical inspection of the
environment
conducting interviews and ad-
ministering questionnaires
off-site
analysis of physical space using
photography or videotape
measureihent of physical space
ergonomic analysis of an indi-
vidual's home, workplace, or
other customary environment
Data Generated. Data generated
may include, but are not limited to: 11
a list of space limitations and
other barriers, including their
dimensions, that limit an indi-
vidual's ability to perform spe-
cific movement tasks during
home, work, and leisure
activities
degree of compliance with stan-
dards set forth in the Americans
with Disabilities Act
recommendations for elimina-
tion of environmental barriers
a list of adaptations, additions,
or modifications that would en-
hance patient safety
Ergonomics or Body Mechanics
Examination
Overview. E?gonomics is the study of
the relationships between people,
work, and the work environment,
using scienthc and engineering princi-
ples to improve those relationships.
Body mechanics describes the interre-
lationships of the muscles and joints as
they maintain or adjust posture in
response to environmental forces. The
physical therapist uses the ergonomics
or body mechanics examination to
examine the work environment on
behalf of patients or clients to deter-
mine the potential for trauma to result
from inappropriate workplace design.
The ergonomics or body mechanics
examination may be conducted after a
work injury or as a preventive mea-
sure, particularly when an individual is
returning to the work environment
after an extended absence.
The ergonomics or body mechanics
examination produces information
used in identlfylng the possible or
acmal cause(s) of dificulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. An ergonomics
or body mechanics examination is
appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and lei-
sure tasks and movements
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
ab~lormalitiesin movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
inability to perform specific
mclvement tasks
impaired balance or frequent
falling
Physical Therapy / Volume 75, Number 8 /August 1995
impaired motor function and
learning
impaired sensation
abnormal body alignment and
movement patterns
inadequate circulation, recur-
rent ischemia, or claudication
frequent injury
Tests and Measures. Tests and
measures for performing an ergonom-
ics examination include, but are not
limited to:
ergonomic analysis of job tasks
or activities to assess the
following:
essential functions of the job
task or activity
work postures required to
perform the job task or
activity
joint range of motion used to
perform the job task or
activity
strength required in the work
postures necessary to perform
the job task or activity
repetition/work/rest cycling
during the job task or activity
sources of potential trauma
vibration
tools, devices, or equipment
used
endurance required to per-
form aerobic endurance
activities
assessment of work hardening
or work conditioning, including
identification of needs related to
physical, functional, behavioral,
and vocational status
administration of batteries of
work performance
review of safety and accident
reports
assessment of dexterity and
coordination
observation of the individual
performing selected movements
or activities
determination of dynamic capa-
bilities and limitations during
specific work activities
video analysis of the patient or
client at work
computer-assisted motion analy-
sis of the patient or client at
work
Tests and measures for performing a
body mechanics examination include,
but are not limited to:
measurement of height, weight,
and girth
observation of the individual
performing selected movements
or activities
determination of dynamic capa-
bilities and limitations during
specific work activities
videotape analysis of the patient
or client performing selected
movements or activities
computer-assisted motion analy-
sis of the patient or client per-
forming selected movements or
activities
Data Generated. Data generated
may include, but are not limited to:
height in feet and inches or
meters and centimeters
weight in pounds or kilograms
girths of extremities and chest
amount of dficulty experienced
or pain expressed during the
performance of specific job
tasks or activities
a list of potential and actual er-
gonomic stressors
body alignment, timing, and se-
quencing of component move-
ments during specific job tasks
or activities
levels of strength, flexibility, and
endurance
level of effort in specific move-
ment tasks
aerobic capacity or endurance
levels of gross and fine motor
function
difference between predicted
and actual performance
safety records and accident
reports
physical, functional, behavioral,
and vocational status
level of work performance
work-related systemic neuro-
musculoskeletal restoration
needs
 temporal and spatial characteris-
tics of movements during job
tasks or activities
Gait and Balance Examination
Overview. Gait is the manner in
which a person walks, characterized
by rhythm, cadence, step, stride, and
speed. Balance is the ability to main-
tain the body in equilibrium with
gravity both statically (eg, while sta-
tionary) and dynamically (eg, while
walking). The physical therapist uses
the gait and balance examination to
investigate disturbances in gait and
balance because they frequently lead
to decreased mobility, a decline in
functional independence, and an in-
creased risk of falls. Gait and balance
problems often involve dficulty in
integrating sensory, motor, and neural
processes. The physical therapist also
uses the gait and balance examination
to determine whether the patient is a
candidate for an assistive, adaptive,
supportive, or protective device.
The gait and balance examination
produces ~nformationused in identify-
ing the possible or actual cause(s) of
dficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the de-
termination of appropriate
interventions.
Clinical Indications. A gait and bal-
ance examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to ~ e r f o r mself care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficitcs) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
incontinence, bowel, and
bladder difficulty
inability to participate in
athletics
Tests and Measums. Tests and
measures for performing a gait and
balance examination include, but are
not limited to:
identification of gait
characteristics
identification and quantification
of static and dynamic balance
characteristics
analysis of biomechanical, ar-
throkinematic, and other spatial
and temporal characteristics of
gait and balance with and with-
out the use of assistive, adap-
tive, supportive, or protective
devices
analysis of spatial and temporal
characteristics of gait and bal-
ance using- kinematic, kinetic,
and electromyographic (EMG)
f ~ ^ + ^
LCZiLZi
application of balance and gait
analysis rating scales
Physical Therapy / Volume 75, Number 8 /August 1995
analysis of gait on various ter-
rains, in different physical envi-
ronments, and in water
administration of functional am-
bulation profiles
videotape analysis of patient's
movement to assess gait or
balance
EMG analysis of patient's move-
ment to assess gait or balance
computer-assisted analysis of
patient's movement
application of gait analysis rat-
ing scales
assessment of safety awareness
ergonomic analysis of gait
application of mechanical and
electrical weight-bearing scales
and force plates
Data Generated. Data generated
may include, but are not limited to:
qualitative and quantitative de-
scriptions of gait and balance
gait cycle, gait deviations, and
the safety and quality of gait
over time in different environ-
ments and on a variety of
surfaces
safety and quality of gait and
the gait cycle over time using
assistive, adaptive, supportive,
or protective devices
a list of surfaces and elevations
patient is able to negotiate
number ratings from standard-
ized gait testing instruments
charts and videos that reflect
gait pattern changes over time
a list of patient activities that
aggravate or diminish difficulties
with gait
patient's perception of gait
problems
level of safety awareness
weight-bearing ability, including
standardized measures of
weight-bearing in pounds or
kilograms
Integumentary Integrffy
Examination
Overview. Integumentary integrity is
the health of the skin, including its
ability to serve as a barrier to environ-
mental threats (eg, bacteria, parasites).
The physical therapist uses an integu-
mentary integrity examination to as-
sess the effects of a wide variety of
problems that result in skin and sub-
cutaneous changes, including pressure
and vascular insufficiency ulcers, burns
and other traumas, as well as a num-
txr of diseases (eg, connective tissue
disorders). The integumentary integrity
examination is also used to obtain
more information about circulation
through inspection of the skin or the
nail beds.
The integumentary integrity examina-
tion produces information used in
identlfying the possible or actual
cause(s) of difficulties during the pa-
tient's performance of essential every-
day activities, leisure pursuits, and
work tasks. Selection of specific tests
and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a diag-
nosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. An integumen-
tary integrity examination is appropri-
ate in the presence of:
Suspected or identified pathol-
ogy, injury, or developmental
delay that prevents normal per-
formance of daily activities, in-
cluding self care, home manage-
ment, community or work
reintegration, and leisure
Requirements of employment
that specify specific minimum
capacity for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
Physical Therapy /Volume 75, Number
gait deficit(s1 and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
incontinence, bowel and
bladder difficulty
loss of integumentary integrity
inability to perform specific
movement tasks
Tests and Measures. Tests and
measures for performing an integu-
mentary integrity examination include,
but are not limited to:
determination of the sensory
and temperature sensitivity of
the skin
observation and palpation of
part or all of an extremity at rest
and during activity
observation of burn, skin condi-
tion, wound, or wound drainage
administration of skin tempera-
ture tests, including thermistors
and thermography
palpation of tissue or scar mo-
bility, turgor, and texture
measurement of wound depth
and size, using grid photogra-
phy or other techniques
observation of wound contrac-
tion and scar tissue (cicatrix)
observation of nail beds
administration of photosensitiv-
ity tests
assessment of activities and pos-
tures that aggravate or relieve
pain or other disturbed
sensations
Data Generated. Data generated
may include, but are not limited to:
girths in inches or centimeters
or volumetric displacement in
milliliters
characterization of the extremity
in terms of color and tempera-
ture (in degrees or words)
skin condition
characterization of a wound (eg,
inflamed, macerated, necrotic)
characterization of wound drain-
age (eg, serous, serosanguine-
ous, pus, slough)
skin temperature in degrees
degree of soft tissue and scar
mobility
wound dimensions in square or
cubic inches or centimeters
description of wound contrac-
tion and scar tissue (cicatrix)
grid photograph of wound
minimal erythema1 dose reac-
tions in seconds
a list of activities and postures
that aggravate or relieve pain or
other disturbed sensations
Joint lnteg~i@and Mobility
Examination
0verview.Joint integrity is the con-
formance of joints to expected ana-
tomic, biomechanical, and kinematic
norms. Joint mobility is the capacity of
a joint to be moved passively in cer-
tain ways that take into account the
structure and shape of the joint surface
as well as characteristics of the tissue
surrounding the joint. The assessment
of joint mobility involves the perfor-
mance of accessory joint movements
by the physical therapist because these
movements are not under the volun-
tary control of the patient. The physi-
cal therapist uses the joint integrity
and mobility examination to determine
whether there is excessive or lirmted
motion of the joint. Excessive joint
motion necessitates a program of
protection, while limited joint motion
calls for interventions to increase mo-
bility and enhance functional
capability.
The joint integrity and mobility exami-
nation produces information used in
identlfying the possible or actual
cause(s) of difficulties during the pa-
tient's performance of essential every-
day activities, leisure pursuits, and
work tasks. Selection of specific tests
and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The exarnina-
tion will lead to an evaluation, a diag-
nosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A joint integrity
and mobility examination is appropri-
ate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, leisure,
and sports or fitness training
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
edema or effusion
soft-tissue limitation
Tests and Measures. Tests and
measures for performing a joint integ-
rity and mobility examination include,
but are not limited to:
assessment of pain and soreness
quantification of pain using
standard pain scales
observation of the nature and
quality of movement of the joint
or body part during the perfor-
mance of specific movement
tasks
palpation and observation of
specific joint mobility in re-
sponse to manual provocation
of the joint
assessment of joint hyper- and
hypomobility
assessment of sprain
measurement of connective tis-
sue laxity
Data Generated. Data generated
may include, but are not limited to:
quantity and quality of joint
movement
grades and classification systems
of joint mobility
classification and grade of sprain
clinical signs or pain in re-
sponse to a specific test of
provocation
Motor Function hamination
Overview. Motor function is the abil-
ity to learn or demonstrate the skillful
and efficient assumption, maintenance,
modification, and control of voluntary
postures and movement patterns. The
physical therapist uses the motor func-
tion examination in the diagnosis of
underlying pathology. Deficits in mo-
tor function reflect the type, location,
and extent of the pathology, which
may be a neurologic disease or other
disorder. Weakness and paralysis are
common manifestations of most neu-
rologic disease; however, abnormal
movement patterns and timing, unco-
ordination, clumsiness, involuntary
movements, or abnormal postures
may also indicate neurologic disease
or other disorders.
The motor function examination pro-
duces information used in idennfying
the possible or actual causecs) of diffi-
culties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
Physical Therapy / Volume 75, Number 8 / August 1995
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A motor func-
tion examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial and temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
impaired performance of spe-
cific movement tasks
soft tissue limitations
inadequate circulation, recur-
rent ischemia, or claudication
somatosensory deficit
 altered level of consciousness
and comprehension
Tests and Measures. Tests and
measures for performing a motor
function examination include, but are
not limited. to:
administration of motor assess-
ment scales
analysis of head, trunk, and
limb movement
analysis of posture during sit-
ting, standing, and locomotor
activities appropriate for age
(eg, hopping, skipping, running,
jumping)
administration of physical per-
formance scales
assessment of sensorimotor
integration
assessment of motor control and
motor learning
assessment of dexterity, coordi-
nation, and agility
analysis of gait
performance of electrophysi-
ologic tests (eg, diagnostic and
kinesiologic electromyography
[EMG], motor nerve conduction
testing)
analysis of stereotyped
movements
Data Generated. Data generated
may include, but are not limited to:
difference between predicted
and actual performance
degree that maturation is coordi-
nated with stages of
development
descriptions of skill and effi-
ciency of motor function, in-
cluding- the ability to initiate,
contrc~l,and terminate
movement
timing, accuracy, sequencing,
and number of repetitions of
specific movement patterns and
postures
scores and comparisons to stan-
dardized age and sex norms for
motor performance
characteristics of muscle activity
during movement
conduction velocity along pe-
ripheral motor nerves
amplitude, duration, waveform,
and frequency of normal or ab-
Physical Therapy / Volume 75, Number 8 / August 1995
normal electrical potentials in
muscles
description of synergies, athe-
totic movements, etc
Muscle Performance Examination
(Including Strength, h w e r , and
Endurance)
Overview. Muscle p@onnance is the
capacity of a muscle to do work (force
X distance). The performance of an
individual muscle depends on its char-
acteristics of length, tension, and ve-
locity. Integrated muscle performance
over time is mediated by neurologic
stimulation, fuel storage, and fuel
delivery, as well as balance, timing,
and sequencing of contraction. The
physical therapist uses the muscle
performance examination to determine
the patient's ability to produce move-
ments that are prerequisite to func-
tional activity.
The muscle performance examination
produces information used in identify-
ing the possible or actual cause(s) of
difficulties during the patient's perfor-
rnance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findings of the patient
and Systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications, A muscle perfor-
mance examination is appropriate in
the ~resenceof:
1
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, leisure,
and sports or fitness training
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s1 and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
inability to perform specific
movement tasks
abnormal power
weakness of the pelvic floor
muscle
Tests and Measures. Tests and
measures for conducting a muscle
performance examination include, but
are not limited to:
administration of manual muscle
tests
administration of functional
muscle testing
administration of computer-
assisted electromechanical mus-
cle tests
performance of dynamometry
performance of electrophysi-
ologic tests (eg, EMG, nerve
conduction velocity)
assessment of muscle flaccidity
and spasticity
quantification of pain and
soreness
assessment of perineal integrity
Data Generated. Data generated
may include, but are not limited to:
numbers, percentages, or letter
grades from standardized grad-
 ing systems for manual and
functional muscle testing
force, velocity, torque, work,
and power of muscle
performance
changes in muscle performance
over time
consistency of effort and
performance
amplitude, duration, waveform,
and frequency of EMG signals
descriptions of the muscle con-
tractions (eg, maximal, painful,
smooth, coordinated, cogwheel)
expressions of pain, soreness, or
other symptoms produced by
provocation of muscle
contractions
description of the strength of
the pelvic floor
Neummotor Development and
Sensow Integration Examination
Overview. Neumrnotor development is
the acquisition and evolution of move-
ment slulls throughout the lifespan.
Sensoy integration is the ability to
integrate information from the envi-
ronment in order to produce normal
movement outputs. The physical ther-
apist uses the neuromotor develop-
ment and sensory integration exarnina-
tion to assess motor capabilities in
both children and adults. The exami-
nation may be used to assess mobility,
achievement of motor milestones and
normal responses, postural control,
and volitional and nonvolitional move-
ment. The physical therapist will also
employ the examination to test bal-
ance, righting and equilibrium reac-
tions, eye-hand coordination, and
other motor capabilities.
The neuromotor develo~mentand
sensory integration examination pro-
duces information used to identlfy the
possible or actual cause(s) of diacul-
Eies during the patient's performance
of essential everyday activities, leisure
pursuits, and work tasks. Selection of
specific tests and measures will de-
pend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specdic activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
86 / 731
determination of appropriate
interventions.
Clinical Indications. A neuromotor
development and sensory integration
examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
motor deficits (eg, weakness;
paralysis; uncoordination; ab-
normal spatial and temporal
patterns of movement; tone;
spasticity; flaccidity; and
pathological reflexes)
gait deficit(s) and
disturbances
postural deficits
abnormalities of flexibility
and strength
biomechanical and arthroki-
nematic limitations
im~airedbalance or freauent
falling
* impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
somatosensory deficit
Tests and Measures. Tests and
measures for performing a neuromotor
development and sensory integration
examination include, but are not lim-
ited to:
Physical Therapy / Volume 75, Number 8 /August 1995
administration of a battery of
tests of sensory integration
administration of a battery of
tests of motor development
assessment of gross and fine
motor skills
evaluation of language
development
assessment of equilibrium and
righting reactions
administration of tests of motor
development
assessment of function
screening for age- and sex-
appropriate development
analysis of gait and posture
analysis of reflex and movement
patterns
assessment of alertness
assessment of behavioral
response
assessment of dexterity, agility,
and coordination
Data Generated. Data generated
may include, but are not limited to:
normal and abnormal motor
patterns
difference between predicted
and actual performance
gross and fine motor develop-
mental age
presence or absence of primitive
reflexes
qualitative description of the
organization and processing of
information
description of postural
alignment
description of movement
asymmetries
description of characteristics of
normal, age-appropriate move-
ment patterns, postures, and
sequences
Orthotic Requirements
Examination
Ovenriew. An orthosis is a device (eg,
a splint, a brace, a shoe insert) to
support weak or ineffective joints or
muscles and may serve to enhance
performance. The physical therapist
uses the orthotic requirements exami-
nation to determine the need for an
orthotic device in individuals not cur-
rently using one and to evaluate the
appropriateness and fit of those or-
thotic devices already in use. The
physical therapist correlates the pa-
tient's problems with available ortho-
ses to make a choice that best serves
the patient. For example, the physical
therapist may have to choose between
an orthosis that provides maximum
control of motion and one that permits
considerable movement.
The orthotic requirements examination
produces information used in identify-
ing the possible or actual cause(s) of
difficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs spechc activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventior~s.
Clinical Indications. An orthotic
requirements examination is appropri-
ate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
veloprnental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
Physical Tlierapy / Volume 75, Number 8 /August 1995
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
inadequate circulation, recur-
rent ischemia. or claudication
Tests and Measures. Tests and
measures for performing an orthotic
requirements examination include, but
are not limited to:
analysis of the potential to re-
mediate impairments, functional
limitations, or disabilities with
an orthotic device
assessment of appropriate com-
ponents of an orthotic device
analysis of alignment and fit of
an orthotic device and inspec-
tion of related changes in skin
condition
observation of the individual
wearing an orthotic device for
intended effects and benefits
(including energy conservation
and expenditure)
assessment of the individual's
ability to put on and remove an
orthotic device and to under-
stand its use and application
videotaped analysis of the pa-
tient's or client's movement
while wearing an orthotic
device
computer-assisted analysis of the
patient's or client's movement
while wearing a device
review of reports provided by
the patient, family, significant
other, and caregivers
Data Generated. Data generated
may include, but are not limited to:
energy expenditure
requirements
deviations and dysfunctions that
can be corrected or alleviated
by an orthotic device
alignment of anatomical parts
with an orthotic device
effectiveness of orthotic device
in providing protection, promot-
ing stability, or improving per-
formance of tasks and activities
levels of comfort, cosmesis, and
effectiveness using an orthotic
device
ability to put on and remove an
orthotic device and to under-
stand its use and application
level of compliance with use of
an orthotic device
Pain Examination
Overview. Pain is a disturbed sensa-
tion causing suffering or distress. The
physical therapist uses the pain exarni-
nation to determine the intensity,
quality, and temporal and physical
characteristics of any pain that is sig-
rdicant to the patient. The physical
therapist may hypothesize a cause or
mechanism for the pain(s) through
this examination. The examination
may also be used to determine
whether a referral to a physician or
mental health professional is
appropriate.
The pain examination produces infor-
mation used in identifying the possible
or actual cause(s1 of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient
performs specific activities. The exami-
nation will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. A pain examina-
tion is appropriate in the presence of:
Suspected or identified pathol-
ogy, injury, or developmental
delay that prevents normal per-
formance of daily activities, in-
cluding self care, home manage-
ment, community or work
reintegration, and leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
 Change in daily activities or
lifestyle
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
Tests and Measums. Tests and
measures for performing a pain exami-
nation include, but are not limited to:
observation of pain behavior
and reactiods) during specific
movements
administration of pain
questionnaires
administration of visual analog
scales
administration of graphic rating
scales
determination of muscle sore-
ness by classification and grade
interview of the patient to elicit
perceived sensations (eg, phan-
tom pain) and verbal descriptors
of discomfort, tenderness, or
soreness
administration of pressure al-
gometry and dolorimetry
administration of symptom mag-
nification scales or indices
Data Generated. Data generated
may include, but are not limited to:
expressions of pain in response
to tests of provocation and dur-
ing specific movement tasks
consistency of patient's re-
sponses to pain
behavior or painful reaction(s)
observed during particular
movement tasks
number ratings from standard-
ized rating instruments
charts that reflect changes in
pain reaction(s) over time
charts that reflect the somatic
distribution of pain
expressions of sensory and tem-
poral qualities of pain
list of activities that aggravate or
relieve pain
response to noxious stimuli
Posture Gramination
Ovewiew. Posture is the alignment
and positioning of the body in relation
to gravity, center of mass, and basis of
support. The physical therapist uses
the posture examination to assess
structural abnormalities as well as the
ability to right oneself with gravity.
Good posture is a state of muscular
and skeletal balance that protects the
supporting structures of the body
against injury or progressive deformity.
Findings from the posture examination
may lead the physical therapist to
perform additional examinations (eg,
joint integrity and mobility, respiration
and circulation).
The posture examination produces
information used in identifying the
possible or actual cause(s) of dficul-
ties during the patient's performance
of essential everyday activities, leisure
pursuits, and work tasks. Selection of
specific tests and measures will de-
pend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A posture exam-
ination is appropriate in the presence
of:
Physical Therapy / Volume 75, Number 8 /August 1 9 5
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Pregnancy
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s1 and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
Tests and Measures. Tests and
measures for performing a posture
examination include, but are not lim-
ited to:
visual estimation of posture
alignment
observation of posture using a
posture grid or plumb line
computer-assisted analysis of the
patient's posture during
movement
still photography of the patient
observation of resting posture
assumed in any position
Data Generated. Data generated
may include, but are not limited to:
 postural alignment while stand-
ing, sitting, lying, or during
movement
alignment and symmetry of
body landmarks within segmen-
tal planes while at rest or in
motion
deviations from anticipated pos-
tural alignments within lines or
grid marks in various views
Prosthetic Requirements
Examination
Overview. A pmthesis is an artificial
device, often mechanical or electrical,
used to replace a missing part of the
body. Physical therapists use the pros-
thetic req~~irements examination for
patients wearing a prosthesis and also
for those who might benefit from one.
The physical therapist chooses a pros-
thesis that will permit the patient max-
imum freedom of movement and
functional capability with a minimum
of discomfort and inconvenience.
The prosthetic requirements examina-
tion produces information used in
identifying the possible or actual
cause(s) d difficulties during the pa-
tient's performance of essential every-
day activities, leisure pursuits, and
work task:s. Selection of specific tests
and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a diag-
nosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A prosthetic
requirements examination is appropri-
ate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Physical 'Therapy / Volume 75, Number 8 / August 1995
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s1 and
disturbances
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
inadequate circulation, recur-
rent ischemia, or claudication
in residual limb and/or adja-
cent segment
loss of part or all of a limb
Tests and Measures. Tests and
measures for performing a prosthetic
requirements examination include, but
are not limited to:
analysis of the potential to re-
mediate impairments, functional
limitations, or disabilities with a
prosthetic device
analysis of the practicality and
ease of use of a prosthetic
device
assessment of appropriate com-
ponents of a prosthetic device
analysis of alignment and fit of a
device and inspection of related
changes in skin condition
observation of the individual
wearing a prosthetic device for
intended effects and benefits
(including energy conservation
and expenditure)
assessment of the individual's
ability to put on and remove a
prosthetic device
videotaped analysis of the pa-
tient's or client's movement
while wearing a prosthetic
device
computer-assisted analysis of the
patient's or client's movement
while wearing a prosthetic
device
review of reports provided by
the patient, family, significant
other, and caregivers
assessment of residual limb
and/or adjacent segment for
range of motion, strength, skin
integrity, and edema
Data Generated. Data generated
may include, but are not limited to:
energy expenditure
requirements
deviations and dysfunctions that
can be corrected or alleviated
by a prosthetic device
practicality and ease of use of a
proposed prosthetic device
alignment of anatomical parts
with a prosthetic device
effectiveness of a prosthetic de-
vice in providing protection,
promoting stability, or improv-
ing performance of tasks and
activities and enhancing func-
tion at home and in community
expressions of comfort, cosme-
sis, and effectiveness using a
prosthetic device
ability to put on and remove a
prosthetic device
level of compliance with use of
a device
range of motion, strength, skin
integrity, and edema in residual
limb and/or adjacent segment
Range of Motion Examination
(Including Muscle Length)
Overview. Range of motion describes
the space, distance, or angle through
which a patient can move a joint or
series of joints. Muscle length is mea-
sured during various stages of tension
(from resting at full extension through
the contractile range); muscle length,
in conjunction with joint integrity and
connective tissue extensibility, deter-
mines flexibility. The physical therapist
uses the range of motion examination
to determine the function and biome-
chanics of a joint, which include its
734 / 89
flexibility and movement characteris-
tics. Adequate range of motion is
valuable for injury prevention because
it allows the tissues to adjust to irn-
posed stresses.
The range of motion examination
produces information used in identify-
ing the possible or actual cause(s) of
dficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specific tests and measures will
depend on the findmgs of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A range of mo-
tion examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
gait deficit(s) and
disturbances
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inability to perform specific
movement tasks
soft tissue limitations
inadequate circulation, recur-
rent ischemia, or claudication
Tests and Measures. Tests and
measures for performing a range of
motion examination include, but are
not limited to:
quantification of pain and sore-
ness of soft tissue
observation and palpation of
muscles, tendons, and associ-
ated soft tissue during multi-
segment motion
determination of range using a
tape measure, flexible ruler, or
electronic device
determination of muscle sore-
ness by classification and grades
performance of goniometry
digitized analysis of motion
performance of posturography
palpation of muscles, joints, or
soft tissue
Data Generated. Data generated
may include, but are not limited to:
expressions of pain or tender-
ness in muscle(s), joint(s), and
soft tissue during movements or
activities that require elongation
of muscle(s)
range of joint motion in degrees
findings of passive tension dur-
ing multi-segment movement
that requires elongation of
muscle
deviations from planes in de-
grees or inches or centimeters
excursion distances in inches or
centimeters
Reflex Integrity Examination
Overview. A refex is a stereotyped
reaction to any of a variety of sensory
stimuli. The physical therapist uses the
reflex integrity examination to deter-
mine the excitability of the nervous
system and the integrity of the neuro-
muscular system.
Physical Therapy / Volume 75, Number 8 /August 1995
The reflex integrity examination pro-
duces information used in identifying
the possible or actual cause(s) of d f i -
culties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specfic tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A reflex integrity
examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
motor deficits (eg, weakness,
paralysis, uncoordination, ab-
normal spatial and temporal
patterns of movement, tone,
spasticity, flaccidity)
gait deficit(s) and
disturbances
postural deficits
abnormalities in flexibility or
strength
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
 inability to perform specific
movement tasks
somatosensory deficit
altered state of consciousness
Tests and Measums. Tests and
measures for performing a reflex in-
tegrity examination include, but are
not limited to:
determination of the presence,
absence, or exaggeration of de-
velopmentally appropriate
reflexes
assessment of normal reflexes
(eg, deep tendon reflex)
assessment of pathologic re-
flexes (eg, Babinski)
performance of electrophysi-
ologic testing (eg, H-reflex)
elicitation of postural, equilib-
rium, and righting reactions
Data Generated. Data generated
may include, but are not limited to:
presence, absence, or exaggera-
tion of normal and/or patho-
logic reflexes
difference between predicted
and actual performance
variation in reflex activity over
time or with positioning
time of conduction over reflex
pathway
Self-Cane and Home-
Management Examination
(Including Activities of Daily
Living and lnstmmental Activities
of Daily Living)
Overview. Self care is the set of activ-
ities comprising daily living, eg, rising
from bed, dressing, bathing, eating,
and toileting. Home management is a
set of more complex activities that
comprise maintaining a home, eg,
shopping, cooking, housekeeping,
managing money, and driving a car or
using public transportation. The physi-
cal therapist uses the self care or
home management examination to
determine whether an individual can
perform the tasks necessary for inde-
pendent daily living. In addition, the
physical therapist uses the self care or
home management examination to
determine whether the patient is a
candidate for an orthosis or an assis-
Physical Therapy / Volume 75, Number 8 /August 1995
tive, adaptive, supportive, or protec-
tive device. Finally, the physical thera-
pist uses this examination to
determine whether the patient is a
candidate for body mechanics training
or an organized hnctional training
program. In every case the physical
therapist integrates the patient's per-
ceptions and expectations into the
examination process.
The self care and home management
examination produces information
used in identlfylng the possible or
actual cause(s) of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
findings of the patient history and
systems review. The examination may
require testing while the patient per-
forms specific activities. The examina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. A self care and
home management examination is
appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care or
home management tasks and
movements
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care or
home management tasks and
movements:
pain
weakness
lack of mobility
lack of endurance
lack of flexibility
gait deficit(s1 and
disturbances
postural deficits
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
inadequate circulation, recur-
rent ischemia, or claudication
incontinence, bowel and
bladder diaculty
inability to perform specific
movement tasks
Tests and Measunes. Tests and
measures for performing a self-care
and home-management examination
include, but are not limited to:
administration of the activities of
daily living scale
administration of the instrumen-
tal activities of daily living scale
performance of functional range
of motion and muscle tests
assessment of physiologic re-
sponses during self-care and
home-management activities
review of daily activity logs
observation of the individual
performing self-care and home-
management activities
review of reports provided by
the individual, family member,
significant other, or caregiver
administration of questionnaires
and conduct of interviews with
the individual and others as
appropriate
Data Generated. Data generated
may include, but are not limited to:
level of performance of self-care
and home-management activities
and dependence on human and
mechanical assistance
spatial and temporal require-
ments for performing specific
tasks related to self care and
care of the household
vital signs and physiologic re-
sponse during self-care and
home-management activities
numerical scores on standard-
ized rating scales
movement patterns during per-
formance of self-care and home-
management activities
patient's daily activity level
Sensory Integtfty Examination
(Including Pmprioception and
Kinesthesb)
Overview. A s m oy integrity exami-
nation is the assessment of peripheral
sensory processing (eg, sensitivity to
touch) and cortical sensory processing
(eg, two-point and sharp/dull discrimi-
nation). Proprioception includes posi-
tion sense, the awareness of the joints
at rest, and kinesthesia, the awareness
of movement. The physical therapist
uses the sensory integrity examination
to determine the integrity of the so-
matosensory system. Somatosensory
abnormalities are frequent indicators
of pathology.
The sensory integrity examination
produces information used in identify-
ing the possible or actual cause(s) of
difficulties during the patient's perfor-
mance of essential everyday activities,
leisure pursuits, and work tasks. Selec-
tion of specdic tests and measures will
depend on the findings of the patient
history and systems review. The exam-
ination may require testing while the
patient performs specific activities. The
examination will lead to an evaluation,
a diagnosis, a prognosis, and the
determination of appropriate
interventions.
Clinical Indications. A sensory integ-
rity examination is appropriate in the
presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopmental delay that prevents
normal performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
motor deficits (eg, weakness,
paralysis, uncoordination, ab-
normal spatial and temporal
patterns of movement, tone,
spasticity, flaccidity, and
pathological reflexes)
disturbances in balance
somatosensory deficit
altered state of consciousness
disturbance in gait, particu-
larly when selectively present
in conditions of low vision
postural deficits
abnormalities in movement,
flexibility, or strength
biomechanical and arthroki-
nematic limitations
impaired balance or frequent
falling
impaired motor function and
learning
impaired sensation
sympathetic disturbances
inability to perform specific
movement tasks
soft tissue limitations
inadequate circulation, recur-
rent ischemia, or claudication
Tests and Measures. Tests and
measures for performing a sensory
integrity examination include, but are
not limited to:
assessment of gross receptive
(eg, vision, hearing) or expres-
sive (eg, verbalization) deficits
assessment of superficial sensa-
tions (eg, sharp/dull discrimina-
tion, temperature, light touch,
pressure)
assessment of deep (propriocep-
tive) sensations (eg, movement
sense or kinesthesia, position
sense)
assessment of combined (corti-
cal) sensations (eg, stereognosis,
tactile localization, two-point
discrimination, vibration, texture
recognition)
performance of electrophysi-
ologic testing (eg, sensory nerve
conduction testing)
assessment of skin integrity in
cases of decreased sensation
Physical Therapy / Volume 75, Number 8 /August 1995
Data Generated. Data generated
may include, but are not limited to:
difference between predicted
and actual performance
visual or auditory acuity
verbalization skills
presence, absence, or distortion
of superficial sensory capacities
presence, absence, or distortion
of perception of movement by
extremities
presence, absence, or distortion
of joint position sense
accuracy of cortical perceptions
(eg, tactile recognition of ob-
jects, recognition of symbols
drawn on the skin, ability to
localize touch sensations)
conduction times and velocities
along peripheral and/or central
musculoskeletal sensory
pathways
presence of skin breakdown or
injury that may cause decreased
sensation
Ventilation, Respiration, and
Circulation Bramination
Overview. Ventilation is the move-
ment of a volume of gas into and out
of the lungs. Respi'ration refers prima-
rly to the exchange of oxygen and
carbon dioxide across a membrane
into and out of the lungs as well as
the cells. Circulation is the passage of
blood through the heart, blood ves-
sels, organs, and tissues; it also de-
scribes the oxygen delivery system.
The physical therapist uses the ventila-
tion, respiration, and circulation exam-
ination to determine whether the pa-
tient has an adequate ventilatory
pump, oxygen uptake, and oxygen
delivery system to perform activities of
daily living, ambulation, and aerobic
exercise.
The ventilation, respiration, and circu-
lation examination produces informa-
tion used in identdjmg the possible or
actual cause(s) of difficulties during
the patient's performance of essential
everyday activities, leisure pursuits,
and work tasks. Selection of specific
tests and measures will depend on the
findings of the patient h t o r y and
systems review. The examination may
require testing while the patient per-
forms specfic activities. The exarnina-
tion will lead to an evaluation, a
diagnosis, a prognosis, and the deter-
mination of appropriate interventions.
Clinical Indications. A ventilation,
respiration, and circulation examina-
tion is appropriate in the presence of:
Physical disability, impaired sen-
sorimotor function, pain, or de-
velopnlental delay that prevents
normal. performance of daily
activities, including self care,
home management, community
or work reintegration, and
leisure
Requirements of employment
that specify minimum capacity
for performance
A need to initiate or change a
prevention or wellness program
Expectations or indications of
one or more of the following
impairments or functional limita-
tions experienced when at-
tempting to perform self care,
home management, community
or work reintegration, or leisure
tasks and movements:
pain
weakness
lack of mobility
lack of endurance
postural deficits
abnormalities in movement,
flexibility, or strength
inadequate circulation, recur-
rent ischemia, or claudication
abnormal breathing patterns
or abnormal blood gases
dyspnea at rest or o n exertion
impaired ventilation
abnormal cough or airway
protection responses
sympathetic disturbances
chest congestion
Physical Therapy / Volume 75, Number 8 / August 1995
inability to perform specific
movement tasks
edema, including edema of
pregnancy
dizziness or palpitations
effects of thoracic or abdomi-
nal surgery
Tests and Measures. Tests and
measures for performing a ventilation,
respiration, and circulation exarnina-
tion include, but are not limited to:
obtainment of standard vital
signs (blood pressure, heart, and
respiratory rate)
observation of chest movements
and breathing patterns at rest
and during exercise
calculation of respiratory rate at
rest and during exercise
observation for cyanosis
auscultation and percussion of
the heart and lungs
auscultation of major vessels for
bruits
palpation of pulses (eg, for in-
tegrity of the vascular system)
palpation of the chest wall (eg,
for diaphragmatic excursion; for
chest wall expansion, mobility,
or pain; for fremitus)
application of perceived exer-
tion scales and dyspnea scales
assessment of cough and
sputum
assessment of phonation
classfication of edema through
volumetrics and girths
gas analysis to measure oxygen
consumption
assessment of activities that ag-
gravate or relieve edema, pain,
or other disturbed sensations
assessment of ability to perform
activities of daily living and in-
strumental activities of daily
living
performance of pulmonary func-
tion tests and measures of venti-
latory mechanics
performance of pulse oximetry
performance of arterial blood
gas analysis
Data Generated. Data generated
may include, but are not limited to:
report of vital signs and blood
gases
characteristics of normal and
abnormal heart and lung sounds
peripheral circulation integrity
mobility of chest wall, rib integ-
rity, and presence of spinal
curves that could affect chest
expansion
characteristics of the pulse
description of perceived exer-
tion grading and dyspnea at rest
and during activity
characteristics of cough, sputum,
phonation, and skin
grading of edema using stan-
dardized number scales
girths in inches or centimeters
or volumetric displacement in
milliliters
a list of activities that aggravate
or relieve edema, pain, or other
disturbed sensations
description of chest movements
and breathing patterns at rest
and during activity
description of ventilatory muscle
integrity, strength, and
endurance
description of the work of
breathing and ventilatory re-
serve capacity
ability to perform activities of
daily living and instrumental
activities of daily living
oxygen saturation
Chapter Three:
Interventions Provided by Physical Therapists

This chapter describes the fifth ele-
ment of physical therapist patient
management, ie, intervention. Figure
2, the schema describing the physical
therapist's approach to patient man-
agement that was presented in Chap
ter One, is shown below with inter-
vention highlighted.
The APTA believes that policy deci-
sions about the use of physical ther-
apy personnel and resources to man-
age patients with impairments, func-
tional limitations, and disabilities
should be based on knowledge of the
elements of physical therapy patient
management. The Association notes
prevent recurrence of clinical prob-
lems, and promote wellness.
Any physical therapy intervention
includes four critical components:
1) development of a patient manage-
ment program that encourages inde-
pendence; 2) patient-related instruc-
tion; 3) development of the capacity
of patients, family members, signifi-
cant others, and caregivers to partici-
pate effectively; and 4) promotion of
proactive, wellnessariented lifestyles.
Intervention
Intervention is the purposeful and
sis, and prognosis. Decisions deter-
mining intervention are contingent
upon the timely monitoring of the
patient's response and the progress
made toward achieving outcomes.
There are three intervention
components:
direct intervention
patient-related instruction
coordination, communication,
and documentation
b Dimct Intervention. This process
includes the selection, application, and
modification of one or more therapeu-
tic interventions. Three interventions

-
therapeutic exercise, functional train-
that, while all health services incur skilled interaction of the physical ther- ing in self care and home manage-
costs, failing to intervene appropriately apist with the patient, using various ment, and functional training in com-
and prevent illness and neglecting to methods and techniques to produce munity or work reintegration activi-
rehabilitate individuals with impair- changes in the patient's condition tie-form the core elements in most
ments, Functional limitations, and consistent with the evaluation, diagno-
physical therapy plans of care. These
disability leads to greater costs at per-
sonal and societal levels. This docu-
ment is a first step in providing policy-
makers with the information needed
to make decisions about the cost-
effectiveness of physical therapy
services.

Physical therapy interventions include EXAMINATION

ongoing examination and modification
of the treatment plan for each patient
when necessary. The interventions
selected are based on the complexity EVALUATION
of the patient's clinical problems.
Treatment plans include discharge
planning that begins early and is
based on the actual and expected
treatment outcomes that are deter-
mined by periodic reexamination. As
soon as clinically appropriate, patients
are Informed of their prognoses and
begin, with the assistance of the thera-
pist, long-range planning for managing
any residual impairment, functional
limitation, or disability. Through ap-
propriate education, patients are also
encouraged to develop health habits Flgum 2. m e elements of physical therapist patient management leading to opti-
to maintain or improve their function, mal outcome.

94 / 739 Physical Therapy / Volume 75, Number 8 /August 1995

plans of care frequently include the
use of other interventions to augment
functional training and therapeutic
exercise.
The selection of any physical therapy
intervention should be supported by
the following:
examination (including history
and systems review), evaluation,
and diagnosis that support phys-
ical therapist intervention
plan of care designed to im-
prove function using interven-
tions of appropriate intensity,
frequency, and duration to
achieve specific goals efficiently
with available resources
prognosis that is associated with
improved or maintained health
status through the remediation
of impairments, functional limi-
tations, or disabilities
The intenrentions available to the
physical therapist in developing a
treatment program include, but are not
limited to, the following:
therapeutic exercise (including
aerobic conditioning)
functional training in self care
and home management (includ-
ing activities of daily living and
instrumental activities of daily
living)
functional training in community
or work reintegration (including
instrumental activities of daily
living, work hardening, and
work conditioning)
manual therapy techniques (in-
cluding mobilization and
manipulation)
prescription, fabrication, and
application of assistive, adap-
tive, supportive, and protective
devices and equipment
airway clearance techniques
debridement and wound care
physical agents and mechanical
modalities
electrcjtherapeutic modalities
patient-related instruction
Physical therapists select interventions
based on the data gathered from the
examination process. Factors that
influence the complexity of the inter-
Physical Therapy / Volume 75, Number 8 / August 1995
vention and the evaluation process
include, but are not limited to, the
following:
* severity of current problem
stability of the patient's
condition
pre-existing conditions
level of impairment(s)
probability of prolonged impair-
ment, functional limitations, and
disability
social supports and living
environment
multiple sites or systems
involvement
overall physical function and
health status
potential discharge destination
11. Patient-related Instruction. This
process includes instruction of the
patient, groups of patients, families,
and other caregivers regarding the
patient's current condition, treatment,
and transition to his or her role at
home, at work, or in the community.
In addition to imparting information,
instruction may also include training in
maintenance activities and primary
and secondary prevention.
111. Coordination, CommunicationJ
and Documentation. These pro-
cesses ensure that the patient receives
appropriate, coordinated, comprehen-
sive, and cost-effective services be-
tween admission and discharge. The
services include, but are not limited to,
the following:
patient care conferences
communications (telephone, fax,
etc)
documentation of all elements
of patient management
coordination of care with pa-
tients, significant others, family
members, caregivers, and other
health professionals
record reviews
discharge planning
Clinical documentation states:
the specific mode(s) of interven-
tions selected and the parame-
ters of their application
the direct effects of each inter-
vention in terms of impairment
status (change in level of pain,
sensation, reflexes, strength, en-
durance, range, and quality of
joint movement)
changes since previous interven-
tion and any alteration(s) in
technique or intervention plan
Changes in functional limitations
and disability, especially as they
relate to meaningful, practical,
and sustained change in the pa-
tient's life. If pain reduction is a
goal, the outcome should be
documented in terms of reduc-
tion in level of pain as it relates
to a change in functional
performance.
Documentation should follow the
APIA Guidelinesfor Physical i%erapy
Documentation (Appendix 111).
For all physical therapy interventions:
Initiation of a specific procedure
is based on a clinical plan with
expected outcomes. Routine
monitoring determines the need
for any alteration(s1 in an inter-
vention or the plan of care.
The physical therapist assesses
the patient's (significant other's,
family's, or caregiver's) ability to
perform the intervention inde-
pendently. When it is appropri-
ate, any individual who can per-
form an intervention
independently should be in-
structed in its safe and effica-
cious application.
Discontinuance of a procedure
may be indicated because of
lack of progress, lack of patient
tolerance, lack of patient moti-
vation, attainment of maximum
improvement, the achievement
of expected outcomes, or the
determination of a more effec-
tive alternative
The interventions used, includ-
ing their frequency and dura-
tion, are consistent with the pa-
tient's needs and physiologic
and cognitive status, the goals
of treatment, and resource
constraints
For each intervention, four areas are
discussed:
740 / 95
 Overview-Provides an intro-
duction to the intervention.
Modes of Intervention-Lists
the possible methods, proce-
dures, or techniques of the
intervention.
CMcal Indications-De-
scribes general criteria for ap-
propriate use of the
intervention.
Benefits-Addresses expected
positive results from the
intervention.
The use of any physical therapy inter-
vention, unless performed by a physi-
cal therapist or under the direction or
supervision of a physical therapist, is
not physical therapy nor should it be
represented or reimbursed as such.
Therapeutic Execise (Including
Aerobic Conditioning)
OvefView. Therapeutic exercise con-
sists of a broad group of activities
intended to improve a patient's
strength, muscle length, range of mo-
tion, endurance, breathing, balance,
coordination, posture, motor function,
motor development, or confidence
when any of a range of problems
constrains the patient's ability to per-
form a functional activity. Therapeutic
exercise is a part of fitness and well-
ness programs designed to promote
overall well-being or, in general, to
prevent complications related to inac-
tivity or overuse. This intervention
may be used during pregnancy and
the post-partum period to improve
function and reduce stress. It may also
be used (with proper guidance) in
patients with hematologic and o n c e
logic disorders to combat fatigue and
systemic breakdowns. Therapeutic
exercise may also prevent further
complications and decrease use of
health care resources during and after
surgery or hospitalization.
Therapeutic exercise includes activities
to improve physical function and
health status (or reduce or prevent
disability) resulting from impairment(s)
by identdying specific performance
goals that will allow patients to
achieve a higher functional level in the
home, school, workplace, or commu-
nity. It also incorporates activities to
allow well clients to improve or main-
tain their health or performance status
(for work, recreational, or sports pur-
poses) and prevent or minimize future
potential health problems.
Therapeutic exercise is performed
actively, passively, or against resis-
tance. When the patient cannot partici-
pate actively due to weakness or other
problems, passive exercise may be
necessary. Resistance may be provided
manually, by gravity, through use of a
weighted apparatus, or by mechanical
or electromechanical devices. Aquatic
physical the physical and
properties water
facilitate patient performance.
Modes of Intervention. Therapeutic
exercise includes, but is not limited to:
stretching
strengthening
active assistive
active
resistive, using manual resis-
tance, pulleys, weights, hy-
draulics, elastics, robotics,
and mechanical or electrome-
chanical devices
neuromuscular relaxation, inhi-
bition, and facilitation
neuromuscular re-education
motor training or retraining
developmental activities
breathing exercises, ventilatory
muscle training
aerobic endurance activities,
using cycles, treadmills, step-
pers, pools, manual resistance,
pulleys, weights, hydraulics,
elastics, robotics, and mechani-
cal or electromechanical devices
aquatic exercises
conditioning and reconditioning
ambulation and elevation
training
balance and coordination
training
body mechanics and ergonom-
ics training
posture awareness training
play or leisure activities
Clinical Indications. Before applying
therapeutic exercise, a thorough ex-
amination is performed to identdy
Physical Therapy / Volume 75, Number 8 /August 1 9 5
those conditions that would prevent
the use of this intervention or indicate
that it is to be applied with caution.
Candidates for therapeutic exercise are
individuals restricted from completing
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardioDulmonarv
perip(eral vasc;lar
integumentary
lymphatic
endocrine or metabolic
genitourinary
Candidates for therapeutic exercise
also include, but are not limited to,
individuals who are:
at risk of developing cardiovas-
cular, neuromusculoskeletal, or
pulmonary impairments
severely deconditioned
pre- or post-surgical intervention
pre- or post-partum
diabetic or osteoporotic or at
risk of developing diabetes or
osteoporosis
engaged in recreational, orga-
nized amateur, or professional
athletics
Benefits. All benefits of therapeutic
exercise are measured in terms of
remediation or prevention of impair-
ments, functional limitations, and
&ability. Specific benefits related to
therapeutic exercise include, but are
not limited to:
improved physical function and
health status
improved quality and quantity
of joint movement
reduced signs and symptoms of
joint and soft tissue swelling and
inflammation
improved quality and quantity
of movement between and
across body segments
improved weight-bearing status
improved ambulation and eleva-
tion abilities
reduction in secondary
impairments
increased mobility
increased tolerance to positions
and activities
 increased capacity to execute
physical tasks
increased endurance
reduced risk of system
impairment
decreased disability from acute
or chronic illnesses
decreased service utilization,
cost, and risk of recurrence
increased independence
decreased level of supervision
or care
improved self-management
reduced risk factors
increased sense of well-being
and decreased stress
reduced pre- and post-operative
complications
decreased pain
improved ability to perform ac-
tivities of daily living
Functional Training in Self Can?
and Home Management
(Including Activities of Daily
Living and lnstmmental Activities
of Daily Living)
Overview. Functional training in self
care and home management includes
a broad group of performance activi-
ties designed to improve a patient's
neuromusculoskeletal, cardiovascular,
and pulmonary capacities. Functional
training is used to improve the physi-
cal function and health status of indi-
viduals with physical disability, im-
paired sensorimotor function, pain,
injury, or disease; it is also used for
well individuals. It is frequently based
on activities associated with growth
and development.
The physical therapist targets the pa-
tient's problems with performing a
movement or task and specifically
directs the functional training to allevi-
ate impairments, functional limitations,
and disabilities. In applying functional
training, the physical therapist may
choose from a number of options,
including training in activities of daily
living, instrumental activities of daily
living, body mechanics, and usage of
therapeutic appliances, orthoses, and
prostheses. Organized functional train-
ing programs such as back schools
may also be selected.
Physical Therapy / Volume 75, Number 8 / August 1995
Modes of Intervention. Functional
training activities include, but are not
limited to:
activities of daily living training,
eg,
bed mobility
transfer training
ambulation training
wheelchair mobility
developmental activity
play or leisure activity
instrumental activities of daily
living training, eg,
shopping
cooking
housekeeping
house chores
money management
assistive, adaptive, supportive,
or protective devices training
orthotic training
prosthetic training
body mechanics training
organized functional training
programs, eg, back schools
Clinical Indications. Before applying
functional training in self care and
home management, a thorough exam-
ination is performed to identlfy those
conditions that would prevent the use
of this intervention or indicate that it is
to be applied with caution. Candidates
for functional training are individuals
constrained in their ability to complete
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
genitourinary
endocrine or metabolic
Candidates for functional training also
include patients with functional defi-
cits of a risk of developing them.
Benefits. All benefits of functional
training are measured in terms of
remediation or prevention of impair-
ments, functional limitations, and
disability. Specific benefits related to
functional training in self care and
home management include, but are
not limited to:
improved safety
increased mobility
increased tolerance to positions
and activities
increased capacity to execute
essential life tasks
improved performance of activi-
ties of daily living and instru-
mental activities of daily living
(including increased strength,
endurance, and efficiency and
safety of movement)
appropriate use of prosthetic or
orthotic devices
appropriate use of assistive,
adaptive, supportive, and pro-
tective devices
decreased disability from illness
or injury
increased independence
decreased level of supervision
of care
decreased service utilization,
cost, and risk of recurrence
Functional Training in
Community or Work
Reintegration (Including
lnstmmental Activities of Daily
Living, Work Hardening, and
Work Conditioning)
Overview. Functional training in com-
munity or work reintegration includes
a broad group of activities designed to
return the patient to the community
and/or to work as quickly and effi-
ciently as possible. It involves improv-
ing a patient's physiologic capacities in
order to facilitate the fulfillment of
community- and work-related roles.
Functional training is used to imprave
the physical function and health status
of individuals with physical disability,
impaired sensorimotor function, pain,
injury, or disease; it is also used for
well individuals. It is frequently based
on activities associated with growth
and development.
The physical therapist targets the pa-
tient's problems in performing a
movement, community activity, or job
task and specilically directs the func-
tional training to enable the patient to
return to the community or work
environment. A variety of approaches
may be taken, depending on the pa-
tient's needs. For example, the physi-
cal therapist may provide training in
the instrumental activities of daily
living to patients who need to live
more independently, or body mechan-
ics and posture awareness training if a
patient is deficient in these areas.
Work hardening and work condition-
ing are specialized functional training
programs aimed at reducing the dis-
ability and functional limitations result-
ing from impairment(s) associated
with job-related injuries.
Modes of Intervention. Functional
training activities include, but are not
limited to:
instrumental activities of daily
living, eg, shopping, cooking,
housekeeping, money
management
use of assistive, adaptive, sup-
portive, or protective devices
use of orthotic devices
use of prosthetic devices
posture awareness training
body mechanics training
organized functional training
programs, eg, back schools
conditioning or reconditioning
environmental or job task
adaptation
dexterity and coordination
training
injury prevention or reduction
ergonomic stressor reduction
job coaching
job simulation
Clinical Indications. Before a pro-
gram of functional training in commu-
nity or work reintegration is initiated, a
thorough examination is performed to
identlfy those conditions that would
prevent the use of this intervention or
indicate that it is to be applied with
caution. Candidates for functional
training in community or work reinte-
gration (including instrumental activi-
ties of daily living, work hardening,
and work conditioning) are individuals
constrained in their ability to complete
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
endocrine or metabolic
genitourinary
Candidates for functional training in
community or work reintegration also
include, but are not limited to, individ-
uals with:
a job-related disability or func-
tional limitation
a known work-injury-related
impairment
Benefits. All benefits of functional
training community or work reintegra-
tion activities are measured in terms of
a remediation or prevention of impair-
ments, functional limitations, and
disability. Specific benefits related to
community or work reintegration
include, but are not limited to:
improved safety when perform-
ing community and job tasks
increased mobility
increased tolerance to positions
and activities
.
increased ca~acitv, to execute
- -
physical tasks
minimized costs of job-related
injuries
reduced disability associated
with acute or chronic problems
acquisition of behaviors that
foster healthy habits, wellness,
and prevention
decreased service utilization,
cost, and risk of recurrence
increased independence
reduced secondary impairments
increased awareness and usage
of community resources
Manual Therapy Techniques
(Including Mobilization and
Manipulation)
Overview. Manual therapy consists of
a broad group of passive interventions
in which physical therapists use their
hands to administer skilled move-
ments designed to modulate pain,
increase joint range of motion, reduce
or eliminate soft tissue inflammation,
induce relaxation, improve contractile
Physical Therapy / Volume 75, Number 8 /August 1995
and noncontractile tissue extensibility,
andlor improve pulmonary function.
These interventions employ a variety
of techniques, such as the application
of graded forces.
Physical therapists use manual therapy
techniques to improve physical func-
1
I
tion and health status (or reduce or I
prevent disability) resulting from im-
pairment(~)by identlfylng specific
performance goals that will allow
patients to achieve a higher functional
level in the home, school, workplace,
or community. They also use these
techniques, including therapeutic
massage and soft tissue mobilization
and manipulation, for well clients to
give them a greater sense of well-
being, to induce relaxation, and to
improve physical function.
Modes of Intervention. Manual
therapy techniques include, but are
not limited to:
passive range of motion
joint mobilization and
manipulation
manual traction
connective tissue massage
soft tissue mobilization and
manipulation
therapeutic massage
Clinical Indications. Before applying
manual therapy techniques, a thor-
ough examination is performed to
identlfy those conditions that would
prevent the use of this intervention or
indicate that it is to be applied with
caution. Candidates for manual ther-
apy techniques are individuals con-
strained in their ability to complete
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
genitourinary
Candidates for manual therapy tech-
niques also include, but are not lim-
ited to, individuals who have:
limited range of motion
 soft tissue swelling
pain
scar tissue or contracted tissue
spasm
joint hypomobility
Benefits. AU benefits of manual ther-
apy techniques are measured in terms
of a remediation or prevention of
impairments, functional limitations,
and disability. Specific benefits related
to manual therapy techniques include,
but are not limited to:
improved physical function and
health status
improved quality and quantity
of joint movement
reduced signs and symptoms of
joint and soft tissue swelling and
inflammation
improved mobility
increased tolerance to positions
and activities
increased capacity to perform
movement tasks
improved quality and quantity
of movement between and
across body segments
reduced secondary impairments
increased capacity to execute
physical tasks
decreased disability from acute
or chronic illnesses
decreased service utilization,
cost, and risk of recurrence
PrescriptionI Fabrication, and
Application of Assistive, Adaptive,
SupportiveI and Pnotective
Devices and Equipment
Overview. The prescription, fabrica-
tion, and application of assistive, adap-
tive, supportive, and protective de-
vices and equipment includes the use
of a broad group of therapeutic appli-
ances to reduce the level of physical
disability, impaired sensorimotor func-
tion, and pain caused by musculoskel-
etal, neuromuscular, integumentary,
peripheral vascular, lymphatic, and/or
cardiopulmonary pathology, injury,
developmental delay, or inherited
conditions. These procedures are often
used in conjunction with functional
training, work conditioning and work
hardening, and other interventions,
and should be selected in the context
Physical Therapy / Volume 75, Number
of the patient's social and cultural activity demands by performance
environment. deficits in the following body systems:
neuromusculoskeletal
The physical therapist targets the pa-
cardiopulmonary
tient's problems with movement tasks
peripheral vascular
and selects (or fabricates) the most
integumentary
appropriate equipment or device, then
lymphatic
fits it and trains the patient in its use
endocrine or metabolic
and application. The goal is for the
genitourinary
patient to function at a higher level
and to decrease the effects of
Benefits. All benefits of these thera-
impairment.
peutic devices and equipment are
measured in terms of a remediation or
Assistive, adaptive, supportive, and
prevention of impairments, functional
protective devices and equipment
limitations, and disability. Specific
include, but are not limited to, splints,
benefits related to the prescription,
casts, prostheses, corsets, orthoses,
fabrication, and application of assis-
ambulation devices, wheelchairs or
tive, adaptive, supportive, and protec-
other mobility aids, activities-fdaily
tive devices and equipment include,
living and employment-related assis-
but are not limited to:
tive devices, and corrective and pro-
tective taping. improved safety
improved quality and quantity
Modes of Intervention. The selection of joint movement
of these therapeutic devices and reduced signs and symptoms of
equipment includes, but is not limited joint and soft tissue swelling and
to, the prescription, fabrication, and inflammation
application of: improved mobility
increased tolerance to positions
orthoses (eg, braces, shoe
and activities
inserts)
increased capacity to execute
prostheses (eg, artificial limbs
physical tasks requiring inde-
and joints)
pendent movement
assistive devices (eg, crutches,
improved joint stability
canes, walkers, casts)
improved tissue healing
adaptive devices (eg, long-
prevention of deformity
handled reachers, raised toilet
reduced complications
seats, wheelchairs and other
decreased disability associated
mobility devices)
with acute or chronic illness
supportive devices (eg, support-
decreased service utilization,
ive taping, elastic wrap, com-
cost, and risk of recurrence
pression garments, corsets, neck
increased independence and
collars, splints, casts)
self-esteem
protective devices (eg, braces,
decreased level of supervision
protective taping, helmets, of care
splints)
reduced secondary impairments
improved weight-bearing status
Clinical Indications. Before prescrib- decreased loading on a body
ing, fabricating, or applying these
devices and equipment, a thorough Pa*
improved physical function and
examination is performed to identlfy
health status
those conditions that would prevent
the use of these devices and equip-
Airway Clearance Techniques
ment or indicate that they should be
applied with caution. Candidates for Overview. Airway clearance tech-
assistive, adaptive, supportive, and niques include a broad group of activ-
protective devices and equipment are
ities used to manage or prevent conse-
individuals constrained in their ability
quences of acute and chronic lung
to complete necessary job, task, or diseases and impairments, including
those associated with surgery. Airway
clearance techniques may be used
with therapeutic exercise, manual
therapy techniques, or mechanical
modalities to improve pulmonary
function.
The physical therapist performs airway
clearance techniques to improve phys-
ical function and health status (or
reduce or prevent disability) resulting
from impairment(s) by identifying
specific performance goals that will
allow the patient to achieve a higher
functional level in the home, school,
workplace, or community.
Modes of Intervention. Airway clear-
ance techniques include, but are not
limited to:
postural drainage and
positioning
chest percussion, vibration, and
shaking
active cycles of breathing
autogenic drainage
forced expiratory pressure
techniques to maximize
ventilation
assistive cough techniques
suctioning
Clinical Indications. Before applying
airway clearance techniques, a thor-
ough examination is performed to
identify those conditions that would
prevent the use of this intervention or
indicate that it is to be applied with
caution. Candidates for airway clear-
ance techniques are individuals with
inadequate ventilation and limited
ability to clear lung secretions because
of performance deficits in the follow-
ing body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
genitourinary
Candidates for airway clearance tech-
niques also include, but are not lim-
ited to, patients with:
acute or chronic lung conditions
impaired airway protection
impaired airway clearance
impaired ventilatory pump
altered breathing patterns
risk of complications from anes-
thesia or surgery
exacerbation and progression of
chronic disease
Benefits. All benefits of airway clear-
ance techniques are measured in
terms of a remediation or prevention
of impairments, functional limitations,
and disability. Specific benefits related
to airway clearance techniques in-
clude, but are not limited to:
improved lung function
improved quality of breathing
improved exercise tolerance
improved cough
increased airway clearance, in-
cluding patients on mechanical
ventilation
resolution of acute atelectasis
reduced complications during
hospitalization
decreased disability associated
with acute or chronic illness
decreased service utilization,
cost, and risk of recurrence
decreased level of supervision
of care
decreased secondary
complications
increased physical functioning
increased independence in self
care for airway clearance
techniques
..
improved health status and so-
cia1 interaction
Debridement and Wound Care
Overview. Debridement is a therapeu-
tic procedure involving removal of
nonviable tissue from a wound bed,
most often by the use of instruments
or enzymes. Wound care includes
procedures used to achieve a clean
wound bed, to promote a moist
wound environment or facilitate auto-
lytic debridement, and to absorb ex-
cessive exudation from a wound
complex.
The desired effects of debridement
and wound care can be achieved in a
variety of ways. The physical therapist
almost always uses debridement and
wound care as supportive, short-term
Physical Therapy / Volume 75, Number 8 /August 1995
components of the early part of a
treatment plan to augment other active
or functionally oriented procedures.
These interventions are subsequently
discontinued as treatment progresses
and wound healing occurs.
Debridement and wound care are
used directly by the physical therapist,
who determines the appropriate tech-
nique based on the functional needs
of the patient and direct physiological
effects desired.
Modes of Intervention. Methods of
debridement and wound care include,
but are not limited to:
sharp debridement
debridement with other agents
dry dressings
wet dressings
topical agents (eg, enzymes)
hydrotherapy
Clinical Indications. Candidates for
debridement include, but are not lim-
ited to, patients with wounds that:
have nonviable tissue
show signs
a of inflammation
have full- or partial-thickness
skin lesions
are exuding or undergoing re-
epithelialization and/or connec-
tive tissue replacement
Benefits. All benefits of debridement
and wound care are measured in
terms of a remediation or prevention
of impairments, functional limitations,
and disability. Specific benefits related
to debridement and wound care in-
clude, but are not limited to:
reduced complications
improved wound and soft tissue
status
reduced wound size
reduced secondary impairments
improved physical function and
health status
reduced risk factors from
infection
enhanced wound healing
Physical Agents and Mechanical
Modalities
Overview. Physical agents use heat,
sound, or light energy to increase
connective tissue extensibility, modu-
late pain, reduce or eliminate soft
tissue inflammation and swelling
caused by musculoskeletal injury or
circulatory dysfunction, increase the
healing rate of open wounds and soft
tissue, remodel scar tissue, or treat
skin conditions.
Mechanical modalities include a broad
group of procedures (eg, traction,
continuous passive motion) to modu-
late pain, stabilize an area that re-
quires temporary support, increase
range of motion, or apply distraction,
approximation, or compression.
Both physical agents and mechanical
modalities are typically used in con-
junction with or in preparation for
other physical therapy interventions
such as therapeutic exercise and func-
tional training.
The physical therapist uses physical
agents and mechanical modalities to
improve physical function and health
status (or reduce or prevent disability)
resulting from impairment(s) by identi-
fying specific performance goals that
wdl allow patients to achieve a higher
functional level in the home, school,
workplace, or community.
Modes of Intervention. Physical
agents include, but are not limited to:
deep thermal modalities (eg,
ultrasound)
athermal modalities (eg, pulsed
ultrasound, pulsed electromag-
netic fields)
superficial thermotherapy (eg,
heat, paraffin baths, hot packs,
fluidotherapy) and cryotherapy
modalities (eg, cold packs, ice
massage)
hydrotherapy (eg, whirlpool,
tanks, contrast baths)
phototherapies (eg, ultraviolet)
Mechanical modalities include, but are
not limited to:
Physical 'Therapy / Volume 75, Number 8 / August 1995
traction (sustained, intermittent,
or positional)
continuous passive motion
(CPM)
tilt table or standing table
mechanical percussion
compression therapies (eg, vaso-
pneumatic compression devices,
compression bandaging, com-
pressive garments, taping)
Clinical Indications Before using
either physical agents or mechanical
modalities, a thorough examination is
performed to identlfy those conditions
that would prevent the use of these
interventions or indicate that they are
to be applied with caution. Candidates
for physical agents or mechanical
modalities are individuals who are
constrained in their ability to complete
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
endocrine or metabolic
genitourinary
Candidates for physical agents also
include, but are not limited to, patients
with:
observable soft tissue inflamma-
tion and swelling
pain disorder
open wounds
circulatory compromise
integumentary deformities
skin conditions
Candidates for mechanical modalities
also include, but are not limited to,
patients with:
pain disorders
disk disorders
nerve injury
sprains or strains
joint disorders that limit motion
assisted weight-bearing or up-
right activity needs
Benefits. All benefits of physical
agents and mechanical modalities are
measured in terms of a remediation or
prevention of impairments, functional
limitations, and disability.
Specific benefits related to physical
agents include, but are not limited to:
improved physical function and
health status
improved quality and quantity
of joint movement
reduced signs and symptoms of
joint and soft tissue swelling and
pain
improved skin and wound status
enhanced healing of tissues
reduced sequelae of soft tissue
and circulatory disorders
improved cosmesis
reduced complications
increased mobility
increased tolerance to positions
and activities
increased capacity to perform
movement tasks
debridement of nonviable tissue
without surgical intervention
decreased secondary
impairments
Specific benefits related to mechanical
modalities include, but are not limited
to:
improved physical function and
health status
improved quality and quantity
of joint movement
reduced signs and symptoms of
joint and soft tissue swelling and
inflammation
improved neurologic status
improved hemodynamic re-
sponse to change in position
decreased pain
improved healing of bony
segments
decreased mobility restrictions
increased tolerance to positions
and activities
increased capacity to perform
movement tasks
decreased secondary
impairments
Electmtherapeutic Modalities
Overview. Electrotherapeutic modali-
ties include a broad group of physical
agents that use electricity to modulate
or decrease pain; reduce or eliminate
soft tissue inflammation caused by
musculoskeletal, neuromuscular, pe-
ripheral vascular, or integumentary
injury, disease, developmental delay,
or surgery; maintain strength after
injury or surgery; decrease unwanted
muscular activity; assist muscle con-
traction in gait or other functional
training; or increase the rate of healing
of open wounds. Electrotherapeutic
modalities are generally components
of a treatment plan used to augment
other active or functionally oriented
procedures.
Modes of lntewention Electrothera-
peutic modalities include, but are not
limited to:
alternating, direct, and pulsed
current (eg, high-voltage gal-
vanic stimulation, interferential
current)
neuromuscular electrical stimu-
lation (NMES)
functional electrical stimulation
(FES) for improving posture or
movement
transcutaneous electrical nerve
stimulation (TENS)
iontophoresis
electrical muscle stimulation
biofeedback
Clinical Indications. Before applying
electrotherapeutic modalities, a thor-
ough examination is performed to
identlfy those conditions that would
prevent the use of this intervention or
indicate that it is to be applied with
caution. Candidates for electrothera-
peutic modalities are individuals con-
strained in their ability to complete
necessary job, task, or activity de-
mands by performance deficits in the
following body systems:
neuromusculoskeletal
cardiopulmonary
peripheral vascular
integumentary
lymphatic
genitourinary
Candidates for electrotherapeutic mo-
dalities also include, but are not lim-
ited to, patients with:
observable soft tissue
inflammation
pain disorders
open wounds
functions that will improve by
using functional electrical
stimulation
motor function that can be en-
hanced by biofeedback
impaired muscle contraction that
could be improved with electri-
cal stimulation
prolonged or permanent
paralysis
Benefits. A l benefits of electrothera-
peutic procedures are measured in
terms of a remediation or prevention
of impairments, functional limitations,
and disability. Specific benefits related
to electrotherapeutic modalities in-
clude, but are not limited to:
improved physical function
improved health status
improved quality and quantity
of joint movement
reduced signs and symptoms of
joint and soft tissue swelling and
inflammation
improved skin and wound status
increased mobility
increased tolerances to positions
and activities
increased capacity to execute
physical tasks
reduced complications
reduced secondary impairments
decreased pain
Patient-mlated Instruction
Overview. Patient-related instruction
is the process of imparting information
and developing slulls to promote
independence and to allow care to
continue after discharge. Instruction
should focus on the patient as well as
the family, significant others, and other
caregiven to ensure short- and long-
term compliance with the physical
therapy interventions and the preven-
tion of future disability. The develop-
ment of an ihtruction program is
consistent with the goals of the plan
of care. Patient-related instruction may
include:
information about the cause of
the patient's impairment, func-
tional limitation, or disability;
the prognosis; and the purposes
Physical Therapy / Volume 75, Number 8 /August 1995
and potential complications of
the interventions
instruction and assistance in
making appropriate decisions on
the management of the patient
instruction and assistance in im-
plementing interventions under
the direction of the physical
therapist
Modes of Intervention. The activities
that should be included in the devel-
opment of a patient-related instruction
program include, but are not limited
to:
verbal instruction
written or pictorial instruction
computer-guided instruction
actual practice by the patient or
caregiver
use of audio and visual aids for
both teaching and home
reference
return demonstration
periodic re-examination
Clinical Indications. A patient-related
instruction program should be devel-
oped for all patients for whom physi-
cal therapy is indicated. A thorough
examination must be performed to
determine whether the patient's cogni-
tive, physical, or resource status would
allow the patient to perform a home
management program independently
or only with the assistance of famdy,
significant others, or other caregivers.
Family memben, sigmficant others,
and other caregiven, including home
health aides, are instruction candidates
when required to assist the patient in
a management plan.
Benefits All benefits of patient-
related instruction programs are mea-
sured in terms of remediation or pre-
vention of impairment, functional
limitation, and disability. Specfic ben-
efits related to patient-related instruc-
tion programs include, but are not
limited to:
improved physical function and
health status
improved safety for the patient,
significant others, family, and
caregivers
 enhanced progress by extending
direct care
increased patient, significant
other, family, and caregiver
knowledge and awareness of
the patient's condition, progno-
sis, and management
enhanced decision-making
about the health of the patient
and use of health care resources
Physical Therapy / Volume 75, Number 8 /August 1995
by the patient, family, or
caregivers
acquisition of behaviors that
foster healthy habits, wellness,
and prevention
improved levels of performance
in employment, recreational,
and sports activities
reduced disability associated
with acute or chronic illnesses
decreased service utilization,
cost, and risk of recurrence
increased independence
decreased level of supervision
or care
reduced secondary impairments
increased capacity to execute
physical tasks
Appendixes follow.
Appendix I. A Glossay of Operational Definitions
in Physical Therapy
Activities of Daily Living: The self-care, communica-
tion, and mobility skills (eg, rising from bed, using
the toilet, dressing, and eating meals) required for
independence in everyday living.
Aerobic Activity/Conditioning: The performance of
exercise (eg, running, swimming, cycling) to in-
crease endurance.
Aerobic Capacity: A measure of the ability to perform
work or participate in activity over time using the
body's oxygen uptake, delivery, and energy re-
lease mechanisms.
Affective: Relating to the expression of emotion; eg, af-
fective disorder.
Afferent: Proceeding from the peripheral to the central
nervous system.
Airway Clearance Techniques: A broad group of activi-
ties used to manage or prevent consequences of
acute and chronic lung diseases and impairments,
including those associated with surgery.
Algometer (Pressure> An instrument for measuring the
degree of sensitivity to a painful stimulus.
Ambulation: Walking, with or without the use of assis-
tive devices.
Americans With Disabilities Act: The 1990 federal stat-
ute that prohibits discrimination against disabled
individuals in employment, public accommoda-
tions, etc.
Amplitude: The maximum difference between an alter-
nating current's peak and average values.
Anaerobic Threshold: The point during exercise at
whiCh a person cannot supply enough oxygen to
meet the demands of the body.
Anthropometric Characteristics: Human body mea-
surements such as height, weight, girth, and body
fat composition.
Approx&nation: Bringing together two joint surfaces.
Arousal: The stimulation to action or to physiologic
readiness for activity.
Arrhythmia: An irregular or abnormal heart rhythm.
Arthrokinematic: Describing the motion of a joint with-
out regard to the forces producing that motion or
resulting from it; describing the structure and
shape of joint surfaces.
Assistive, Adaptive, Supportive, and Protective De-
vices: A variety of implements or equipment used
to aid individuals in performing tasks or move-
ments. Assistive devices, which include crutches
and canes, involve rather simple technologies;
adaptive devices, which include such technologies
as a wheelchair and the long-handed reacher, are
generally more complex. Supportive devices in-
clude taping, compression garments, corsets, and
neck collars, while protective devices include
braces and helmets.
Atelectasis: Airlessness of the lungs due to failure of ex-
pansion or resorption of air from the alveoli.
Athermal: Not using heat, describing, for example, a
modality such as pulsed ultrasound.
Athetotic: Describing an impaired movement often
marked by slow, writhing movements of the
hands.
Auditoly: Related to the ability to hear.
Auscultation: The act of listening to internal body
sounds (eg, the heartbeat).
Autogenic Drainage: Airway clearance through the pa-
tient's own efforts (coughing, etc).
Back School: A structured educational program about
low back problems, usually offered to a group of
patients.
Balance: The ability of an individual to maintain the
body in equilibrium with gravity both statically
(eg, while stationary) and dynamically (eg, while
walking).
Biofeedback: A training technique that enables an indi-
vidual to gain some element of voluntary control
over muscular or autonomic nervous system func-
tions using a device that produces auditory or vi-
sual stimuli.
BiomechanicaL. Describing the action of forces on the
body, especially as they affect the musculoskeletal
system.
Body Mechanics: The interrelationships of the muscles
and joints as they maintain or adjust posture in
response to environmental forces.
Bruit: An auscultatory (internal body) sound, especially
an abnormal one (eg, a blowing murmur heard
over an aneurysm).
Caregiver: One who provides care, often used to de-
scribe a person other than a health professional.
Case Management: The coordination of patient care or
client activities.
Cicatrix: Scar; the fibrous tissue replacing the normal
tissues destroyed by injury or disease.
Circulation: The passage of blood through the heart,
blood vessels, organs, and tissues; it also describes
the oxygen delivery system.
Claudication: A complex of symptoms associated with
absence of lower limb pain at rest but increasing
discomfort and pain with walking, causing the pa-
tient to limp.
Physical Therapy / Volume 75, Number 8 / August 1995
Client: An individual(s1, business(es), agency(ies1, or
other organizational entity receiving consultative
services; a client would not typically be described
as a patient.
Clinical Indications: The patient factors (symptoms,
impairments, deficits, etc) that suggest that a par-
ticular kind of care (examination, intervention)
would be appropriate.
Cluster: A set of observations, data, etc, that frequently
occur as a group in a single patient.
Cognition: The act or process of knowing, including
both awareness and judgment.
Cogwheel: A type of spasticity characterized by stiff, re-
stricted movements.
Community or Work Reintegration: The process of
resuming one's role(s) in the community or at
work.
Compression Therapy: Treatment using devices or
techniques that decrease the density of a part of
the body through the application of pressure.
Conduction: Transmission of electrical energy. Conduc-
tion velocity: The speed at which electrical energy
is transmitted.
Consultation: The provision by a physical therapist of a
professional, expert opinion or of advice.
Consumer: One who acquires, uses or purchases goods
or service; any actual or potential recipient of
health care.
Continuous Passive Motion (CPM): The use of a de-
vice that allows a joint (eg, the knee) to be exer-
cised without the involvement of the patient, often
in the early postoperative period.
Contrast Bath: Immersing the patient sequentially in
cold and hot water.
Cortical: Involving the cerebral cortex; referring to tracts
in the spinal cord that mediate information to and
from the cerebral cortex.
Cosmesis: A concern in therapeutics, especially in surgi-
cal operations, for the appearance of the patient.
Cranial Nerve: One of twelve paired nerves (eg, olfac-
tory, optic) that emerge from or enter the brain.
Critical Inquiry: The process of applying the principles
of scientific methods to read and interpret profes-
sional literature, participate in research activities,
and analyze patient care outcomes, new concepts,
and findings.
Cryotherapy: Therapeutic application of cold (eg, ice).
Cyanosis: A bluish or purplish discoloration of the skin
due to a severe oxygen deficiency.
Debridement: Excision of contused and necrotic tissue
from the surface of a wound. Autolytic: Self-
debridement, ie, removal of contused or necrotic
tissue through the action of enzymes in the tissue.
Sharp: Debridement using a sharp instrument.
Deficit: .4 shortfall in amount or quality. Developmental:
Difference between expected and actual (lower)
performance in an aspect of development (eg, mo-
tor, communication, social). Expressive: A shortfall
Physical Therapy / Volume 75, Number 8 /August 1995
in expression (eg, in speech). Receptive: A shortfall
in the skills involving reception (eg, in vision, in
hearing).
Developmental Delay: The failure to reach expected
age-specific performance in one or more areas of
development (eg, motor, sensory-perceptual).
Diagnosis: A label encompassing a cluster of signs and
symptoms, syndromes, or categories. It is also the
decision reached as a result of the diagnostic pro-
cess, which is the evaluation of information ob-
tained from the patient examination organized into
clusters, syndromes, or categories.
Disability: The inability to engage in age- and sex-
specific roles in a particular social context and
physical environment.
Dislocation: A disturbance or disarrangement of the
usual relationship of bones as they enter into the
formation of a joint.
Distraction: The act of pulling apart the surfaces of a
joint.
Dolorimeter: A device to measure pain.
Dressing: A material (eg, topical agent, gauze) applied
to a lesion.
Dynamometry: Measuring the degree of muscular
power.
Dyspnea: Shortness of breath; subjective difficulty or dis-
tress in breathing frequently manifested by rapid,
shallow breaths; usually associated with serious
disease of the heart or lungs.
Edema: An accumulation of fluid, often occurring as part
of the inflammatory process after trauma.
Education: Knowledge or skill obtained or developed by
a learning process; a process designed to change
behavior by formal instruction and/or supervised
practice, which includes teaching, training, infor-
mation sharing, and specific instructions.
Efferent: Sending information away from the central ner-
vous system.
Effusion: The escape of fluid into a body part or tissue.
Electrical Device: An instrument or modality that ap-
plies electrical current to biologic tissue for pain
control, tissue healing, or muscle dysfunction; an
instrument that records electrical activity from ex-
citable tissues of the body for purposes of neuro-
muscular diagnosis, education, or relaxation.
Electrical Impedance: A method of analyzing body
composition (eg, percentage of body fat) by send-
ing an electrical current through the body and
measuring resistance.
Electrical Potential: The amount of electrical energy
residing in specific tissues.
Electrical Stimulation: Treatment through the applica-
tion of electricity. Functional: The application of
electrical stimulation to particular peripheral
nerves to allow paretic and paralyzed muscles to
make functional and purposeful movements.
Electrogoniometry: The measurement of the movement
of a joint using an electrical potentiometer.
Electromechanical Equipment: Mechanical devices or
systems electrically activated, as by a solenoid.
Electrophysiologic Concerned with the electrical activ-
ity of various body tissues or systems.
Electrophysiologic Testing: The process of examining
the relationships of body functions to electrical
phenomena, such as the effects of electrical stimu-
lation on the tissues, the production of electrical
currents by organs and tissues, and the therapeutic
use of electrical current.
Electrotherapeutic Modalities: A broad group of thera-
peutic physical agents (eg, neuromuscular electri-
cal stimulation, iontophoresis).
EM& Electromyography; the recording of the electrical
activity of a muscle.
Endocrine: The body system concerned with glands and
other structures that make substances such as hor-
mones and other substances that influence metab-
olism and other body functions; the pituitary
gland, thyroid gland, etc, have endocrine
functions.
Endurance: The ability to perform work over time.
Environmental, Home, and Work Barriers: The phys-
ical impediments that keep individuals from func-
tioning optimally in their surroundings, including
safety hazards (eg, throw rugs, slippery surfaces),
access problems (eg, narrow doors, high steps),
and home or office design (eg, excessive distance
to negotiate, multiple-story environment).
Ergonoidcs: The study of work, including the applica-
tion of the life sciences to well-being and work
performance, which relates human factors (height,
weight, etc) to work requirements; the study of
the relationships between people, work, and the
work environment, using scientific and engineer-
ing principles to improve those relationships.
Erythemal: Describing an abnormal redness of the skin.
Evaluation: A dynamic process in which the physical
therapist makes clinical judgments based on data
gathered during the examination.
Evoked Potentials: The electrical signals recorded from
a sensory receptor, nerve, muscle, etc of the cen-
tral nervous system that has been stimulated, most
often by electricity (eg, auditory evoked
potentials).
Examination: The process of obtaining a patient history,
performing relevant systems reviews, and selecting
and administering specific tests and measures.
Excursion: Movement within the body, with return to
the original site implied (eg, excursion of the
diaphragm).
Exudation: The process of expressing material through a
wound, usually characterized as oozing.
Fluidotherapy "Dry whirlpool"; the application of dry
heat through a fluidotherapy machine.
Force Plate: A plate embedded in the floor used to mea-
sure the force that a person exerts when walking.
Fremitus: A sensation felt when placing a hand on a
part of the body (eg, the chest) that vibrates dur-
ing speech.
Function: The special, normal, or proper action of any
part or organ; those activities identified by an indi-
vidual as essential to support physical and psycho-
logical well-being as well as create a personal
sense of meaningful living; the action specifically
for which a person or thing is fitted or employed;
an act, process, or series of processes that serve a
purpose; to perform an activity or to work prop-
erly or normally.
Functional LLmitation: A restriction of the ability to per-
form a physical action, activity, or task in a typi-
cally expected, efficient, or competent manner.
Gait: The manner in which a person walks, characterized
by rhythm, cadence, step, stride, and speed.
Gas Analysis: Laboratory testing of a gas, as in blood
gas analysis, in which oxygen and carbon dioxide
concentrations are measured and the pH
determined.
Goal: The long-term statement(s) that define the patient's
expected level of performance at the end of the
rehabilitation process; the functional outcomes of
therapy, indicating the amount of independence,
supervision, or assistance required and the equip-
ment or environmental adaptation necessary to
ensure adequate performance. Desired outcomes
may be stated as long-term or short-term as deter-
mined by the needs of the patient and the setting.
Goniometxy Manual: The measurement of the move-
ment of a joint by manual methods. Electrical: See
electrogoniometry.
Graded Forces: A term used in manual therapy to de-
note the application by the physical therapist of
varying amounts of pressure on the patient's body.
Graphic Rating Scale: A tool that permits a patient to
express the location of pain by pointing to an il-
lustration (eg, of the human body) and the integ-
rity of pain by using various symbols (eg, X =
sharp, 0 = dull).
Grid Marks: Background lines used to assess posture
(curvature, etc) during an examination.
Health Care Provider: A person or organization offering
health services directly to patients or clients.
Health Promotion: Activity designed to develop healthy
behaviors in such areas as diet, avoidance of drug
abuse, etc.
Health Status: The level of an individual's physical,
mental, affective, and social function; health status
is an element of well-being.
Hemianopsia: Loss of vision for one-half of the visual
field of one or both eyes.
Hemostat: Anything that arrests, chemically or mechani-
cally, the flow of blood from an open vessel.
Herniated Disk: The protrusion of one of the spinal
disks into an opening in the spinal cord, thereby
compressing the nerve root.
Physical Therapy / Volume 75, Number 8 / August 1995
History: An account of past and present health status
that includes the identification of complaints and
provides the initial source of information about the
patient. The history also suggests the patient's abil-
ity to benefit from physical therapy services.
Home, Environmental, or Architectural Barriers:
The physical impediments (eg, stairs, slippery sur-
faces, kitchen layout) that restrain or obstruct a
person's ability to function in the home or other
usual environment.
Hubbard Tank: A shallow tank made of stainless steel,
Plexiglas, or tile, for administering hydrotherapy.
Hydrodynamic: Concerned with the flow of liquids.
Hydrotherapy: Treatment with external water.
Hypomobility/Hypermobility:Abnormally low or high
movement or ability to move (eg, of a joint).
Immunodeficiency Inadequate functioning of the im-
mune system, seen in AIDS and some other
disorders.
Impairment: A loss or abnormality of physiological, psy-
chological, or anatomical structure or function.
Infrared Heat: A therapy using thermal radiation with a
wavelength greater than the red end of the visible
spectrum.
Innervation: The supply of nerve fibers to a part of the
body, such as an organ.
Instrumental Activities of Daily Living: Activities such
as shopping, cooking, housekeeping, managing
money, etc, that are important components of
maintaining an independent lifestyle.
Integrity: The characteristic of being whole or fully func-
tional; see integumentary integrity and joint integ-
rity below.
Integumentary Integrity The health of the skin, in-
cluding its ability to serve as a barrier to environ-
mental threats (eg, bacteria, parasites).
Intervention: The purposeful and skilled interaction of
the physical therapist with the patient, using vari-
ous methods and techniques to produce changes
in the patient's condition.
Iontophoresis: Introduction of the ions of a medication
under the tissues by means of electric current.
Ischemh Local anemia due to mechanical obstruction
(mainly arterial narrowing) of the blood supply.
Joint Integrity: The conformance of the joints to ex-
pected anatomic, biomechanic, and kinematic
norms.
Joint Mobility: The ability to move a joint; takes into
account the structure and shape of the joint sur-
face as well as characteristics of tissue surrounding
the joint.
Kinematic: Having to d o with the possible motions of a
part or all of the human body.
Kinesthesia: The awareness of the body's or a body
part's movement.
Laxity: Looseness, eg, laxity of a joint.
Physical 'Therapy/ Volume 75, Number 8 /August 1995
Loading: The force placed on a body part (eg, a foot,
the feet); used often in describing the employment
of an assistive device.
Lymphatic: Concerned with the lymph nodes and ves-
sels, which comprise a system for collecting fluid
from the tissues and adding it to the venous blood
system.
Manipulation: A therapeutic movement, usually of small
amplitude, accomplished at the end of the avail-
able range of motion but within the anatomical
range at a speed over which the client has no
control.
Manual Therapy: A broad group of skilled hand move-
ments used by the physical therapist to mobilize
soft tissues and joints for the purpose of modulat-
ing pain, increasing range of motion, etc.
Maceration: Softening by the action of a liquid.
Magnetic Fields Energy, Pulsed: A therapy using the
intermittent application of energy produced by
magnetic fields.
Mastication: Chewing.
Mechanical: Caused by or derived from machinery; ha-
bitual, routine, automatic; related to, controlled or
affected by physical forces (eg, traction device).
Biomechanical: the physical structure, forces, and
movements in the human body.
Mentation: A mechanism of thought or mental activity.
Metabolic: Concerned with metabolism, the sum of all
physical and chemical changes that take place
within an organism; all energy and material trans-
formations that take place within living cells.
Microvolt: One millionth of a volt.
Mobilization: A therapeutic movement accomplished
within the available range of motion at a speed
that the patient cannot control.
ModaUty(ies): Physical agent(s), including, but not lim-
ited to, thermal, acoustic, light, mechanical, or
electrical energy, applied to produce therapeutic
changes in biologic tissue.
Motor Function: The ability to learn or demonstrate the
skillful and efficient assumption, maintenance,
modification, and control of voluntary postures
and movement patterns. Fine: Refers to relatively
delicate movements such as using a fork, tying a
shoelace, etc. Gross: Refers to larger-scale move-
ments such as assuming an upright position, carry-
ing a bag, etc.
Mucous: Covered with or as if in mucus; a secretion pro-
duced by the mucous membranes.
Multi-segment Motion: Simultaneous movement of sev-
eral parts of the body.
Muscle Length: The length of the muscle during various
stages of tension (from resting at full extension
through the contractile range); in conjunction with
joint integrity and connective tissue extensibility,
muscle length determines flexibility.
Muscle Performance: The capacity of a muscle to d o
work (force X distance).
Necrotic: Dead, as in necrotic tissue.
Nerve: A band of tissue that conducts impulses and con-
nects parts of the nervous system with other
organs.
Nerve Root Compression: A squeezing of one of two
bundles of nerve fiber emerging from the spine;
frequently caused by a herniated disk.
Nervous System: The brain, spinal cord, nerves, and
ganglia. Central nervous system: The brain and
spinal cord. Peripheral nervous system: The system
of nerves in the extremities.
Neural: Having to do with a nerve or nerves.
Neuromotor Development: The acquisition and evolu-
tion of movement skills throughout the lifespan.
Nonvolitional: Involuntary, not controllable.
Objective: A measurable behavioral statement of an ex-
pected response or outcome; something worked
toward or striven for; a statement of direction or
desired achievement that guides actions and
activities.
Orthosis: A device (eg, a shoe insert, splint, brace) that
supports weak or ineffective joints or muscles.
Osteoporotic: Pertaining to or characterized by a porous
condition of the bones; refers to a reduction in the
quantity of bone or atrophying of skeletal tissue.
Oxygen Consumption:The amount of oxygen inspired
minus the amount of oxygen exhaled.
Oxygen Saturation: The degree to which oxygen is
present in a particular substance.
Outcome: The result of physical therapy management
expressed in five areas: prevention and manage-
ment of symptom manifestation, consequences of
disease (impairment, disability, and/or role limita-
tion), cost-benefit analysis, health-related quality of
life, and patient satisfaction. A successful outcome
includes improved or maintained physical function
when possible, slows functional decline where the
status quo cannot be maintained, and/or is consid-
ered meaningful by the patient.
Outcomes Analysis: A systematic examination of patient
outcomes in relation to selected patient variables
(eg, age, sex, diagnosis, interventions performed);
outcomes analysis may be used in quality assess-
ment, economic analysis of practice, etc.
Pain: A dsturbed sensation causing suffering or distress.
Palpation: Examination using the hands (eg, palpation
of the spleen).
PamEm Bath: A superficial heat treatment using paraffin
wax and mineral oil.
Pathomechanical: Describing a disturbance in function
not resulting from a disease.
Pathophysiological: Describing the functional changes
that accompany a particular disease or syndrome.
Pathway A conduction route for nerve impulses. Sen-
sorypathway: A conduction route for nerve im-
pulses from the sense organs.
Patient: One who is being treated for an illness or injury;
an individual receiving health care.
Percussion (Mechanical): A diagnostic procedure in
which the clinician taps a body part with a finger
or a rubber-headed hammer to estimate its density.
Performance Battery: A set of tests designed to mea-
sure a patient's or client's ability to function in a
particular area(s1.
Peripheral Circulation: The movement of blood
through the extremities.
Peripheral Vascular: Concerned with the blood vessels
of the extremities.
Phonation: Character of speech.
Photosensitivity: Sensitivity of the skin to light, usually
due to the action of certain drugs (or plants, or
other substances).
Phototherapy Treatment using the application of light.
Ultraviolet: Light therapy using rays with wave-
lengths beyond the violet end of the visible
spectrum.
Physical Agent: A form of mechanical, radiant, thermal,
acoustic, or electrical energy that is applied to bio-
logical tissues in a systematic manner to achieve a
therapeutic effect; a therapeutic modality used to
treat physical problems.
Physical Function: The measurement of physiological,
biomechanical, social, and psychological perfor-
mance in practical or goal-oriented terms.
Physical Therapist: A licensed health professional who
offers services designed to preserve, develop, and
restore maximum physical function.
Physical Therapist Assistant: An educated health care
provider who performs physical therapy proce-
dures and related tasks that have been selected
and delegated by the supervising physical
therapist.
Physical Therapy Aide: A non-licensed worker, trained
under the direction of a physical therapist, who
performs designated routine physical therapy
tasks.
Planes (midline and segmental): Imaginary flat sur-
faces drawn through the body; the midline plane
bisects the body vertically, while segmental planes
are drawn at various angles.
Plumb Line: A simple mechanism to measure verticality
(eg, of posture) consisting of a suspended cord or
similar device with a weight on one end.
Postural Drainage: Placing the body in a position that
causes fluid to drain from the lungs.
Postural Reactions: The adjustments of the body to
gravity required for normal performance; the abil-
ity to alter the position of the head, trunk, and
extremities to balance one's body with gravity.
Posture: The alignment and positioning of the body in
relation to gravity, center of mass, and basis of
support.
Posture Grid: A large, lined chart placed on a wall that
permits an evaluation of the postural alignment or
deviation from alignment of a person standing in
front of it.
Physical Therapy / Volume 75, Number 8 / August 1995
Postmgraphy: Procedures to test standing posture, bal-
ance, and equilibrium sense.
Power: Work produced per unit of time.
Presenting Problem: The specific dysfunction that
causes an individual to seek attention or interven-
tion (ie, chief complaint).
Prevention: Activities concerned with slowing or stop-
ping the occurrence of both mental and physical
illness and disease; minimizing the effects of a dis-
ease or impairment on disability; reducing the se-
verity or duration of an illness. Primary: Prevent-
ing the development of disease in a susceptible or
potentially susceptible population through specific
measures such as immunization and through gen-
eral health promotion efforts. Secondaty: Seeking
to shorten the duration of illness, reduce severity
of' diseases, decrease the possibility of contagion,
and limit sequelae through early diagnosis and
prompt therapy. Tertiaty: Attempting to limit the
degree of disability and promoting rehabilitation
and restoration of patients with chronic and irre-
versible diseases.
Primary Care: The provision of integrated, accessible
health care services by clinicians who are account-
able for addressing a large majority of personal
health care needs, developing a sustained partner-
ship with patients, and practicing in the context of
family and community. (From the Institute of Med-
icine, 1994.)
Proactive: Seizing the initiative; responding actively
rather than passively; performing an action with
the idea of influencing events.
Prognosis: The determination of the level of maximal
improvement that might be attained by the patient
and the amount of time needed to reach that level.
Proprioception: The reception of stimuli from within
the body (eg, from muscles, from tendons); in-
cludes position sense (the awareness of the joints
at rest) and kinesthesia (the awareness of
movement).
Prosthesis: An artificial device, often mechanical or elec-
trical, used to replace a missing part of the body.
Pulse Oximetry: Measurement of the oxygen saturation
of hemoglobin in a finger through a small device
that is attached to that finger.
Pulses: The dilations of arteries (occasionally veins or
vascular organs) that correspond to the beating of
the heart.
Range of Motion: Describes the space, distance, or an-
gle through which a patient can move a joint or
series of joints.
Re-epitheliallzation: Skin growth to replace skin loss
due to a wound or other injury.
Reflex: A stereotyped reaction to a variety of sensory
stimuli.
Referral: A recommendation that a patient seek service
from another health care provider or resource.
Physical Therapy / Volume 75, Number 8 1August 1995
Rehabilitative: Concerned with restoration of a patient
to full or at least improved function.
Remediation: The act or process of providing some de-
gree of relief for a patient's clinical problem(s).
Respiration: A term that refers primarily to the exchange
of oxygen and carbon dioxide across a membrane
into and out of both the lungs and cells.
Respiratory Quotient: The ratio of the carbon dioxide
that the body tissues give off to the amount of ox-
ygen that they absorb.
Righting: Adjusting or restoring the body to a desired
position.
Role: A behavior pattern that defines a person's social
obligations and relationships with others (eg, fa-
ther, husband, son).
Screening: Determining the need for further examination
or consultation by a physical therapist or for refer-
ral to another health professional. Cognitive
screening: Briefly assessing a patient's thinking
process (eg, ability to process commands).
Secondary Care: The management of patients seen ini-
tially by another practitioner and then referred to
physical therapy; secondary care is provided in a
wide range of settings, from hospitals to
preschools.
Self Care:The set of activities that comprise daily living,
eg, rising from bed, dressing, bathing.
Self-Limited (disease): A disease or condition that runs
a definite course within a limited time with or
without treatment.
Sensory: Having to d o with sensations or the senses;
includes peripheral sensory processing (eg, sensi-
tivity to touch) and cortical sensory processing
(eg, two-point and sharp/dull discrimination).
Sensory Integration: The ability to integrate information
from the environment in order to produce normal
movement outputs.
Sequential Casting: A process in which the patient is
recasted several times, with each cast less restric-
tive than the previous one.
Serous: Like serum, watery.
Serosanguineous: Containing both serum and blood.
Sequelae: Aftereffects of a disease or injury.
SignLficant Other: A person who fulfills some or all of
the roles of a spouse for another to whom he/she
is not married; sometimes called a life partner.
Slough: Necrotic tissue separated from living tissue.
Somatic: Concerned with the body.
Somatosensory: Having to d o with the sensations re-
ceived in the skin and deep tissues. Somatosensoty
deficit: A shortfall in the reception of sensations in
the skin and deep tissues.
Spinal Curve: An abnormal curvature of the spinal col-
umn (eg, S-curve, kyphosis).
Splinting, Dynamic: Functional splinting that aids in the
movements initiated by the patient and/or controls
the plane and range of motion.
Sprain: A joint injury without dislocation or fracture in-
volving possible ligament or tendon rupture.
Sputum: Expectorated matter, especially mucus, expelled
during diseases of the air passages.
Stereognosis: Comprehending the form of an object by
touching it.
Strain: Injury from overuse or improper use.
Strengthening, Active Assistive: A form of strength-
building exercise in which the physical therapist
applies resistance through the range of motion of
the patient's active movement.
Strengthening, Resistive: Any form of active exercise in
which a dynamic or static muscular contraction is
resisted by an outside force. The external force
may be applied manually or mechanically.
Stressor: A stimulus that causes a stress.
Sympathetic Disturbance: A malfunction in the sympa-
thetic part of the autonomic nervous system,
which governs smooth muscle and the contraction
of blood vessels.
Symptom Magnification Scale: An examination tool
used to elicit descriptions of levels of pain.
Syndrome: The aggregate of signs and symptoms associ-
ated with any morbid process that together consti-
tute the picture of a known disease.
Synergy: The capability of properly grouping move-
ments in order to perform acts that require special
adjustments.
Systems Review'. A brief or limited examination that
provides additional information about the patient's
general health to help the physical therapist for-
mulate a diagnosis and select an intervention
program.
Telemetry: The science of measuring a quantity, trans-
mitting the results to a distant station, and there
interpreting, indicating, and recording the results.
TENS (Transcutaneous Electrical Nerve Stimulation):
The use of electrical energy to stimulate cutaneous
and peripheral nerves via electrodes on the skin's
surface.
Tertiary Care: Highly specialized care, usually including
a referral. Tertiary care may be defined by the set-
ting (eg, an organ transplant unit) or by the so-
phistication of the service.
Tests and Measures: General methods and techniques
used to conduct an examination.
Therapeutic Exercise: A wide range of activities (eg,
biking, walking, weightlifting) designed to increase
strength, improve cardiovascular fitness, increase
flexibility, enlarge range of motion, or otherwise
increase a person's functional capacity.
Thermal: Using heat, as in a thermal agent, for its thera-
peutic effects.
Thermistor: A device for determining temperature; may
be extremely small and may also be used to estab-
lish and maintain temperature.
Thermography: A process of measuring temperature by
means of a registering thermometer, one form of
which records every temperature variation and
registers its rise and fall on a circular temperature
chart turned by clockwork.
Thermotherapy: Treatment through the application of
heat, causing vasodilation and thus speeding up
the healing process.
Tilt Table/Standing Table: Two kinds of tables used to
bring patients from a supine to a vertical position
in a deliberate manner.
Tissue: Collection of similar cells and the intercellular
substances that surround them. Contractile:Drawn
together, as in scar tissue.
Topical Agent: An ointment, medication, etc, applied to
the skin for its therapeutic effect.
Torque: A force that produces rotation or twisting of a
part upon its axis.
Traction: The therapeutic use of tension created by a
pulling force. Mechanical: The use of tractive
forces to produce a combination of distraction and
gliding to relieve discomfort and increase tissue
flexibility; also called passive mobilization.
Transfer Training: Practical instruction in getting into or
out of bed, moving from a wheelchair to a chair,
etc.
Treatment: One or more interventions used to cure or
ameliorate a disease or pathological condition or
otherwise produce changes in the patient's health
status; the sum of the therapies offered to a patient
during a complete episode of care.
Triage: An initial review of a patient or prospective pa-
tient to determine the need for further treatment.
Turgor: Fullness, swelling.
Ulcer: A break in the skin surface or in a mucous mem-
brane with loss of tissue, usually accompanied by
inflammation. Decubitus: Bedsore. Vascular insuf-
Jiciency ulcers: Lesions caused by occlusion of a
blood vessel or other vascular disorder.
Ultrasound: A diagnostic or therapeutic technique using
high-frequency sound waves. Used therapeutically,
ultrasound produces heat. Pulsed ultrasound:The
application of therapeutic ultrasound at frequent
predetermined levels.
Vasopneumatic Compression Device: A device in-
tended to decrease swelling by "milking fluid"
away from an area, eg, an inflatable sleeve
strapped around a patient's swollen extremity.
Ventilation: The movement of a volume of gas into and
out of the lungs.
Vestibular: Describing the sense of balance located in
the inner ear.
Visceral: Related to the internal organs.
Visual Analog Scale: A tool that permits someone to
express a perception or judgment (eg, of pain) by
pointing to a location on a visual scale.
Vital Signs: Heart rate, blood pressure, temperature, and
respiration rate.
Volitional: Intentional, as in controlled movement.
Physical Therapy / Volume 75, Number 8 / August 1995
Volumeters, Graduated: Containers for holding fluid
marked by a series of lines indicating volume.
Volumetric Displacement: The amount of a fluid that
leaves a container (of any size) following the in-
troduction of part or all of the human body.
Wellness: A concept that embraces a proactive, positive
approach to good health. Wellness advocates seek
to increase a person's level of health as a preven-
tive measure to guard against future disease.
Work Conditioning: An intensive, work-related, goal-
oriented treatment program designed specifically
to restore an individual's systemic neuromusculo-
skeletal functions (strength, endurance, movement,
flexibility, and motor control), and cardiopulmo-
nary functions. The objective of the work condi-
Physical Therapy / Volume 75, Number 8 /August 1995
tioning program is to restore the client's physical
capacity and function to enable the client to return
to work.
Work Hardening: Highly structured, goal-oriented, indi-
vidualized treatment program designed to return to
work. Work hardening programs, which are inter-
disciplinary in nature, use real or simulated work
activities designed to restore physical, behavioral,
and vocational functions. Work hardening ad-
dresses the issues of productivity, safety, physical
tolerances, and worker behaviors.
Wound Care: Procedures used to achieve a clean wound
bed, promote a moist environment or facilitate
autolytic debridement, or absorb excessive exuda-
tion from a wound complex.

Appendix II. Code of Ethics and Guidefor Professional ConducP
American Physical Therapy Association
Guide for Professional
Conduct
Purpose
This Guide for Professional Conduct
(Guide) is intended to serve physical
therapists who are members of the
American Physical Therapy Association
(Association) in interpreting the Code of
Ethics (Code) and matters of profes-
sional conduct. The Guide provides
guidelines by which physical therapists
may determine the propriety of their con-
duct. The Code and the Guide apply to
all physical therapists who are Associa-
tion members. These guidelines are sub-
ject to changes as the dynamics of the
profession change and as new patterns
of health care delivery are developed
and accepted by the professional com-
munity and the public. This Guide is
subject to monitoring and timely revision
by the Judicial Committee of the
Association.
Interpreting Ethical Principles
The interpretations expressed in this
Guide are not to be considered all inclu-
sive of situations that could evolve under
a specific principle of the Code, but
reflect the opinions, decisions, and ad-
vice of the Judicial Committee. While the

Code of Ethics statements of ethical principles apply

universally, specific circumstances de-
termine their appropriate application. In-
put related to current interpretations or
Preamble situations requiring interpretation is en-
This Code of Ethics sets forth ethical principles for the physical therapy couraged from Association members.
profession. Members of this profession are responsible for maintaining Principle 1
and promoting ethical practice. This Code of Ethics, adopted by the Physical therapists respect the rights and
American Physical Therapy Association, shall be binding on physical dignity of all individuals.
therapists who are members of the Association. 1.1 Attitudes of Physical Therapists
Principle 1 A. Physical therapists shall recognize
that each individual is different from all
Physical therapists respect the rights and dignity of all individuals. other individuals and shall respect and
Principle 2 be responsive to those differences.
Physical therapists comply with the laws and regulations governing the B. Physical therapists are to be guided
at all times by concern for the physical,
practice of physical therapy. psychological, and socioeconomic wel-
Principle 3 fare of those individuals entrusted to
their care.
Physical therapists accept responsibility for the exercise of sound judg-
C. Physical therapists shall not engage
ment. in conduct that constitutes harassment
Principle 4 or abuse of, or discrimination against,
colleagues, associates, or others.
Physical therapists maintain and promote high standards for physical
therapy practice, education, and research. 1.2 Confidential lnformation
A. lnformation relating to the physical
Principle 5 therapist-patient relationship is confi-
Physical therapists seek remuneration for their services that is de- dential and may not be communicated
served and reasonable. to a third party not involved in that pa-
tient's care without the prior written con-
Principle 6 sent of the patient, subject to applicable
law.
Physical therapists provide accurate information to the consumer about
B. lnformation derived from compo-
the profession and about those services they provide. nent-sponsored peer review shall be
Principle 7 held confidential by the reviewer unless
written permission to release the infor-
Physical therapists accept the responsibility to protect the public and mation is obtained from the physical
the profession from unethical, incompetent, or illegal acts. therapist who was reviewed.
Principle 8 C. lnformation derived from the work-
ing relationships of physical therapists
Physical therapists participate in efforts to address the health needs of shall be held confidential by all parties.
the public. D. lnformation may be disclosed to ap-
Adopted by the House of Delegates propriateauthorities when it is necessary
June 1981 to protect the welfare of an individual or
Amended June 1987
the community. Such disclosure shall be
Amended June 1991
American Physical Therapy Association
in accordance with applicable law.

112 1757 Physical Therapy /Volume 75, Number 8 / August 1995

1.3 Patient Relations 4. Develop plan of care, including
Physical therapists shall not engage Short- and
in any sexual relationship or activity, 5. Select and delegate appropriate
whether consensual or ~ o ~ c o ~ s ~ ~ tasks
s u ~ofI ,~ l a of
with any patient while a physical thera-
6. Assess competence of supportive
pisvpatient relationship exists. personnel to perform assigned tasks.
1.4 Informed Consent
Physical therapists shall obtain patient
informed consent before treatment.
Principle 2
Physical therapists comply with the laws
and regulations governing the practice of
physical therapy.
2 1 Professional Practice
Physical therapists shall provide consul-
tation, evaluation, treatment, and pre-
ventive care, in accordance with the
laws and regulationsof the jurisdiction(s)
in which they practice.
Principle 3
Physical therapists accept responsibility
for the exercise of sound judgment.
3.1 Acceptance of Responsibility
A. Upon accepting an individual for
provision of physical therapy services,
physical therapists shall assume the re-
sponsibility for evaluating that individual;
planning, implementing, and supervising
the therapeutic program; reevaluating
and changing that program; and main-
taining adequate records of the case,
including progress reports.
B. When the individual's needs are be-
yond the scope of the physical thera-
pist's expertise, or when additional ser-
vices are indicated, the individual shall
be so informed and assisted in identify-
ing a qualified provider.
C. Regardless of practice setting,
physical therapists shall maintain the
ability to make independent judgments.
3.2 Delegation of Responsibility
A. Physical therapists shall not dele-
gate to a less qualified person any activ-
ity which requires the unique skill, knowl-
edge, and judgment of the physical
therapist.
B. The primary responsibility for phys-
ical therapy care rendered by supportive
personnel rests with the supervising
physical therapist. Adequate supervision
requires, at a minimum, that a supervis-
ing physical therapist perform the follow-
ing activities:
1. Designate or establish channels of
written and oral communication.
2. Interpret available information con-
cerning the individual under care.
3. Provide initial evaluation.
Physical Therapy / Volume 75, Number 8 /August 1995
goals.
n care.
..
7. Direct and su~ervisesupportive ~er-
sonnel in delegated tasks.
8. Identify and document precautions,
special problems, contraindications,
goals, anticipated progress, and plans
for reevaluation.
9. Reevaluate, adjust plan of care
when necessary, perform final evalua-
tion, and establish follow-up plan.
3.3 Provision of Services
A. Physical therapists shall recognize
the individual's freedom of choice in
selection of physical therapy services.
B. Physical therapists' professional
practices and their adherence to ethical
principles of the Association shall take
preference over business practices. Pro-
visions of services for personal financial
gain rather than for the need of the
individual receiving the services are
unethical.
C. When physical therapists judge that
an individual will no longer benefit from
their services, they shall so inform the
individual receiving the services. Physi-
cal therapists shall avoid overutilization
of their services.
D. In the event of elective termination
of a physical therapisvpatient relation-
ship by the physical therapist, the ther-
apist should take steps to transfer the
care of the patient, as appropriate, to
another provider.
3.4 Referral Relationships
In a referral situation where the referring
practitioner prescribes a treatment pro-
gram, alteration of that program or ex-
tension of physical therapy services
beyond that program should be under-
taken in consultation with the referring
practitioner.
3.5 Practice Arrangements
A. Participation in a business, partner-
ship, corporation, or other entity does
not exempt the physical therapist,
whether employer, partner, or stock-
holder, either, individually or collectively,
from the obligation of promoting and
maintaining the ethical principles of the
Association.
B. Physical therapists shall advise their
employer(s) of any employer practice
that causes a physical therapist to be in
conflict with the ethical principles of the
Association. Physical therapist employ-
ees shall attempt to rectify aspects of
their employment that are in conflict with
the ethical principles of the Association.
Principle 4
Physical therapists maintain and pro-
mote high standards for physical therapy
practice, education, and research.
4.1 Continued Education
A. Physical therapists shall participate
in educational activities that enhance
their basic knowledge and provide new
knowledge.
B. Whenever physical therapists pro-
vide continuing education, they shall en-
sure that course content, objectives, and
responsibilities of the instructional fac-
ulty are accurately reflected in the pro-
motion of the course.
4.2 Review and Self Assessment
A. Physical therapists shall provide for
utilization review of their services.
B. Physical therapists shall demon-
strate their commitment to quality assur-
ance by peer review and self assess-
ment.
4.3 Research
A. Physical therapists shall support re-
search activities that contribute knowl-
edge for improved patient care.
B. Physical therapists engaged in re-
search shall ensure:
1. the consent of subjects;
2. confidentiality of the data on individ-
ual subjects and the personal identities
of the subjects;
3. well-being of all subjects in compli-
ance with facility regulations and laws of
the jurisdiction in which the research is
conducted;
4. the absence of fraud and plagiarism;
5. full disclosure of support received;
6. appropriate acknowledgment of in-
dividuals making a contribution to the
research;
7. that animal subjects used in re-
search are treated humanely and in
compliance with facility regulations and
laws of the jurisdiction in which the re-
search experimentation is conducted.
C. Physical therapists shall report to
appropriate authorities any acts in the
conduct or presentation of research that
appear unethical or illegal.
4.4 Education
A. Physical therapists shall support
quality education in academic and clini-
cal settings.
B. Physical therapists functioning in
the educational role are responsible to
the students, the academic institutions
and the clinical settings for promoting
ethical conduct in educational activities.
Whenever possible, the educator shall
ensure:
1. the rights of students in the aca-
demic and clinical setting;
2, appropriate confidentiality of per-
sonal information;
3. professional conduct toward the
student during the academic and clinical
educational processes;
4, assignment to clinical settings pre-
pared to give the student a learning
experience.
C. Clinical educators are responsible
for reporting to the academic program
student conduct that appears to be un-
ethical or illegal.
Principle 5
Physical therapists seek remuneration
for their services that is deserved and
reasonable.
5.1 Fiscally Sound Remuneration
A. Physical therapists shall never place
their own financial interest above the
welfare of individuals under their care.
B. Fees for physical therapy services
should be reasonable for the service
performed, considering the setting in
which it is provided, practice costs in the
geographic area, judgment of other or-
ganizations and other relevant factors.
C. Physical therapists should attempt
to ensure that providers, agencies, or
other employers adopt physical therapy
fee schedules that are reasonable and
that encourage access to necessary
services.
5.2 Business PracticesIFee Arrangements
A. Physical therapists shall not:
1. directly or indirectly request, re-
ceive, or participate in the dividing,
transferring, assigning, or rebating of an
unearned fee.
2. profit by means of a credit or other
valuable consideration, such as an un-
earned commission, discount, or gratu-
ity in connection with furnishing of phys-
ical therapy services.
B. Unless laws impose restrictions to
the contrary, physical therapists who
provide physical therapy services in a
business entity may pool fees and mon-
eys received. Physical therapists may
divide or apportion these fees and mon-
eys in accordance with the business
agreement.
C. Physical therapists may enter into
agreements with organizations to pro-
vide physical therapy services if such
agreements do not violate the ethical
principles of the Association.
5.3 Endorsement of Equipment or Services
A. Physical therapists shall not use in-
fluence upon individuals under their care
or their families for utilization of equip-
ment or services based upon the direct
or indirect financial interest of the phys-
ical therapist in such equipment or ser-
vices. Realizing that these individuals
will normally rely on the physical thera-
pists' advice, their best interest must
always be maintained as well as their
right of free choice relating to the use of
any equipment or service. While it can-
not be considered unethical for physical
therapists to own or have a financial
interest in equipment companies, or ser-
vices, they must act in accordance with
law and make full disclosure of their
interest whenever such companies or
services become the source of equip-
ment or services for individuals under
their care.
B. Physical therapists may be remu-
nerated for endorsement or advertise-
ment of equipment or services to the lay
public, physical therapists, or other
health professionals provided they dis-
close any financial interest in the pro-
duction, sale, or distribution of said
equipment or services.
C. In endorsing or advertising equip-
ment or services, physical therapists
shall use sound professional judgment
and shall not give the appearance of
Association endorsement.
5.4 Gifts and Other Considerations
A. Physical therapists shall not accept
nor offer gifts or other considerations
with obligatory conditions attached.
B. Physical therapists shall not accept
nor offer gifts or other considerations
that affect or give an objective appear-
ance of affecting their professional
judgment.
Principle 6
Physical therapists provide accurate in-
formation to the consumer about the
profession and about those services they
provide.
6.1 Information about the Profession
Physical therapists shall endeavor to ed-
ucate the public to an awareness of the
physical therapy profession through
such means as publication of articles
and participation in seminars, lectures,
and civic programs.
Physical Therapy / Volume 75, Number 8 /August 1995
6.2 Information about Services
A. lnformation given to the public shall
emphasize that individual problems can-
not be treated without individualized
evaluation and plansfprograms of care.
B. Physical therapists may advertise
their services to the public.
C. Physical therapists shall not use, or
participate in the use of, any form of
communication containing a false, pla-
giarized, fraudulent, misleading, decep-
tive, unfair, or sensational statement or
claim.
D. A paid advertisement shall be iden-
tified as such unless it is apparent from
the context that it is a paid advertise-
ment.
Principle 7
Physical therapists accept the responsi-
bility to protect the public and the pro-
fession from unethical, incompetent, or
illegal acts.
7.1 Consumer Protection
A. Physical therapists shall report any
conduct that appears to be unethical,
incompetent, or illegal.
B. Physical therapists may not partici-
pate in any arrangements in which pa-
tients are exploited due to the referring
sources enhancing their personal in-
comes as a result of referring for, pre-
scribing, or recommending physical
therapy.
7.2 Disclosure
The physical therapist shall disclose to
the patient if the referring practitioner
derives compensationfrom the provision
of physical therapy. The physical thera-
pist shall ensure that the individual has
freedom of choice in selecting a provider
of physical therapy.
Principle 8
Physical therapists participate in efforts
to address the health needs of the
public.
8.1 Pro Bono Service
Physical therapists should render pro
bono publico (reduced or no fee) ser-
vices to patients lacking the ability to pay
for services, as each physical therapist's
practice permits.
Issued by Judicial Committee
American Physical Therapy Association
October 1981
Last Amended January 1995
Guide for Conduct of the
Affiliate Member
Purpose
This Guide is intended to serve physical
therapist assistants who are affiliate
membersof the ~~~~i~~~ physical ~ h
~ s i of~
~in the~interpretation
~ revision
the Standards of Ethical Conduct for the
Physical Therapist Assistant, providing
guidelines by which they may determine
the propriety of their conduct. These
guidelines are subject to change as new
patterns of health care delivery are de-
veloped and accepted b~ the ~ r o f e s -
sional community and the public. This
~Guide~ is subject
- to monitoringand timely
~ i by the
~ Judicial
~ Committee of the
Association.
Interpreting Standards
The interpretations expressed in this
Guide are not to be considered all inclu-
sive of situations that could evolve under
a specific standard of the Standards of
Ethical Conduct for the Physical Thera-
pist Assistant but reflect the opinions,
decisions, and advice of the Judicial
Committee. While the statements of eth-
ical standards apply universally, specific
circumstances determine their appropri-
ate application. Input related to current
interpretations or situations requiring in-
terpretation is encouraged from APTA
members.
Standard 1
Physical therapist assistants provide ser-
vices under the supervision of a physical
therapist.

1.1 Supervisory Relationships

Standards of Ethical Physical therapist assistants shall work

under the supervision and direction of a
physical therapist who is properly cre-
Conduct for the dentialed in the jurisdiction in which the
physical therapist assistant practices.

Physical Therapist 1.2 Performance of Service

A. Physical therapist assistants may
not initiate or alter a treatment program

Assistant without prior evaluation by and approval

of the supervising physical therapist.
B. Physical therapist assistants may
Preamble modify a specific treatment procedure in
accordance with changes in patient
Physical therapist assistants are responsible for maintaining and pro- status.
moting high standards of conduct. These Standards of Ethical Conduct C. Physical therapist assistants may
for the Physical Therapist Assistant shall be binding on physical thera- not interpret data beyond the scope of
pist assistants who are affiliate members of the Association. their physical therapist assistant edu-
cation.
Standard 1 D. Physical therapist assistants may
Physical therapist assistants provide services under the supervision of respond to inquiries regarding patient
status to appropriate parties within the
a physical therapist.
protocol established by a supervising
Standard 2 physical therapist.
Physical therapist assistants respect the rights and dignity of all indi- E. Physical therapist assistants shall
refer inquiries regarding patient progno-
viduals. sis to a supervising physical therapist.
Standard 3
Standard 2
Physical therapist assistants maintain and promote high standards in
Physical therapist assistants respect the
the provision of services, giving the welfare of the patients their highest rights and dignity of all individuals.
regard.
2.1 Attitudes of Physical Therapist
Standard 4 Assistants
Physical therapist assistants provide services within the limits of the A. Physical therapist assistants shall
law. recognize that each individual is different
from all other individuals and respect
Standard 5 and be responsive to those differences.
Physical therapist assistants make those judgments that are commen- B. Physical therapist assistants shall
be guided at all times by concern for the
surate with their qualifications as physical therapist assistants. dignity and welfare of those patients
Standard 6 entrusted to their care.
Physical therapist assistants accept the responsibility to protect the C. Physical therapist assistants shall
not engage in conduct that constitutes
public and the profession from unethical, incompetent, or illegal acts. harassment or abuse of, or discrimina-
Adopted by the House of Delegates tion against, colleagues, associates, or
June 1982 others.
Amended June 1991

Physical 'Therapy / Volume 75, Number 8 / August 1995

2.2 Request for Release of Information
Physical therapist assistants shall refer
all requests for release of confidential
information to the supervising physical
therapist.
2.3 Protection of Privacy
Physical therapist assistants must treat
as confidential all information relating to
the personal conditions and affairs of the
persons whom they serve.
2.4 Patient Relations
Physical therapist assistants shall not
engage in any sexual relationship or
activity, whether consensual or non-
consensual, with any patient while a
physical therapist assistanvpatient rela-
tionship exists.
Standard 3
Physical therapist assistants maintain
and promote high standards in the pro-
vision of setvices, giving the welfare of
patients their highest regard.
3.1 lnformation About Services
A. Physical therapist assistants may
provide consumers with information re-
garding provision of services within the
protocol established by a supervising
physical therapist.
B. Physical therapist assistants may
not use, or participate in the use of, any
form of communication containing a
false, fraudulent, misleading, deceptive,
unfair. or sensational statement or claim.
3.2 Organizational Employment
Physical therapist assistants shall advise
their employer(s) of any employer prac-
tice that causes them to be in conflict
with the Standards of Ethical Conduct
for the Physical Therapist Assistant.
3.3 Endorsement of Equipment
Physical therapist assistants may not
endorse equipment or exercise influence
'Reprinted with permission of the American Physical Therapy Association.
on patients or families to purchase or
lease equipment except as directed by a
physical therapist acting in accord with
the in paragraph 5.3.A. of the
Guide for Professional Conduct.
3.4 Financial Considerations
Physical therapist assistants shall never
place their own financial interest above
the welfare of their patients.
3.5 Exploitation of Patients
Physical therapist assistants shall not
participate in any arrangements in which
patients are exploited. Such arrange-
ments include situations where referring
sources enhance their personal incomes
as a result of referring for, delegating,
prescribing, or recommending physical
therapy services.
Standard 4
Physicaltherapist assistants provide ser-
vices within the limits of the law.
4.1 Supervisory Relationships
Physical therapist assistants shall com-
ply with all aspects of law. Regardless of
the content of any law, physical therapist
assistants shall provide services only
under the supervision and direction of a
physical therapist who is properly cre-
dentialed in the jurisdiction in which the
physical therapist assistant practices.
4.2 Representation
~ ' i c %f;s';
~ ~
therapists.
Standard 5
Physical therapist assistants make those
judgments that are with
their qualifications as physical therapist
assistants.
Physical Therapy / Volume 75, Number 8 /August 1935
5.1 Patient Treatment
Physical therapist assistants shall report
all untoward patient responses to a su-
pervising physical therapist.
5.2 Patient Safety
Physical therapist assistants may refuse
to carry out treatment procedures that
they believe to be not in the best interest
of the patient.
5.3 Qualifications
Physical therapist assistants may not
carry out any procedure that they are not
qualified to provide.
5.4 Discontinuance of Treatment Program
Physical therapist assistants shall dis-
continue immediately any treatment pro-
cedures that in their judgment appear to
be harmful to the patient.
5.5 Continued Education
Physical therapist assistants shall con-
tinue participation in various types of
educational activities that enhance their
skills and knowledge and provide new
skills and knowledge.
Standard 6
Physical therapist assistants accept the
responsibility to protect the public and
the profession from unethical, incompe-
tent, or illegal acts.
6.1 Consumer Protection
Physical ~
therapist ~
assistants ~ report~
shall ~
any conduct that appears to be unethical
or illegal.
Issued by Judicial Committee
American Physical Therapy Association
October 1981
Last Amended January 1995
Appendix III. Guidelines for Physical Therapy Documentationa

These guidelines were developed by a subgroup of APTA's Advisory Panel o n Documentation a n d were adopted
by APTA's Board of Directors in 1993.

APTA thanks Karl Gibson, MS, PT; Stephen Haley, PhD, PT; a n d Robert Babbs, MPA, PT, for their work in re-
searching a n d preparing these guidelines.

Guidelines for Physical Therapy Documentation BOD 03-9523-61 [Amended BOD 11-94-33-107; BOD
06 -9,+09-13; Adopted BOD 03-93-21-551

01995 by the American Physical Therapy Association. All rights reserved.

For more information about this and other APTA publications, contact the American Physical Therapy Association, 1111 North Fairfax Street, Alexandria, VA
22314-1 488. [Publication No. P-1131

Introduction
The American Physical Therapy Association (APTA) is committed to meeting the physical therapy needs of society, to meeting the needs
and interests of its members, and to developing and improving the art and science of physical therapy, including practice, education, and
research. To help meet these responsibilities, the APTA Board of Directors has approved the following guidelines for physical therapy
documentation. It is recognized that these guidelines do not reflect all of the unique documentation requirements associated with the
many specialty areas within the physical therapy profession. These guidelines are intended to be used as a foundation for the
development of more specific documentation guidelines in specialty areas, while at the same time providing guidance for the physical
therapy profession across all practice settings.

Operational Definitions
Guidehes: APTA defines "guidelines" as approved, nonbinding statements of advice.
Documentation: Any entry into the client record, such as: consultation report, initial examination report, progress note, flowsheet/
checklist that identifies the carehervice provided, reexamination report, or summation of care.

I. General Guidelines
A. AU documentation must comply with the applicable j~ictionaVregulatoryrequirements.
1. AU handwritten entries should be made in ink
2. Informed consent shall be obtained a s required by the AFTA Standards of Practice.
2.1 The physical therapist has sole responsibility for providing information to the patient and for obtaining the patient's
informed consent in accordance with jurisdictional law before initiating physical therapy.
2.2 Those deemed competent to give consent are competent adults. When the adult is not competent, and in the case
of minors, a parent or legal guardian consents as the surrogate decision maker.
2.3 The information provided to the patient should include the following: (a) a clear description of the treatment ordered
or recommended, (b) material (decisional) risks associated with the proposed treatment. (c) expected benefits of
treatment, (d) comparison of the benefits and risks possible with and without treatment, and (e) reasonable
alternatives to the recommended treatment. The physical therapist should solicit questions from the patient and
provide answers. The patient should be asked to acknowledge understanding and consent before treatment
proceeds.
Examples of ways in which to accomplish this documentation:
2.3.1 Signature of patient/guardian on long or short consent form,
2.3.2 Notatiodentry of what was explained by the physical therapist or the physical therapist assistant in the official
record, and
2.3.3 Filing of a completed consent checklist signed by the patient.
3. Charting errors should be corrected by drawing a single h e through the error and initlallng and dating the
chart.
4. Identification:
4.1 Include patient's full name'and identification number, if applicable, on all official documents.
4.2 All entries must be dated and signed with the provider's full name and appropriate designation (eg, PT, PTA).
4.3 Documentation by students (SPT/SPTA) shall be countersigned by a licensed physical therapist.
4.4 Documentation by graduates (GPT/GPTA) or others pending receipt of an unrestricted license shall be countersigned
by a licensed physical therapist.
5. Documentation should include the manner in which physical therapy services are initiated.
Examples include:
5.1 Self-referravdirect access,
5.2 Attachment of the referral/consultation request by a qualified practitioner, and

Physical Therapy / Volume 75, Number 8 /August 1995

 5.3 File copy of correspondence to referral source as acknowledgment of the referral.

11. Initial Exadnation and Evaluation/Consultation

A. Documentation is requjred at the onset of each episode of physkal therapy care.
B. Elements include:
1. Obtalnlng a history and identifying risk factors:
1.1 History of the presenting problem, current complaints, and precautions (including onset date).
1.2 Pertinent diagnoses and medical history.
1.3 Demographic characteristics, including pertinent psychological, social, and environmental factors.
1.4 Prior or concurrent services related to the current episode of physical therapy care.
1.5 Comorbidities that may affect goals and treatment plan.
1.6 Statement of patient's knowledge of problem.
1.7 Goals of patient (and family members and significant others, if appropriate).
2. Selecting and administering tests and measures to determine patient status in a number of areas. The
following is a partial list of these areas, with illustrative tests and measures:
2.1 Arousal, mentation, and cognition.
Examples include objective findings related, but not limited, to the following areas:
2.1.1 Level of consciousness,
2.1.2 Ability to process commands,
2.1.3 Alertness, and
2.1.4 Gross expressive and receptive deficits.
2.2 Neuromotor development and sensory integration.
Examples include objective findings related, but not limited, to the following areas:
2.2.1 Gross and fine motor skills,
2.2.2 Reflex and movement patterns, and
2.2.3 Dexterity, agility, and coordination.
2.3 Range of motion.
Examples include objective findings related: but not limited, to the following areas:
2.3.1 Extent of joint motion,
2.3.1 Pain and soreness of surrounding soft tissue, and
2.3.2 Muscle length and flexibility.
2.4 Muscle performance.
Examples include objective findings related, but not limited, to the following areas:
2.4.1 Strength,
2.4.2 Power, and
2.4.3 Endurance.
2.5 Ventilation, respiration, and circulation.
Examples include objective findings related, but not limited, to the following areas:
2.5.1 Vital signs,
2.5.2 Breathing patterns, and
2.5.3 Heart sounds.
2.6 Posture.
Examples include objective findings related, but not limited, to the following areas:
2.6.1 Static posture, and
2.6.2 Dynamic posture.
2.7 Gait and balance.
Examples include objective findings related, but not limited, to the following areas:
2.7.1 Characteristics of gait,
2.7.2 Functional ambulation, and
2.7.3 Characteristics of balance.
2.8 Self-care or home-management status.
Examples include objective findings related, but not limited, to the following areas:
2.8.1 Activities of daily living,
2.8.2 Functional capacity, and
2.8.3 Static and dynamic strength.
2.9 Community or work reintegration.
Examples include objective findings related, but not limited, to the following areas:
2.9.1 Instrumental activities of daily living,
2.9.3 Functional capacity, and
2.9.3 Adaptive skills.
2.10 Other characteristics of patient performance (eg, integumentary integrity, aerobic capacity, or endurance).
3. Evaluation (a dynamic process in which the physical therapist makes cl€nical judgments based on data
gathered during the examhation).
4. Diagnosis (a label encompassing a cluster of signs and symptoms, syndromes, or categories that reflects the
information obtained from the examination).
5. Goals:
5.1 Patient (and family members and significant others, if appropriate) is involved in establishing goals.
5.2 All goals are stated in measurable terms.

118 / 763 Physical Therapy / Volume 75, Number 8 /August 1995

 5.3 Goals are linked to problems identified in the examination.
5.4 Short- and long-term goals are established when applicable. (May include potential for achieving goals.)
6. htervention plan or recommendation requirements:
6.1 Shall be related to realistic goals and expected functional outcomes.
6.2 Should include frequency (eg, two times per week) and duration (eg, 3 weeks) to achieve the stated goals.
6.3 Should include patient and family/caregiver educational goals.
6.4 Should involve appropriate collaboration and coordination of care with other professionals/services.
7. Signature and appropriate designation of physical therapist.

III. Documentation of the Continuum of Care

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

IV. Summation of Care

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

"Reprinted with permission of the American Physical Therapy Association.

Physical Therapy / Volume 75, Number 8 /August 1995