Gary Brooks* & Lawrence P. Cahalin
INTRODUCTION
The Guide to Physical Therapist Practice has been an important publication for the physical therapy community both nationally and internationally. It was developed out of a need to better define the role of the physical therapist (PT) in the changing health care arena.1–8 Jules Rothstein, the editor of the journal Physical Therapy, presented his opinions about the role of the Guide in two separate editorials preceding the publication of the 1st and 2nd editions of the Guide.3,4 Box 2-1 provides an overview of several of the comments made by Dr. Rothstein regarding the Guide including the definition of a guide (directions along a path): the fact that the Guide, to its credit, is nonspecific (drawing large circles; practice patterns that are broadly defined) and that the Guide is a “very gross first approximation of what we do and what we should do … and possibly what we can do.”3,4 Dr. Rothstein concluded his editorial by stating that there is a need (1) for research to help narrow the circle (to develop practice patterns that are less broad and with more specificity) for future versions of the Guide, (2) for dialogue from all clinicians about whether the Guide helps or does not help them in their practice, and (3) to clarify particular items or change them in the future.3
BOX 2-1
Editorial Comments Regarding the Preferred Practice Patterns
First Edition Comments
1.Definition of a guide as directions along a path.
2.The Guide is nonspecific and therefore good.
3.The Guide is not “intended to serve as clinical guidelines … and represents expert consensus.”
4.The Guide draws large circles (practice patterns that are broadly defined).
5.The Guide is a “very gross first approximation of what we do and what we should do … and possibly what we can do.”
6.The Guide has developed documents that will allow us to gain consensus on practice that can lead to the examination and refinement of that practice.
7.The Guide offers fodder for researchers and clinic managers.
8.The Guide begins to define the world of physical therapist practice.
9.There is a need for research to help narrow the circle (to develop practice patterns that are less broad with more specificity) for future versions of the Guide.
10.There is a need for dialogue from all clinicians about whether the Guide helps or does not help them in their practice.
11.There is a need to clarify particular items or change them in the future.
Second Edition Comments
1.The Guide forms a framework for describing and implementing practice.
2.The Guide has proven that it can be an invaluable adjunct to our literature.
3.Physical therapists need to understand what this new edition is—and what it is not.
4.The Guide contains the opinions of our colleagues on how to manage patients and clients—which is very different from evidence for practice.
5.The Guide is a work in progress.
6.It is hoped that the next edition of the Guide will appear soon—one that will be created not because of political necessity, but because of the need to codify a growing body of scientific knowledge.
7.We should look forward to a third edition of the Guide that relies less on personal views and more on evidence that becomes available in the public arena, evidence that deals directly with clinical practice and that has been published in peer-reviewed literature.
8.The Guide could never achieve the stated goal of “… standardizing terminology used in and related to physical therapist practice.” The Guide instead contains an official or semiofficial version of how terms should be used. The journal Physical Therapy will continue to depend on scientific literature for the evolution of terms and definitions.
9.The Guide should accurately describe tests, interventions, and preferred practice patterns.
10.The Guide can greatly enhance practice—when it is properly used.
11.If the Guide is viewed as containing immutable truths, however, we will be using it incorrectly.
12.It is hoped that the next edition of the Guide will be based primarily on evidence—and that physical therapists will use that evidence.
Editorial comments made by Jules Rothstein in editorials preceding the publication of the 1st and 2nd editions of the Guide.3,4
Prior to the publication of the 2nd edition of the Guide, Dr. Rothstein made several statements similar to those mentioned previously, but it appeared that he was more cautious about the role of the Guide in physical therapy.4 The following remarks, and others shown in Box 2-1, are examples of the apparent caution Dr. Rothstein has about the Guide. Some of the comments are that (1) the Guide should accurately convey what the tests, interventions, and preferred practice patterns are; (2) the Guide can greatly enhance practice—when it is properly used; (3) if the Guide is viewed as containing immutable truths, however, we will be using it incorrectly; and (4) the next edition of the Guide will be based primarily on evidence—and that PTs will use that evidence.4 Related to the need for evidence and appropriate use of available evidence is the emphasis that Dr. Rothstein made on the Clinical Research Agenda, which likely has significant implications for both physical therapy practice and the future development of the Guide.5
One goal of this textbook is to use peer-reviewed published research to narrow the circle (to develop more specific practice patterns using hypothesis-oriented algorithms) and to clarify particular items, depending on peer-reviewed published research, published in the Guide (under the Cardiovascular and Pulmonary Practice Patterns). We hope that dialogue will ensue in physical therapy classrooms and clinics. It is also our hope that through such dialogue and evidence-based medicine, cardiovascular and pulmonary physical therapy examinations and managements will be (1) more easily taught and understood, (2) more effective, and (3) justified to our patients, other health care providers, and health care payers.
DEVELOPMENT OF THE GUIDE
The Guide has been a work in progress for many years. Box 2-2 shows the chronological development of the Guide. The first step in the development of the Guide was a request from one of the American Physical Therapy Association’s (APTA’s) state components to develop practice parameters for physical therapy that could be provided to third-party payers and health care policymakers.1,2,8
BOX 2-2
The Chronological Development of the Guide
1.Request from one of the APTA’s state components to develop practice parameters for physical therapy which could be provided to third-party payers and health care policymakers in 1992.
2.Development of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management (“Volume I”) by an APTA board-appointed task force from 1992 to 1995.
3.The publication of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management in August 1995.
4.Initiation of the process needed for the development of Volume II, which “was to be composed of descriptions of preferred physical therapist practice for patient groupings defined by common physical therapist management” in the fall of 1995.
5.APTA Board of Directors Oversight Committee, Project Advisory Group, and Panel members for the Musculoskeletal, Neuromuscular, Cardiopulmonary, and Integumentary Practices selected in the fall of 1995.
6.Development of the Practice Patterns by the Panel members for the Musculoskeletal, Neuromuscular, Cardiopulmonary, and Integumentary Practices from the fall of 1995 through 1996.
7.Field Review of the developed Practice Patterns late in 1996.
8.Analysis of the Field Review Results and editing of Practice Patterns through most of 1997.
9.Publication of Volume II as Part II of the Guide in November 1997.
10.APTA Board of Directors Oversight Committee, Project Editors for Parts I and II (consisting of three members of which two were members of the 1995–1997 Project Advisory Group and one was a member of the 1995–1997 APTA Board of Directors Oversight Committee), and a Task Force on Development of Part III of the Guide (consisting of 13 members of which 4 were members of one of the 1995–1997 practice panels and 2 were members of the 1995–1997 Project Advisory Group) were selected in 1998–1999.
11.Development of Part III of the Guide by two task forces (one task force to examine the available literature pertaining to tests and measures used in the assessment of the four primary areas of physical therapy [cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular] and one task force to retrieve and review the available literature on tests and measures of health status, health-related quality of life, and patient/client satisfaction) from 1998 to 2000.
12.Field reviews and presentations at APTA national meetings of comprehensive lists of tests and measures used by physical therapists throughout 1999–2000.
13.Revisions to the Guide in June 1999.
14.Revisions to the Guide in November 1999.
15.The Guide (Parts I and II) is edited and appears to undergo a limited field review in 1999–2000.
16.Publication of the 2nd edition of the Guide to Physical Therapist Practice in January 2001.
17.Part III of the Guide available on CD-ROM in the summer of 2001.
Several other important steps in the development of the Guide included the development of A Guide to Physical Therapist Practice, Volume I: A Description of Patient Management (“Volume I”) by an APTA board-appointed task force beginning in 1992, which included Roger Nelson, John Barbis, Eileen Hamby, Catherine Page, Robert Post, Gretchen Swanson, and Marilyn Moffat as the Practice Parameters Project Core Group; and Marilyn Moffat, Andrew Guccione, Roger Nelson, and Jayne Snyder as the task force to review practice parameters and taxonomy documents, the publication of Volume I in August of 1995, and the initiation of the process needed for the development of Volume II.1,2,6–8
As mentioned previously and documented in Box 2-2, following the acceptance of Part I by the APTA’s board of directors, work began on Part II of the Guide in 1995. This effort was led by the Board Oversight Committee (BOC), made up of the current APTA president and two vice presidents, which appointed a six-member Project Advisory Group (PAG) to over see the development of preferred practice patterns for each of the four domains of practice. Together, the BOC and PAG chose 24 physical therapists with broad expertise in overall and specialty practice, familiarity with the scientific method and documentation procedures, and a willingness to work together to complete the project. These therapists formed the four panels of experts that created and revised the preferred practice patterns over the next 2 years. The cardiopulmonary panel of experts included Gary Brooks, Lawrence Cahalin, Dianne Carrio, Nancy Ciesla, and Ellen Hillegass.2,8
The pattern development process involved consensus of expert opinion as well as use of available scientific evidence to support or refute the examinations and interventions used in PT practice. Key concepts that guided the panelists during their deliberations included the Disablement Model, prevention and wellness considerations, the continuum of care across various practice settings and across the life span, and the influence of gender and culture. Each panel was charged with developing one primary prevention practice pattern.2,8
The development of the preferred practice patterns was an extensive process that included numerous consensus developing meetings among practice pattern specialty area panels; dialogue and feedback from the PAG and BOC; select reviews; suggestions; edits from APTA administration, components, and clinical specialists; and numerous field reviews from the APTA membership. After 2 years of meetings at APTA headquarters in Alexandria, VA (complete with floods, blizzards, and numerous other adventures), and countless phone calls and e-mails, the panels presented the PAG and BOC with a total of 34 preferred practice patterns. The patterns were meant to cover a broad array of patient/client problems, but were not intended to be totally inclusive. There are certainly patient/client situations that may not come under one of the preferred practice patterns; new features have been added and even new patterns have been proposed. Nor were the patterns meant to be prescriptive; in other words, they are not recipes in a cookbook. Rather, the patterns were meant to “describe common sets of management strategies used by physical therapists for selected patient/client diagnostic groups.”2
It is apparent from Box 2-1 that an important part of the development of the Guide is dialogue (in the form of both the written and the spoken word) from PTs about the Guide. Searches of MEDLINE and CINAHL identified only a few articles related to the practice patterns and the Guide (Box 2-3).9–15 It is hoped that the profession will continue to critically appraise the clinical utility of this document.
BOX 2-3
Published Literature About the Guide to Physical Therapist Practice
1.Rothstein J. Editorial. Phys Ther. 1997;77:1-3.
2.Rothstein J. On the second edition of the Guide. Phys Ther. 2001;81:6-8.
3.Hillegass E. Applying the cardiopulmonary practice patterns: case study of a person with multisystem problems. Cardiopulm Phys Ther J. 1999;10(3):84-89.
4.Cahalin LP. Applying the cardiopulmonary practice patterns: heart failure. Cardiopulm Phys Ther J. 1999;10(3):90-97.
5.Bourgeois MC. Diagnosing pulmonary impairment: a lung volume reduction surgery case that uses the patient management model. Cardiopulm Phys Ther J. 1999;10(3): 98-100.
6.Schuster NB. Simultaneous implementation of two cardiopulmonary preferred practice patterns across the continuum of care. Phys Ther Case Rep. 1999;2(6):241-248.
7.Gordon J, Quinn L. Guide to physical therapist practice: a critical appraisal. Neurol Rep. 1999;23(3):122-128.
8.Focused issue: the Guide to physical therapist practice. GeriNotes. 1999;6(5):1-35.
9.Giallonardo L. Guide in action: patient with total hip replacement. PT Magazine. 2000;8(9):76-88.
This textbook will present numerous reviews of the literature with occasional research syntheses and meta-analyses when sufficient and adequate literature was available. The following sections will discuss particular aspects of Parts I and II of the Guide and will present methods to use the Guide and this textbook in an educational and clinical setting.
PART I OF THE GUIDE TO PHYSICAL THERAPIST PRACTICE
Part I of the 2nd edition of the Guide to Physical Therapist Practice consists of three chapters that specifically outline the roles of a PT. The majority of material in these three chapters was developed by expert consensus during the time period between 1992 and 1995 and was first published in the journal Physical Therapy in August 1995.1
Chapters 1 through 3 of the 2nd edition of the Guide follow a similar format to the original 1995 publication. However, major revisions and additions were made to the 2nd edition.8,16 The majority of revisions made to Chapters 1through 3 of Part I occurred during the time period between the publication of the 1st and 2nd editions (1997–2001).2,6–8 The major revisions included the development of disablement within the realm of physical therapy, including risk reduction and prevention as well as health, wellness, and fitness interventions, as well as identifying the goals of many management techniques as outcomes.8 For example, the role of disablement (as described by Nagi and others) in physical therapy examination and management has been extensively reviewed. As such, the specific pathologies, impairments, functional abilities or limitations, disabilities, and quality of life issues have been incorporated in all appropriate areas of the physical therapy examination and management process described in Chapters 2 and 3, respectively. Likewise, attempts were made to incorporate disablement into the role of the PT as described in Chapter 1.8 Table 2-1 provides an overview of the manner in which this was accomplished. The examination and management of various domains of disablement have now been identified to be an important aspect of physical therapy.
TABLE 2-1 Revisions of Part I (Chapters 1–3) and Part II of the Guide: Several Key Differences and Effects on Physical Therapy
Disablement and Functioning
Much of the practice pattern design and language is based on the disablement schema developed by Nagi, in which pathology, impairment, functional limitations, and disabilities have been identified as the key areas of disablement (Fig. 2-1).17–20 Pathology has been defined as the interruption of normal processes of an organism to regain normalcy; impairment, as anatomical, physiological, mental or emotional abnormalities, or loss; functional limitations or functional abilities of a person, as limitations in performance of the person; and disability, as the limitation in the performance of socially defined roles or tasks.17–20 Figure 2-1 shows that extra- and intraindividual factors and risk factors can also affect disablement and require examination and possibly therapeutic intervention.
FIGURE 2-1 The influence of extraindividual factors, intraindividual factors, and risk factors on disablement. (Reprinted from Social Science and Medicine, Vol. 38. Verbrugge and Jette, “The Disablement Process,” p. 4, 1994, with permission from Elsevier.)
The key domains under which the preferred practice patterns (and ultimately physical therapy diagnosis) are subsumed are impairments and functional abilities. In fact, the majority of the preferred practice patterns begin with the word impairment and are often clarified with a statement of function which are further defined in relationship to a specific pathology. Such a process is common in the development of a diagnosis and a hypothesis-oriented algorithm.21,22
Developing a complete physical therapy diagnosis requires a more detailed discussion of the possible methods used to classify disablement and disability.21,22 The Nagi model described above and shown in Fig. 2-1 has been used extensively in the development of the preferred practice patterns.17–22 However, the more recent World Health Organization (WHO) classification of disablement and disability (International Classification of Functioning, Disability, and Health; ICF) has been considered to be a superior conceptual model because of a focus on functioning in health and disease (eliminating the distinctions between healthy and disabled persons) within a context of personal and environmental factors (Fig. 2-2).23–25 Figure 2-3 further outlines the ICF model with several additional components, constructs, and categories.
FIGURE 2-2 The WHO classification of disablement and disability via the ICF and interaction of concepts. (Reprinted from International Classification of Functioning, Disability and Health; ICF. Geneva, Switzerland: World Health Organization; 2001, with permission of the World Health Organization.)
FIGURE 2-3 Structure of the WHO classification of disablement and disability via the ICF. (Reprinted from International Classification of Functioning, Disability and Health; ICF. Geneva, Switzerland: World Health Organization; 2001, with permission of the World Health Organization.)
The structure of the ICF model shown in Figs. 2-2 and 2-3 is likely to enhance the physical therapy diagnosis of impairments and functional abnormalities, but the lack of association with the current APTA practice patterns may make the application of the ICF model to the practice patterns difficult.17–25 Despite this, the major strengths of the ICF model are the broad biopsychosocial view of health and subdomains shown in Fig. 2-3.23–25 Examination of Fig. 2-3 will help to clarify the manner by which the ICF model and its subdomains may be applied to the APTA-preferred practice patterns.
Figure 2-3 shows the structure of the WHO classification of disablement and disability. The ICF model (moving downward from the top of the figure) consists of a functioning and disability part (Part 1) and a contextual part (Part 2). The contextual part contains two component parts consisting of environmental and personal factors. The environmental factors are defined as the physical, social, and attitudinal environment in which people live and conduct their lives and include factors such as products and technology, the natural environment and adapted environments, support and relationships, attitudes, and available services and policies. The personal factors are defined as the background of a person’s life and include factors such as gender, race, age, habits, and a variety of psychological attributes.23–25
The functioning and disability part of the ICF model contains two component parts consisting of (1) body functions and structures and (2) activities and participation. Constructs or qualifiers of each of the component parts delineate the manner by which the component parts may affect a patient and as shown in the fourth level of the ICF model in Fig. 2-3 include change in body functions, change in body structures, capacity, performance, and facilitator/barrier. A particular strength about the ICF is that a particular change in body function and body structure (both are qualifiers) can be quantified using a 5-point scale from no impairment to a severe impairment. Furthermore, the other two qualifiers under activities and participation (capacity and performance) provide quantifiable measures that represent individuals’ ability to optimally function in their environment with assistive device or accommodations (performance) and without assistive device or accommodations (capacity).23–25
The bottom portion of Fig. 2-3 consists of domains and categories at different levels and represents a further delineation of each component and qualifier positioned above it. For example, the domains under both of the qualifiers capacity and performance, and thus the component “activities and participation” include learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, and community life.23–25 The above structure provides a broader, yet more specific assessment of function, disability, and health.
The ICF model has been reported to have substantial clinical utility with an important distinction between it and other models being the potential for multicultural application and comparability.23–25 However, a better understanding of the ICF model and its application to physical therapy and the APTA practice patterns is needed to facilitate its full use in physical therapy. In fact, a major area in need of investigation is the measurement characteristics of ICF concepts and categories and their ability to discriminate between the two primary parts of the ICF as well as among the different vertical levels of the ICF.23–25 It also appears that investigation of the ICF and the Guide to Physical Therapist Practice is needed.
Overview of Part 1 Chapters
The following section provides a brief overview of the three chapters in Part 1 of the Guide to Physical Therapist Practice. The specific sections of Chapter 1 include the education and qualifications of the PT; practice settings; types of patients and clients; scope of practice; the roles of the PT in primary, secondary, and tertiary care as well as prevention and wellness; elements of patient/client management, outcomes of PT care, discharge planning, other professional roles; and the direction and supervision of other health care personnel.8 Important changes in Chapter 1, since the 1995 publication, include a more detailed description of the PT and the roles of a PT (including clients, not just patients as potential recipients of physical therapy care); expansion of the elements of patient or client management leading to optimal outcomes (with outcomes and discharge planning being important additions and significant expansion in the types of data that may be generated from a patient/client history); and minimal expansion of other professional roles of the PT in consultation, education, critical inquiry, and administration (but with a movement of prevention and wellness to a common rather than “other” professional role).8
Two of the previous sections worthy of further discussion include the distinction between patients and clients seen by the PT and the potential role of the PT in prevention and wellness. The distinction between patients and clients is important because prior to the publication of Part I of the Guide, most PT care was considered to be provided (whether true or not) to patients rather than to clients. Several of the main differences and effects on the PT are shown in Table 2-1. Likewise, the role of the PT in prevention and wellness reflects the vision of treating clients and actually preventing disablement. The emphasis on such a role and the necessary changes are also shown in Table 2-1. The five elements of patient/client management shown in Fig. 2-4 provide a foundation for the PT to participate and direct PT intervention and assume a variety of roles. The types of data that may be generated from a patient/client history are shown in Fig. 2-5.8
FIGURE 2-4 The five elements of patient/client management. (Reprinted from American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001 Jan;81(1):9-746, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited. All rights reserved.)
FIGURE 2-5 The types of data that may be generated from a patient/client history. (Reprinted from American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001 Jan;81(1):9-746, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited. All rights reserved.)
Chapter 2 describes the tests and measurements that a PT may use in the management of patients or clients. Twenty-four categories of tests and measures have been presented as in the 1st edition,2 but there is now an attempt to include clinical indications for the tests and measures within particular domains of disablement.8 An example of the integration of the tests and measures within the Disablement Model is shown in Table 2-2.
TABLE 2-2 Examples of the Integration of the Tests and Measures Within Disablement
Chapter 3 lists different interventions that may be provided by the PT. Figure 2-6 identifies the three components of physical therapy intervention (Coordination, Communication, and Documentation; Patient/Client-Related Instruction; and Procedural Interventions) along with a listing of the nine specific procedural interventions.8 All of the sections within Chapter 3 have been expanded including the clinical considerations, interventions, and anticipated goals and expected outcomes.
FIGURE 2-6 The three components of physical therapy intervention (coordination, communication, and documentation; patient-/client-related instruction; and procedural interventions) along with a listing of the nine specific procedural interventions. (Reprinted from American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001 Jan;81(1):9-746, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited. All rights reserved.)
As in Chapter 2, an attempt to include clinical considerations for procedural interventions within particular domains of disablement has been made.8 These changes are shown in Fig. 2-5. The breadth of PT is apparent in the variety of tests and measures as well as in the direct treatments that may be provided by a PT, which are listed in Chapters 2 and 3, respectively. These tests and measures and interventions are listed in the most appropriate domain of disablement. Examples of this are shown in Table 2-3. This is an important addition to the 2nd edition of the Guide to Physical Therapist Practice.8 A major part of disablement and PT tests and measures and interventions are outcomes. Identification of appropriate and measurable outcomes for specific patient populations is needed in PT. Many of the goals listed in the intervention sections of the cardiopulmonary practice patterns of the 1st edition of the Guide are likely important outcomes for patients with cardiovascular and pulmonary disease. In fact, these goals have now been identified as expected outcomes in the 2nd edition.8 Although the goals and expected outcomes of specific cardiovascular and pulmonary PT outcomes have now been identified, the manner in which to attain these goals is not clear. The goals of the practice patterns are shown in Box 2-4.8 It is important to note that the Guide is “not intended to serve as a clinical guideline” and that it at best represents expert consensus.8 However, a more specific examination approach and treatment plan is needed in physical therapy. Fortunately, a substantial literature exists for cardiovascular and pulmonary care that provides an adequate evidence base for specific examination and treatment techniques in persons with cardiovascular and pulmonary diseases.
BOX 2-4
Goals of the Practice Patterns
1.To describe PT practice in general, using the disablement model as the basis.
2.To describe the roles of PTs in primary, secondary, and tertiary care; in prevention; and in the promotion of health, wellness, and fitness.
3.To describe the setting in which PTs practice.
4.To standardize terminology used in, and related to, PT practice.
5.To delineate the tests and measures and the interventions that are used in PT practice.
6.To delineate preferred practice patterns that will help PTs (1) improve quality of care, (2) enhance the positive outcomes of physical therapy services, (3) enhance patient/client satisfaction, (4) promote appropriate utilization of health care services, (5) increase efficiency and reduce unwarranted variation in the provision of services, and (6) diminish the economic burden of disablement through prevention and the promotion of health, wellness, and fitness initiatives.
TABLE 2-3 Major Revisions in Chapters 1–3 of Part I of the Guide to Physical Therapy: Development of Disablement Within Physical Therapy
The purpose of this textbook is to identify specific tests and measures that are most appropriate and informative when examining and treating persons with cardiovascular and pulmonary diseases. Observation of particular test results can provide diagnostic, prognostic, and therapeutic direction. The specialized tests that can provide this information will be presented in the practice pattern chapters of this textbook (Chapters 15–20). The following section will review the material in Part II of the Guide to Physical Therapist Practice.
PART II OF THE GUIDE TO PHYSICAL THERAPIST PRACTICE
Although Part I of the Guide is meant to define PT for the profession, for other professionals, and for the public, the intent of Part II is to link the elements of Part I with recognizable groups of patients and clients.2,8 In devising the preferred practice patterns, PT is staking a claim to a unique field of clinical management and inquiry. The patterns, in effect, establish PT diagnoses that give therapists a common framework on which to base their practice. As we shall see, the act of placing a patient in a practice pattern establishes the diagnosis and provides a broad range of interventions from which the PT can choose. A term used by the Guide to characterize the patterns is “boundaries.”8 Within the boundaries established by the pattern, a clinician is free to choose any examinations that will confirm, or perhaps refute, the diagnosis and interventions that will lead to the successful achievement of desired goals and outcomes. In this sense the Guide is not prescriptive; that is, it neither mandates, recommends, nor suggests which examinations or interventions should be used for a given patient/client scenario. Keep in mind that the Guide is a work in progress. Part III will catalog tests and measures that PTs use in examination and measurement of outcomes. Part III will also refer to available evidence that provides the scientific basis for clinical use of the tests and measures cited.16
The Preferred Practice Patterns
The preferred practice patterns for cardiovascular and pulmonary physical therapy are listed in Table 2-4. Of note for these practice patterns is the combining of several practice patterns initially developed as separate practice patterns in the first edition of the Guide and the development of one additional practice pattern (Impaired Circulation and Anthropometric Dimensions Associated with Lymphatic System Disorders).8
TABLE 2-4 Cardiovascular and Pulmonary Preferred Practice Patterns
The defining features of the common sets of management strategies used by PTs for selected patient/client diagnostic groups are those based primarily on patient diagnostic groups with some aspect of disablement associated with particular diagnoses. Many of the impairments that define the patterns are conceptually linked (“associated with” or “secondary to” are the terms used in the Guide) with a medical diagnosis or a surgical procedure.2,8 This linkage implies that the patient/client conditions that PTs see in the clinic are closely related to medical diagnoses; however, it is the impairments and the potential functional limitations and disabilities that are the focus of PT management. The Disablement Model reminds us that functional limitations pertain to the whole person and that disability pertains to the individual’s role in society.
For every pattern, a Patient/Client Diagnostic Classification is listed. Under this heading is located a more detailed description of the features that define the pattern, including a list of Inclusion and Exclusioncriteria. The Inclusion and Exclusion criteria refer to general categories of medical/surgical diagnoses or conditions that either qualify or disqualify an individual from each pattern. Also listed are Findings That May Require Classification in Additional Patterns. These, typically, are diagnoses with features that are common to multiple practice patterns. The page immediately following the title page for each pattern supplies a list of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes that may be present in patients/clients who qualify for each of the patterns. The ICD-9-CM codes are standard numeric codes corresponding to specific diagnoses and subcategories of diagnoses that are used for billing and research purposes.
The next part of each pattern is the Examination section. This section contains the Patient/Client History, Systems Review, and Tests and Measures that a PT might choose for patients/clients in the pattern. Following this is the section pertaining to Evaluation, Diagnosis, and Prognosis. Included in this section is a statement of the Expected Range of Number of Visits Per Episode of Care, which discloses the anticipated span of PT visits across all involved practice settings. An episode of care, for example, may begin when the patient/client is in the acute hospital, continues in a rehabilitation facility, and ends in a home care environment. Note the clause stating that the range covers 80% of persons in the diagnostic group. This covers patients or clients who may require more (or less) care beyond the published range for each pattern. Variables that may influence how often or how many times a patient/client may be seen are included under Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode. These factors comprise many of the intra- and extraindividual factors that impact functional limitations according to the Disablement Model.17
Intervention comes next. This portion lays out all of the potential Procedural Interventions that may be used in clinical management as well as interventions related to Coordination, Communication, and Documentation and Patient-/Client-Related Instruction. The first three Procedural Interventions listed for most of the cardiovascular and pulmonary patterns are considered to be fundamental PT interventions. These are Therapeutic Exercise (including aerobic conditioning), Functional Training in Self-Care and Home Management (including ADL and IADL), and Functional Training in Community and Work (job/school/play), Community, and Leisure Integration or Reintegration (including IADL, work hardening, and work conditioning).8
The final section comprises Reexamination, Global Outcomes for Patients/Clients in (each) Pattern and Criteria for Termination of Physical Therapy Services. Potential outcomes of PT intervention span the range of elements in the Disablement Model—from pathology/pathophysiology to disabilities—and they also include risk reduction/prevention, improvements in health, wellness, and fitness; more efficient use of societal resources and patient/client satisfaction.8
The philosophy behind the Guide recognizes the importance of prevention in physical therapy practice. In the preferred practice patterns, the Guide encompasses all three types of prevention. Primary prevention seeks to prevent the occurrence of disease. The Guide includes primary prevention practice patterns in all four clinical domains. For the cardiovascular/pulmonary practice patterns, Pattern A is the primary prevention pattern. Its focus is on cardiovascular risk-factor reduction through aerobic training and lifestyle change. Secondary prevention involves prevention of disease progression and the development of related diseases. For example, PT interventions for persons with diabetes, such as aerobic conditioning, do not “cure” the patient of diabetes, but can and do prevent many of the undesirable complications of diabetes and may help the patient to control his or her blood glucose level. Tertiary prevention attempts to prevent disability resulting from disease. An example of tertiary prevention may be seen in pulmonary rehabilitation, where PT interventions that involve therapeutic exercise and patient/client instruction in breathing strategies may slow the progression of disability associated with chronic obstructive pulmonary disease.
LIMITATIONS OF PARTS I AND II OF THE GUIDE
Readers of the Guide expecting to find recipes for how to manage a patient with, for example, myocardial infarction or cystic fibrosis will be disappointed. Indeed, that the Guide is not a “cookbook” is not so much a limitation as it is a strength. Clinicians using their professional judgment may choose from a broad array of tests and measures as well as from interventions. Nonetheless, the Guide has been criticized for its lack of clarity with regard to an ordering or prioritizing of its components for specific practice patterns.13 Although this criticism is not entirely unfounded, it should be kept in mind that the Guide was never meant to be prescriptive, that is, to delineate what PTs should or should not do in the management of their patients/clients. It will be up to future revisions of, and additions to, the Guide, as well as to publications such as this one, to color in the maps for each practice pattern as evidence becomes available.
There is also controversy regarding the concept of diagnoses that are unique to PT. Gordon and Quinn argue that the preferred practice patterns are largely pathology based, though their remarks are in reference to the neuromuscular patterns. However, the cardiovascular and pulmonary practice patterns are impairment based as well as pathology based. Each pattern, with the exception of the primary prevention pattern, focuses primarily on impairment in aerobic capacity and/or ventilation and secondarily on the associations with very broadly defined pathologic features. Both “impaired aerobic capacity,” and “impaired ventilation”—two primary elements common to most of the cardiovascular and pulmonary practice patterns—are consistent with the definition of impairments in the Disability Model (see Fig. 2-1).
Remember, too, that the Guide is a work in progress. Revisions have been and will continue to be made. Not all patient groups seen by PTs are represented in the current revision, though the breadth of the practice patterns has increased by the addition of new patterns. As it evolves, the Guide will provide PTs with more clinically useful information and guidance. It is the purpose of this textbook to help provide some guidance to the PT caring for the disablement associated with cardiovascular and pulmonary disorders.
THE DISABLEMENT PROCESS MODEL
The Guide to Physical Therapist Practice is rooted in a theoretical model that is characterized as the disablement process. This model has been articulated by Verbrugge and Jette and is based on a classification framework that was developed by Nagi.17 It is an attractive and useful model for physical therapy practice and research for several reasons. First, the Disablement Model contrasts with the traditional medical model in which a disease or diagnosis, rather than a person, is treated. The model recognizes that multiple pathologic conditions may, and often do, coexist in individuals, particularly in the elderly and in those who have disabling developmental or acquired conditions. There is not a straightforward, one-to-one relationship between a particular pathologic condition, for example, coronary heart disease, and its outcome in a given individual or population. Some individuals become limited in their activities as a result of the pathologic condition; others experience few or no limitations. The Disablement Model provides a means by which we can acknowledge the value of services that may not directly impact medical diagnoses but instead impact important personal and societal consequences of disease, namely, the development of disability.
Another attractive feature of the Disablement Model is that it recognizes the process inherent in the progression from disease to disability. Process implies a dynamic, potentially interactive continuum that may be affected at various points in positive or negative ways. The interventions provided by PTs are examples of actions that help to halt or slow the progression from disease to disability. The model helps clinicians to organize their thinking about what aspect of the disablement process an examination measures or how intervention will impact the slowing or prevention of disability. Figure 2-1 illustrates the main pathway of the Disablement Model, in addition to other factors that contribute to the process.
The Guide suggests that PTs are involved, primarily, in the management of impairments, functional limitations, and disability. Pathology may or may not be a management concern for the PT in the area of cardiovascular and pulmonary disorders. PTs may intervene in the presence of “… changes in physical function and health status resulting from injury, disease or other causes.”2,8 The degree to which “changes in health status” may reflect involvement in pathology needs further investigation and clarification.
Impairments, such as decreased range of motion and decreased strength and deconditioning, are features with which PTs are perhaps most familiar. Functional limitations are aspects of the patient/client that pertain to specific activities, for example, rolling over, sitting up from a supine position, or walking. According to Verbrugge and Jette, these activities may be necessary components of particular activities of daily living (ADL), but they are not, themselves, ADL.17 In the Disability Model, ADL are classified in the disability domain, including tasks such as moving in bed, transferring from a bed to a chair, and ambulating across a room.
A clinical example may help to distinguish between a functional limitation and a disability. A PT visits a woman, who has a diagnosis of congestive heart failure at her home. The therapist observes members of the woman’s family assisting her frequently with tasks such as moving in bed, sitting up and getting to a chair, and walking across the room to the bathroom. When the therapist examines the patient, however, she requires very little assistance to perform the same tasks. This illustrates the social context in which disabilities occur. The patient in this instance has a higher level of disability than her functional limitations would seem to indicate—the disability being exacerbated by the interaction of the patient with her family. Indeed, one of the key points of interest in both the Disablement Model and the Guide is that elements of the main pathway may or may not be causally related. In other words, having an impairment may or may not guarantee a functional limitation, nor does having a functional impairment guarantee a disability. As can be seen in the clinical example, the level of disability may exceed the level expected based solely on the degree of functional limitation present. Because of this, it is important to utilize specialized tests and measures that provide important information that can clarify the diagnosis and prognosis and provide direction for examination and management techniques. The information from such specialized tests and measures has been referred to as threshold behaviors and will be further discussed in the following section.18 Threshold behaviors can be defined as measurable behaviors at the pathology, impairment, functional, disability, quality of life, intra- or extraindividual, or risk-factor level.
Figure 2-1 also shows the other inputs that may influence how impairments translate into functional limitations and how functional limitations translate into disabilities. To continue with the clinical example, the patient’s family exacerbated the disability by helping too much (provided excessive external support), and the patient was willing to accept that assistance (perhaps an example of external locus of control). The PT would presumably mitigate the disability through rehabilitation interventions, the outcome of which would be independence in ADL. The line distinguishing functional limitations from disabilities can be quite blurry, which may be why the Guide combined the two concepts in its classification of outcomes. However, identification of threshold behaviors is necessary to determine specifics about the disablement associated with cardiovascular and pulmonary disorders.
DEVELOPMENT OF THRESHOLD BEHAVIORS WITHIN THE DISABLEMENT OF CARDIOVASCULAR AND PULMONARY DISORDERS: A PHYSICAL THERAPY PERSPECTIVE
Physical therapy is presently undergoing rapid and monumental change. Educational, clinical, and social aspects of physical therapy have recently been questioned and have resulted in different approaches to physical therapy education and clinical care. These changes have partly been responsible for the development of the preferred practice patterns for physical therapy just described. As mentioned, the preferred practice patterns for physical therapy “provide information about common management strategies for specific patient/client diagnostic groups.”2,8 The purpose of this last section is to describe how specific evidence-based objective observations and measurements of cardiovascular and pulmonary function can be used to (1) identify the appropriate preferred practice pattern for a patient with specific cardiovascular and pulmonary measurements, (2) direct further physical therapy examinations, and (3) direct physical therapy management interventions.
As previously stated, much of the practice pattern design and language is based on the disablement schema developed by Nagi and others in which pathologies, impairments, functional abilities or limitations, disabilities, and quality of life issues have been identified as important areas of physical therapy.17–20 Recent, but limited research has demonstrated the important role that measurement of specific impairments, functional abilities, disabilities, and quality of life issues may have for physical therapy research and practice.17–39 Measurement in these areas is important because with such measurements the success or failure of physical therapy interventions may be predicted. Improved predictive ability of physical therapy interventions will likely lead to more efficient care provided to the patients in greatest need of physical therapy and to the patients who will most likely benefit from particular therapeutic interventions. Predicting success or failure from medical or physical therapy appears to be dependent on identifying threshold levels. Test measurements, physical performance, or measured behaviors above or below a particular level frequently direct medical care to the most appropriate patients. Identifying similar threshold behaviors in physical therapy requires a clear definition of a threshold behavior. An extensive medical literature and limited physical therapy literature suggest that threshold behaviors can be defined as measurable behaviors at the impairment, functional, disability, quality of life, intra- or extraindividual, or risk-factor level that identifies the specific need and type of physical therapy intervention to provide to a patient.
A Physical Therapy Example of a Threshold Level
An example of allocating physical therapy to patients most likely to benefit from a particular intervention has been described by Jette,38 who used data previously reported by Buchner et al.39 They hypothesized that a curvilinear relationship exists between measures of muscle force (impairment) and the gait speed (functional status) of frail elderly persons.39 This hypothetical relationship is shown in Fig. 2-7. The curvilinear shape shown in Fig. 2-7 suggests the possibility that a threshold level exists in regard to the relationship between muscle force and gait speed. Above a particular threshold level of muscle force and gait speed, disability is absent. Below the threshold level, disability is present. The presence of specific threshold levels of behavior in particular areas of physical therapy will likely result in some patient populations receiving physical therapy care, whereas other patient populations receive no treatment or at least education in the prevention of disability. Repeat patient examinations may find that an initial measured behavior above the threshold has decreased below the threshold level and will likely require physical therapy intervention to prevent disability. Therefore, it appears that physical therapy interventions should be provided to those patients below a particular threshold behavior.
FIGURE 2-7 An example of a threshold behavior.
In fact, Jette states that the “benefit from physical therapy (eg, exercise in frail older persons), in part, will depend on the status of the target group.”18 This can be further understood by again viewing Fig. 2-7in which the frail and near-frail adults from studies 1 and 2, respectively, received benefit from exercise.39 However, the asymptomatic adults of study 3 received no benefit from exercise. The asymptomatic adults of study 3 demonstrated no improvement in gait or muscle force production because the average relationship between gait speed and muscle force was far above the threshold level, whereas the average relationships of gait speed and muscle force of the frail and near-frail adults were below the threshold level. The average of the frail adults was lower than that of the near-frail adults and resulted in a larger improvement from exercise than that seen in the near-frail adults.39
The allocation of physical therapy in this manner will likely result in more effective physical therapy care but will require more extensive tests and measures and, in particular, measurements of the relationships among physical therapy measurements, interventions, and patient outcomes. Furthermore, it appears that there is a need to measure the relationships within, between, and among pathologies, impairments, functional abilities, disabilities, and quality-of-life issues. Understanding these relationships will enable physical therapy care to be provided to the correct patients at the correct time and with a better understanding of the behaviors needed to amend or discontinue a physical therapy intervention.
A Cardiovascular and Pulmonary Physical Therapy Example of a Threshold Level
The clinical application of threshold behaviors to physical therapy can be exemplified with several measurements made in a research study investigating the clinical utility of the 6-minute walk test in persons with heart failure.40 The purpose of this study was to investigate the relationship between the 6-minute walk test (a functional performance measure) and (1) peak oxygen consumption (an impairment measure) or (2) survival (an important measurement of health outcome) in persons with heart failure. These relationships were investigated to see whether a functional performance threshold behavior (walking) could help to evaluate patients’ (1) appropriateness for cardiac transplantation and (2) response to physical therapy without measuring oxygen consumption.
Figure 2-8 shows long-term survival stratified by distance ambulated during the 6-minute walk test and by peak oxygen consumption. Patients ambulating less than 300 m had a poorer survival than those patients ambulating greater than 300 m, and patients with a peak oxygen consumption less than 14 mL/kg/min also had a poorer survival than those patients with a peak oxygen consumption greater than 14 mL/kg/min.40 These examples demonstrate the important role that the threshold value of 300 m has in determining survival in persons with heart failure. Measurements of impairment, function, disability, and quality of life and the relationships among them can also be useful when examining patient status and the effectiveness of physical therapy intervention.
FIGURE 2-8 (Top) Long-term survival stratified by 6-minute walk test distance less than 300 m (light line) or greater than 300 m (dark line). (Bottom) Long-term survival stratified by peak oxygen consumption less than 14 mL/kg/min (light line) or greater than 14 mL/kg/min (dark line). (Used with permission from Hillegass E, Sadowsky S. Essentials of Cardiopulmonary Physical Therapy. 2nd ed. WB Saunders; 2001.)
Ambulating a distance of 300 m during the 6-minute walk test provides a threshold behavior level that can be useful not only for the prediction of survival but also for the medical management of a person with heart failure and in directing physical therapy intervention.40
CLINICAL CORRELATE
Heart failure patients ambulating a threshold distance of less than 300 m are frequently provided more extensive medical and physical therapy management than patients ambulating a distance greater than 300 m.
Specific Methods to Integrate Threshold Behaviors with the Cardiovascular and Pulmonary Practice Patterns
An overview of the methods to use this textbook with the cardiovascular and pulmonary practice patterns is provided in Box 2-5. The information presented in this book should complement the use of the practice patterns and help to implement optimal examination and management techniques based on published literature. However, several recent changes in the 2nd edition of the Guide will be presented so that the application and integration of several threshold behaviors with the cardiovascular and pulmonary practice patterns can be better understood.8
BOX 2-5
Method to Integrate the Guide with the Textbook
Use the Guide to:
1.Go to page 471 of the 2nd edition of the Guide to find the list of the cardiopulmonary practice patterns—identify the pattern most likely to fit the patient.
2.Go to the exclusion criteria of the most appropriate practice pattern and examine the patient characteristics and medical history to determine whether or not the patient should be excluded from the identified practice pattern.
3.Go to the inclusion criteria of the chosen practice pattern and determine whether or not the patient should be included in the identified practice pattern.
4.Examine the ICD-9 codes to determine if the patient has been identified to fit this practice pattern. Although this is a helpful step, not all ICD-9-CM codes have been listed for each practice pattern.
Use the Textbook to:
5.Go to the cardiovascular and pulmonary practice pattern chapters of this textbook (Chapters 15–20).
6.Use the specialized tests and measurements listed in the identified cardiovascular and pulmonary practice pattern chapters to either confirm or refute the choice of practice patterns, thus rendering a physical therapy diagnosis.
7.Use the results of the specialized tests and measurements to direct the specific physical therapy interventions listed in each chapter and in the hypothesis-oriented algorithms listed in each chapter.
8.Use the specialized tests and measurements to reexamine the patient and determine the results of the hypothesis-oriented algorithmic interventions.
Three major changes that have been made to the 2nd edition of the Guide in the cardiovascular and pulmonary practice patterns that are worthy of discussion include the grouping of several of the practice patterns and changes in the inclusion/exclusion criteria of several of the practice patterns from the 1st edition, as well as the addition of an additional practice pattern (impaired circulation and anthropometric dimensions associated with lymphatic system disorders).8
In the 1st edition of the Guide, a distinction between cardiac pump dysfunction and failure was made. This was also true for ventilatory pump dysfunction and potential for failure. The 2nd edition found no useful distinction between cardiovascular dysfunction and failure, and they were combined into one practice pattern. Pulmonary dysfunction and failure were combined in a similar way.3 The combination of these particular practice patterns is in keeping with the manner in which this textbook has been developed. By maintaining two separate identifiable conditions and treatment arms within several of the practice patterns, we believe that specific evidence-based tests and measurements can be used to identify the key pathology and area of disablement most affected by the primary pathology.
The other areas in need of further discussion are the inclusion/exclusion criteria for the new practice patterns related to ventilatory pump dysfunction/failure and respiratory failure. The Guide is unclear regarding into which of these practice patterns the patient requiring mechanical ventilation is to be placed. This placement issue is discussed in Chapters 18 and 19 of this textbook. Because dysfunction and failure have been combined, the utilization of specific tests and measures to differentiate them becomes of paramount importance. One example of the process used to distinguish between ventilatory pump dysfunction and failure involves examining the patient for the presence of paradoxical breathing (see Fig. 2-9). This is described in detail in Chapters 9 and 19 of this textbook.
FIGURE 2-9 Two types of paradoxical breathing patterns suggestive of ventilatory pump failure. (A) Upper chest paradoxical breathing pattern. (B) Abdominal paradoxical breathing pattern. (Modified, with permission, from Massery M. The patient with neuromuscular or musculoskeletal dysfunction. In: Principles and Practice of Cardiopulmonary Physical Therapy. 3rd ed. Mosby Yearbook; 1996.)
USING THE GUIDE WITH THIS TEXTBOOK—A CLINICAL CASE STUDY
The abdominal paradoxical breathing pattern shown in Fig. 2-9B will be utilized in the following case study (Box 2-6). A 65-year-old male patient with a very long history of cigarette smoking and severe shortness of breath at rest and during exertion was referred to physical therapy for exercise training and patient education. The PT was provided several baseline measurements (Box 2-6). A quick glance at Box 2-6 reveals that the patient has been a long-time smoker, which has produced severe emphysema and many impairments and functional limitations.
BOX 2-6
A Patient with Chronic Obstructive Pulmonary Disease and “Some” Baseline Data—A Case Study Integrating the Use of the Guide with the Textbook*
Patient History and Inclusion Criteria for Preferred Practice Pattern 6E of the Guide
•A 65-year-old male with a very long history of cigarette smoking and complaints of severe shortness of breath at rest and during self-care.
•Markedly abnormal pulmonary function test results revealing severe chronic obstructive pulmonary disease (COPD) and severe hyperinflation of the lungs due to emphysema.
•Rapid respiratory rate and decreased movement of air in and out of the mouth (tidal volume).
•Markedly decreased breath sounds.
•Decreased strength and endurance of the ventilatory muscles.
•Decreased arterial oxygen and increased carbon dioxide levels.
•Observation of an abdominal paradoxical breathing pattern (Fig. 2-7B).
Method to Integrate the Guide with the Textbook
1.Go to page 471 of the Guide to identify the most likely practice pattern under which the patient falls. Based on the previous information, the patient will best fit under Practice Patterns C, E, or F.
2.The exclusion criteria for Practice Pattern C exclude neonates with respiratory failure and patients with respiratory failure requiring mechanical ventilation, but include patients with COPD who have airway clearance dysfunction. The above patient does not have airway clearance dysfunction and so he is excluded from Practice Pattern C.
3.The exclusion criteria for Practice Pattern F also exclude neonates with respiratory failure and patients with cardiovascular pump failure, but include patients with COPD who have respiratory failure. The above patient does not have respiratory failure and so he is excluded from Practice Pattern F.
4.In view of the above exclusion/inclusion criteria, this patient best fits under Practice Pattern E. Several ICD-9 CM codes fit this patient under the ICD-9-CM codes of Practice Pattern E including Codes 492 (emphysema), 492.8 (other emphysema), and 786.0 (dyspnea and respiratory abnormalities).
5.Go to Chapter 19 of this textbook.
6.Find the hypothesis-oriented algorithm of Chapter 19 and identify the primary test directing the algorithm (observation of an abdominal paradoxical breathing pattern) and the secondary tests (eg, pulmonary function, arterial blood gas, and diaphragmatic excursion test results) further directing the examination and management of this patient.
7.Forward Lean Test: Note correction of abdominal paradoxical breathing pattern and
a.decreased the respiratory rate, shortness of breath, and arterial carbon dioxide level.
b.increased the tidal volume, arterial oxygen level, breath sounds, and strength/endurance of the ventilatory muscles.
8.Use Forward Lean as an intervention: Note improvement in ability to perform functional tasks.
*Bolded areas are inclusion criteria for Practice Pattern E.
Much of the previous information is important as inclusion criteria listed for Practice Pattern E (ventilatory pump dysfunction or failure), but it does not provide much specificity about the pathology or other areas of disablement affected by the emphysema. Because of this, the use of a specialized test that has been shown to distinguish between ventilatory pump dysfunction and failure is necessary (Box 2-6).
Observation of an abdominal paradoxical breathing pattern can distinguish a failing ventilatory pump from a dysfunctional ventilatory pump. The specifics of this specialized test are briefly described in Box 2-6 and thoroughly discussed in Chapters 9 and 19 of this textbook as well as on the CD-ROM. The specific treatments provided to patients with ventilatory pump failure (breathing with paradox) and dysfunction (breathing without paradox, but demonstrating one of the problems in the second level on the left-hand side of Fig. 2-10) are presented in Fig. 2-10. Other specific interventions that can be provided to patients based on specific results from specialized tests are given in the practice pattern chapters of this textbook (Chapters 15–21).
FIGURE 2-10 A brief example of a hypothesis-oriented algorithm for the examination and management of persons with impaired ventilation and respiration/gas exchange associated with ventilatory pump dysfunction or failure.
SUMMARY
This overview of the practice patterns and threshold behaviors reveals that there is indeed an eminent paradigm shift in physical therapy research and clinical care. A modest number of investigations have demonstrated significant relationships between areas of disablement and physical therapy examination or intervention.21–39 Similar investigations are likely to be performed, and more specific disablement measurements will likely be found. The results from these investigations will identify specific patient populations who will likely benefit from specific physical therapy interventions and allow physical therapy outcomes to be predicted. Specific interventions and outcomes will likely be determined and predicted by identifying “threshold behaviors.” PTs have historically measured impairments, and some have focused on the functional abilities of patients. Recently, more PTs have begun to measure impairments, functional abilities, disabilities, and quality of life issues. These additional measurements of disablement are likely to improve patient examinations and the implementation of future physical therapy. Hopefully, the new evidence obtained from this paradigm shift will find its way into future editions of the Guide. An additional issue worthy of attention is the manner that the ICF conceptual model will be implemented within the Guide and the preferred practice patterns of physical therapy. Addressing the above issues will serve to make the Guide even more clinically useful.
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