Neurologic interventions for physical therapy [Fourth edition.] 9780323661751, 0323661750


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Table of contents :
Contents
SECTION 1: Foundations
1. The Roles of the Physical Therapist and Physical Therapist Assistant in Neurologic Rehabilitation
2. Neuroanatomy
3. Motor Control and Motor Learning
4. Motor Development
SECTION 2: Children
5. Positioning and Handling to Foster Motor Function
6. Cerebral Palsy
7. Myelomeningocele
8. Genetic Disorders
9. Autism Spectrum Disorder
SECTION 3: Adults
10. Proprioceptive Neuromuscular Facilitation
11. Stroke
12. Traumatic Brain Injuries
13. Spinal Cord Injuries
14. Other Neurologic Disorders
Index
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NEUROLOGIC INTERVENTIONS for PHYSICAL THERAPY

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NEUROLOGIC INTERVENTIONS for

PHYSICAL THERAPY

Fourth Edition

SUZANNE “TINK” MARTIN, PT, PhD Professor Emerita Physical Therapy University of Evansville Evansville, Indiana

MARY KESSLER, PT, MHS Dean College of Education and Health Sciences Associate Professor Physical Therapy University of Evansville Evansville, Indiana

Elsevier 1600 John F. Kennedy Blvd. Ste. 1800 Philadelphia, PA 19103-2899 NEUROLOGIC INTERVENTIONS FOR PHYSICAL THERAPY, FOURTH EDITION

ISBN: 978-0-323-66175-1

Copyright © 2021 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2016, 2007, and 2000. ISBN 9780323661751

Content Strategist: Lauren Willis Content Development Specialist: Sara Watkins Publishing Services Manager: Deepthi Unni Project Manager: Srividhya Vidhyashankar Design Direction: Bridget Hoette

Printed in China Last digit is the print number:

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To my husband, Terry, who has always been there with love and support, and to my parents, John and Sue Delker, who were always supportive of my educational endeavors. Finally, to all the children, families, colleagues, and students who taught me what was important in life. Tink Martin To Craig, my husband, who continues to provide me with love, support, and encouragement to pursue this and all of my other professional goals, and to Kyle and Kaitlyn, who still like to see their photographs in print but more importantly were there to listen and encourage me to finish this edition. Thank you all from the bottom of my heart. A final word of thanks to my parents, John and Judy Oerter, and my family who have always encouraged me to work hard and strive for excellence. You have always believed in me and my ability to succeed. Mary Kessler

AC K N OW L E D G M E N T S I again want to acknowledge the dedication and hard work of my colleague, friend, and coauthor, Mary Kessler. Mary’s focus on excellence is evident in the updated adult chapters, as well as in the introductory chapter. Special thanks to Dawn Welborn-Mabrey for her marvelous pediatric insights. A huge thank you to Dr. Beth Ennis for her contribution to the new chapter on autism. Thank you to the physical therapist assistant and doctor of physical therapy students at the University of Evansville. You are the reason this book happened in the first place and the reason it has evolved into its present form. Thank you to past contributors, Dr. Pam Ritzline, Mary Kay Solon, Dr. Donna Cech, and Terry Chambliss. I also want to acknowledge the work of those at Elsevier, Lauren Willis and Sara Watkins, for seeing us through the timely completion of the fourth edition. Tink Martin I must thank my good friend, mentor, colleague, and coauthor, Tink Martin. Without Tink, none of these editions would have been completed. She has continued to take care of many of the details, always keeping us focused on the end result. Tink’s ongoing encouragement and support have been most appreciated. A special thank you to all of the students at the University of Evansville. They are the reason that we originally started this project, and they have continued to encourage and motivate us to update and revise the text. Several individuals contributed significantly to the completion of this edition, including Dr. Tzurei Chen, Dr. Jason Pitt, Dr. Jordana Lockwich, Maghan Bretz, and Lauren Rennie. Additional thanks must be extended to all of the individuals who have assisted us in the past, including Dr. Catherine McGraw, Sara Snelling, Dr. Pam Ritzline, Mary Kay Solon, Janet Szczepanski, Terry Chambliss, Suzy Sims, Beth Jankauski, and Amanda Fisher. Every person mentioned has contributed to the overall excellence and success of this text. Mary Kessler

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P R E FAC E We are pleased that the first three editions of Neurologic Interventions for Physical Therapy led to the request for a fourth edition. A new chapter on autism has been added to meet the needs of the clinicians working with this growing population, and the recognition that physical therapy has much to offer the children and families. We have updated references and maintained the developmental flow of the text. The role of neural plasticity and the understanding that motor development can enhance cognition and language are reinforced in the earlier chapters. Patient cases have been revised to assist students in problem solving and documentation. It has been one of the highlights of my professional career to contribute to the literature in our field. Tink Martin We are gratified by the very positive responses to the first three editions of the Neurologic Interventions for Physical Therapy text. In an effort to make a good reference even better, we have taken the advice of reviewers and our physical therapist and physical therapist assistant students to complete a fourth and final edition for the two of us. The sequence of chapters still reflects a developmental trend with motor development, handling, and positioning, and interventions for children coming before the content on adults. Chapters on specific pediatric disorders and neurologic conditions seen in adults remain, as well as introductory chapters on physical therapy practice and the role of the physical therapist assistant. The review of basic neuroanatomy structure and function and the chapter on proprioceptive neuromuscular facilitation have been revised and

continue to provide foundational knowledge. The intervention components of each chapter have been enhanced to emphasize function and the use of current best evidence in the physical therapy care of these patients. Concepts related to neuroplasticity, the Core Outcome Measures, high intensity gait, and task-specific training are also included. All patient cases have been reworked again to reflect current practice and are formatted in a way to assist students with their documentation skills. We continue to see that the text is used by students in both physical therapist assistant and doctor of physical therapy programs, and this certainly has broad appeal. However, as we indicated in our last preface, we continue to be committed to addressing the role of the physical therapist assistant in the treatment of children and adults with neurologic deficits. Additionally, the use of the textbook by physical therapy students should increase the understanding of and appreciation for the psychomotor and critical thinking skills needed by all members of the rehabilitation team to maximize the function of patients with neurologic deficits. The Evolve site continues to be enhanced as we try to insert additional resources for faculty and students. The mark of sophistication of any society is how well it treats the young and old, the most vulnerable segments of the population. We hope in some small measure that our continuing efforts will make it easier to unravel the mystery of directing movement, guiding growth and development, and relearning lost functional skills to improve the quality of life for the people we serve. Mary Kessler

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LIST OF CONTRIBUTORS Meghan Bretz

Elizabeth Ennis

Suzanne Martin

Director St. Vincent Evansville & University of Evansville Physical Therapy Neurologic Residency Rehabilitation Ascension St. Vincent Evansville, Indiana Adjunct Faculty Physical Therapy University of Evansville Evansville, Indiana

Associate Professor, Chair Physical Therapy Bellarmine University Louisville, Kentucky Coowner All About Families, PLLC Louisville, Kentucky

Professor Emerita Physical Therapy University of Evansville Evansville, Indiana

Tzurei Chen Assistant Professor Physical Therapy Pacific University Hillsboro, Oregon

Kevin Chui Director and Professor School of Physical Therapy and Athletic Training Pacific University Hillsboro, Oregon

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Mary Kessler Dean College of Education and Health Sciences Associate Professor Physical Therapy University of Evansville Evansville, Indiana

Jordana Lockwich Assistant Professor Physical Therapy University of Evansville Evansville, Indiana

Jason Pitt Assistant Professor Physical Therapy University of Evansville Evansville, Indiana

TA B L E O F C O N T E N T S Preface, vii List of Contributors, viii

SECTION 1: Foundations 1 2 3 4

The Roles of the Physical Therapist and Physical Therapist Assistant in Neurologic Rehabilitation, 1 Neuroanatomy, 12 Motor Control and Motor Learning, 41 Motor Development, 66

SECTION 2: Children 5 6 7 8 9

Positioning and Handling to Foster Motor Function, 103 Cerebral Palsy, 144 Myelomeningocele, 189 Genetic Disorders, 220 Autism Spectrum Disorder, 272

SECTION 3: Adults 10 11 12 13 14

Proprioceptive Neuromuscular Facilitation, 294 Stroke, 348 Traumatic Brain Injuries, 423 Spinal Cord Injuries, 453 Other Neurologic Disorders, 525

Index, 563

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SECTION 1

Foundations

1 The Roles of the Physical Therapist and Physical Therapist Assistant in Neurologic Rehabilitation OBJECTIVES After reading this chapter, the student will be able to: 1. Discuss the International Classification of Functioning, Disability, and Health and its relationship to physical therapy practice.

2. Explain the role of the physical therapist in patient/client management. 3. Describe the role of the physical therapist assistant in the treatment of adults and children with neurologic deficits.

INTRODUCTION

loses health. Disease is defined as a pathologic state manifested by the presence of signs and symptoms that disrupt an individual’s homeostasis or internal balance. Impairments are alterations in anatomic, physiologic, or psychological structures or functions. Functional limitations occur as a result of impairments and become evident when an individual is unable to perform everyday activities that are considered part of the person’s daily routine. Examples of physical impairments include a loss of strength in the anterior tibialis muscle or a loss of 15 degrees of active shoulder flexion. These physical impairments may or may not limit the individual’s ability to perform functional tasks. Inability to dorsiflex the ankle may prohibit the patient from achieving toe clearance and heel strike during ambulation, whereas a 15-degree limitation in shoulder range of motion may have little impact on a person’s ability to perform self-care or dressing tasks. According to the disablement model, a disability results when functional limitations become so great that the person is unable to meet age-specific expectations within the social or physical environment (Verbrugge and Jette, 1994). Society can erect physical and social barriers that interfere with a person’s ability to perform expected life roles. The societal attitudes encountered by a person with a disability can result in the community’s perception that the individual is handicapped. Fig. 1.1 depicts the Nagi classification system of health status. The second edition of the Guide to Physical Therapist Practice incorporated the Nagi Disablement Model into its conceptual framework of physical therapy practice. The use of this model directed PTs to focus on the relationship between impairment and functional limitation and the patient’s ability to perform everyday activities within the patient’s home and community (APTA, 2003).

The practice of physical therapy in the United States continues to change to meet the increased demands placed on service provision by reimbursement entities and federal regulations. The profession has seen an increase in the number of physical therapist assistants (PTAs) providing physical therapy interventions for adults and children with neurologic deficits. PTAs are employed in outpatient clinics, inpatient rehabilitation centers, extended-care and pediatric facilities, school systems, and home health care agencies. Traditionally, the rehabilitation management of adults and children with neurologic deficits consisted of treatment derived from the knowledge of disease and interventions directed at the amelioration of patient signs, symptoms, and functional impairments. Physical therapists (PTs) and PTAs “help individuals maintain, restore, and improve movement, activity, and functioning, thereby enabling optimal performance and enhancing health, well-being, and quality of life” (APTA, 2014). Physical therapy services are provided across the lifespan to children and adults “who have or may develop impairments, activity limitations, and participation restrictions” (APTA, 2014). These limitations develop as a consequence of various health conditions including those of the “musculoskeletal, neuromuscular, cardiovascular, pulmonary, and/or integumentary system” or the negative consequences of the interaction of personal and environmental factors on human performance (APTA, 2014). Sociologist Saad Nagi developed a model of health status that has been used to describe the relationship between health and function (Nagi, 1991). The four components of the Nagi Disablement Model (disease, impairments, functional limitations, and disability) evolve as the individual

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SECTION 1

Foundations

Disease

Impairment

Functional limitation

Disability

Handicap

Pathology

Alteration of structure and function

Difficulty performing routine tasks

Significant functional limitation; cannot perform expected tasks

Societal disadvantage of disability

Fig. 1.1 Nagi classification system of health status.

Health condition (disorder or disease)

Body functions and structures

Participation

Activities

Environmental factors

Personal factors

Fig. 1.2 Model of the International Classification of Functioning, Disability, and Health. (From Cech D, Martin S: Functional movement development across the life span, ed 3, St. Louis, 2012, Elsevier.)

The World Health Organization (WHO) developed the International Classification of Functioning, Disability, and Health (ICF), which was endorsed by the American Physical Therapy Association (APTA) in 2008. This system provides an updated frame of reference for physical therapy practice and standard language to describe health, function, and disability at both the individual and population level, and is incorporated into the third edition of the Guide to Physical Therapist Practice. Fig. 1.2 illustrates the ICF model. Health is much more than the absence of disease; rather, it is a condition of physical, mental, and social well-being that allows an individual to participate in functional activities and life situations (WHO, 2013; Cech and Martin, 2012). A biopsychosocial model of health is central to the ICF and defines a person’s health status and functional capabilities by the interactions between one’s biological, psychological, and social domains (Fig. 1.3). This conceptual framework recognizes that two

individuals with the same medical diagnosis might have very different functional outcomes and levels of participation based on environmental and personal factors. The ICF also presents functioning and disability in the context of health and organizes the information into two distinct parts. Part 1 addresses the components of functioning and disability as they relate to the health condition. The health condition (disease or disorder) results from the impairments and alterations in an individual’s body structures and functions (physiologic and anatomic processes). Activity limitations present as difficulties performing a task or action and encompass physical as well as cognitive and communication activities. Participation restrictions are deficits that an individual may experience when attempting to meet social roles and obligations within the environment. Functioning and disability are therefore viewed on a continuum in which functioning encompasses performance of activities and participation and disability implies activity limitations and restrictions in one’s ability to participate in life situations such as employment, education, or relaxation (Centers for Disease Control and Prevention, 2017; WHO, 2013). Part 2 of the ICF recognizes the contextual factors “external environmental factors (e.g., social attitudes, architectural characteristics, legal and social structures, and climate and terrain)” and internal personal factors (age, sex, social, and educational background, coping strategies, profession, life experiences, and other factors) that influence a person’s response to the presence of a disability and the interaction of these factors on one’s ability to participate in meaningful activities (APTA, 2014). Fig. 1.4 provides a diagram of the ICF Model of Functioning and Disability. All factors must be considered to determine the impact, both positive and negative, these factors have on function and participation (APTA, 2014; WHO, 2013).

BIOPHYSICAL DOMAIN

PSYCHOLOGICAL DOMAIN

SOCIOCULTURAL DOMAIN

Sensorimotor tasks

Affect Motivation Cognitive ability

Social roles Cultural roles

FUNCTIONAL STATUS Fig. 1.3 The three domains of function—biophysical, psychological, sociocultural—must operate independently as well as interdependently for human beings to achieve their best possible functional status. (From Cech D, Martin S: Functional movement development across the life span, ed 3, St. Louis, 2012, Elsevier.)

CHAPTER 1

The Roles of the Physical Therapist and Physical Therapist Assistant

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ICF

Part 1: Functioning and disability

Body functions and structures

Change in body function

Change in body structure

Part 2: Contextual factors

Activities and participation

Capacity

Performance

Environmental factors

Personal factors

Facilitator/ barrier

Fig. 1.4 Structure of the International Classification of Functioning, Disability, and Health (ICF) Model of Functioning and Disability. (Adapted from [http://www.apta.org], with permission of the American Physical Therapy Association. © 2019 American Physical Therapy Association. All rights reserved.)

The ICF emphasizes enablement rather than disability (Cech and Martin, 2012). In the ICF model, there is less focus on the cause of the medical condition and more emphasis directed to the impact that activity limitations and participation restrictions have on the individual. As individuals experience a decline in health, it is also possible that they may experience some level of disability. Thus the ICF “mainstreams the experience of disability and recognizes it as a universal human experience” (WHO, 2002). An ICF for Children and Youth has been developed to provide greater detail for children from birth to age 18 years. This document addresses the “body functions and structures, activities, participation, and environments specific to infants, toddlers, children, and adolescents” and provides a framework for common language and documentation as it relates to health status and disability in children (APTA, 2014; WHO, 2007). Fig. 1.5 provides an example of the ICF applied to children with cerebral palsy, autism, and attention-deficit/ hyperactivity disorder. The third edition of the Guide to Physical Therapist 3.0 recognizes the critical roles that PTs and PTAs play in providing “rehabilitation and habilitation, performance enhancement, and prevention and risk-reduction services” for patients and the overall population (APTA, 2014). Additionally, as professionals we play a critical role in developing standards for our practice and in recommending health care policy to ensure access, availability, and quality, patient-centered physical therapy care (APTA, 2014). It is important that therapists continue to appreciate our role in optimizing patient function as various functional skills are needed in domestic, vocational, and community environments. Within the third edition of the Guide to Physical Therapist Practice 3.0 (APTA, 2014), functioning is defined as “an umbrella term for body functions, body structures, activities and participation. Functioning is the positive

interaction between an individual with a health condition and that individual’s environmental and personal factors” (APTA, 2014). Individuals often define themselves by what they are able to accomplish and how they are able to interact in the world (Cech and Martin, 2012). Function “comprises activities that an individual identifies as essential to support his or her physical, social, and psychological well-being and to create a personal sense of meaningful living” (APTA, 2014). Function is related to age-specific roles in a given social context and physical environment and is defined differently for a child of 6 months, an adolescent of 15 years, and a 65-year-old adult. Factors that contribute to an individual’s functional performance include personal characteristics (age, race, sex, level of education), physical ability, sensorimotor skills, emotional status (depression, anxiety, self-awareness and self-esteem), and cognitive ability (intellect, motivation, concentration, and problem-solving skills). The environment in which the adult or child lives and works, such as one’s home, school, or community, social supports, and the social and cultural expectations placed on the individual by the family, community, or society all impact performance of functional tasks and quality of life (APTA, 2014; Cech and Martin, 2012).

THE ROLE OF THE PHYSICAL THERAPIST IN PATIENT MANAGEMENT As stated earlier, PTs are responsible for providing rehabilitation, habilitation, and services to maintain health and function, prevent functional decline, and in individuals who are healthy enhance performance (APTA, 2014). Ultimately, the PT is responsible for performing a review of the patient’s history and systems, and for administering appropriate tests and measures to determine an individual’s need for physical therapy services. If after the examination the PT concludes

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SECTION 1

Foundations Neurodevelopmental disorders: cerebral palsy, autism spectrum disorder, attention-deficit-hyperactivity disorder

• • • • • •

Body functions/Body structures Mental functions • Structures of the Sleep pattern nervous system Pain • Structures related to movement Vision and hearing Physical fitness • Structures involved in Control of voice and speech movements

Activities • Learning and applying knowledge • Communication • Eating and drinking • Dressing • Mobility • Doing chores

Environmental factors • Family, peers, and social support • Adapted toys • Sound/light quality • Assistive technologies • Societal attitudes • Health, education, social services • Policies

Participation • Playing with peers • Going to the movies • Attending school • Playing team sports • Dating • Finding a job/working

Personal factors • Motivation • Priorities and goals • Age-developmental stage • Personal interests

Fig. 1.5 The International Classification of Functioning, Disability, and Health biopsychosocial model applied to neurodevelopmental disorders. (From Schiariti V, Mahdi S, Bolte S: International Classification of Functioning, Disability, and Health Core Sets for cerebral palsy, autism spectrum disorder, and attention-deficit-hyperactivity disorder, Dev Med Child Neurology 60:933–941, 2018.)

that the patient will benefit from services, a plan of care is developed that identifies the goals, expected outcomes, and the interventions to be administered to achieve the desired patient outcomes (APTA, 2014). The PT may also determine that the patient is not appropriate for physical therapy services and will recommend referral or consultation to another health care provider. The steps the PT utilizes in patient/client management are outlined in the third edition of the Guide to Physical Therapist Practice, and include examination, evaluation, diagnosis, prognosis, interventions, and outcomes. The PT integrates these elements to optimize the patient’s health, function, or physical performance. Fig. 1.6 identifies the element of patient/client management. In the examination, the PT collects data through a review of the patient’s history and a review of systems, and then administers appropriate tests and measures to determine the patient’s need for services (APTA, 2014). The PT evaluates the data, interprets the patient’s responses to tests and measures, and integrates that data with information obtained during the review of history and systems. Within the evaluation process, the therapist establishes a physical therapy diagnosis based on the patient’s level of impairment and functional limitations. A differential diagnosis (a systematic process to classify patients into diagnostic categories) may be used. When PTs provide a differential diagnosis, they do so with consideration of the impact of the health condition on system function, especially the movement system, and take into consideration the entire person (APTA, 2014). Once the diagnosis is established,

EXAMINATION

EVALUATION

DIAGNOSIS

PROGNOSIS

INTERVENTION

OUTCOMES Fig. 1.6 The elements of patient/client management. (Adapted from [http://www.apta.org], with permission of the American Physical Therapy Association. © 2019 American Physical Therapy Association. All rights reserved.)

CHAPTER 1

The Roles of the Physical Therapist and Physical Therapist Assistant

the PT develops a prognosis, which is the predicted level of functional improvement and an estimate to the amount of time needed to achieve those levels. As the PT determines the patient’s prognosis, he or she must consider what the patient is capable of functionally, and what is likely to be habitual for the patient. Patient motivation is important to consider during this process. Therefore the PT must understand “the difference between what a person currently does and what the person potentially could do” as he or she makes a prognosis and develops realistic, achievable functional goals and outcomes (APTA, 2014). It is also important to note that the patient must be an active participant in this process and the PT must follow the decisions made by the patient as they relate to what constitutes meaningful function (APTA, 2014). Intervention is the element of patient management in which the PT or the PTA interacts with the patient through the administration of “various interventions to produce changes in the [patient’s] condition that are consistent with the diagnosis and prognosis” (APTA, 2014). Interventions are organized into nine categories: “patient or client instruction (used with every patient and client and in every practice setting); airway clearance techniques, assistive technology, biophysical agents; functional training in self-care and domestic, work, community, social, and civic life; integumentary repair and protection techniques; manual therapy techniques; motor function training; and therapeutic exercise” (APTA, 2014). The PT must prescribe the type and intensity of the interventions as well as the method, mode, duration, frequency, and progression. Reexamination of the patient may be necessary and includes performance of appropriate tests and measures to determine if the patient is progressing with treatment, if modifications in the techniques administered are needed, or if the episode of care is complete. “Outcomes are the actual results of implementing the plan of care that indicate the impact on functioning (body functions and structures, activities, and participation)” (APTA, 2014). The PT must determine the impact selected interventions have had on the following: disease or disorder, impairments, activity limitations, participation, risk reduction and prevention, health, wellness, fitness, societal resources, and patient satisfaction (APTA, 2014). The development of the plan of care is the final step in the examination, diagnostic, and prognostic process. It is developed in collaboration with the patient, and if necessary other individuals who are involved in the patient’s care. Goals should be developed to impact functioning (body functions and structures, activities, and participation) and should be objective, measurable, functionally oriented, time measurable, and meaningful to the patient. Goals may be written as short or long term depending on the practice setting. The plan of care must also discuss the patient’s discharge from services, “conclusion of the episode of care” and follow-up visits or referrals needed (APTA, 2014). If a patient has not achieved his or her goals, a report of the patient’s current status and rationale for discontinuation of services is provided. Other aspects of patient/client management include coordination, “the working together of all parties involved

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with the patient,” communication, and documentation of services provided (APTA, 2014). Documentation includes any and all entries into the patient’s health record and should include the services provided and the patient’s response to treatment administered. All documentation for physical therapy services should follow the APTA’s Guidelines. (APTA, 2014). Interventions are designed to produce changes in a patient’s condition. The PT will select interventions based on information obtained in the examination and that are based on the patient’s current condition and prognosis. Physical therapy interventions are designed to optimize patient function, emphasize patient education and instruction, and promote individual health, wellness, and fitness with the goal of preventing reoccurrence of the condition. Interventions are administered by the PT and when indicated by others involved in the patient’s plan of care. PTAs may be “appropriately utilized in components of the intervention and in collection of selected examination and outcomes data” (APTA, 2018a). All other tasks remain the sole responsibility of the PT. The guidelines for direction and supervision of PTAs follow those suggested by Dr. Nancy Watts in her 1971 article on task analysis and division of responsibility in physical therapy (Watts, 1971). This article was written to assist PTs with guidelines for delegating patient care activities to support personnel. Although the term delegation is not used today because of the implications of relinquishing patient care responsibilities to another practitioner, the principles of patient/client management, as defined by Watts, can be applied to the provision of present-day physical therapy services. PTs and PTAs unfamiliar with this article are encouraged to review it because the guidelines presented are still appropriate for today’s clinicians and are referenced in APTA documents.

THE ROLE OF THE PHYSICAL THERAPIST ASSISTANT IN TREATING PATIENTS WITH NEUROLOGIC DEFICITS There is little debate as to whether PTAs have a role in treating adults with neurologic deficits, as long as the individual needs of the patient are taken into consideration and the PTA follows the plan of care established by the PT. PTAs are the only health care providers who “assists a physical therapist in practice” (APTA, 2018a). The primary PT is still ultimately responsible for the patient, both legally and ethically, and is responsible for the actions of the PTA relative to patient management that can include the performance of selected interventions and the collection of certain examination and outcomes measures (APTA, 2018a). The APTA has identified the following responsibilities as those that must be performed exclusively by the PT (APTA, 2018a): 1. Interpretation of referrals when available 2. Initial examination, evaluation, diagnosis, and prognosis 3. Development or modification of the plan of care, which includes the goals and expected outcomes and is based on results of the initial examination

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Foundations

4. Determination of when the expertise and decision-making capabilities of the PT requires the PT to personally render services and when it is appropriate to utilize a PTA 5. Revision of the plan of care if indicated 6. Conclusion of a patient’s episode of care 7. Responsibility for communication related to a “hand off ” 8. Oversight of all documentation for services rendered The APTA has stated that it is the responsibility of the PT to perform the examination, evaluation, diagnosis, prognosis, intervention, and outcomes. The entire evaluation, the creation of the patient’s diagnosis and prognosis as well as components of the examination, intervention, and outcomes must be exclusively performed by the PT because of the need for continuous assessment and synthesis of information. Additionally, the APTA has identified selected interventions that are performed solely by the PT, which include “spinal and peripheral joint mobilization/manipulation and dry needling, which are components of manual therapy; and sharp selective debridement, which is a component of wound management” (APTA, 2018b). Any intervention that requires immediate and continuous examination and evaluation is to be performed by the PT (APTA, 2018b). As stated earlier, PTAs may be utilized in administering interventions and in the collection of certain examination and outcomes. Before directing the PTA to perform specific components of the intervention, the PT must critically evaluate the patient’s condition (stability, acuity, criticality, and complexity), he or she must also consider the practice setting in which the intervention is to be delivered, the type of intervention to be provided, and the predictability of the patient’s probable outcome to the intervention (APTA, 2018a). The guidelines proposed follow those suggested by Dr. Watts (Watts, 1971). In addition, the knowledge base of the PTA, his or her level of experience, training, and skill level must be considered when determining which tasks can be directed to the PTA. The APTA has developed two algorithms (PTA direction and PTA supervision; Figs. 1.7 and 1.8) to assist PTs with the steps that should be considered when a PT decides to direct certain aspects of a patient’s care to a PTA and the subsequent supervision that must occur. Even though these algorithms exist, it is important to remember that communication between the PT and PTA must be ongoing to ensure the best possible outcomes for the patient. PTAs are also advised to become familiar with the Problem-Solving Algorithm Utilized by PTAs in Patient/Client Intervention (Fig. 1.9) as a guide for the clinical problem-solving skills a PTA should employ before and during patient interventions (APTA, 2007). PTs and PTAs are advised to refer to APTA policy documents, their state practice acts, and the Commission on Accreditation in Physical Therapy Education guidelines for the most up-to-date information regarding interventions that are considered outside the scope of practice for the PTA. Practitioners are also encouraged to review individual state practice acts and payer requirements for supervision requirements as they relate to the PT/PTA relationship (Crosier, 2011).

State practice acts often describe the scope of practice and supervision requirements for PTAs. It is also important to note that levels of supervision are also described by the APTA. The APTA identifies three levels of supervision including: general supervision in which the PT is not required to be onsite but is available by telecommunications; direct supervision in which the PT is “physically present and immediately available for direction and supervision and has direct contact with the patient during each visit”; and direct personal supervision in which the PT or PTA is “immediately available to direct and supervise tasks that are related to patient management. The direction and supervision is continuous and telecommunications does not meet the requirement of direct personal supervision” (APTA, 2012). It is important to note that various policy documents define and mandate different levels of supervision (Crosier, 2010). Unfortunately, in our current health care climate, there are times when the decision as to whether a patient should be treated by a PTA is determined by productivity concerns and the patient’s payer source and not the patient’s rehabilitation needs. An issue affecting some clinics and PTAs is the denial of payment by some insurance providers for services provided by a PTA. Consequently, decisions regarding the utilization of PTAs are sometimes determined by financial remuneration and not by the needs of the patient.

THE PHYSICAL THERAPIST ASSISTANT AS A MEMBER OF THE HEALTH CARE TEAM The PTA functions as a member of the rehabilitation team in all treatment settings. Members of this team include the primary PT; the physician; speech, occupational, and recreation therapists; nursing personnel; the psychologist; case manager; and the social worker. However, the two most important members of this team are the patient and his or her family. In a rehabilitation setting, the PTA is expected to provide interventions to improve the patient’s functional independence and participation in life situations. Relearning motor activities, such as bed mobility, transfers, ambulation skills, stair climbing, and wheelchair negotiation, if appropriate, are emphasized to enhance the patient’s functional mobility. In addition, the PTA participates in patient and family education and is expected to provide input into the patient’s discharge plan. Patient and family instruction include providing information, education, and the actual training of patients, families, significant others, or caregivers, and is a part of every patient’s plan of care (APTA, 2014). As is the case in all team activities, open and honest communication and mutual respect among all team members is crucial to maximize the patient’s participation and achievement of an optimal functional outcome. Although PTAs work with adults who have had strokes, spinal cord injuries, and traumatic brain injuries, some PTs have viewed pediatrics as a specialty area of practice. This narrow perspective is held even though PTAs work with children in hospitals, outpatient clinics, schools, and community settings, including fitness centers and sports-training facilities.

CHAPTER 1

The Roles of the Physical Therapist and Physical Therapist Assistant PTA Direction Algorithm (See Controlling Assumptions)

Physical therapist (PT) completes physical therapy patient/client examination and evaluation, establishing the physical therapy diagnosis, prognosis, and plan of care.

Are there interventions within the plan of care that are within the scope of work of a PTA?

No

PT provides patient/client intervention for interventions that are not within the scope of work of the PTA, including all interventions requiring ongoing evaluation.

No

PT provides patient/client intervention and determines when/if the patient/client health conditions have stabilized sufficiently to direct selected interventions to a PTA.

No

PT provides patient/client intervention and determines when/if the prognostic conditions have changed sufficiently to direct selected interventions to a PTA.

No

PT provides patient/client intervention; assesses the limits of the PTA’s personal scope of work, identifies areas for PTA development, and assists the PTA in obtaining relevant development opportunities.

Yes

Is the patient/client’s condition sufficiently stable to direct the intervention to a PTA?

Yes

Are the intervention outcomes sufficiently predictable to direct the intervention to a PTA?

Yes

Given the knowledge, skills, and abilities of the PTA, is the intervention within the personal scope of work of the individual PTA?

Yes

Given the practice setting, have all associated risks and liabilities been identified and managed?

No

PT provides patient/client intervention and identifies solutions for unmanaged risk and liabilities.

No

PT provides patient/client intervention when payer requirements do not permit skilled physical therapy services to be provided by a PTA.

Yes

Given the practice setting, have all associated payer requirements related to physical therapy services provided by a PTA been managed?

Yes

Direct intervention to the PTA while: • Maintaining responsibility and control of patient/client management; • Providing direction and supervision of the PTA in accordance with applicable laws and regulations; and • Conducting periodic reassessment/reevaluation of the patient as directed by the facility, federal and state regulations, and payers.

Fig. 1.7 Physical therapist assistant (PTA) direction algorithm. (Adapted from [http://www.apta.org], with permission of the American Physical Therapy Association. © 2019 American Physical Therapy Association. All rights reserved.)

7

8

Foundations

SECTION 1

PTA Supervision Algorithm (See Controlling Assumptions)

Complete physical therapy examination, evaluation, and plan of care, including determination of selected interventions that may be directed to the PTA.

Establish patient/client condition safety parameters that must be met prior to initiating and during intervention(s) (e.g., resting heart rate, max pain level).

Review results of physical therapy examination/ evaluation, plan of care (POC), and safety parameters with the PTA.

Provide needed information and/or direction to the PTA.

Yes Are there questions or items to be clarified about the selected interventions or safety parameters?

PTA collects data on patient/client condition relative to established safety parameters.

No

Follow up with patient/client including reexamination if appropriate.

No Have the established patient/client condition safety parameters been met?

PTA initiates selected intervention(s) directed by the PT.

Yes

Monitor patient/client safety and comfort, progression with the selected intervention, and progression within the plan of care through discussions with PTA, documentation review, and regular patient/client interviews.

Is patient/client safe and comfortable with selected intervention(s) provided by the PTA?

Do the data collected by the PTA indicate that there is progress toward the patient/client goals?

Yes

No

Continue to monitor and communicate regularly with the PTA.

No

Do the data collected by the PTA indicate that the patient/client goals may be met?

Yes

Yes

Has the PTA tried permissible modifications to the selected intervention(s) to ensure patient/client safety/comfort?

Has the PTA progressed the patient/client within the selected intervention as permitted by the plan of care?

Has the PTA tried permissible modifications to the selected intervention(s) to improve patient/client response?

Yes

No

Yes

Reevaluate patient/client and proceed as indicated.

No

Provide needed information and/or direction to the PTA.

Yes

Continue to monitor and communicate regularly with the PTA.

Reevaluate patient/client and proceed as indicated.

No

Continue to monitor and communicate regularly with the PTA or reevaluate patient/client.

No

Reevaluate patient/client and proceed as indicated.

Provide needed information and/or direction to the PTA.

Fig. 1.8 Physical therapist assistant (PTA) supervision algorithm. (Adapted from [http://www.apta.org], with permission of the American Physical Therapy Association. © 2019 American Physical Therapy Association. All rights reserved.)

Communicate with PT and follow as directed

No/ Uncertain

Can modifications be made to the selected intervention(s) to ensure patient/client safety/comfort?

Stop/interrupt intervention(s)

No/ Uncertain

Read physical therapy examination/ evaluation and plan of care (POC) and review with the physical therapist

Yes

Yes

No

Yes

Yes

Yes

Interrupt/stop intervention(s)

Communicate with PT and follow as directed

Yes/ Uncertain

Communicate with PT and follow as directed

No/ Uncertain

Communicate with PT and follow as directed

No/ Uncertain

Communicate results of patient/client intervention(s) and data collection, including required documentation

Yes

Does the data comparison indicate that the safety parameters established by the PT about the patient's/client's condition have been met?

Does the data comparison indicate that the expectations established by the PT about the patient's/client's response to the interventions have been met?

Can modifications be made to the selected intervention(s) to improve patient's/client's response?

No

Compare results with previously collected data

Initiate selected intervention(s) as directed by the PT

Compare results with previously collected data and safety parameters established by the PT

No/Uncertain

Does the data comparison indicate that there is progress toward the expectations established by the PT about the patient's/client's response to the interventions?

Collect relevant data

Collect data on patient/client current condition (e.g., chart review, vitals, pain, and observation)

Communicate with PT for clarification

The Roles of the Physical Therapist and Physical Therapist Assistant

Fig. 1.9 Problem-solving algorithm utilized by physical therapist assistants (PTAs) in patient/client intervention. (Adapted from [http://www.apta.org], with permission of the American Physical Therapy Association. © 2019 American Physical Therapy Association. All rights reserved.)

Make permissible modifications to intervention(s)

Continue selected intervention(s)

Is patient/client safe and comfortable with selected intervention(s)?

Are there questions or items to be clarified about the selected interventions?

(See Controlling Assumptions on previous page.)

Problem-Solving Algorithm Utilized by PTAs in Patient/Client Intervention

CHAPTER 1

9

10

SECTION 1

Foundations

Although some areas of pediatric physical therapy are specialized, many areas are well within the scope of practice of the generalist PT and PTA. The Academy of Pediatric Physical Therapy in their fact sheet state that “Physical therapist assistants may be involved with the delivery of physical therapy services under the direction and supervision of a licensed PT” (APPT, 2019). Additionally, the Academy states that “Physical therapists and physical therapist assistants must be graduates of accredited educational programs and comply with rules of state licensure and practice guidelines” (APPT, 2019). Practitioners may secure additional knowledge, certification, and credentials to recognize specialization in pediatrics (APPT, 2019). The provision of pediatric services in school systems by PTAs is supported, however, because of supervision requirements it may be difficult for school systems to meet the PT/ PTA supervision requirements. This can be especially problematic in rural areas where the number of providers may be limited. When it is possible to comply with supervisio