M O V E Clinical Protocols M E N T - Biodex...Evidence-Based Clinical Protocols - Management of...

Evidence-Based

Clinical Protocols

- Management of Persons with Movement Disorders,Neurologic Pathologies, or General Deconditioning:An Integrated Protocol Using Instrumentation

CLINICAL EDITORS

Loretta M. Knutson, PhD, PT, PCS andJeanne Cook, MSPT, CWS

Dept of Physical TherapySouthwest Missouri State UniversitySpringfield, MO 65809

Morgan F. Boyle III MEd, ATCBiodex Medical Systems20 Ramsay RoadShirley, NY 11967-4704

CONTRIBUTOR

Art Nelson PhD. PTPhysical Therapy AssociatesClove Rd.Staten Island, NY

“The Clinical Advantage”™

BIODEXBiodex Medical Systems, Inc.

20 Ramsay Road, Shirley, New York, 11967-4704, Tel: 800-224-6339 (In NY and Int’l. call 631-924-9000), Fax: 631-924-9338, Email: [email protected], www.biodex.com

fn: 03-063

MOVEMENT D

ISORDERS

(#945-352)

Evidence-Based

Clinical Protocols1) Introduction and

Special Considerations

EVIDENCE-BASED CLINICAL PROTOCOLFOR THE MANAGEMENT OF PERSONS WITH

MOVEMENT DISORDERS,NEUROLOGIC PATHOLOGIES, OR GENERAL

DECONDITIONING: AN INTEGRATEDPROTOCOL USING INSTRUMENTATION

Introduction

PURPOSE

The material contained in the following pages presents an instrumented protocol of physical therapy management for patients withmovement disorders.

The protocol format is not intended to be a “cookbook” to patient management, as cookbook types of protocols can diminish theimportance of clinician education and experience. Instead, the protocol is intended to supplement clinical practice, clinician educa-tion, and experience. The instrumentation described in the protocol is used for patient measurement and intervention. Objectivedocumentation is used to track episodes of care, patient progress, and program efficacy. Forms included with the protocol comple-ment objective documentation for patients, referring physicians, and third-party payers.

Numerous forces impact rehabilitation practice today. Some of these forces include:

• Growth of knowledge pertaining to new treatmentsTreadmill training with unweighing systemsBicycle training programsBenefits of strengthening programsElectrical Stimulation of Muscle in Strengthening and Functional ProtocolsMedication management of spasticityConstraint-induced or forced-use therapy

• Alternative models of intervention Blocked periods of Intense Physical Therapy services – (e.g. Trahan and Malouin 2002 1)Work hardening programs Group vs individual intervention programsTechnologically-driven or instrumented programs

• Philosophical grounding in the disablement models

• Concepts of what constitutes "best practice"

• Development of practice guidelines; e.g. The Guide to Physical Therapist Practice

• Research to support evidence-based practice

• Practice expectations for objective documentation, quantifiable measures, and outcomes assessment

• Reimbursement requirements

• Cost-effective patient management

Reflecting on these forces, the protocol described in this document has been developed to support patient management in physi-cal therapy. Health care is stepping into a new era. This protocol provides an example of new directions being taken in physicaltherapy practice, specifically in the neuromuscular and conditioning areas.

© BIODEX MEDICAL SYSTEMS, INC. 1-1

1-2 INTRODUCTION

PHILOSOPHICAL AND PRACTICE BACKGROUND

Protocols can facilitate professional growth. They provide a starting point, rather than an ending point or cookbook. Cookbookapproaches emerge when a protocol is applied without reflection and when modifications specific to the individual client are notmade. The protocol presented in this document employs a systematic patient management process whereby intervention is based ondocumented objective clinical findings, patient response and intervention modification as needed, and outcomes monitoring. Usedin this way, the protocol can support broader study of service efficacy, "best practice" and growth of the physical therapy profession.

An important reflection on health care practice is embodied in the question, "do we make a difference"? A true profession willendeavor to be accountable for its future by conducting clinical research to help answer this question. Protocols can offer a frame-work upon which the scrutiny of science may be applied with the ultimate aim to improve the quality of care.

Physical therapists, particularly those in neurological practice, are not widely accustomed to using protocols. Traditionally, eachpatient has been treated as an individual and each therapist has sought to acquire their own particular art for making a differencefor the patient. While embracing the value of individual patient needs, and clinician art, we must recognize that some interventionsmay be more effective than others, and we have an obligation to establish those interventions.

Protocols are more common in orthopedic than neurological practice. Perhaps this is related to the relative ease of quantifyingexamination data in orthopedic practice. Comparatively, neurological practice involves more qualitative dimensions like cognitive,behavioral and "muscle tone" descriptions. This is changing as technology and new tests and measures emerge. We now have theability to quantify and systematically measure many clinical findings in the neurological area.

Increasingly, third-party payers expect health professionals to justify service and to define expected outcomes in quantitative termsfor various patient diagnostic groups. Thus, we must re-think traditional habits of practice and consider lessons from peers.Protocols can provide valuable starting points for justification of practice and growth.

Instead of protocols threatening physical therapists’ autonomy in designing individual patient treatment, they give us the opportuni-ty to scrutinize what we do and to specifically target the ideal frequency, intensity, duration, and type of services rendered. Aerobictraining guidelines, now universally accepted, evolved from developing and testing exercise protocols. Pharmaceutical research haslong-recognized the need for dose-response studies. Surgical and post-surgical protocols are common. Prosthetic management pro-tocols have greatly improved the quality of care for persons with amputations. Similarly, progress is likely in neurological rehabilita-tion if we can define a program of care, enroll patients in that defined program, and revise the program or protocol over time asfindings direct.

FOUNDATIONS IN THE GUIDE TO PHYSICAL THERAPIST PRACTICE AND THE DISABLEMENT MODEL

Two forces directly influenced the way in which the protocol has been written. One is the Guide to Physical Therapist Practice.(2)The other is the philosophy generated by the disablement models.

The Guide, first written in 1997 and then revised in 2001, describes five elements of patient management: Examination,Evaluation, Diagnosis, Prognosis and Intervention. These elements, or steps, are logical and we have chosen to follow them inorganizing the overall protocol. Approval has been secured from the American Physical Therapy Association, APTA, to reprint select-ed forms from the Guide. These are identified as they appear. In several sections these forms are supplemented for expanded datatracking. Still, the foundation of stepwise care remains because it offers a powerful support to improving patient care.

In the past 30 years, philosophical foundations for classifying disruption in human function have been described. The foundations,known as disablement models, have reshaped rehabilitation throughout the world and shifted focus from disease, pathology orcondition to the impact or consequences of conditions on function (3, 4). The models described include those by the World HealthOrganization (WHO) (6), Nagi (8), the National Center for Medical and Rehabilitation Research (NCMRR) (9), and the Institute ofMedicine (9). The first model, published by WHO in 1980 was known as the ICIDH (International Classification of Impairments,Disabilities and Handicaps). Unlike WHO’s previous more medically oriented model, the International Classification of Disease (ICD),which classified diseases for mortality study, the ICIDH addressed consequences of disease relative to the experiences of peoplewho live with the conditions. The ICIDH highlighted the importance of rehabilitation personnel in the care of persons with chronic

needs. In the summer of 1998, WHO presented their revised ICIDH model, the ICIDH-2 "beta version". Landmark enhancementsincluded introduction of "neutral" terminology and attention to the "universality" of disablement. Language like "avoiding participa-tion restriction" and aiming for "participation" rather than "preventing a disability [or handicap]" emerged. Broader application topersons, not patients, was apparent and the continuum from health to disability was accentuated. The role of prevention was alsohighlighted and the importance of environmental context was stressed. (See Table 1.)

Table 1. Disablement Model Language Variations

WHO ICIDH Nagi WHO ICIDH-2

Disease Pathophysiology Disorder or disease

Impairment Impairment Body function and structure

Disability Functional Limitation Activity

Handicap Disability Participation Contextual, environmental personal factors

Disablement models have led physical therapists to recognize that some areas of patient examination address the impairment levelwhile others address functional limitations or disability. Using the revised WHO language, client activity and participation are consid-ered. The shift from away from impairments assures that we address issues important to our clients and their families in their home,work and recreational lives. The shift does not imply the end to testing muscle strength (an impairment level measure), merely thatwe stress higher levels on the model. The Examination section of the protocol has been written to cut across the higher three levelsof the disablement model.

DOCUMENTATION FORMS

Documentation forms have been included to facilitate use of the protocol. Weekly patient charting and forms for daily notes areincluded. A majority of these forms were created specific to this protocol. The clinician is encouraged to use these forms to monitorpatient outcome and to support clinical investigation. Each Section of the protocol begins with a description of how to use theforms and the clinician is encouraged to review these descriptions.

THE PROTOCOL AS A DYNAMIC DOCUMENT

The protocol is a work in progress, dynamic, intended for revision as findings from case studies or group research direct. Therefore,this document is step 1. Clinician feedback is welcome. Currently, the physical therapy authors are undertaking case validation stud-ies to explore client response and outcome following participation in the protocol. Such efforts are welcome and, as indicated, willlead to revision.


1-4 INTRODUCTION

ABOUT THE AUTHORS

Dr. Knutson and Mrs. Cook are on faculty in the Department of Physical Therapy at Southwest Missouri State University. Mr. Boyleis an athletic trainer by background and an employee of Biodex Medical Systems, Inc. Their collaboration has resulted in this pro-tocol designed for use under the direction of a physical therapist. The protocol is based on a collective 40 years of experience inphysical therapy.

January, 2003

REFERENCES:

1. Trahan J, Malouin F. Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study. Dev Med and ChildNeurol. 2002; 44:233-239.

2. Guide to Physical Therapist Practice. Alexandria, Va.: American Physical Therapy Association; rev 1999.

3. Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Educational Programs forthe Preparation of Physical Therapists. In: 1997-1998 Accreditation Handbook. Alexandria, Va: American Physical TherapyAssociation; 1997.

4. Verbrugge L, Jette A. The disablement process. Soc Sci Med. 1994;38:1-14.

5. Jette AM. Physical disablement concepts for physical therapy research and practice. Phys Ther. 1994;74:380-386.

6. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland; 1980.

7. ICIDH-2: International Classification of Impairments, Activities, and Participation: BETA-1 Draft for Field Trials.http://www.who.int/msa/mnh/ems/icidh/icidh.htm. Accessed January 27, 1999.

8. Nagi SZ. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, (eds). Disability in America.Washington DC: National Academy Press, 1991.

9. Research Plan for the National Center for Medical Rehabilitation; Research. Washington, DC. US Dept of Health and HumanServices; March 1993. NIH Publication No.93-3509. (Also found in part athttp://silk.nih.gov/silk/NCMRR/Archive/RPlan/Plan.htm January 27, 1999.

10. Brandt EN, Pope AM (eds). Enabling America: Assessing the Role of Rehabilitation and Engineering. Institute of Medicine.National Academy Press. Washington D.C., 1997.

11. Schenkman M, Butler RB. A model for multisystem evaluation, interpretation and treatment for individuals with neurologicdysfunction. Phys Ther. 1989; 69:538-547.

12. Harris BA and Dyrek DA.. A model of orthopedic dysfunction for clinical decision making in physical therapy practice. PhysTher. 1989; 69:548-553.

13. Jette AM. Diagnosis and classification by physical therapists: a special communication. Phys Ther. 1989;69:967-969.

14. Jette AM. Outcomes research: Shifting the dominant research paradigm in physical therapy. Phys Ther. 1995;75:568-577.

15. Guccione AM. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991; 71:499-503. (Commentary and response, p 503-504).

16. Healthy People 2010. http://www.healthypeople.gov/document/. Accessed January 10, 2003.

Patients likely to be enrolled in the protocol are those who show movement disorders due to a wide variety of neurological andorthopedic pathologies. Clients with cardiopulmonary conditions that result in deconditioning may also be candidates for the inter-ventions described in the protocol. The protocol has been designed to support the stepwise sequence of patient management asadvocated in the Guide to Physical Therapist Practice (2nd edition, Phys. Ther. 2001; 81:9-744, APTA). The clinician is expectedto set patient goals and establish the direction of intervention based on patient examination and evaluation. The protocol aims toimprove a patient’s strength, balance and ambulation. Patients, for whom these goals fit, may be candidates with the followingconsiderations in mind:

• Use of this protocol is not a substitute for sound clinical judgment.

• Tests and measures are proposed but additional tests or measures may be needed.

• Patient inclusion in the interventions described in the protocol must depend on the clinician’s interpretation of individualpatient status. This interpretation should be documented under Evaluation in the patient’s report.

• Progression is dependent on the patient’s ability determined from reassessment (repeat examination and evaluation). Theprotocol is designed to be carried out in 1-3 blocks of 4 weeks and the clinician must determine whether the 4-, 8- or 12-week protocol is employed based on the patient’s assessment and progress.

BEFORE GETTING STARTED:

• Tests and measures used in the protocol should only be performed with medically stable patients. Stability should be achievedin: Prescription Medication; Blood Pressure and Circulation; Respiration; Mental Capacity for Cognition and Behavior; andBowel/Bladder Control. Decreased or absent sensation should also be noted and caution taken accordingly.

• Goals should be determined collaboratively with the patient and their family/caregiver after the patient Examination(history, systems review and tests and measures) and Evaluation (interpretation of the data gathered).

• The protocol is divided into three 4-week blocks of intervention.

• Reassessment is performed every 4 weeks, as recommended by the Clinical Practice Guidelines established by the United StatesDepartment of Health and Human Services, to assess neuromuscular improvement.

• The protocol involves use of Biodex instrumentation including the Gait Trainer treadmill, the Biodex Multi-Joint System, TheBiodex Unweighing System and the Biodex Balance System.

• Treatments should be modified based on the patient’s response and with the patient’s well-being in mind.

• Should no improvement be noted by week 4, alternative intervention strategies may be necessary to challenge the patient. Ifalternative programming also fails to lead to improvement, intervention may be terminated, a maintenance program may beoutlined, or the patient may need to be referred to another health professional.





special consideration

1-6 INTRODUCTION

PATIENT CONSIDERATIONS:

• Patients should be medically stable before starting an active program of physical therapy.

• Breaks should be incorporated throughout the treatment session as needed, especially with deconditioned patients.

• Unstable joints should not be assessed with isokinetics at low speeds due to increased translational and compressive forces.

• When using the Biodex Multi-Joint System to gain passive range of motion, keep the speeds low with moderate torque levels toprevent a stretch reflex and possible injury to the muscles.

• Weight bearing activities of the lower extremities should only be attempted in a safe environment. Initial standing activities maybe performed using a Biodex Unweighing System to provide safety for the patient and the clinicians involved in treatment.

• When using the Biodex Unweighing System make sure patients have evacuated their bladder/bowels. Consider the patient’s boweland bladder status when using this equipment because the upright position and harness system may affect the patient’s control.

• The treatment area should be clear and free of debris and obstacles to prevent falls.

• Be sure to address all components of a patient’s rehabilitation needs.

FORMS DESIGNED TO SUPPORT CLINICAL RESEARCH

Special documentation forms to support clinical research were created for use in this protocol. The "Outcome Measures TrackingForm" under the Outcomes section (designed as a pull out form) and the "Intervention Grid and Daily Notes" form under theIntervention section can facilitate clinical studies through patient progress monitoring and analysis of service frequency and dura-tion. Clinical research on the protocol’s ability to achieve desired patient outcomes may lead to future protocol revisions.

• Clustering the direct intervention into 4-week blocks with re-assessment after each block provides a scheduled approach totracking patient progress.

• Entering the frequency of visits per week may help the clinician see whether higher or lower frequency of visits is desirable.

• When a patient continues in the protocol 8 or 12 weeks, determination should be made of the added benefit of the longerprogram over a 4-week program.

Evidence-Based

Clinical Protocols2) Examination

- Patient History

- System Review

- Tests and Measures

This step in the patient management process has been defined as "The processof obtaining a history, performing a systems review, and selecting and adminis-tering tests and measures to gather data about the patient/client. The initialexamination is a comprehensive screening and specific testing process thatleads to a diagnostic classification. The examination process also may identifypossible problems that require consultation with or referral to another provider".(The Guide to Physical Therapist Practice, APTA, Alexandria, VA 2001).

The American Physical Therapy Association (APTA) Guide to Physical Therapist Practice identifies three components, History,Systems Review, and Tests and Measures, as comprising the Examination phase of patient management. Each component isdescribed below. The clinician should become familiar with the forms associated with these components as found in this section.Additional forms specific to each patient’s needs, or as required in some clinical centers, may be used by the clinician, especially toaddress Tests and Measures.

The first component, History, should address background information important to understanding the patient/client current condi-tion. The first two History forms used in this section are drawn from the Guide to Physical Therapist Practice, and reprinted withpermission of APTA . They are printed on front and back sides. The first form, Outpatient Form, should be selected when thepatient enrolled in the protocol is an outpatient. The second form, Inpatient Form, is used if the patient is an inpatient. A BiodexProtocol Supplement to the history forms is added in this section as a single page. The patient’s preferred name and phone numberand the names and contact information for key health care providers can be entered on this page. At the bottom, space is provid-ed for additional notes about previous treatments should the clinician wish to enter notes in text form.

The second component of the patient management process is Systems Review. Systems Review is used to identify the areaswhich will require detailed testing. The screening should cover the four practice pattern categories outlined in the Guide:Cardiovascular/Pulmonary, Musculoskeletal, Integumentary and Neuromuscular. The form used to facilitate Systems Review is alsoreprinted from the Guide with permission (1). In addition to the four practice pattern areas, one additional area of appraisal isnoted - Communication, Affect, Cognition, Learning Style. Information secured with this last area may help the clinician select testsand measures and communicate with the client at their understanding level. In some cases alternative communication and patienteducation strategies may be indicated. A Biodex Protocol Supplement to the systems review form draws attention to posturalhypotension if it is a concern and allows pictorial notation of skin lesions. An area for notes by the clinician is also provided on thesupplemental page.

The third component, Tests and Measures, should provide detailed information about patient status and performance. The formcreated for this component is a 7-sheet document (14 pages printed front to back). This form should be used at the initial examina-tion. Subsequent reassessment may not require the lengthiness of this form. Rather, the clinician may use the "Outcome MeasuresTracking Form" found and described under Outcomes, the last section of this monograph. One additional sheet, a listing of the 24Test and Measure categories, is found in this section as reprinted with permission from the Guide1. This sheet may be a helpfulreminder of the various tests and measures categories available to the clinician. The lined space on this additional sheet can beused to enter findings from tests and measures not found on the protocol 7-sheets. The clinician is referred to the Guide to PhysicalTherapist Practice: Part Three available on CD-ROM2 for detailed listings of specific tests and measures.

REFERENCES

1. Permission granted January 2003.

2. APTA, 1111 North Fairfax Street, Alexandria, VA.





examination

IDENTIFICATION INFORMATION1 Name:

a Last

b First c MI d Jr/Sr

Month Day Year

2 Admission Date: ��

Month Day Year

3 Date of Birth: ��

4 Sex: a �� Male b �� Female

5 Dominant Hand: a �� Right b �� Left c �� Unknown

6 Race 7 Ethnicity 8 Languagea �� American Indian a �� Hispanic or a �� English

or Alaska Native Latino understood b �� Asian b �� Not Hispanic b �� Interpreterc �� Black or African or Latino needed

American c �� Primaryd �� Hispanic or language:

Latino ____________e �� Native Hawaiian or

Other Pacific Islanderf �� White

9 Educationa Highest grade completed (Circle one): 1 2 3 4 5 6 7 8 9 10 11 12

b �� Some college/technical schoolc �� College graduated �� Graduate school/advanced degree

10 Has patient completed an advance directive? a �� Yes b �� No

11 Referred by: __________________________________________

12 Reasons for referral to physical therapy: ________________________________________________________________________

DOCUMENTATION TEMPLATE FORPHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT Today’s Date:

Inpatient Form, Page 1 Patient ID#:

Inpa

tient

His

tory

16 Caregiver Status Presence of family member/friend willing andable to assist patient/client? a �� Yes b �� No

15 Available Social Supports (family/friends) 0=No 1=Possibly yes 2=Definitelya Emotional supportb Intermittent physical support with ADLs

or IADLs—less than dailyc Intermittent physical support with ADLs

or IADLs—dailyd Full-time physical support (as needed)

with ADLs or IADLse All or most of necessary tranportation

17 EMPLOYMENT/WORK (Job/School/Play)

a �� Working full-time outside of home

b �� Working part-timeoutside of home

c �� Working full-time from home

d �� Working part-timefrom home

e �� Homemakerf �� Studentg �� Retiredh �� Unemployed

i Occupation:____________________________________________

Willing/AbleNow Postdischarge��

��

��

14 Lives(d) With (1)–Admission (2)–Expected atDischarge

a Alone �� b Spouse only �� c Spouse and other(s) �� d Child (not spouse) �� e Other relative(s) �� (not spouse or children)

f Group setting �� g Personal care attendant �� h Unknown �� i Other ________________________________________________

SOCIAL HISTORY 13 Cultural/Religious

Any customs or religious beliefs or wishes that might affect care?______________________________________________________

LIVING ENVIRONMENT18 Devices and Equipment (eg, cane, glasses, hearing aids,

walker)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

19 Type of Residence (1)–Admission (2)–Expected atDischarge

a Private home �� b Private apartment �� c Rented room �� d Board and care/assisted ��

living/group homee Homeless (with or ��

without shelter)f Long-term care facility ��

(nursing home)g Hospice �� h Unknown �� i Other ________________________________________________

20 Environmenta Stairs, no railing �� b Stairs, railing �� c Ramps �� d Elevator �� e Uneven terrain �� f Other obstacles: ________________________________________

a Day services/programs ��b Home health services ��c Homemaking services ��d Hospice ��e Meals on Wheels ��

f Mental health services ��g Respiratory therapy ��h Therapies—PT, OT, SLP ��i Other (eg, volunteer) ��

______________________

21 Past Use of Community Services 0=No 1=Unknown 2=Yes

22 GENERAL HEALTH STATUSa Patient/client rates health as:

�� Excellent �� Good �� Fair �� Poor

b Major life changes during past year? (1) �� Yes (2) �� No

DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT Inpatient Form, Page 2

23 SOCIAL/HEALTH HABITS (Past and Current) a Alcohol

(1) How many days per week does patient/client drink beer, wine, orother alcoholic beverages, on average? ______ (2) If one beer, one glass of wine, or one cocktail equals one drink, how many drinks does patient/client have, on an average day? _____

b Smoking(1) Currently smokes tobacco?

(a) �� Yes1. �� Cigarettes: # of packs per day _____

2. �� Cigars/pipes: # per day ____(b) �� No

(2) Smoked in past? (a) �� Yes Year quit: ��

(b) �� No

c Exercise(1) Exercises beyond normal daily activities and chores?

(a) �� YesDescribe the exercise: _________________________

1. On average, how many days per week does patient/client exercise or do physical activity? _____

2. For how many minutes, on an average day? __

(b) �� No

24 FAMILY HISTORYCondition: Relationship to Patient/Client: Age at Onset (if known):

a Heart disease ____________________________________ __________________________________

b Hypertension ____________________________________ __________________________________

c Stroke ____________________________________ __________________________________

d Diabetes ____________________________________ __________________________________

e Cancer ____________________________________ __________________________________

f Other: ______________________ ____________________________________ __________________________________

______________________________ ____________________________________ __________________________________

25 PATIENT/CLIENT MEDICAL/SURGICAL HISTORY: ____________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

27 MEDICATIONS (List): ____________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

28 OTHER CLINICAL TESTS (List):

Month Year

__________________________________ �� __________________________________ �� __________________________________ �� __________________________________ ��

26 FUNCTIONAL STATUS/ACTIVITY LEVEL (Check all that apply):a �� Difficulty with locomotion/movement:

(1) �� bed mobility(2) �� transfers(3) �� gait (walking)

(a) �� on level(b) �� on stairs(c) �� on ramps(d) �� on uneven terrain

b �� Difficulty with self-care (such as bathing, dressing, eating, toileting)

c �� Difficulty with home management (such as household chores, shopping, driving/transportation)

d �� Difficulty with community and work activities/integration(1) �� work/school(2) �� recreation or play activity

Findings

___________________________________________

___________________________________________

___________________________________________

___________________________________________

© American Physical Therapy Association 1999; revised September 2000, January 2001, January 2002


Patient’s Full Name __________________________________________________

Patient prefers to be called __________________________________________________

Phone Number __________________________________________________

Primary Care Physician __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

• Other Health Care Providers (seen regularly)

Name __________________________________________________

Discipline __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

Name __________________________________________________

Discipline __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

Notes Regarding Previous Treatments:_______________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

BIODEX PROTOCOLSUPPLEMENT

TO EXAMINATIONpatient history

© American Physical Therapy Association 1999; revised September 2000, January 2002

1 Name:

a Last

b First c MI d Jr/Sr

2 Street Address: __________________________________________

City State Zip

Month Day Year

3 Date of Birth: ��

4 Sex: a �� Male b �� Female

5 Are you: a �� Right-handed b �� Left-handed

6 Type of Insurance: a �� Insurer ______________________________

b �� Workers’ Comp c �� Medicare d �� Self-pay e �� Other

7 Race: 8 Ethnicity: 9 Language:a �� American Indian a �� Hispanic or a �� English

or Alaska Native Latino understood b �� Asian b �� Not Hispanic b �� Interpreterc �� Black or African or Latino needed

American c �� Language youd �� Hispanic or speak most

Latino often: e �� Native Hawaiian or ____________

Other Pacific Islanderf �� White

10 Education:a Highest grade completed (Circle one): 1 2 3 4 5 6 7 8 9 10 11 12

b �� Some college / technical schoolc �� College graduated �� Graduate school / advanced degree

SOCIAL HISTORY11 Cultural/Religious: Any customs or religious beliefs or wishes that

might affect care? ______________________________________________________

12 With whom do you live:a �� Aloneb �� Spouse onlyc �� Spouse and other(s)d �� Child (not spouse)e �� Other relative(s) (not spouse or children)f �� Group settingg �� Personal care attendanth �� Other:

13 Have you completed an advance directive? a �� Yes b �� No

14 Who referred you to the physical therapist:

________________________________________________________

15 Employment/Work (Job/School/Play)a �� Working full-time b �� Working part-time

outside of home outside of homec �� Working full-time d �� Working part-time

from home from homee �� Homemaker f �� Student g �� Retired h �� Unemployedi Occupation: ___________________________________________

LIVING ENVIRONMENT

18 Where do you live:a �� Private homeb �� Private apartmentc �� Rented roomd �� Board and care / assisted living / group homee �� Homeless (with or without shelter)f �� Long-term care facility (nursing home)g �� Hospiceh �� Other: ____________________________________________

_________________________________________________

19 GENERAL HEALTH STATUSa Please rate your health:

(1) �� Excellent (2) �� Good (3) �� Fair (4) �� Poor

b Have you had any major life changes during past year? (eg, new baby,job change, death of a family member) (1) �� Yes (2) �� No

20 SOCIAL/HEALTH HABITS a Smoking

(1) Currently smoke tobacco? (a) �� Yes 1. �� Cigarettes:# of packs per day __

2. �� Cigars/Pipes: # per day __

(b) �� No

(2) Smoked in past? (a) �� Yes Year quit: �� (b) �� No

b Alcohol (1) How many days per week do you drink beer, wine, or other

alcoholic beverages, on average? ___ (2) If one beer, one glass of wine, or one cocktail equals one

drink, how many drinks do you have, on an average day? ___

c ExerciseDo you exercise beyond normal daily activities and chores?

(a) �� Yes Describe the exercise: __________________________1. On average, how many days per week

do you exercise or do physical activity? _______2. For how many minutes, on an average day? ____

(b) �� No

21 FAMILY HISTORY (Indicate whether mother, father, brother/sister,aunt/uncle, or grandmother/grandfather, and age of onset if known) a Heart disease: ___________________________________________b Hypertension: ___________________________________________c Stroke:_________________________________________________d Diabetes:_______________________________________________e Cancer: ________________________________________________f Psychological: ___________________________________________g Arthritis: ______________________________________________h Osteoporosis: ___________________________________________i Other:_________________________________________________

DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPISTPATIENT/CLIENT MANAGEMENT

Outpatient Form 1, Page 1Today’s Date: ______________Patient ID#:

16 Does your home have:a �� Stairs, no railingb �� Stairs, railingc �� Rampsd �� Elevatore �� Uneven terrainf �� Assistive devices (eg,

bathroom): __________g �� Any obstacles:________________________

17 Do you use:a �� Caneb �� Walker or rollatorc �� Manual wheelchaird �� Motorized wheelchaire �� Glasses, hearing aidsf �� Other: _____________

____________________________________

Out

patie

nt H

isto

ry

25 MEDICATIONSa Do you take any prescription medications? (1) �� Yes (2) �� No

If yes, please list: __________________________________________________________________________________________

b Do you take any nonprescription medications? (Check all that apply)

(1) �� Advil/Aleve(2) �� Antacids(3) �� Ibuprofen/

Naproxen(4) �� Antihistamines(5) �� Aspirin

(6) �� Decongestants(7) �� Herbal supplements(8) �� Tylenol(9) �� Other: __________________

________________________________________________

(1) �� Arthritis(2) �� Broken bones/

fractures(3) �� Osteoporosis(4) �� Blood disorders(5) �� Circulation/vascular

problems(6) �� Heart problems(7) �� High blood

pressure(8) �� Lung problems(9) �� Stroke

(10) �� Diabetes/high blood sugar

(11) �� Low blood sugar/hypoglycemia

(12) �� Head injury

(13) �� Multiple sclerosis(14) �� Muscular dystrophy(15) �� Parkinson disease(16) �� Seizures/epilepsy(17) �� Allergies(18) �� Developmental or growth

problems(19) �� Thyroid problems(20) �� Cancer(21) �� Infectious disease

(eg, tuberculosis, hepatitis)

(22) �� Kidney problems(23) �� Repeated infections(24) �� Ulcers/stomach problems(25) �� Skin diseases(26) �� Depression(27)�� Other:_________________

For women only: Have you been diagnosed with:e Pelvic inflammatory

disease? (1) �� Yes (2) �� No

f Endometriosis? (1) �� Yes (2) �� No

g Trouble with your period? (1) �� Yes (2) �� No

h Complicated pregnancies ordeliveries?

(1) �� Yes (2) �� No i Pregnant, or think you might

be pregnant? (1) �� Yes (2) �� No

j Other gynecological or obstet-rical difficulties?

(1) �� Yes (2) �� NoIf yes, please desribe:________

(1) �� Chest pain(2) �� Heart palpitations(3) �� Cough(4) �� Hoarseness(5) �� Shortness of breath(6) �� Dizziness or blackouts(7) �� Coordination problems(8) �� Weakness in arms or legs(9) �� Loss of balance(10) �� Difficulty walking(11) �� Joint pain or swelling(12) �� Pain at night

(13) �� Difficulty sleeping(14) �� Loss of appetite(15) �� Nausea/vomiting(16) �� Difficulty swallowing(17) �� Bowel problems(18) �� Weight loss/gain(19) �� Urinary problems(20) �� Fever/chills/sweats(21) �� Headaches(22) �� Hearing problems (23) �� Vision problems(24) �� Other:________________

b Within the past year, have you had any of the following symptoms? (Check all that apply)

a �� Angiogramb �� Arthroscopyc �� Biopsyd �� Blood testse �� Bone scan f �� Bronchoscopyg �� CT scanh �� Doppler ultrasoundi �� Echocardiogramj �� EEG (electroencephalogram)

k �� EKG (electrocardiogram)

l �� EMG (electromyogram)

m �� Mammogramn �� MRIo �� Myelogramp �� NCV (nerve conduction velocity)

q �� Pap smearr �� Pulmonary function tests �� Spinal tapt �� Stool testsu �� Stress test (eg, treadmill, bicycle)

v �� Urine testsx �� X-raysy �� Other:________________

26 OTHER CLINICAL TESTS—Within the past year, have you had any ofthe following tests? (Check all that apply)

22 MEDICAL/SURGICAL HISTORYa Please check if you have ever had:

c Have you taken any medications previously for the condition for which you are seeing the physical therapist?(1) �� Yes (2) �� No If yes, please list:______________________

____________________________________________________

c Have you ever had surgery? (1) ��Yes (2) �� NoIf yes, please describe, and include dates:

Month Year

_________________________ �� _________________________ �� _________________________ ��

For men only: d Have you been diagnosed with prostate disease? (1) �� Yes (2) �� No

DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENTOutpatient Form, Page 2


23 CURRENT CONDITION(S)/CHIEF COMPLAINT(S)a Describe the problem(s) for which you seek physical therapy:

____________________________________________________________________________________________________________

Month Year

b When did the problem(s) begin (date)? �� c What happened? ________________________________________

______________________________________________________d Have you ever had the problem(s) before?

(1) �� Yes(a) What did you do for the problem(s)? ________________

________________________________________(b) Did the problem(s) get better?

1. �� Yes 2. �� No(c) About how long did the problem(s) last?______________

(2) �� No

(1) �� Acupuncturist (2) �� Cardiologist(3) �� Chiropractor(4) �� Dentist(5) �� Family practitioner(6) �� Internist(7) �� Massage therapist(8) �� Neurologist(9) �� Obstetrician/gynecologist

(10) �� Occupational therapist(11) �� Orthopedist(12) �� Osteopath(13) �� Pediatrician(14) �� Podiatrist(15) �� Primary care physician(16) �� RheumatologistOther:______________________

24 FUNCTIONAL STATUS/ACTIVITY LEVEL (Check all that apply):a �� Difficulty with locomotion/movement:

(1) �� bed mobility(2) �� transfers (such as moving from bed to chair, from

bed to commode)(3) �� gait (walking)

(a) �� on level (c) �� on ramps(b) �� on stairs (d) �� on uneven terrain

b �� Difficulty with self-care (such as bathing, dressing, eating, toileting)

c �� Difficulty with home management (such as household chores, shopping, driving/transportation, care of dependents)

d �� Difficulty with community and work activities/integration(1) �� work/school(2) �� recreation or play activity

23 Current Condition(s)/Chief Complaint(s) (continued)e How are you taking care of the problem(s) now? ________________

______________________________________________________f What makes the problem(s) better? __________________________

______________________________________________________g What makes the problem(s) worse? __________________________

____________________________________________________________________________________________________________

h What are your goals for physical therapy? ____________________________________________________________________________

i Are you seeing anyone else for the problem(s)? (Check all that apply)


Patient’s Full Name __________________________________________________

Patient prefers to be called __________________________________________________

Phone Number __________________________________________________

Primary Care Physician __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

• Other Health Care Providers (seen regularly)

Name __________________________________________________

Discipline __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

Name __________________________________________________

Discipline __________________________________________________

Address __________________________________________________

Phone Number __________________________________________________

Notes Regarding Previous Treatments:_______________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________


TO EXAMINATIONpatient history

COMMUNICATION, AFFECT, COGNITION, LEARNING STYLECommunication (eg, age-appropriate) ��

Orientation x 3 (person/place/time) ��

Emotional/behavioral responses ��

How does patient/client best learn? �� Pictures �� Reading �� Listening �� Demonstration �� Other: ______________________________

Learning barriers:�� None�� Vision�� Hearing�� Unable to read�� Unable to understand what is read�� Language/needs interpreter�� Other: ____________________________________________

Education needs:��Disease process�� Safety��Use of devices/equipment��Activities of daily living��Exercise program��Other: _____________________________________________

NotImpaired Impaired

CARDIOVASCULAR/PULMONARY SYSTEM �� Heart rate: ____________________________

Respiratory rate:________________________

Blood pressure: ________________________

Edema: ________________________________

INTEGUMENTARY SYSTEM �� Integrity

Pliability (texture): _____________________Presence of scar formation: ______________Skin color: __________________________Skin integrity: ________________________

NotImpaired Impaired

MUSCULOSKELETAL SYSTEMGross Symmetry ��

Standing: ____________________________Sitting: ______________________________Activity specific: ______________________

Gross Range of Motion ��

Gross Strength ��

Other: ________________________________

NEUROMUSCULAR SYSTEMGross Coordinated Movements

Balance ��

Gait ��

Locomotion ��

Transfers ��

Transitions ��

Motor function (motor control, motor learning) ��

DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT

Systems Review


Height ______________________

Weight ______________________

Syst

ems

Revi

ew


TO EXAMINATIONsystems review

POSTURAL HYPOTENSION (CARDIOPULMONARY)Take BP and HR supine. Wait 3 minutes, retake BP and HR standing

• SUPINEBP _________ HR __________

• STANDINGBP _________ HR __________

INTEGUMENTARY(optional diagram for denoting areas of concern.)

NOTES:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

( / / )________________________________________________________________________________________________________________CLINICIAN SIGNATURE AND DATE

(OPTIONAL SPACE FOR NOTES OR DRAWINGS BY CLINICIAN)



TO EXAMINATION

PATIENT NAME______________________________________ CLINICIAN_______________________________________ DATE __________________________

These seven sheets (14 pages) can be used as part of client initial examination. The completed form may be placed in the patient’schart or used as a worksheet for dictation of the patient report. If the patient is to be enrolled in the Movement Disorders protocol,we suggest that relevant data be transcribed to the shorter "Outcome Measures Tracking Form" found in Appendix A.

Tests and measures categories were chosen based on those considered valuable for patients likely to be enrolled in the MovementDisorders protocol. The language is similar but not exact to that outlined in the Tests and Measures categories of the Guide toPhysical Therapist Practice. The clinician should use the Guide and their clinical knowledge to supplement the items on this form asneeded for each patient. The last page of this section lists the 24 Guide categories.

1. RANGE OF MOTION AND MUSCLE TENSION Note goniometric measurements for each body part and limitations due to resistance to passive stretch(stiffness or hypertonia).

RANGE OF MOTION SPASTICITY MEASURE

Right Left Right Left

Shoulder ____ ____ ____ ____

Elbow ____ ____ ____ ____

Trunk ____ ____ ____ ____

Hip ____ ____ ____ ____

Knee ____ ____ ____ ____

Ankle ____ ____ ____ ____


tests and measures

NOTES AND OBSERVATIONS:


2. SENSORY AND REFLEX INTEGRITY

• Sensation and Dermatome TestingNote pain and altered sensation on the chart below

• Deep Tendon Reflex TestingTest reflexes before muscle testing. Place patient in position of 90 deg set dynamometer to Isometric Mode and strappatient into attachment. Tap tendon 5-6 times and observe curves produced. Record duration of curve below.

Right Left

Ankle ____ ____

Knee ____ ____

Biceps ____ ____

• Primitive Reflex Influence (if observable in posture and movement)

2-16 TESTS AND MEASURES

USE THE SYMBOLS BELOW TO NOTE PAIN AND DECREASED SENSATION

PAIN= XX

ANESTHESIA= 00

PARESTHESIA= ///






• ProprioceptionRecord average degrees from target and average difference between each side for each body part tested. If using thedynamometer, the passive portions should be performed at 2 deg/sec.

Knee Active Positioning Passive Positioning

Right Left Difference Right Left Difference

Position 1 ____ ____ ____ ____ ____ ____

Position 2 ____ ____ ____ ____ ____ ____

Position 3 ____ ____ ____ ____ ____ ____

Ankle Active Positioning Passive Positioning


Position 1 ____ ____ ____ ____ ____ ____

Position 2 ____ ____ ____ ____ ____ ____

Position 3 ____ ____ ____ ____ ____ ____

Shoulder Active Positioning Passive Positioning


Position 1 ____ ____ ____ ____ ____ ____

Position 2 ____ ____ ____ ____ ____ ____

Position 3 ____ ____ ____ ____ ____ ____





3. MUSCLE PERFORMANCE AND MOVEMENTPerform 10 repetitions at each speed and record results below. Make sure the ROM is equal between sides

• Peak Torque

Knee Extension/Flexion Ankle Plantar/Dorsiflexion60 deg/sec 120 deg/sec 60 deg/sec 120 deg/sec

EXT FLX EXT FLX TOTAL PD DF PD DF TOTAL

R + + + = + + + =

L + + + = + + + =

Total ankle Tqs/Total Knee Tqs_______/_______x100% =

• Average Power

Knee Extension/Flexion Ankle Plantar/Dorsiflexion60 deg/sec 120 deg/sec 60 deg/sec 120 deg/sec

EXT FLX EXT FLX TOTAL PD DF PD DF TOTAL

R + + + = + + + =

L + + + = + + + =

Total ankle Tqs/Total Knee Tqs_______/_______x100% =




Fallers

Your Score

Non-FallersStrength Index 5 10 15 20 25 30

Fallers

Your Score

Non-FallersStrength Index 5 10 15 20 25 30


• Curve AnalysisPlace a check mark on the line corresponding to the quality of the Isokinetic curve for each body part at the specified speed.

Ankle Knee Hip

R L R L R L

30 deg/sec ___ ___ ___ ___ ___ ___

60 deg/sec ___ ___ ___ ___ ___ ___

120 deg/sec ___ ___ ___ ___ ___ ___

180 deg/sec ___ ___ ___ ___ ___ ___

Ankle Knee Hip

R L R L R L

30 deg/sec ___ ___ ___ ___ ___ ___

60 deg/sec ___ ___ ___ ___ ___ ___

120 deg/sec ___ ___ ___ ___ ___ ___

180 deg/sec ___ ___ ___ ___ ___ ___

• Note specific findings regarding curve quality and information for each joint below:

Ankle:

R Total Work_________ Peak Torque________

L Total Work_________ Peak Torque________

Knee:



Hip:





4. GAIT, LOCOMOTION & BALANCE

• Gait CharacteristicsEnter age, Right and Left leg lengths, Histogram display, Time 6 minutes, start cycle/second at the low end of the nor-mal range, increase until comfortable walking speed is achieved for the patient, monitor Heart Rate and %SpO2.

Total Time Minutes

Total Distance Meters

Average Walking Speed Meters/Sec

Right Left Stride Length

• Average Step Length ____ + ____ = ___________

• Coefficient of Variance ____ % ____ %

Not sufficient for independence Sufficient for independence

Distance

Patient’s ResultsMeters 50 100 150 200 250 300 350 400 450 500 550 600

Fallers Non-Fallers

Velocity

Patient’s ResultsMeters 0.01 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

Fallers Non-Fallers

Stride Length

Patient’s ResultsMeters 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10

• Step Length Variability Goal <13%

Right _____ Left _____




• Balance Five 20-second trials, level 8, 30-second rest period between sets. Report presents average of the five trials

Overall Balance Index

Standard Deviation

• Compare the patient’s score to the ranges below.

17-35 yrs.

36-53 yrs.

54-71 yrs.

72-89 yrs.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

Risk Factor




5. SELF CARE & HOME MANAGEMENT, WORK, COMMUNITY & LEISURE INTEGRATION OR REINTEGRATION

• Questions for Functional Assessment(PLEASE CIRCLE ONE PHRASE FROM EACH CATEGORY THAT BEST DESCRIBES YOUR SITUATION)

Daily Living Skills

Feeding

(7) Are you able to feed yourself from a tray or table using ordinary utensils? Can you cut meat?Can you pour liquids from open containers?

(4) If you use a spork or rocker knife or other helpful aid, are you able to feed yourself in a reasonablelength of time?

(2) Are you able to feed yourself with some help from another person, for example, to help you raise a cup toyour mouth or to cut meat?

(0) Do you depend on another person to feed you?

Dress Upper Body

(7) Are you able to get clothes out of your closets and drawers and put them on and remove them from yourupper body by yourself, including bra, slip, pullovers, and front opening shirts and blouses, as well as manag-ing zippers, buttons, and snaps?

(4) If someone lays your clothes out for you or hands them to you, are you able to dress your upper body byyourself even if it takes a little more time, or do you need some help with closures, such as buttons, zippers,snaps, or hooks? Do you use aids such as reachers, dressing hooks, button hooks, or zipper pulls?

(2) Does someone help you put on your blouse or shirt or sweater because you are limited by pain, lack ofstrength, or limited range of motion?

(0) Do you depend on another person to dress your upper body?

Dress Lower Body

(7) Are you able to put on undergarments, slacks, socks, nylons, and shoes by yourself? Can you tie shoelaces?

(4) Are you able to put on undergarments, slacks, socks, nylons, and shoes by yourself if they are laid out for youor handed to you? Do you use dressing aids such as long handled reachers? Do you avoid shoes that havelaces or buckles, or do you use elastic laces or Velcro shoe closures by yourself?

(2) Does someone help you to put on undergarments, slacks, nylons, or shoes?

(0) Do you depend on another person to dress your lower body?

Grooming

(7) Are you able to comb and brush and shampoo your hair, shave, apply makeup, clean your teeth or dentures,and manage nail care by yourself without adaptations or modifications?

(4) Do you use assistive devices or adapted methods for grooming? If someone places what you need withinreach, are you then able to complete grooming activities unaided? Do you use long handled combs or brush-es, suction brushes for cleaning nails or dentures, adapted shaving equipment or adapted key for rollingtoothpaste tubes?

(2) Does someone actually help you shampoo or brush your hair, shave, apply makeup, clean your teeth or den-tures, or manicure your nails?

(0) Do you depend on someone else entirely for your grooming needs?



Care of Perineum/Clothing at Toilet

(7) Are you able to go to the bathroom by yourself including managing your clothes, wiping yourself (and plac-ing sanitary napkins or tampons)?

(4) Are you able to manage your clothing at the toilet and wipe yourself independently although it may be diffi-cult, or do you use aids such as an extended reacher for wiping yourself or clothing aids?

(2) Does someone help you with your clothing at the toilet or assist you with wiping yourself (or in placement ofsanitary napkins or tampons)? Do you depend on someone else to manage your clothes at the toilet for youor to wipe you (or to place sanitary napkins or tampons)?

(0) Do you depend on someone else to manage your clothes at the toilet for you or to wipe you (or place sani-tary napkins or tampons)?

Wash or Bathe

(7) Are you able to wash and dry your entire body by yourself, including your back and feet? Are you able to turnwater faucets?

(4) Do you use bathing aids such as long handled bath brushes or sponges? Are you unable to reach some partsof your body for bathing or drying thoroughly but can still manage without help?

(2) Are you able, to bathe and dry most parts of your body and have someone help you with the rest?

(0) Does someone else bathe you?

Vocational

(2) Are you employed full-time in your usual occupation? Are you a full-time homemaker and require no assis-tance? Are you retired for other than medical reasons?

(0) Not able to do the above.

Mobility

Supine to Sit

(7) When you are lying on your back, can you sit up without using your arms or without rolling to the side? Canyou do this smoothly and easily?

(4) Do you use your arms to help you sit tip, or do you roll to the side before sitting up? Do you have to try sever-al times before sitting up?

(2) Does someone help you to sit up?

(0) Are you unable to sit up?

Sitting to Standing

(7) Are you able to stand up from a regular chair without using your arms?

(4) Do you need to use, your arms to help you stand up, or do you need to try several times?

(2) Does someone need to help you stand up out of a chair?

(0) Do you depend on someone else entirely to get you out of a chair?

Transfer-Toilet

(7) Are you able to get on and off the toilet easily and without using your hands?

(4) Do you need to use your arms to help you get on and off the toilet, or do you require assistive devices suchas elevated toilet seats or grab bars?

(2) Does someone need to help you get on and off the toilet?

(0) Are you unable to use the toilet?



Transfer-Tub or Shower

(7) Are you able to get in and out of a tub or shower safely?

(4) Can you get in and out of a tub or shower using aids such as grab bars or special seat or lift?

(2) Does someone need to help you to get in and out of the tub or shower?

(0) Are you unable to get in and out of the tub or shower?

Transfer-Automobile

(7) Can you get in and out of a car easily, including opening and closing the door?

(4) Can you get in and out of a car by yourself if you use aids such as grab bars or if someone opens the door foryou?

(2) Does someone help you get in and out of a car?

(0) Are you unable to get in and out of a car even with assistance?

Walk on Level

(7) Are you able to walk two blocks at an even pace without using a cane, crutches, walker, or adapted shoes?

(4) Do you need a cane, crutches, or walker to walk two blocks?

(2) Can you walk one block with assistance?

(0) Are you unable to walk one block even with assistance?

Walk Outdoors

(7) Are you able to walk outdoors at least two blocks without avoiding rough terrain such as grass, sand, gravel,curbs, ramps, or hills?

(4) Do you try to avoid uneven terrain? Do you use a crutch or cane for safety or balance purposes only whenoutside?

(2) Must you use a cane or crutches to walk at least two blocks on uneven terrain?

(0) Are you unable to walk on uneven terrain?

Up and Down Stairs

(7) Can you go up and down at least five steps safely, step over step without using the hand rail or other sup-port?

(4) Are you able to go up and down at least five steps if you use a hand rail, cane, or crutches or if you go onestep at a time?

(2) Do you need someone to help you go up and down at least five steps?

(0) Are you unable to go tip and down at least five steps even with help?

Wheelchair/ 10 Yards

(7) Are you able to push your wheelchair without help for 10 yards? Can you turn corners and get close to bed,table, and toilet?

(4) Do you use a motorized wheelchair?

(2) Do you need someone to help you maneuver your wheelchair around corners or to help you position it?

(0) Are you unable to push your wheelchair 10 yards?

Source:Orthopedic Physical Assessment, Second Edition, Magee, pp.16, 17, Modified from Convery, F. R., et. al Polyarticulardisability: A functional assessment. Arch, Phys. Med. Rehab. 58:498, 1977.



• Total Score Daily Living Skills ________Place a mark on the scale to indicate the patient’s score

49 28 14 0

Independent Independent Need Some Completelywith assistance dependent

assistive devices from others

• Total Score Daily Living Skills ________Place a mark on the scale to indicate the patient’s score

63 36 18 0

Independent Independent Need Some Completelywith assistance dependent

assistive devices from others



6. QUALITY OF LIFE

• The Nottingham Health Profile (North American Version)

Completed as a self assessment by the client. Look down the list carefully and check the box under YES for any problems you have at the present. Check thebox under NO for any problems you do not have.

Please answer every questions. If you are not sure whether to answer yes or no to a problem check whicheveranswer you think is more true at the present time.

YES NO

I’m tired all the time

I have pain at night

Things are getting me down

YES NO

I have unbearable pain

I take pills to help me sleep

I’ve forgotten what its like to enjoy myself

YES NO

I’m feeling on edge

I find it painful to change positions

I feel lonely

YES NO

I can only walk about indoors

I find it hard to bend

Everything is an effort

YES NO

I’m waking up in the early hour of the morning

I’m unable to walk at all

I’m finding it hard to make contact with people

Remember, if you are not sure whether to answer yes or no to a problem, check whichever answer you think more true at the moment.

YES NO

The days seem to drag

I have trouble getting up and down stairs or steps

I find it hard to reach things



YES NO

I’m in pain when I walk

I lose my temper easily these days

I feel there is nobody I am close to

YES NO

I lie awake for most of the night

I feel as if I’m losing control

I’m in pain when I’m standing

YES NO

I find it hard to get dressed by myself

I soon run out of energy

I find it hard to stand for a long time(e.g. at the kitchen sink, waiting in line)

YES NO

I’m in constant pain

It takes me a long time to get to sleep

I feel I am a burden to people

YES NO

Worry is keeping me awake at night

I feel that life is not worth living

I sleep badly at night

YES NO

I’m finding it hard to get along with people

I need help to walk about outside(e.g. a walking aid or someone to support me)

YES NO

I’m in pain when going up and down stair or steps

I wake up feeling depressed

I’m in pain when I’m sitting



• Clinician Score Summary for the Nottingham Health Profile Each YES answer is 1 pointEach NO answer is 0 points

Add up all of the YES answers and input score below and place a line on the scale. The more YES answers the greater the distressthe patient is feeling.

• Total Score ________

38 0

Greater Distress Less Distress


KEY TO TESTS AND MEASURES:

NOTES:________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

1 Aerobic Capacity/Endurance2 Anthropometric Characteristics3 Arousal, Attention, and Cognition4 Assistive and Adaptive Devices5 Circulation (Arterial, Venous, Lymphatic)6 Cranial and Peripheral Nerve Integrity7 Environmental, Home, and Work (Job/School/Play) Barriers8 Ergonomics and Body Mechanics9 Gait, Locomotion, and Balance

10 Integumentary Integrity11 Joint Integrity and Mobility12 Motor Function (Motor Control and Motor Learning)13 Muscle Performance (Including Strength, Power, and Endurance)

14 Neuromotor Development and Sensory Integration15 Orthotic, Protective, and Supportive Devices16 Pain17 Posture18 Prosthetic Requirements19 Range of Motion (Including Muscle Length)20 Reflex Integrity21 Self-Care and Home Management (Including Activities of Daily

Living and Instrumental Activities of Daily Living)22 Sensory Integrity 23 Ventilation and Respiration/Gas Exchange 24 Work (Job/School/Play), Community, and Leisure Integration or

Reintegration (Including Instrumental Activities of Daily Living)


Tests and Measures


Test

s an

d M

easu

res

Evidence-Based

Clinical Protocols3) Evaluation

This step in the patient management process has been defined as a dynamicprocess in which the physical therapist makes clinical judgments based on datagathered during the examination. This process also may identify possible prob-lems that require consultation with or referral to another provider. (The Guideto Physical Therapist Practice, APTA, Alexandria, VA 2001).




purpose

The purpose of the Evaluation, Diagnosis, and Prognosis sections is to serve as a bridge between Examination and Intervention.Individuals whose examination reveals strength impairments should be considered candidates for the Multi-Joint Dynamometer.Those with balance limitations should be considered candidates for the Balance System. Those with gait limitations should be con-sidered candidates for the Gait Trainer. When all three findings are identified, then all three interventions could be appropriate;however protocol guidelines should never replace sound clinical judgment (Fig. 1).

Fig. 1: Selection of interventions based on examination findings.


Biodex Multi-Joint System

Biodex Balance System

Biodex Gait Trainer

Integrated instrumented interventionusing all 3 devices.

STRENGTHIMPAIRMENTS

BALANCELIMITATIONS

GAITLIMITATIONS

LIMITATION INALL 3 AREAS

This step in patient management is parallel to "assessment" described in the former SOAP note format of patient documentation.Similar to assessment, evaluation draws on the information (subjective and objective) gathered to that point and reports the inter-pretation of that information, stating how the data are of significance to the patient. Projecting how that information is pertinentto the rehabilitation potential can be addressed in general terms under Evaluation, such as stating to what extent the patient is acandidate for intervention. Specific details of expected outcomes of intervention including time frames should be described underPrognosis. However, the choice of where to address these items in a given patient’s report may be influenced by context andshould therefore be left to the clinician’s discretion.

PATIENT MANAGEMENT PROCESS, DOCUMENTATION AND GROUNDING IN THE DISABLEMENT MODEL

Disablement Model

Disorder or diseaseBody function or structure

ActivityParticipation

Contextual, Environmental, Personal factors

The process of evaluation begins early in the examination process. Using the Figure above, consider a patient with a neurologiccondition or in a deconditioned state. The physical therapist’s knowledge about the medical condition/diagnosis and the patient’sage are enough to form preliminary presumptions, even before initiating contact with the patient. As the components of examina-





evaluation

EXAMINATION

EVALUATION

DIAGNOSIS

PROGNOSIS

INTERVENTION

SUBJECTIVE ANDOBJECTIVE

ASSESSMENT PLAN

tion (history, systems review, and tests and measures) are completed, the presumptions are ruled in or out. New informationemerges. Gradually the clinician’s impressions and judgments are shaped as knowledge of the condition is coupled with knowl-edge of the individual and the environment in which the individual functions. The reflective clinician considers contextual factorsand how the findings affect the patient as defined within the disablement model. The resulting impressions and reflections clarifythe subsequent patient management steps that lead to intervention.

The breadth and depth of clinician reflection in the evaluation process becomes apparent in the wording of patient documentation.Findings intrinsic to the patient are merged with factors in the patient’s environment to interpret fully the significance for the patient.

If a patient does not perceive limitations in activities, participation, etc, objective findings to the contrary may lead to a differentintervention or no intervention. The intervention selected may need to be instructional in nature versus procedural.

As American society sees more cultures resident in communities, and as health professionals move to different areas of the countryor world, knowledge and sensitivity of cultural issue becomes increasingly important. Sensitivity requires judging the impact of apatient’s condition from contexts of ethnicity, environment, community, culture, faith, financial standing, and education so that real-istic goals are established.

The documentation of evaluation may address:

• Severity and number of morbidities (findings)

• Interrelationship (presence and significance) of co-morbidities

• Whether findings are chronic or acute

• Stability of the condition(s)

• At what level of the disablement model the findings have importance

• Patients level of understanding and cooperation

• Concerns or goals of the patient or the patient’s family

• Environmental considerations, e.g. social and socio-economic supports, culture, religion, and education

3-4 EVALUATION

Evidence-Based

Clinical Protocols4) Diagnosis

This step in the patient management process has been defined as "Both theprocess and the end result of evaluating examination data, which the physicaltherapist organizes into defined clusters, syndromes, or categories to helpdetermine the prognosis (including the plan of care) and the most appropriateintervention strategies." (The Guide to Physical Therapist Practice, APTA,Alexandria, VA 2001).

Physical therapists engage in the diagnostic process via the use of "practice patterns" as described in the Guide to PhysicalTherapist Practice.1 Using common terminology supports communication and collaboration in tracking outcomes and improvingquality care. For many years leaders in the profession have advocated physical therapist diagnosis and teaching diagnostic skills ineducational programs.2-9

While medical diagnosis is based typically on disease and pathology, physical therapist diagnosis should consider the other, morefunctional, levels of the disablement models rather than the disease level. The practice patterns described in the Guide to PhysicalTherapist Practice begin to achieve this aim. They also address more than diagnosis. Each pattern has suggested examples ofappropriate tests and measures, interventions, and duration of service.

Using the practice patterns on the following page, the clinician should select those that apply to their patient. The name of thepractice pattern(s) should be entered on the second page of the Outcomes Tracking Form, under Diagnosis. The practice patternsare clustered into four categories according to the body systems commonly affected in physical therapy clientele: Musculoskeletal,Neuromuscular, Cardiopulmonary, and Integumentary. Patients may have conditions that are defined by one or more practice pat-terns, within or across the four categories. Most patients for whom this protocol is appropriate are likely to have diagnoses that fallwithin the Neuromuscular, Musculoskeletal, or Cardiopulmonary practice patterns.

The terms used in the practice patterns (diagnostic labels) were first published in the 1997 edition of the Guide to Physical TherapistPractice. In that first edition, 34 categories of practice patterns were described. Clinician feedback led to modifications in the second edi-tion (2001) resulting in the current 32 categories. Practice patterns will continue to evolve and clinician input will be vital to that process.

REFERENCES

1. Guide to Physical Therapist Practice. Alexandria, VA: American Physical Therapy Association; 2001.

2. Sahrman SA. Diagnosis by the physical therapist - a prerequisite for treatment: a special communication. Phys Ther1988;68:1703-1706.

3. Rose SJ. Editor's note: diagnosis and direct access. Phys Ther 1989;69:1-2.

4. Rose SJ. Physical therapy diagnosis: role and function. Phys Ther 1989;69:535-537.

5. Echternach JL and Rothstein JM. Hypothesis-oriented algorithms. Phys Ther 69:559-564, 1989.

6. May BJ and Dennis JK. Expert decision making in physical therapy - a survey of practitioners. Phys Ther 1991;71:190-206.

7. Guccione AM. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther 1991;71:499-503. (Commentary and response follow, p503-504)

8. Correnti E. Reading the Signs. Clin Man 1992;12:274-277. (example)

9. Dekker J, van Baar ME, Chr Curfs E, Kerssens JJ. Diagnosis and treatment in physical therapy: an investigation of their rela-tionship. Phys Ther 1993;73:568-577. (commentaries and response follow p 577-580)





diagnosis

PRACTICE PATTERNS (DIAGNOSES) AS DEFINED BY THE GUIDE TO PHYSICAL THERAPIST PRACTICE

• Musculoskeletal PatternsA: Primary Prevention/Risk Reduction for Skeletal Demineralization B: Impaired PostureC: Impaired Muscle PerformanceD: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with

Connective Tissue DysfunctionE: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with

Localized InflammationF: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with Spinal DisordersG: Impaired Joint Mobility, Muscle Performance and Range of Motion Associated with FractureH: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with Spinal DisordersI: Impaired Joint Mobility, Motor Function, Muscle Performance and Range of Motion Associated with Bony or Soft

Tissue SurgeryJ: Impaired Joint Motor Function, Muscle Performance and Range of Motion Gait, Locomotion, and Balance Associated

with Amputation

• Neuromuscular PatternsA: Primary Prevention/Risk Reduction of Balance and FallingB: Impaired Neuromotor DevelopmentC: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous

System-Congenital Origin or Acquired in Infancy or ChildhoodD: Impaired Motor Function, and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous

System-Acquired in Adolescence or AdulthoodE: Impaired Motor Function, and Sensory Integrity Associated with Progressive Disorders if the Central Nervous SystemF: Impaired Peripheral Nerve Integrity and Muscle Performance associated with Peripheral Nerve Injury G: Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies H: Impaired Motor Function, Peripheral Integrity and Sensory Integrity Associated with Nonprogressive Disorders of the

Spinal CordI: Impaired Arousal, Range of Motion, and Motor Control Associated with Coma, Near Coma, or Vegetative State

• Cardiovascular/Pulmonary PatternsA: Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary DisordersB: Impaired Aerobic Capacity/Endurance Associated With DeconditioningC: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity / Endurance Associated with

Airway Clearance DysfunctionD: Impaired Aerobic Capacity/Endurance Associated with Cardiovascular Pump Dysfunction or failure E: Impaired Ventilation and Respiration/Gas Exchange Associated with Ventilatory Pump Dysfunction of FailureF: Impaired Ventilation, Respiration/Gas Exchange, Associated with Respiratory Failure G: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated with Respiratory Failure

in NeonateH: Impaired Circulation and Anthropometric Dimension Associated with Lymphatic System Disorders.

• Integumentary PatternsA: Primary Prevention/Risk Reduction for Integumentary DisordersB: Impaired Integumentary Integrity Associated with Superficial Skin InvolvementC: Impaired Integumentary Integrity Associated with Partial Thickness Skin Involvement and Scar FormationD: Impaired Integumentary Integrity Associated with Full Thickness Skin Involvement and Scar FormationE: Impaired Integumentary Integrity Associated with Skin Involvement Extending Into Fascia, Muscle, or

Bone and Scar Formation

4-2 DIAGNOSIS

Evidence-Based

Clinical Protocols5) Prognosis

(Including the Plan of Care)

This step in the patient management process has been defined as "Determinationof the level of optimal improvement that may be attained through interventionand the amount of time required to reach that level. The plan of care specifies theinterventions to be used and their timing and frequency." (The Guide to PhysicalTherapist Practice, APTA, Alexandria, VA 2001).

Patient prognosis involves prediction or projection for the future. Accurate prediction requires a mixture of knowledge, experience, criti-cal reflection, and judgment. Patient specific findings from the examination must be considered and interpreted. The interpretation ofexamination data (evaluation) is highly important and must include consideration of comorbidities and cultural factors. Examinationand evaluation lead to a diagnosis or assignment of a practice pattern. Knowledge of that diagnosis or condition also contributes toaccurate prediction. Further, prognosis draws on knowledge of types of interventions, and, access to those interventions.

In the prognosis section of a patient report, goals and expected outcomes are documented. For example, if the prediction is madethat a patient will walk faster as a result of intervention, a goal of achieving a certain percent increase in walking velocity can beestablished. Accurate prediction increases the chance of success with goal attainment. Goal based intervention is important in clini-cal practice because evidence suggests that progress is more likely when goals are established and targeted. Goals and expecta-tions for outcome should be established in conjunction with the patient/client to enhance goal validity. Evidence has shown thatpatients who participate in goal setting are more likely to achieve desired outcomes.





prognosis

PROGNOSIS

CRITICAL REFLECTION

CRITIC

ALREFLECTIO

N

CRITICALREFLECTION

Patient specificexamination data

Accurateinterpretation ofthe examination

Evaluation ofcomorbidities

Knowledge ofcultureand environment

Correctdiagnosis

Knowledge ofinterventions

Knowledge ofdiagnosisor condition

Experience

Accessto interventions

CRITICALREFLECTION

The prognosis section of a report may address:

• Expected natural history (natural course in the absence of intervention) given examination findings and diagnosis.Potential for change without physical therapy.

• Expected outcome given intervention. Potential for physical therapy to have a positive impact on patient status.

• The patient’s goals and desired outcomes set by the patient and the physical therapist. Goals may be written in terms ofshort and long term.

• Recommended best course of intervention to achieve the goals as known from consensus, expert opinion, or clinicalresearch evidence.

• Desired duration of intervention to achieve goals.

• Desired intensity (frequency) of service to achieve goals.

• Anticipated outcome with intervention.

Advanced skill in writing prognostic statements comes with reflective practice. Experienced clinicians who continually seek newknowledge and apply that knowledge to practice are most likely to develop skill in this area. Knowledge must be sought continual-ly, appreciating that a changing knowledge base may alter interpretations and plans of care.

In this protocol we have designed forms that allow an intense program, up to five times weekly. The intensity should be deter-mined by professional judgment when evidence from existing clinical research, or consensus, does not provide more specific direc-tion. Determinations are influenced by examination findings, access to services, and the patient’s tolerance.

5-2 PROGNOSIS

Anticipated Goals: ________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Expected Outcomes: ______________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Interventions: ______________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Education (including safety, exercise, and disease information): ______________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Who was educated? �� Patient/client �� Family (name and relationship): ______________________________________________________________How did patient/family demonstrate learning:

�� Patient/client verbalizes understanding�� Family/significant other verbalizes understanding�� Patient/client demonstrates correctly�� Demonstration is unsuccessful (describe): __________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Discharge Plan: __________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Frequency of Visits/Durationof Episode of Care:________________________

________________________

________________________


Plan

of C

are


Plan of Care

5-4 PROGNOSIS

Evidence-Based

Clinical Protocols6) Intervention

This step in the patient management process has been defined as "the pur-poseful and skilled interaction of the physical therapist with the patient/clientand, if appropriate, with other individuals involved in care of the patient/client,using various physical therapy methods and techniques to produce changes inthe condition that are consistent with the diagnosis and prognosis. The physi-cal therapist conducts a reexamination to determine changes in patient/clientstatus and to modify or redirect intervention. The decision to reexamine maybe based on new clinical findings or on lack of patient/client progress. Theprocess of reexamination also may identify the need for consultation with orreferral to another provider." (The Guide to Physical Therapist Practice, APTA,Alexandria, VA 2001).

Physical therapy intervention entails all activities that support a patient in achieving their goals. The experienced professional appre-ciates that this entails activities beyond direct, hands-on care.

THE WORD SHIFT

The word "treatment" while common in clinical practice may not encompass all that is desired. A shift in words to "intervention" isemerging. Treatment, through common usage, brings to mind those "things" that a practitioner does "to" a patient, implying"hands-on" activities. As such, the word "treatment" connotes hands-on activity despite an argument that physical therapists alsoengage in other interventions. By adopting the term "Intervention", the broader professional activities that include patient/clienteducation, advocacy, participation in a patient staffing, referral, consultation, and patient documentation are captured.

THE CATEGORIES OF INTERVENTION

The myriad of interventions that we employ in patient service have been categorized in the Guide to Physical Therapist Practice(APTA, Alexandria, VA 2001) as follows:

• Coordination, Communication, and Documentation

• Patient/Client-related Instruction

• Procedural Interventions

We support the categorization and language used in the Guide to Physical Therapist Practice. Some degree of hierarchy is suggested bythe categorization, with procedural interventions noted last. We encourage clinicians to attend to all three categories of intervention.

THIS PROTOCOL

This protocol is primarily designed as a procedural intervention. Nonetheless, patient education and family education are encour-aged. The last section of this manual provides sample letters that can be used to assure appropriate communication with a patient’sprimary physician. Correspondence with other disciplines assures the coordination of services needed to optimally meet the needsof patients engaged in rehabilitation.

Each instrument used in the protocol can offer benefit to the patient. The choice to use all or part of the instrumentation dependson the clinician’s judgment as to what will best meet a given patient’s needs. The purpose of the Evaluation, Diagnosis, andPrognosis sections is to serve as a bridge between Examination and Intervention. Individuals whose examination reveals strengthimpairments should be considered candidates for the Multi-Joint Dynamometer. Those with balance limitations should be consid-ered candidates for the Balance System. Those with gait limitations should be considered candidates for the Gait Trainer. When allthree findings are identified, then all three interventions could be appropriate; however protocol guidelines should never replacesound clinical judgment (Fig. 1). The descriptions of benefits from each device are noted on the Guidelines for Progression foreach device, also found in this section.





intervention

Fig. 1: Strength, balance and gait concerns may indicate need for all 3 intervention instruments.

The clinician has been provided with the forms labeled, "Intervention Grid and Daily Notes" for use in documenting patient inter-vention. Instructions for using this form are found on the next page entitled "Using the Intervention Grid and Daily Notes".

6-2 INTERVENTION

Biodex Multi-Joint System

Biodex Balance System

Biodex Gait Trainer

Integrated instrumented interventionusing all 3 devices.

STRENGTHIMPAIRMENTS

BALANCELIMITATIONS

GAITLIMITATIONS

LIMITATION INALL 3 AREAS

USING THE INTERVENTION GRID AND DAILY NOTES

The Intervention Grid and Daily Notes is comprised of two pages. The first page is intended for use with each 4-week block of inter-vention. The second page should be used for daily notes for one week. The second page should be duplicated for subsequent weeks.

• Intervention Grid (Page 1)

The Intervention Grid (page 1) records the specific dates that interventions and assessment/reassessments are performed. It mayalso be used to record units (CPT, or other) for billing purposes. Shaded sections represent areas addressed in the protocol.

Along the top of the Intervention Grid there are six columns, one titled "Billing Codes", one titled "Interventions", and four entitled "Week".

Document the appropriate week number of the protocol, (e.g., Week 1, Week 2, etc.). Under each week, there are five boxes,allowing documentation for up to a 5-day week treatment plan. Insert the appropriate date here. If treatment is 5 days per week,each box will be filled with a date. A treatment frequency of 2-3 times per week can be documented by crossing through, or leav-ing blank those spaces not needed.

The "Interventions" column contains headings to record the specific intervention(s) you have developed in your plan of care.Interventions included in the protocol are pre-printed for you and are found in the shaded sections for quick reference.

Under the "Billing Codes" heading, and to the left of each intervention, insert the appropriate billing code specific to that par-ticular intervention.

Depending upon facility preference, there are several ways to document completion of each intervention, (or assessment/reassess-ment, as appropriate).

When each intervention is completed you may:Place a check mark to the right of the intervention listing, under the appropriate date.Place your initials to the right of the intervention listing, under the appropriate date.Record the actual minutes involved in performing the intervention under the appropriate date.Record the "units" (15 minutes per unit) involved in performing the intervention under the appropriate date.

At the bottom of the Intervention Grid is space to record completion of an assessment/reassessment.

• Daily Notes (Page 2)

The Daily Notes (page 2) allows space to record narrative comments. Narrative comments can be made daily, weekly, or as need-ed, depending upon facility and clinician preference.

The Daily Notes page is divided into spaces for five days of notes, corresponding to the 5-day per week date spaces of theIntervention Grid. Use the Daily Notes to record narrative data at a frequency that corresponds to your facility guidelines. If narra-tive notes are written on a daily basis, there will be four Daily Notes pages for each Intervention Grid completed. If the treatmentfrequency 2-3 times per week, fewer Daily Notes pages will be required.


6-8 INTERVENTION

AUTHORS

Loretta M. Knutson, PhD, PT, PCS Dept. of Physical Therapy, Southwest Missouri State University

Jeanne Cook MSPT, CWS. Dept. of Physical Therapy, Southwest Missouri State University

Evidence-Based

Clinical Protocols7) Progress and

Outcome Monitoring

Outcomes assessment is an important step in delivery of quality health careservices. The five steps of patient management as described in the Guide toPhysical Therapist Practice (APTAs, Alexandria, VA 2001) should lead topatient/client results that are positive and reflect improvement across thedomains of the disablement model.

There are many ways to determine and document if a patient is making progress or achieving expected outcomes.1, 2 All ways mustaddress the expectations defined by the patient goals set during the patient management process. Determining if goals have beenmet is important for the clinician and the patient because program continuation, change or discontinuation will be determined bythe success, or lack thereof, in attaining goals. Progress and outcome assessment, along with documentation, are also importantfor service reimbursement. The forms included in this protocol were designed to aide the process of progress and outcomes moni-toring, and documentation.

A hallmark of good outcomes-assessment is that the impact of the patient management process (which includes intervention) cutsacross the various levels of the disablement model. As a review, these levels may be labeled in various ways. In the table below wehave shaded the model currently used by the World Health Organization. A similar table, Table 1, was found in the Introduction sec-tion of this protocol and is repeated here to help the clinician be cognizant and reflective on how service can impact patient healthand wellness on practical levels. Such reflection helps us as professionals to advocate for our patients and address questions like: Doesthe condition or disease affect only body function and structure, or does it also affect the patient’s activity level? Did our interventionchange the patient’s function and structure or the patient’s activity level? After intervention is the patient better able to participate inimportant areas of their life? Do environmental barriers exist that have not been addressed? This "across level" monitoring yields a moreholistic view of health and wellness than was once true in health care. This contemporary view of rehabilitation places the patient cen-tral in importance and gives contextual framing to patient goals and subsequent progress or outcomes-assessment.

WHO ICIDH Nagi WHO ICIDH-2Disease Pathophysiology Disorder or disease

Impairment Impairment Body function and structure

Disability Functional Limitation Activity

Handicap Disability Participation Contextual, environmentalpersonal factors

The Outcome Measures Tracking form is designed to address outcomes that cut across the various levels of disablement. Weencourage the clinician to use them and to assure that the integrated protocol using instrumentation promotes improvementacross all levels of disablement.

REFERENCES

1. Knutson LM, Schimmel PA, Ruff A. Standard task measurement for mobility: Thirty Second Walk Test. Pediatr Phys Ther 1999;11:183-190.

2. David KS. Monitoring progress for improved outcomes. Phys Occup Ther Pediatr. 1996; 16:47-76.





progress and outcome monitoring

USING THE OUTCOME MEASURES TRACKING FORM

Use this form as an adjunctive record to the Examination: Tests and Measures form, used for initial examination and then as the pri-mary record for subsequent patient documentation. Shaded sections represent areas addressed in the protocol.

When completing an initial patient examination, use the appropriate initial examination sheets to record items related to history, systemsreview, and tests and measures, then transfer any relevant "fingertip" * data to the Outcome Measures Form to track outcome data.

• Box 1 Circle "Assessment" if the data on this form is from the initial examination (i.e., Examination: Tests and Measures.)Circle "Reassessment" if you are using this form as part of a 4-, 8-, 12-week, or other reassessment.

• Box 2Enter the week number, and the date.

• Box 3Record the patient’s resting vital signs.

• Box 4If you have indicated "Assessment", indicate where specific information related to history, systems review, and tests andmeasures may be found (i.e., Examination: Tests & Measures Form, dictated report, or other.)If this is a "Reassessment", use this box to document any changes or new information.

• Box 5Complete balance tests and record appropriate data.

• Box 6Indicate in the space provided any assistive devices used.Complete the 6 minute walk test on the Gait Trainer treadmill with or without up to 40% unweighing (refer to "GaitTrainer – Guidelines for Progression Algorithm") and record results. Record the following both with and without Unweighing.

Step Length SymmetryRight to Left Time DistributionPatient’s Cycle Time versus Normative Data

• Box 7Indicate which tests you are using by checking the box on the left side of the test list.Record Bilateral (or Left/Right) in the space beside the speed settings for each test, and record data related to the following:

PTP (Peak Torque Production)TPSROM (Torque Production through the Set Range of Motion)TCQ (Torque Curve Quality)QP2 (Quality of Power Production)

Indicate "See Attached Sheets" for graphic and raw data scores, or generate a report.

7-2 PROGRESS AND OUTCOME ASSESSMENT

• Box 8Describe any ROM changes.

• Box 9Describe any changes, or new information related to Environmental, Home, and Work barriers.

• Box 10Document the results of the "Self-Care and Home Management" and the "Quality of Life" (Nottingham) questionnaires.

• Box 11Document other tests and measures data, or indicate "See Attached Sheets" or "Not applicable" as appropriate.

• Box 12Document your interpretation of examination data.

• Box 13Document your diagnosis(es) / practice pattern(s) – refer to Diagnosis Section for a list of the practice patterns.

• Box 14Document your prognosis including goals and expected outcomes.

• Box 15Document your planned intervention(s).

• Box 16 Document your discharge plan/summary.


Evidence-Based

Clinical Protocols8) Correspondence

- Letter to Referring Source - Templates

M O V E Clinical Protocols M E N T - Biodex...Evidence-Based Clinical Protocols - Management of...

Documents

Transcript of M O V E Clinical Protocols M E N T - Biodex...Evidence-Based Clinical Protocols - Management of...