Chapter 1: Therapeutic Exercise: Foundational Concepts

Almost everyone, regardless of age, values the ability to function as independently as possible during activities of everyday life. Health-care consumers (patients and clients) typically seek out or are referred for physical therapy services because of physical impairments associated with movement disorders caused by injury, disease, or health-related conditions that restrict their ability to participate in any number of activities that are necessary or important to them. Physical therapy services may also be sought by individuals who have no impairments or functional deficits but who wish to improve their overall level of fitness and quality of life or reduce the risk of injury or disease. An individually designed therapeutic exercise program is almost always a fundamental component of the physical therapy services provided. This stands to reason because the ultimate goal of a therapeutic exercise program is the achievement of an optimal level of symptom-free movement during basic to complex physical activities.

To develop and implement effective exercise interventions, a therapist must understand how the many forms of exercise affect tissues of the body and body systems and how those exercise-induced effects have an impact on key aspects of physical function. A therapist must also integrate and apply knowledge of anatomy, physiology, kinesiology, pathology, and the behavioral sciences across the continuum of patient/client management from the initial examination to discharge planning. To develop therapeutic exercise programs that culminate in positive and meaningful functional outcomes for patients and clients, a therapist must understand the relationships among physical functioning, health, and disability and apply these conceptual relationships to patient/client management to facilitate the provision of effective and efficient health-care services. Lastly, a therapist, as a patient/client educator, must know and apply principles of motor learning and motor skill acquisition to exercise instruction and functional training.

Therefore, the purpose of this chapter is to present an overview of the scope of therapeutic exercise interventions used in physical therapy practice. This chapter also addresses several models of health, functioning, and disability as well as patient/client management as they relate to therapeutic exercise and explores strategies for teaching and progressing exercises and functional motor skills based on principles of motor learning.

Of the many procedures used by physical therapists in the continuum of care of patients and clients, therapeutic exercise takes its place as one of the key elements that lies at the center of programs designed to improve or restore an individual's function or to prevent dysfunction.³

Definition of Therapeutic Exercise

Therapeutic exercise³ is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient/client with the means to:

• Remediate or prevent impairments.

• Improve, restore, or enhance physical function.

• Prevent or reduce health-related risk factors.

• Optimize overall health status, fitness, or sense of well-being.

The beneficial effects of therapeutic exercise for individuals with a wide variety of health conditions and related physical impairments are documented extensively in the scientific literature¹⁶⁶ and are addresssed in each of the chapters of this textbook.

Therapeutic exercise programs designed by physical therapists are individualized to the unique needs of each patient or client. A patient is an individual with impairments and functional deficits diagnosed by a physical therapist and is receiving physical therapy care to improve function and prevent disability.³ A client is an individual without diagnosed dysfunction who engages in physical therapy services to promote health and wellness and to prevent dysfunction.³ Because the focus of this textbook is on management of individuals with physical impairments and functional deficits, the authors have chosen to use the term "patient," rather than "client" or "patient/client," throughout this text. We believe that all individuals receiving physical therapy services must be active participants rather than passive recipients in the rehabilitation process to learn how to self-manage their health needs.

Components of Physical Function: Definition of Key Terms

The ability to function independently at home, in the workplace, within the community, or during leisure and recreational activities is contingent upon physical as well as psychological and social function. The multidimensional aspects of physical function encompass the diverse yet interrelated areas of performance that are depicted in Figure 1.1. These elements of function are characterized by the following definitions.

Balance. The ability to align body segments against gravity to maintain or move the body (center of mass) within the available base of support without falling; the ability to move the body in equilibrium with gravity via interaction of the sensory and motor systems.^{3,85,97,114,151,154,155}

Cardiopulmonary fitness. The ability to perform moderate-intensity, repetitive, total body movements (walking, jogging, cycling, swimming) over an extended period of time.^1,105 A synonymous term is cardiopulmonary endurance.

Coordination. The correct timing and sequencing of muscle firing combined with the appropriate intensity of muscular contraction leading to the effective initiation, guiding, and grading of movement. Coordination is the basis of smooth, accurate, efficient movement and occurs at a conscious or automatic level.^150,154

Flexibility. The ability to move freely, without restriction; used interchangeably with mobility.

Mobility. The ability of structures or segments of the body to move or be moved in order to allow the occurrence of range of motion (ROM) for functional activities (functional ROM).^3,161 Passive mobility is dependent on soft tissue (contractile and noncontractile) extensibility; in addition, active mobility requires neuromuscular activation.

Muscle performance. The capacity of muscle to produce tension and do physical work. Muscle performance encompasses strength, power, and muscular endurance.³

Neuromuscular control. Interaction of the sensory and motor systems that enables synergists, agonists and antagonists, as well as stabilizers and neutralizers to anticipate or respond to proprioceptive and kinesthetic information and, subsequently, to work in correct sequence to create coordinated movement.⁹²

Postural control, postural stability, and equilibrium. Used interchangeably with static or dynamic balance.^65,151,154

Stability. The ability of the neuromuscular system through synergistic muscle actions to hold a proximal or distal body segment in a stationary position or to control a stable base during superimposed movement.^65,154,161 Joint stability is the maintenance of proper alignment of bony partners of a joint by means of passive and dynamic components.¹¹¹

The systems of the body that control each of these elements of physical function react, adapt, and develop in response to forces and physical stresses (stress = force/area) placed upon tissues that make up body systems.^105,110 Gravity, for example, is a constant force that affects the musculoskeletal, neuromuscular, and circulatory systems. Additional forces, incurred during routine physical activities, help the body maintain a functional level of strength, cardiopulmonary fitness, and mobility. Imposed forces and physical stresses that are excessive can cause acute injuries, such as sprains and fractures, or chronic conditions, such as repetitive stress disorders.¹¹⁰ The absence of typical forces on the body also can cause degeneration, degradation, or deformity. For example, the absence of normal weight bearing associated with prolonged bed rest or immobilization weakens muscle and bone.^1,2,12,110 Prolonged inactivity also leads to decreased efficiency of the circulatory and pulmonary systems.¹

Impairment of any one or more of the body systems and subsequent impairment of any aspect of physical function, separately or jointly, can limit and restrict an individual's ability to carry out or participate in daily activities. Therapeutic exercise interventions involve the application of carefully graded physical stresses and forces that are imposed on impaired body systems, specific tissues, or individual structures in a controlled, progressive, safely executed manner to reduce physical impairments and improve function.

Types of Therapeutic Exercise Interventions

Therapeutic exercise procedures embody a wide variety of activities, actions, and techniques. The techniques selected for an individualized therapeutic exercise program are based on a therapist's determination of the underlying cause or causes of a patient's impairments, activity limitations, or participation restrictions (functional limitations or disability). The types of therapeutic exercise interventions presented in this textbook are listed in Box 1.1. Therapists use additional exercise interventions for patients with neuromuscular or developmental conditions.³

NOTE: Although joint mobilization and manipulation techniques often are categorized as manual therapy procedures, not therapeutic exercise,3 the authors of this textbook have chosen to include joint manipulative procedures under the broad definition of therapeutic exercise to address the full scope of soft tissue stretching techniques.

Exercise Safety

Regardless of the types of therapeutic exercise interventions in a patient's exercise program, safety is a fundamental consideration in every aspect of the program whether the exercises are performed independently or under a therapist's direct supervision. Patient safety, of course, is paramount; nonetheless, the safety of the therapist also must be considered, particularly when the therapist is directly involved in the application of an exercise procedure or a manual therapy technique.

Many factors can influence a patient's safety during exercise. Prior to engaging in exercise, a patient's health history and current health status must be explored. A patient unaccustomed to physical exertion may be at risk for the occurrence of an adverse effect from exercise associated with a known or an undiagnosed health condition. Medications can adversely affect a patient's balance and coordination during exercise or cardiopulmonary response to exercise. Therefore, risk factors must be identified and weighed carefully before an exercise program is initiated. Medical clearance from a patient's physician may be indicated before beginning an exercise program.

The environment in which exercises are performed also affects patient safety. Adequate space and a proper support surface for exercise are necessary prerequisites for patient safety. If exercise equipment is used in the clinical setting or at home, to ensure patient safety, the equipment must be well maintained and in good working condition, must fit the patient, and must be applied and used properly.

Specific to each exercise in a program, the accuracy with which a patient performs an exercise affects safety, including proper posture or alignment of the body, execution of the correct movement patterns, and performance of each exercise with the appropriate intensity, speed, and duration. A patient must be informed of the signs of fatigue, the relationship of fatigue to the risk of injury, and the importance of rest for recovery during and after an exercise routine. When a patient is being directly supervised in a clinical or home setting while learning an exercise program, the therapist can control these variables. However, when a patient is carrying out an exercise program independently at home or at a community fitness facility, patient safety is enhanced and the risk of injury or re-injury is minimized by effective exercise instruction and patient education. Suggestions for effective exercise instruction and patient education are discussed in a later section of this chapter.

As mentioned, therapist safety also is a consideration to avoid work-related injury. For example, when a therapist is using manual resistance during an exercise designed to improve a patient's strength or is applying a stretch force manually to improve a patient's ROM, the therapist must incorporate principles of proper body mechanics and joint protection into these manual techniques to minimize his or her own risk of injury.

Throughout each of the chapters of this textbook, precautions, contraindications, and safety considerations are addressed for the management of specific health conditions/pathologies, impairments, and functional deficits and for the use and progression of specific therapeutic exercise interventions.

Background and Rationale for Classification Systems

Knowledge of the complex relationships among health status, functioning, and disability provides a foundation for the delivery of effective health-care services.^80,159 This knowledge, in turn, provides a theoretical framework upon which practice can be organized and research can be based, thus facilitating effective management and care of patients reflected by meaningful functional outcomes.^54,80

Disablement, a term often used in the early health classification models,^{60,67,112,113,115} refers to the impact(s) and functional consequence(s) of acute or chronic conditions, such as disease, injury, and congenital or developmental abnormalities, on specific body systems that compromise basic human performance and an individual's ability to meet necessary, customary, expected, and desired societal functions and roles.^78,112,175

Inherent in the evolution and current application of knowledge of the disablement process in health-care delivery is an understanding that the process is not unidirectional— that is, it is not necessarily unpreventable or irreversible.¹⁹ Furthermore, it is assumed that in most instances, depending on factors such as the severity and duration of the pathological condition and a patient's access to quality health care as well as the motivation and desires of the patient, the progression of the process can indeed be altered and the patient's function improved.^3,19,159,160

An understanding and application of the disablement process shifts the focus of patient management from strict treatment of a disease or injury to treatment of the impact that a disease, injury, or disorder has on a patient's function as well as the identification of the underlying causes of the patient's dysfunction. This perspective puts the person, not solely the disease or disorder, at the center of efforts to prevent or halt the progression of disability by employing interventions that improve a patient's functional abilities while simultaneously reducing or eliminating the causes of disability.^53,159,160

Models of Functioning and Disability—Past and Present

Early Models

Several models that depict the relationships among an individual's overall health status, functioning in everyday life, and disability have been proposed over the past four decades. The first two schema developed were the Nagi model^112,113 and the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) model for the World Health Organization (WHO).⁶⁷ After publication of the original ICIDH model, it was subsequently revised,⁶⁰ with adjustments made in the descriptions of the classification criteria based on input from health-care practitioners as they became familiar with the original model. The National Center for Medical Rehabilitation Research (NCMRR) integrated components of the Nagi model with the original ICIDH model to develop its own model.¹¹⁵ The NCMRR model added interactions of individual risk factors, including physical and social factors, to their classification system.

Although each of these models uses slightly different terminology, each focuses on a spectrum of disablement. Several sources in the literature have discussed, compared and contrasted, or applied the terminology and descriptors used in these and other models.^{53,60,77,78,112,113,115}

Despite the variations in the early models, each taxonomy identified the following key components:

• Acute or chronic pathology

• Impairments

• Functional limitations

• Disabilities, handicaps, or societal limitations

A comparison of terminology used in the Nagi and ICIDH models is summarized in Table 1.1.

Need for a New Framework for Functioning and Disability

The conceptual frameworks of the Nagi, ICIDH, and NCMRR models, although applied widely in clinical practice and research in many health-care professions, have been criticized for their perceived focus on disease and a medical-biological view of disability as well as their lack of attention to the scope of human functioning, including wellness, and to the person with a disability.³³

In response to these criticisms, the WHO undertook a broad revision of its conceptual framework and system for classifying disability described in its ICIDH model. Through a comprehensive consensus process over a number of years, the WHO developed the International Classification of Functioning, Disability and Health (ICF).^{68,69,158159,160} The ICF was designed as a companion to the WHO's International Statistical Classification of Disease and Related Health Problems (ICD), which serves as the foundation for classifying and coding medical conditions worldwide.^68,69

The conceptual framework of the ICF (Fig. 1.2) is characterized as a bio-psycho-social model that integrates abilities and disabilities and provides a coherent perspective of various aspects of human functioning and disability as they relate to the continuum of health. The ICF also is intended to provide a common language used by all health professions for documentation and communication.^81,168

The framework also was designed to place less emphasis on disease and greater emphasis on how people affected by health conditions live.^{33,68,69,81,159,160} Consequently, activity (the execution of a task or action by an individual)¹⁶⁸ lies at the center of the ICF framework. All of the elements of the framework—the health condition, body functions/structures, activity, participation, and contextual factors—are interrelated and have an impact on each other.

The ICF—An Overview of the Model

The ICF is based on a broad view of health and health-related states. The model consists of two basic parts—Part 1: Functioning and Disability and Part 2: Contextual Factors as shown in Table 1.2.^68,69 Part 1 is subdivided into two components: (1) Body Functions and Structures and (2) Activities and Participation. Part 2 is also subdivided into two components: (1) Environmental Factors and (2) Personal Factors.

Functioning is characterized by the integrity of body functions and structures and the ability to participate in life's activities. In contrast, disability is the result of impairments in body functions and/or structures, activity limitations, and participation restrictions. Definitions of key terms are summarized in Box 1.2.^68,69,168 Numerous examples of these components are identified later in this chapter. Inclusion of contextual factors in the model highlights how external influences related to the physical environment and societal expectations and internal influences, such as personal attributes, facilitate or hinder functioning. Environmental factors that could have a positive impact on physical functioning include availability of assistive devices for personal care or household chores and modifications in the workplace or home for accessibility. Personal factors, such as level of motivation, coping skills, or acceptance of a chronic health condition, also affect daily functioning.

In addition to a conceptual model of functioning and disability, the ICF contains an extensive system for describing, classifying, and coding the functions and structures of all body systems, a person's activities and participation, as well as environmental factors that can have a positive or negative effect on functioning. The classification system, in part, provides a process for developing impairment/function-based diagnoses that guide the treatment of individuals with health conditions.

The scope of the ICF goes far beyond this brief overview of the model and related terminology presented in this chapter. To begin to understand the scope and potential use of the ICF in health care, numerous resources are available in print or online for in-depth information.^{68,69,158,159,160}

Components of Functioning and Disability Models and Applications in Physical Therapy

Background

Traditionally, the physical therapy profession has been defined by a body of knowledge and clinical applications that are directed toward the elimination or remediation of disability.¹³⁷

Understanding the disabling consequences of disease, injury, and abnormalities of development and how the risk of potential disability can be reduced, therefore, is fundamental to the provision of effective care and services, which are geared to the restoration of meaningful functioning for patients and their families, significant others, and caregivers. However, as the physical therapy profession has evolved, the scope of practice has moved beyond solely the management of disability and now includes promoting the well-being of healthy individuals and preventing or reducing risk factors that may lead to disability.

During the early 1990s, physical therapists began to explore the potential use of disablement models and suggested that disablement schema and related terminology provided an appropriate framework for clinical decision-making in practice and research.^57,77,147 In addition, practitioners and researchers suggested that consistent use of disablement-related language could be a mechanism to standardize terminology for documentation and communication in the clinical and research settings.⁵⁸ The American Physical Therapy Association (APTA) subsequently incorporated an extension of the Nagi disablement model and related terminology into its evolving consensus document, the Guide to Physical Therapist Practice³ (often called the Guide), which was developed to reflect "best practice" from the initial examination to the outcomes of intervention. The Guide also uses the concept of disablement as a framework for organizing and prioritizing clinical decisions made during the continuum of physical therapy care and services.

Just about the time the second edition of the Guide was published, the WHO adopted and disseminated the ICF, with its newly developed conceptual framework and system for classifying functioning and disability.⁶⁸ Consequently, information about the ICF model and its conceptual framework and terminology was not incorporated into the Guide. In 2008, the APTA officially endorsed the use of the ICF in physical therapy practice to increase awareness of the changing concepts and language of functioning and disability. To facilitate use of the ICF in clinical practice, a recent article in Physical Therapy provided a number of suggestions for integrating the ICF into specific components of the Guide.⁴⁰

Since the initial publication of the ICF in 2001,⁶⁸ however, the ongoing process of integrating ICF concepts and language into physical therapy practice and the scientific literature relevant to physical therapy has been gradual but consistent. For example, use of ICF language for documentation in the clinical setting is now being advocated.¹¹ The most noteworthy application of the ICF can be found in a series of clinical practice guidelines developed and recently published by the Orthopedic Section of the APTA. These guidelines use the ICF as the basis for describing and classifying care provided by physical therapists to patients with selected musculoskeletal conditions.⁵⁰ Information from the guidelines addressing the efficacy of therapeutic exercise interventions for health conditions and associated impairments commonly seen in orthopedic physical therapy practice is discussed in the regional chapters of this textbook.

Regardless of which model of functioning and disability is used as part of the theoretical framework of practice, physical therapists have a responsibility to provide evidence that there are, indeed, links among the elements of functioning and disability that can be identified by physical therapy tests and measures. It is also the responsibility of the profession to demonstrate that not only can physical impairments be reduced, but functional abilities can be significantly enhanced by physical therapy interventions. Examples of evidence that is emerging are integrated into this chapter and interspersed throughout most chapters of the textbook.

In order to provide a transition from language of early disablement models to a more current language, an overview of the key components of health status, functioning, and disability contained in both the Nagi and ICF models is presented in the following sections of this chapter. In addition, a discussion of risk factors and their potential impact on functioning and disability is presented.

Health Conditions (Pathological/Pathophysiological Conditions)

Health conditions, based on the terminology of the ICF framework, are acute or chronic diseases, disorders, or injuries that have an impact on a person's level of activity (see Fig. 1.2).^68,69 The first component of the Nagi disablement model refers to such conditions as active pathology or pathological/pathophysiological conditions (see Table 1.1) that disrupt the body's homeostasis.^112,113

Health conditions are characterized by a set of abnormal findings (clusters of signs and symptoms) that are indicative of alterations or interruptions of structure or function of the body and are primarily identified at the cellular, tissue, or organ/organ system level. Identification and classification of these abnormalities of anatomical structure or physiological process generally are the basis of a medical diagnosis and trigger medical intervention. However, it is well within a physical therapist's scope of practice using appropriate examination tools to identify abnormalities, particularly at the tissue level, that are the sources of musculoskeletal impairments.

Physical therapists in all areas of practice treat patients with a multitude of health conditions. Knowledge of the underlying pathology associated with health conditions is important background information, but it does not tell the therapist how to assess and treat a patient's impairments and subsequent dysfunction that arise from the pathological condition. Despite an accurate medical diagnosis and a therapist's thorough knowledge of specific health conditions, the experienced therapist knows full well that two patients with the same medical diagnosis, such as rheumatoid arthritis, and the same extent of joint destruction (confirmed radiologically) may have very different severities of impairment, activity (functional) limitation, and participation restriction, and, consequently, very different degrees of disability. This emphasizes the need for physical therapists to always pay close attention to the impact(s) of a particular health condition on function when designing meaningful management strategies to improve functional abilities.

Impairments

Impairments of the physiological, anatomical, and psychological functions and structures of the body are a reflection of a person's health status. Typically, impairments are the consequences of pathological conditions and encompass the signs and symptoms that reflect abnormalities at the body system, organ, or tissue level.^3,49,76

Types of Impairment

In the ICF model, impairments are subdivided into impairments of body function and body structure. Physical therapists typically provide care and services to patients with impairments of body function and/or body structure that affect the following systems:

• Musculoskeletal

• Neuromuscular

• Cardiovascular/pulmonary

• Integumentary

Most impairments of these systems are primarily the result of acquired or congenital abnormalities of physiological function or anatomical structure. Some representative examples of physical impairments commonly identified by physical therapists and managed with therapeutic exercise interventions are noted in Box 1.3.

Impairments of body function and body structure. Many of the impairments noted in Box 1.3, such as pain, reduced sensation, decreased ROM, deficits in muscle performance (strength, power, endurance), impaired balance or coordination, abnormal reflexes, and reduced ventilation are classified as impairments of body function.

Some impairments of body structure are readily apparent during a physical therapy examination through visual inspection. Such impairments include joint swelling, scarring, presence of an open wound, and lymphedema or amputation of a limb, or through palpation, such as adhesions, muscle spasm, and joint crepitus. Other structural impairments must be identified by a variety of imaging techniques, such as radiographic imaging to identify joint space narrowing associated with arthritis or magnetic resonance imaging (MRI) to identify a torn muscle or ligament.

Primary and secondary impairments. Impairments may arise directly from the health condition (direct/primary impairments) or may be the result of preexisting impairments (indirect/secondary impairments). A patient, for example, who has been referred to physical therapy with a medical diagnosis of impingement syndrome or tendonitis of the rotator cuff (pathological condition) may exhibit primary impairments of body function, such as pain, limited ROM of the shoulder, and weakness of specific shoulder girdle and glenohumeral musculature during the physical therapy examination (Fig. 1.3 A&B). The patient may have developed the shoulder pathology from a preexisting postural impairment (secondary impairment), which led to altered use of the upper extremity and impingement from faulty mechanics.

Composite impairments. When an impairment is the result of multiple underlying causes and arises from a combination of primary or secondary impairments, the term composite impairment is sometimes used. For example, a patient who sustained a severe inversion sprain of the ankle resulting in a tear of the talofibular ligament and whose ankle was immobilized for several weeks is likely to exhibit a balance impairment of the involved lower extremity after the immobilizer is removed. This composite impairment could be the result of chronic ligamentous laxity (structural impairment) and impaired ankle proprioception from the injury or muscle weakness (functional impairments) due to immobilization and disuse.

Regardless of the types of physical impairment exhibited by a patient, a therapist must keep in mind that impairments manifest differently from one patient to another. Although impairments are often associated with difficulties with some daily living tasks, not all impairments are necessarily linked to activity limitations (functional limitations) and participation restrictions or lead to disability. An important key to effective management of a patient's problems is to recognize functionally relevant impairments, in other words, impairments that directly contribute to current or future limitations and restrictions in a patient's daily life. Impairments that can predispose a patient to secondary health conditions or impairments also must be identified.

Equally crucial for the effective management of a patient's dysfunction is the need to analyze and determine, or at least infer and certainly not ignore, the underlying causes of the identified physical impairments of body function or body structure, particularly those related to impaired movement.^144,145 For example, are biomechanical abnormalities of soft tissues the source of restricted ROM? If so, which soft tissues are restricted, and why are they restricted? This information assists the therapist in the selection of appropriate, effective therapeutic interventions that target the underlying causes of the impairments, the impairments themselves, and the resulting functional deficits.

Although most physical therapy interventions, including therapeutic exercise, are designed to correct or reduce physical impairments of body function, such as decreased ROM or strength, poor balance, or limited cardiopulmonary endurance, the focus of treatment ultimately must be on restoration of function and prevention or reduction of dysfunction. Elimination or reduction of functionally relevant impairments is necessary during treatment. From a patient's perspective, however, successful outcomes of treatment are determined by a reduction or resolution of functional deficits and the restoration or improvement of daily functioning. A therapist cannot simply assume that intervening at the impairment level (e.g., with strengthening or stretching exercises) and subsequently reducing physical impairments (by increasing strength and ROM) generalize to improvement in a patient's level of activity and restoration of functional abilities for daily living. Mechanisms for integrating correction of physical impairments and restoration of functional abilities through task-specific training are explored in a model of effective patient management presented in a later section of this chapter.

Activity Limitations/Functional Limitations

In the language of the ICF, activity limitations occur when a person has difficulty executing or is unable to perform tasks or actions of daily life (see Box 1.2).^{33,68,69,158159,160,168} Functional limitations, which can be considered analogous to activity limitations, are described in the Nagi disablement model (see Table 1.1) as difficulties in functioning that occur at the level of the whole person.^112,113 Nagi also suggests that they are the result of impairments associated with active pathology and are characterized by the reduced ability of a person to perform actions or components of motor tasks in an efficient or typically expected manner. For example, as shown in Figure 1.4, restricted range of motion (impairment) of the shoulder as the result of adhesive capsulitis (health disorder/pathological condition) can limit a person's ability to reach overhead (activity limitation/functional limitation) while performing personal grooming or household tasks.

Limitations in a person's functioning may be physical, social, or psychological in nature. The focus of physical therapy interventions is on the management of limitations of physical functioning while respecting the needs of the whole person and recognizing that social and psychological influences also can limit a person's ability to function. During the course of patient management, if physical therapy interventions are to be effective, the focus of treatment must be directed toward remediating impairments and activity limitations that have the greatest adverse effects on a patient's functioning during daily activities, as well as those that are most important to the patient. Impairments and activity limitations that are or could be directly restricting a patient's participation in his or her roles and responsibilities in the home or community and, therefore, contributing to disability also must be addressed. When impairments and activity limitations restrict participation, a patient's health-related quality of life may begin to deteriorate.

Many studies have linked activity/functional limitations with body function impairments, particularly in older adults. Links have been identified between limited ROM of the shoulder and difficulty reaching behind the head or back while bathing and dressing,¹⁶⁹ between decreased isometric strength of lower extremity musculature and difficulty stooping and kneeling⁶³ as well as a link between decreased lower extremity peak power and reduced walking speed and difficulty moving from sitting to standing.¹²⁹ However, it should also be noted that a single or even several mild impairments of body function or structure often do not cause loss of functioning associated with activity. For example, results of a two-year observational study of patients with symptomatic hip or knee osteoarthritis (OA) demonstrated that increased joint space narrowing (a body structure impairment that is considered an indicator of progression of the disease) confirmed radiologically was not associated with an increase in activity limitations as measured on a self-report assessment of physical functioning.¹⁸ Furthermore, evidence from other studies suggests that the severity and complexity of impairments must reach a critical level, which is different for each person, before degradation of functioning begins to occur.^122,131

Types of Activity Limitations/Functional Limitations

Limitations in the area of physical functioning deal with the performance of sensorimotor tasks—that is, total body actions that typically are components or elements of functional activities. These activities include basic activities of daily living (BADL), such as bathing, dressing, or feeding, and the more complex tasks known as instrumental activities of daily living (IADL), such as occupational tasks, school-related skills, housekeeping, and recreational activities, or community mobility (driving, using public transportation), just to name a few.

Box 1.4 identifies a number of activity limitations/functional limitations that can arise from physical impairments in body function or structure, involve whole-body movements or actions, and are necessary component motions of simple to complex daily living tasks. Defining limitations in this way highlights the importance of identifying abnormal or absent component motions of motor skills through task analysis during the physical therapy examination and later integrating task-specific functional motions into a therapeutic exercise program.

When a person is unable or has only limited ability to perform any of the whole-body component motions identified in Box 1.4, decreased independence in BADL and IADL may occur, quality of life may become compromised, and hence, disability may ensue. The following is an example of this relationship between activity limitations and potential disability. To perform a basic home maintenance task (IADL), such as painting a room, a person must be able to grasp and hold a paintbrush or roller, climb a ladder, reach overhead, kneel, or stoop down to the floor. If any one of these component movements is limited, it may not be possible to perform the overall task of painting the room.

An essential element of a physical therapy examination and evaluation is the analysis of motor tasks to identify the component motions that are difficult for a patient to perform. This analysis helps the therapist determine why a patient is unable to perform specific daily living tasks. This information coupled with identification and measurement of the impairments that are the source of the altered or absent component movement patterns, in turn, is used for treatment planning and selection of interventions to restore function and prevent potential disability.

Participation Restrictions and Disability

As identified in the ICF model (see Table 1.2), participation restrictions are defined as problems a person may experience in his or her involvement in life situations as measured against social standards (see Box 1.2).^{68,69,158159,160,168} More specifically, participation restrictions encompass problems that deal with fulfilling personal or social responsibilities and obligations in relation to societal expectations in the context of a person's attitudes and environment.

Disability is the term in the Nagi model (see Table 1.1) used to describe the inability to participate in activities or tasks related to one's self, the home, work, recreation, or the community in a manner or to the extent that the individual or the community as a whole (e.g., family, friends, coworkers) perceive as "normal."^112,113

To add to the disparity of how terms are defined in various models, the definition of disability in the ICF is not limited to societal or individual functioning. Rather, it is an umbrella term that encompasses impairments of body function and/or structure, activity limitations, and participation restrictions as noted previously in the overview of the ICF model (see Table 1.2).^68,69,168

Social expectations or roles that involve interactions with others and participation in activities are an important part of who each of us is. These roles are specific to age, gender, sex, and cultural background. Categories of activities or roles that, if limited, may contribute to participation restrictions or disability are summarized in Box 1.5. However, it is important to point out that the description of participation restrictions in the ICF primarily focuses on limitations associated with societal functioning, whereas the description of disability in the Nagi model is inclusive of individual functioning in the context of the environment, such as personal care (BADL) and more complex daily living skills (IADL) as well as societal functioning.

Because disability is such a complex process, the extent to which each aspect of functioning or disability affects one's perceived level of disability is not clearly understood. An assumption is made that when impairments and activity limitations are so severe or of such long-duration that they cannot be overcome to a degree acceptable to an individual, a family, or society, the perception of "being disabled" occurs.¹³¹ The perception of disability is highly dependent on a person's or society's expectations of how or by whom certain roles or tasks should be performed.

There is a growing body of evidence suggesting that physical impairments and activity limitations/functional limitations directly or indirectly contribute to participation restrictions or disability.^{76,79,129,169} Consequently, an approach to patient management that focuses on restoring or improving a patient's level of functioning may prevent or reduce disability and may have a positive impact on quality of life.

Prevention of Disability

Understanding the relationships among a health condition, impairments, activity limitations (functional limitations), participation restrictions, and the impact of environmental and personal factors on functioning is fundamental to the prevention or reduction of disability.^19,53,78 The presence of impairments and limitations may or may not lead to loss of independence and result in disability.

Take, for example, a relatively inactive person with longstanding osteoarthritis of the knees. The inability to get up from the floor or from a low seat (activity limitation/functional limitation) because of limited flexion of the knees and power deficits of the hip and knee extensors (impairments in body function) could indeed lead to restricted participation in life's activities and disability in several areas of everyday functioning. Disability could be expressed by problems in self-care (inability to get in and out of a tub or stand up from a standard height toilet seat), home management (inability to perform selected housekeeping, gardening, or yard maintenance tasks), or community mobility (inability to get into or out of a car or van independently).

The perception of disability possibly could be minimized if the patient's functional ROM and strength can be improved with an exercise program and the increased ROM and strength are incorporated into progressively more challenging functional activities or if the physical environment can be altered sufficiently with the use of adaptive equipment and assistive devices.

Adjusting expected roles or tasks within the family might also have a positive impact on the prevention or reduction of disability. Factors within the individual also can have an impact on the prevention, reduction, or progression of disability. Those factors include level of motivation or willingness to make lifestyle changes and accommodations as well as the ability to understand and cope with an adjusted lifestyle.¹⁷⁵ This example highlights that inherent in any discussion of disability is the assumption that it can be prevented or remediated.¹⁹

Categories of prevention. Prevention falls into three categories.³

• Primary prevention: Activities such as health promotion designed to prevent disease in an at-risk population

• Secondary prevention: Early diagnosis and reduction of the severity or duration of existing disease and sequelae

• Tertiary prevention: Use of rehabilitation to reduce the degree or limit the progression of existing disability and improve multiple aspects of function in persons with chronic, irreversible health conditions

Therapeutic exercise, the most frequently implemented physical therapy intervention, has value at all three levels of prevention. For example, the use of resistance exercises and aerobic conditioning exercises in weight-bearing postures is often advocated for the primary and secondary prevention of age-related osteoporosis.^32,62 However, therapists who work with patients with chronic musculoskeletal or neuromuscular diseases or disorders routinely are involved with tertiary prevention of disability.

Risk Factors

Modifying risk factors through an intervention, such as therapeutic exercise, is an important tool for preventing or reducing the impact of health conditions and subsequent impairments, limitations, and restrictions in functioning that may lead to disability. Risk factors are influences or characteristics that predispose a person to impaired functioning and potential disability. As such, they exist prior to the onset of a health condition and associated impairments, limitations, or restrictions.^19,78,175 Some factors that increase the risk of disability are biological characteristics, lifestyle behaviors, psychological characteristics, and the impact of the physical and social environments. Examples of each of these types of risk factor are summarized in Box 1.6.

Some of the risk factors, in particular lifestyle characteristics and behaviors and their impact on the potential for disease or injury, have become reasonably well known because of public service announcements and distribution of educational materials in conjunction with health promotion campaigns, such as Healthy People 2010¹⁷² and Healthy People 2020.¹⁷³ Information on the adverse influences of health-related risk factors, such as a sedentary lifestyle, obesity, and smoking, has been widely disseminated by these public health initiatives. Although the benefits of a healthy lifestyle, which includes regular exercise and physical activity, are well-founded and widely documented,^1,172,173 initial outcomes of a previous national campaign, Healthy People 2000,¹²⁸ suggest that an increased awareness of risk factors has not translated effectively into dramatic changes in lifestyle behaviors to reduce the risk of disease or injury.⁴² This demonstrates that increased knowledge does not necessarily change behavior.

When a health condition exists, the reduction of risk factors by means of buffers (interventions aimed at reducing the progression of a pathological condition, impairments, limitations, restrictions, and potential disability) is appropriate.⁷⁸ This focus of intervention is categorized as secondary or tertiary prevention. Initiating a regular exercise program and increasing the level of physical activity on a daily basis or altering the physical environment by removing architectural barriers or using assistive devices for a range of daily activities are examples of buffers that can reduce the risk of disability. (Refer to Chapter 2 of this textbook for additional information on prevention, reduction of health-related risk factors, and wellness.)

Summary

An understanding of the concepts of functioning and disability; of the relationships among the components of functioning, disability, and health; and of the various models and classification systems that have been developed over the past four decades provides a conceptual framework for practice and research. This knowledge also establishes a foundation for sound clinical decision-making and effective communication and sets the stage for delivery of effective, efficient, meaningful physical therapy care and services for patients.

An understanding of the concepts of functioning and disability coupled with knowledge of the process of making informed clinical decisions based on evidence from the scientific literature provides the foundation for comprehensive management of patients seeking and receiving physical therapy services. Provision of quality patient care involves the ability to make sound clinical judgments, solve problems that are important to a patient, and apply knowledge of the relationships among a patient's health condition(s), impairments, limitations and restrictions in daily activities, and resulting disability throughout each phase of management.

The primary purpose of this section of the chapter is to describe a model of patient management used in physical therapy practice. Inasmuch as clinical reasoning and evidence-based decision-making are embedded in each phase of patient management, a brief overview of the concepts and processes associated with clinical decision-making and evidence-based practice is presented before exploring a systematic process of patient management in physical therapy. Relevant examples of the clinical decisions a therapist must make are highlighted within the context of the patient management model.

Clinical Decision-Making

Clinical decision-making refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations in the context of ptient care.⁸⁴ One of the many areas of clinical decision-making in which a therapist is involved is the selection, implementation, and modification of therapeutic exercise interventions based on the unique needs of each patient or client. To make effective decisions, merging clarification and understanding with critical and creative thinking is necessary.⁹¹ A number of requisite attributes are necessary for making informed, responsible, efficient, and effective clinical decisions.^{39,91,103,152} Those requirements are listed in Box 1.7.

There is a substantial body of knowledge in the literature that describes various strategies and models of clinical decision-making in the context of patient management by physical therapists.^* One such model, the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), describes a series of steps involved in making informed clinical decisions.¹³⁹

The use of clinical decision-making in the diagnostic process also has generated extensive discussion in the literature.^† To assist in the decision-making process and ultimately improve patient care, tools known as clinical prediction rules, first developed in medicine, also have been developed for use by physical therapists.^25,44 Some clinical prediction rules (CPRs) contain predictive factors that help a clinician establish specific diagnoses or improve the accuracy of prognoses, whereas others identify subgroupings of patients within large, heterogeneous groups who are most likely to benefit from a particular approach to treatment or specific therapeutic interventions. To date, some prediction tools in physical therapy have been developed to assist in the diagnosis of health conditions, including osteoarthritis in patients with hip pain¹⁶² and deep vein thrombosis in patients with leg pain.¹³⁴ However, a greater number of CPRs in physical therapy have been established to predict likely responses of patients to treatment. As examples, CPRs have been developed to identify a sub-grouping of patients with patellofemoral pain syndrome who are most likely to respond positively to lumbopelvic manipulation,⁷⁰ patients with low back pain most likely to respond to stabilization exercises,⁶⁴ and those with neck pain for whom thoracic spine manipulation is most likely to be effective.²⁸

It is important to note, however, that little research, thus far, has focused on validation of published CPRs¹⁰ or their impact on the effectiveness of patient care from specific therapeutic interventions. The results of two recent systematic reviews of the literature underscore these points. One review¹⁰ indicated that the quality of the studies on which CPRs to determine treatment effectiveness have been based varies considerably. The results of the other review of CPRs for musculoskeletal conditions¹⁵⁷ demonstrated that currently there is only limited evidence to support the use of these rules to predict the effectiveness of specific interventions or to optimize treatment. Additional information from studies directed toward clinical decision-making is integrated into the remainder of this section on patient management or is addressed in later chapters.

Health care continues to move in the direction of physical therapists being the first-contact practitioners through whom consumers gain access to services without physician referral. Hence, the need to make sound clinical judgments supported by scientific evidence during each phase of patient management has become more essential for physical therapy practitioners.

Evidence-Based Practice

Physical therapists who wish to provide high-quality patient care must make informed clinical decisions based on sound clinical reasoning and knowledge of the practice of physical therapy. An understanding and application of the principles of evidence-based practice provide a foundation to guide a clinician through the decision-making process during the course of patient care.

Definition and Description of the Process

Evidence-based practice is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of an individual patient."¹⁴² Evidence-based practice also involves combining knowledge of evidence from well-designed research studies with the expertise of the clinician and the values, goals, and circumstances of the patient.¹⁴³

The process of evidence-based practice involves the following steps^29,143:

1. Identify a patient problem and convert it into a specific question.

2. Search the literature and collect clinically relevant, scientific studies that contain evidence related to the question.

3. Critically analyze the pertinent evidence found during the literature search and make reflective judgments about the quality of the research and the applicability of the information to the identified patient problem.

4. Integrate the appraisal of the evidence with clinical expertise and experience and the patient's unique circumstances and values to make decisions.

5. Incorporate the findings and decisions into patient management.

6. Assess the outcomes of interventions and ask another question if necessary.

This process enables a practitioner to select and interpret the findings from the evaluation tools used during the examination of the patient and to implement effective treatment procedures that are rooted in sound theory and scientific evidence (rather than anecdotal evidence, opinion, or clinical tradition) to facilitate the best possible outcomes for a patient.

It is impractical to suggest that a clinician must search the literature for evidence to support each and every clinical decision that must be made. Despite time constraints in the clinical setting, when determining strategies to solve complex patient problems or when interacting with third-party payers to justify treatment, the "thinking therapist" has a professional responsibility to seek out evidence that supports the selection and use of specific evaluation and treatment procedures.⁷

Accessing Evidence

One method for staying abreast of evidence from current literature is to read one's professional journals on a regular basis. It is also important to seek out relevant evidence from high-quality studies (randomized controlled trials, systematic reviews of the literature) from journals of other professions.³⁰ Journal articles that contain systematic reviews of the literature or summaries of multiple systematic reviews are an efficient means to access evidence, because they provide a concise compilation and critical appraisal of a number of scientific studies on a topic of interest.

Evidence-based clinical practice guidelines for management of specific physical conditions or groupings of impairments also have been developed; they address the relative effectiveness of specific treatment strategies and procedures. These guidelines provide recommendations for management based on systematic reviews of current literature.^127,146 Initially, clinical practice guidelines that address four broadly defined musculoskeletal conditions commonly managed by physical therapists—specifically knee pain,¹²³ low back pain,¹²⁴ neck pain,¹²⁵ and shoulder pain¹²⁶—were developed by the Philadelphia Panel, a panel of experts from physical therapy and medicine.

As mentioned previously in this chapter, a series of clinical practice guidelines has been created and recently published by the Orthopedic Section of the APTA. These guidelines provide evidence-based recommendations for orthopedic physical therapy management (diagnosis, prognosis, selection of therapeutic interventions, and use of outcome measures) of a number of impairment/function-based groupings that are based on the ICF.⁵⁰ Some examples include clinical practice guidelines for management of neck pain,²⁶ knee pain and mobility impairments,⁹⁴ knee stability impairments,⁹⁵ hip pain and mobility deficits associated with osteoarthritis,²⁷ heel pain associated with plantar fasciitis,¹⁰⁷ and deficits associated with Achilles tendonitis.²² More specific information from these guidelines is integrated into the regional chapters of this textbook.

If articles that contain systematic reviews of the literature on a specific topic have not been published, a therapist may find it necessary and valuable to perform an individual literature search to identify evidence applicable to a clinical question or patient problem. Journals exclusively devoted to evidence-based practice are another means to assist the practitioner who wants to identify well-designed research studies from a variety of professional publications without doing an individual search. These journals provide abstracts of research studies that have been critically analyzed and systematically reviewed.

Online bibliographic databases also facilitate access to evidence. Many databases provide systematic reviews of the literature relevant to a variety of health professions by compiling and critiquing several research studies on a specific patient problem or therapeutic intervention.^7,29,109 One example is the Cochrane Database of Systematic Reviews, which reports peer-reviewed summaries of randomized controlled trials and the evidence for and against the use of various interventions for patient care, including therapeutic exercise. Although a recent study¹⁰⁸ identified CENTRAL (Cochrane Central Registry of Controlled Trials), PEDro (Physiotherapy Evidence Database), PubMed, and EMBASE (Excerpta Medica Database) as the four most comprehensive databases indexing reports of randomized clinical trials of physical therapy interventions, only PEDro exclusively reports trials, reviews, and practice guidelines pertinent to physical therapy.⁹⁹ Easily accessed online databases such as these streamline the search process and provide a wealth of information from the literature in a concise format.

To further assist therapists in retrieving and applying evidence in physical therapist practice from the Cochrane online library, the Physical Therapy journal publishes a recurring feature called Linking Evidence and Practice (LEAP). This feature summarizes a Cochrane review and other scientific evidence on a single topic relevant to physical therapy patient care. In addition, LEAP presents case scenarios to illustrate how the results of the review of evidence can be applied to the decision-making process during patient management.

In support of evidence-based practice, relevant research studies are highlighted or referenced throughout each of the chapters of this text in relationship to the therapeutic exercise interventions, manual therapy techniques, and management guidelines presented and discussed. However, there is also an absence of research findings to support the use of some of the interventions presented. For such procedures, a therapist must rely on clinical expertise and judgment as well as each patient's response to treatment to determine the impact of these interventions on patient outcomes. Examples of how to incorporate the ongoing process of clinical decision-making and application of evidence into each phase of patient management are presented in the following discussion of a model for patient management.

A Patient Management Model

The physical therapy profession has developed a comprehensive approach to patient management designed to guide a practitioner through a systematic series of steps and decisions for the purpose of helping a patient achieve the highest level of functioning possible. This model is illustrated in Figure 1.5.

As described in the Guide to Physical Therapist Practice, the process of patient management has five basic components.^3,14,46

1. A comprehensive examination 2. Evaluation of data collected 3. Determination of a diagnosis based on impairments of body structure and function, functional limitations (activity limitations), and disability (participation restrictions)

2. Establishment of a prognosis and plan of care based on patient-oriented goals

3. Implementation of appropriate interventions

The patient management process culminates in the attainment of meaningful functional outcomes by the patient, which then must be re-examined and re-evaluated before a patient's discharge from care. As the model indicates, the re-examination and re-evaluation process occurs not only at the conclusion of treatment but throughout each phase of patient management. The ability to make timely decisions and appropriate judgments and to develop or adjust an ongoing series of working hypotheses makes transition from one phase of management to the next occur in an effective, efficient manner.

Examination

The first component of the patient management model is a comprehensive examination of the patient. Examination is the systematic process by which a therapist obtains information about a patient's problem(s) and his or her reasons for seeking physical therapy services. During this initial data collection, the therapist acquires information from a variety of sources. The examination process involves both comprehensive screening and specific diagnostic testing. It is the means by which the therapist gathers sufficient information about the patient's existing or potential problems (health conditions, impairments, activity/functional limitations, participation restrictions/disabilities) to ultimately formulate a diagnosis and determine whether these problems can be appropriately treated by physical therapy interventions. If treatment of the identified problems does not fall within the scope of physical therapy practice, referral to another health-care practitioner or resource is warranted. The examination is also the means by which baseline measurements of current impairments, functional deficits and abilities are established as a reference point from which the results of therapeutic interventions can be measured and documented.

There are three distinct elements of a comprehensive examination.³

• The patient's health history

• A relevant systems review

• Specific tests and measures

Throughout the examination process, a therapist seeks answers to an array of questions and concurrently makes a series of clinical decisions that shape and guide the examination process. Examples of some questions to be asked and decisions to be made are noted in Box 1.8.

History

The history is the mechanism by which a therapist obtains an overview of current and past information (both subjective and objective) about a patient's present condition(s), general health status (health risk factors and coexisting health problems), and why the patient has sought physical therapy services. It has been shown in a multi-center study that patients seen in outpatient physical therapy practices have extensive health histories, including use of medications for a variety of medical conditions (e.g., hypertension, pulmonary disorders, and depression) and surgical histories (e.g., orthopedic, abdominal, and gynecological surgeries).¹³

The types of data that can be generated from a patient's health history are summarized in Box 1.9.^3,14,15,87 The therapist determines which aspects of the patient's history are more relevant than others and what data need to be obtained from various sources.

Sources of information about the patient's history include:

• Self-report health history questionnaires filled out prior to or during the initial visit.

• Interviews with the patient, family, or other significant individuals involved in patient care.

• Review of the medical record.

• Reports from the referral source, consultants, or other health-care team members.

The extent of information about a patient's health history that is necessary or available may be extensive or limited and may or may not be readily accessible prior to the first contact with the patient. Compare, for example, the information available to the therapist working in an acute care facility who has ready access to a patient's medical record versus the home health therapist who may have only a patient's medical diagnosis or brief surgical history. Regardless of the extent of written reports or medical/surgical history available, reviewing this information prior to the initial contact with the patient helps a therapist prioritize the questions asked and areas explored during the interview with the patient.

The interview is crucial for determining a patient's chief concerns and functional status—past, current, and desired. It also helps a therapist see a patient's problems from the patient's own perspective, specifically with regard to the perception of limitations in daily functioning or disability. A patient almost always describes a current problem in terms of limited abilities or perceived quality of life, not the presenting impairment(s). For example, a patient might report, "My elbow really hurts when I pick up something heavy" or "I'm having trouble playing tennis (or bowling or unloading groceries from the car)." During the interview, questions that relate to symptoms (in this case, elbow pain) should identify location, intensity, description, and factors that provoke (aggravate) or alleviate symptoms in a 24-hour period.

Collecting health history data through a self-report questionnaire has been shown to be an accurate source of information from patients seen in an outpatient orthopedic physical therapy practice.¹⁷ In addition, depending on a patient's condition and individual situation, the perceptions of family members, significant others, caregivers, or employers are often as important to the overall picture as the patient's own assessment of the current problems.

While taking a health history, it is useful to group the interview questions into categories to keep the information organized. Gathering and evaluating data simultaneously makes it easier to recognize and identify patterns or clusters of signs and symptoms and even to begin to formulate one or more initial, "working" hypotheses about the patient's problem(s), which later will be supported or rejected. Making these judgments helps organize and structure the examination.^138,139,167 Experienced therapists tend to form working hypotheses quite early in the examination process, even while reviewing a patient's chart before the initial contact with the patient.^{71,72,83,104,176} This enables a therapist to determine and prioritize which definitive tests and measures should be selected for the later portion of the examination.⁷²

Systems Review

A brief but relevant screening of the body systems, known as a systems review,³ is performed during the patient interview as a part of the examination process after organizing and prioritizing data obtained from the health history. The greater the number of health-related risk factors identified during the history, the greater is the importance of the review of systems. The systems typically screened by therapists are the cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular systems, although problems in the gastrointestinal and genitourinary systems also may be relevant.^14,16 This screening process gives a general overview of a patient's cognition, communication, and social/emotional responses. Only limited information on the anatomical and physiological status or function of each system is obtained. Table 1.3 identifies each system and gives examples of customary screening procedures used by physical therapists.

NOTE: Some of the information noted in Table 1.3, such as the patient's psychosocial status, may have been gathered previously while reviewing and taking the patient's history and need not be addressed again.

The purpose of screening each system is to identify any abnormalities or deficits that require further or more specific testing by a therapist or another health-care practitioner.^3,14,16,87 The systems review serves to identify a patient's symptoms that may have been overlooked during the investigation of the patient's chief symptoms that precipitated the initial visit to therapy.¹⁶ Findings from the systems review coupled with information about a patient's chief complaints secured from the patient's health history enable a therapist to begin to make decisions about the possible causes of a patient's impairments and functional deficits and to distinguish between problems that can and cannot be managed effectively by physical therapy interventions. If a therapist determines that a patient's problems lie outside the scope of physical therapy practice, no additional testing is warranted and referral to another health-care practitioner is appropriate.^3,14,16,51

Specific Tests and Measures

Once it has been decided that a patient's problems/conditions are most likely amenable to physical therapy intervention, the next determination a therapist must make during the examination process is to decide which aspects of physical function require further investigation through the use of specific tests and measures.

Specific (definitive/diagnostic) tests and measures used by physical therapists provide in-depth information about impairments, activity limitations, participation restrictions/disabilities.^3,45,49,87 The specificity of these tests enables a therapist to support or refute the working hypotheses formulated while taking the patient's health history and performing the systems review. In addition, the data generated from these definitive tests are the means by which the therapist ascertains the possible underlying causes of a patient's impairments and functional deficits. These tests also give the therapist a clearer picture of a patient's current condition(s) and may reveal information about the patient not previously identified during the history and systems review. If treatment is initiated, the results of these specific tests and measures establish objective baselines from which changes in a patient's physical status as the result of interventions are measured.

Given the array of specific tests available to a therapist for a comprehensive physical therapy examination, the guidelines summarized in Box 1.10 should be considered when determining which definitive tests and measures need to be selected and administered.^3,45,46,133

There are more than 20 general categories of specific tests and measures commonly performed by physical therapists.^3,164 These tests are selected and administered to target specific impairments of the structure and function of body systems. Typically, testing involves multiple body systems to identify the scope of a patient's impairments. When examining a patient with chronic knee pain, for example, in addition to performing a thorough musculoskeletal examination, it also would be appropriate to administer tests that identify the impact of the patient's knee pain on the neuromuscular system (by assessing balance and proprioception) and the cardiopulmonary system (by assessing aerobic capacity).

Because many of the health-related conditions as the result of injury or disease discussed in this textbook involve the neuromusculoskeletal system, some examples of specific tests and measures that identify musculoskeletal and neuromuscular impairments are noted here. They include but are not limited to:

• Assessment of pain

• Goniometry and flexibility testing

• Joint mobility, stability, and integrity tests (including ligamentous testing)

• Tests of muscle performance (manual muscle testing, dynamometry)

• Posture analysis

• Assessment of balance, proprioception, neuromuscular control

• Gait analysis

• Assessment of assistive, adaptive, or orthotic devices

An in-depth examination of impairments by means of diagnostic tests provides valuable information about the extent and nature of the impairments and is the foundation of the diagnosis(es) made by a physical therapist. A thorough examination of impairments also helps a therapist select the most appropriate types of exercise and other forms of therapeutic intervention for the treatment plan.

Although specific testing of impairments is crucial, these tests do not tell the therapist how the impairments are affecting the patient's functional capabilities. Therefore, every examination should also include use of instruments that specifically measure extent of activity/functional limitations, participation restrictions, and disability. These tools, often referred to as functional outcome measures, are designed to reflect the impact of a patient's health condition and resulting impairments on functional abilities and health-related quality of life.⁶ These instruments typically supply baseline measurements of subjective information against which changes in a patient's function or perceived level of disability are documented over the course of treatment. These tests may be generic, covering a wide range of functional abilities, or specific to a particular body region, such as upper extremity function. Generic instruments can be used to assess the global functioning of patients who have a wide array of health conditions and impairments but yield less site-specific data than regional tests of functional abilities or limitations.¹³³

The format of functional testing procedures and instruments varies. Some tests gather information by self-report (by the patient or family member);⁸⁶ others require observation and rating of the patient's performance by a therapist as various functional tasks are carried out.⁶ Some instruments measure a patient's ease or difficulty of performing specific physical tasks. Other instruments incorporate temporal (time-based) or spatial (distance-based) criteria, such as measurement of walking speed or distance, in the format.⁵ Test scores also can be based on the level of assistance needed (with assistive devices or by another person) to complete a variety of functional tasks.

Indices of disability measure a patient's perception of his or her degree of participation restriction. These self-report instruments usually focus on BADL and IADL, such as the ability or inability to care for one's own needs (physical, social, emotional) or the level of participation in the community that is currently possible, desired, expected, or required. Information gathered with these instruments may indicate that the patient requires consultation and possible intervention by other health-care professionals to deal with some of the social or psychological aspects of disability.

NOTE: It is well beyond the scope or purpose of this text to identify and describe the many tests and instruments that identify and measure physical impairments, functional deficits, or disability. The reader is referred to several resources in the literature that provide this information.^1,5,6,23,98

Evaluation

Evaluation is a process characterized by the interpretation of collected data. The process involves analysis and integration of information to form opinions by means of a series of sound clinical decisions.³ Although evaluation is depicted as a distinct entity or phase of the patient management model (see Fig. 1.5), some degree of evaluation goes on at every phase of patient management, from examination through outcome. Interpretation of relevant data, one of the more challenging aspects of patient management, is fundamental to the determination of a diagnosis of dysfunction and prognosis of functional outcomes. By pulling together and sorting out subjective and objective data from the examination, a therapist should be able to determine the following:

• A patient's general health status and its impact on current and potential function

• The acuity or chronicity and severity of the current condition(s)

• The extent of structural and functional impairments of body systems and impact on functional abilities

• Which impairments are related to which activity limitations

• A patient's current, overall level of physical functioning (limitations and abilities) compared with the functional abilities needed, expected, or desired by the patient

• The impact of physical dysfunction on social/emotional function

• The impact of the physical environment on a patient's function

• A patient's social support systems and their impact on current, desired, and potential function

The decisions made during the evaluation process may also suggest that additional testing by the therapist or another practitioner is necessary before the therapist can determine a patient's diagnosis and prognosis for positive outcomes from physical therapy interventions. For example, a patient whose chief complaints are related to episodic shoulder pain but who also indicates during the health history that bouts of depression sometimes make it difficult to work or socialize should be referred for a psychological consultation and possible treatment.¹⁴ Results of the psychological evaluation could be quite relevant to the success of the physical therapy intervention.

Addressing the questions posed in Box 1.11 during the evaluation of data derived from the examination enables a therapist to make pertinent clinical decisions that lead to the determination of a diagnosis and prognosis and the selection of potential intervention strategies for the plan of care.

During the evaluation, it is particularly useful to ascertain if and to what extent relationships exist among measurements of impairments, activity/functional limitations, participation restrictions, and the patient's perceived level of disability. These relationships often are not straightforward as indicated in the following investigations.

Although the results of these studies to some extent are related to the choice of measurement tools, these findings highlight the complexity of evaluating disability and suggest that identifying the strength or weakness of the links among the levels of functioning and disability may help a therapist predict more accurately a patient's prognosis, with the likelihood of functional improvement the result of treatment. Evaluating these relationships and answering the other questions noted in Box 1.11 lays the foundation for ascertaining a diagnosis and prognosis and developing an effective plan of care.

Diagnosis

The term diagnosis can be used in two ways—it refers to either a process or a category (label) within a classification system.⁵⁴ Both usages of the word are relevant to physical therapy practice. The diagnosis is an essential element of patient management because it directs the physical therapy prognosis (including the plan of care) and interventions.^{3,45,87,144,167,183}

Diagnostic Process

The diagnostic process is a complex sequence of actions and decisions that begins with: (1) the collection of data (examination); (2) the analysis and interpretation of all relevant data collected, leading to the generation of working hypotheses (evaluation); and (3) organization of data, recognition of clustering of data (a pattern of findings), formation of a diagnostic hypothesis, and subsequent classification of data into categories (impairment-based diagnoses).^{3,36,51,136,145,167,183}

The diagnostic process is also necessary to develop a prognosis (including a plan of care) and is a prerequisite for treatment.^{35,77,136,144,167,183} Through the diagnostic process a physical therapist classifies dysfunction (most often, movement dysfunction), whereas a physician identifies disease.^{51,77,87,136,171} For the physical therapist, the diagnostic process focuses on the consequences of a disease or health disorder¹⁸³ and is a mechanism by which discrepancies and consistencies between a patient's current level of performance and desired level of function and his or her capacity to achieve that level of function are identified.³

Diagnostic Category

A diagnostic classification system developed by physical therapists is useful for delineating the knowledge base and scope of practice of physical therapy.^{3,35,54,77,136,144,182} The use of a common diagnostic classification scheme not only guides treatment,⁶⁴ it fosters clarity of communication in practice and clinical research.^45,77

A diagnostic category (clinical classification) is a grouping that identifies and describes patterns or clusters of physical findings (signs and symptoms of impairments of body functions or structures associated with activity/functional limitations, participation restrictions, and the extent of disability). A diagnostic category also describes the impact of a condition on function at the system level (musculoskeletal, neuromuscular, cardiovascular/pulmonary, integumentary) and at the level of the whole person.³ Within each body system are a number of broad-based diagnostic categories defined by the primary impairments and based on clusters of common impairments exhibited by a patient. Box 1.12 lists the impairment-based diagnostic classifications developed by consensus by physical therapists for the musculoskeletal system.³ The groupings of impairments exhibited by patients with most of the health conditions discussed in this textbook can be classified into at least one of these diagnostic categories.

Patients with different health conditions but similar impairments may be classified by the same diagnostic category. Moreover, it is not uncommon during the diagnostic process for a therapist to identify more than one diagnostic category to describe a patient's impaired function. Complete descriptions of impairment-based diagnostic categories for each body system can be found in the Guide to Physical Therapist Practice.³

Preferred practice patterns, which are identified by the diagnostic categories, represent consensus-based opinions that outline broad patient management guidelines and strategies used by physical therapists for each diagnostic category.^34,56,183 These patterns are not designed to indicate a specific pathway of care, such as an exercise protocol for a specific postoperative condition, but rather are descriptions of all components of patient management from examination through discharge for which physical therapists are responsible. In other words, the preferred practice patterns describe what it is that physical therapists do. For a detailed description of the suggested procedures for each preferred practice pattern for the musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary systems, refer to the Guide.³

NOTE: The impairment/function-based diagnoses in the clinical practice guidelines developed by the Orthopedic Section of the APTA are an alternative to the diagnostic categories identified in the Guide and are based on the classification and coding system described in the ICF. The diagnostic classifications are linked to recommendations for physical therapy interventions based on "best evidence" from the scientific literature.^{22,26,27,94,95,107}

Prognosis and Plan of Care

After the initial examination has been completed, data have been evaluated, and an impairment-based diagnosis has been established, a prognosis (see Fig. 1.5), including a plan of care, must be determined before initiating any interventions. A prognosis is a prediction of a patient's optimal level of function expected as the result of a plan for treatment during an episode of care and the anticipated length of time needed to reach specified functional outcomes.^3,87 Some factors that influence a patient's prognosis and functional outcomes are noted in Box 1.13.

Determining an accurate prognosis is, indeed, challenging even for experienced therapists. The more complex a patient's problems, the more difficult it is to project the patient's optimal level of function, particularly at the onset of treatment. For example, if an otherwise healthy and fit 70-year-old patient who was just discharged from the hospital after a total knee arthroplasty is referred for home-based physical therapy services, it is relatively easy to predict the time frame that will be needed to prepare the patient to return to independence in the home and community. In contrast, it may be possible to predict only incremental levels of functional improvement at various stages of rehabilitation for a patient who has sustained multiple fractures and soft tissue injuries as the result of an automobile accident.

In these two examples of establishing prognoses for patients with musculoskeletal conditions, as with most other patient problems, the accuracy of the prognosis is affected in part by the therapist's clinical decision-making ability based on the following³:

• Familiarity with the patient's current health condition(s) and the surgical intervention(s) and previous history of diseases or disorders

• Knowledge of the process and time frames of tissue healing

• Experience managing patients with similar surgical procedures, pathological conditions, impairments, and functional deficits

• Knowledge of the efficacy of tests and measures performed, accuracy of the findings, and effectiveness of the physical therapy interventions

Plan of Care

The plan of care, an integral component of the prognosis, delineates the following³:

• Anticipated goals.

• Expected functional outcomes that are meaningful, utilitarian, sustainable, and measurable.

• Extent of improvement predicted and length of time necessary to reach that level.

• Specific interventions.

• Proposed frequency and duration of interventions.

• Specific discharge plans.

Setting Goals and Outcomes in the Plan of Care

Developing a plan of care involves collaboration and negotiation between the patient (and, when appropriate, the family) and the therapist.^3,77,87 The anticipated goals and expected outcomes documented in the plan of care must be patient-centered—that is, the goals and outcomes must be meaningful to the patient. These goals and outcomes also must be measurable and linked to each other. Goals are directed at the reduction or elimination of the physical signs and symptoms of pathology and impairments in body function and/or structure that seem to be limiting the patient's functional abilities.³ Outcomes are associated with the amelioration of functional deficits and participation restrictions to the greatest extent possible coupled with achieving the optimal level possible of function, general health, and patient satisfaction.³

Establishing and prioritizing meaningful, functionally relevant goals and determining expected outcomes requires engaging the patient and/or family in the decision-making process from a therapist's first contact with a patient. Patients come to physical therapy not to get stronger or more flexible, but rather, to be able to perform physical activities they enjoy doing or must do in their lives with ease and comfort. Knowing what a patient wants to be able to accomplish as the result of treatment and ascertaining which accomplishments are the most important to the patient helps a therapist develop and prioritize intervention strategies that target the patient's functional limitations and functionally related impairments. This, in turn, increases the likelihood of successful outcomes from treatment.^120,130 Some key questions a therapist often asks a patient or the patient's extended support system early in the examination while taking the history that are critical for establishing anticipated goals and expected outcomes in the plan of care are listed in Box 1.14.^4,87,120,130

An integral aspect of effective goal and outcome setting is explaining to a patient how the health condition and identified impairments are associated with the patient's activity/functional limitations and participation restrictions and why specific interventions will be used. Discussing an expected time frame for achieving the negotiated goals and outcomes puts the treatment plan and the patient's perception of progress in a realistic context. This type of information helps a patient and family members set goals that are not just meaningful but realistic and attainable. Setting up short-term and long-term goals, particularly for patients with severe or complex problems, is also a way to help a patient recognize incremental improvement and progress during treatment.

The plan of care also indicates the optimal level of improvement that will be reflected by the functional outcomes as well as how those outcomes will be measured. An outline of the specific interventions, their frequency and duration of use, and how the interventions are directly related to attaining the stated goals and outcomes also must appear in the plan. Finally, the plan of care concludes with the criteria for discharge. These criteria are addressed following a discussion of elements of intervention in the patient management process.

NOTE: Periodic re-examination of a patient and re-evaluation of a patient's response to treatment may necessitate modification of the initial prognosis and plan of care.

Intervention

Intervention, a component of patient management, refers to any purposeful interaction a therapist has that directly relates to a patient's care³ (see Fig. 1.5). There are three broad areas of intervention that occur during the course of patient management.³

• Coordination, communication, and documentation

• Procedural interventions

• Patient-related instruction

Each of these areas is an essential aspect of the intervention phase of patient management. Absence of just one of these elements can affect outcomes adversely. For example, inclusion of the most appropriate, functionally relevant exercises (procedural intervention) in a treatment program does not lead to a successful outcome if the therapist has not communicated with the necessary parties for an approval or extension of physical therapy services (communication) or if the patient has not learned how to perform the exercises in the program correctly (patient-related instruction). A brief discussion of the three major components of intervention is presented in this section with additional information in the final section of the chapter on exercise instruction, an aspect of patient-related instruction that is most relevant to the focus of this textbook.

Coordination, Communication, and Documentation

The physical therapist is the coordinator of physical therapy care and services and must continually communicate verbally and through written documentation with all individuals involved in the care of a patient. This aspect of intervention encompasses many patient-related administrative tasks and professional responsibilities, such as writing reports (evaluations, plans of care, discharge summaries); designing home exercise programs; keeping records; contacting third-party payers, other health-care practitioners, or community-based resources; and participating in team conferences.

NOTE: Even during the intervention phase of patient management, a therapist might decide that referral to another practitioner is appropriate and complementary to the physical therapy interventions. This requires coordination and communication with other health-care practitioners. For example, a therapist might refer a patient, who is generally deconditioned from a sedentary lifestyle and who is also obese, to a nutritionist for dietary counseling to complement the physical therapy program designed to improve the patient's aerobic capacity (cardiopulmonary endurance) and general level of fitness.

Procedural Interventions

Procedural intervention pertains to the specific procedures used during treatment, such as therapeutic exercise, functional training, or adjunctive modalities (physical agents and electrotherapy). Procedural interventions are identified in the plan of care. Most procedural interventions used by physical therapists, including the many types of therapeutic exercise, are designed to reduce or correct impairments, as depicted in Figure 1.6.

If procedural interventions are to be considered effective, they must result in the reduction or elimination of functional deficits and participation restrictions and, whenever possible, reduce the risk of future dysfunction. Moreover, the efficacy of procedural interventions should be supported by sound evidence, preferably based on prospective, randomized, controlled research studies.

Although the intended outcome of therapeutic exercise programs has always been to enhance a patient's functional capabilities or prevent loss of function, until the past few decades the focus of exercise programs was on the resolution of impairments. Success was measured primarily by the reduction of the identified impairments or improvements in various aspects of physical performance, such as strength, mobility, or balance. It was assumed that if impairments were resolved, improvements in functional abilities would subsequently follow. Physical therapists now recognize that this assumption is not valid. To reduce functional limitations and improve a patient's health-related quality of life, not only should therapeutic exercise interventions be implemented that correct functionally limiting impairments, but whenever possible, exercises should be task-specific—that is, they should be performed using movement patterns that closely match a patient's intended or desired functional activities. In Figure 1.7, strengthening exercises are performed using task-specific lifting patterns.

The importance of designing and implementing exercises that closely replicate the desired functional outcomes is supported by the results of many studies, such as the following study.

Another way to use therapeutic exercise interventions effectively to improve functional ability is to integrate safe but progressively more challenging functional activities that utilize incremental improvements in strength, endurance, and mobility into a patient's daily routine as early as possible in the treatment program. With this functionally oriented approach to exercise, the activities in the treatment program are specific to and directly support the expected functional outcomes. Selection and use of exercise procedures that target more than one goal or outcome are also appropriate and efficient ways to maximize improvements in a patient's function in the shortest time possible.

Effective use of any procedural intervention must include determining the appropriate intensity, frequency, and duration of each intervention and periodic re-examination of a patient's responses to the interventions. While implementing therapeutic exercise interventions, a patient's response to exercise is continually monitored to decide when and to what extent to increase the difficulty of the exercise program or when to discontinue specific exercises. Each of the chapters of this textbook provides detailed information on factors that influence selection, application, and progression of therapeutic exercise interventions.

Patient-Related Instruction

There is no question that physical therapists perceive themselves as patient educators, facilitators of change, and motivators.^{24,47,74,96,116} Patient education spans all three domains of learning: cognitive, affective, and psychomotor domains. Education ideally begins during a patient's initial contact with a therapist and involves the therapist explaining information, asking pertinent questions, and listening to the patient or a family member.

Patient-related instruction, the third aspect of intervention during the patient management process, is the means by which a therapist helps a patient learn how to reduce his or her impairments and functional deficits to get better²⁴ by becoming an active participant in the rehabilitation process. Patient-related instruction first may focus on providing a patient with background information, such as the interrelationships among the primary health condition (pathology) and the resulting impairments and limitations in activity or explaining the purpose of specific interventions in the plan of care. Instruction, such as physical therapist-directed exercise counseling,¹⁶⁵ may be implemented as an alternative to direct supervision of an exercise program and typically focuses on specific aspects of a treatment program, such as teaching a patient, family member, or caregiver a series of exercises to be carried out in a home program; reviewing health and wellness materials; or clarifying directions for safe use of equipment to be used at home.

A therapist must use multiple methods to convey information to a patient or family member, such as one-to-one, therapist-directed instruction, videotaped instruction, or written materials. Each has been shown to have a place in patient education as highlighted by the following studies.

However, written materials, particularly those with illustrations, can be taken home by a patient and used to reinforce verbal instructions from a therapist or videotaped instructions.

To be an effective patient educator, a therapist must possess an understanding of the process of learning, which most often is directed toward learning or modifying motor skills. As a patient educator, a therapist also must be able to recognize a patient's learning style, implement effective teaching strategies, and motivate a patient to want to learn new skills, adhere to an exercise program, or change health-related behaviors.

A therapist's skillful, creative use of all three components of intervention, coupled with vigilant re-examination and re-evaluation of the effectiveness of the interventions selected, paves the way for successful outcomes and a patient's discharge from physical therapy services.

Outcomes

Simply stated, outcomes are results. Collection and analysis of outcome data related to health-care services are necessities, not options.⁵⁹ Measurement of outcomes is a means by which quality, efficacy, and cost-effectiveness of services can be assessed. Patient-related outcomes are monitored throughout an episode of physical therapy care—that is, intermittently during treatment and at the conclusion of treatment.¹²⁰ Evaluation of information generated from periodic re-examination and re-evaluation of a patient's response to treatment enables a therapist to ascertain if the anticipated goals and expected outcomes in the plan of care are being met and if the interventions that have been implemented are producing the intended results. It may well be that the goals and expected outcomes must be adjusted based on the extent of change or lack of change in a patient's function as determined by the level of the interim outcomes. This information also helps the therapist decide if, when, and to what extent to modify the goals, expected outcomes, and interventions in the patient's plan of care.

There are several broad areas of outcomes commonly assessed by physical therapists during the continuum of patient care. They are listed in Box 1.15.

Functional Outcomes

The key to the justification of physical therapy services in today's cost-conscious health-care environment is the identification and documentation of successful patient-centered, functional outcomes that can be attributed to interventions.^{3,5,23,55,163} Functional outcomes must be meaningful, practical, and sustainable.¹⁶³ Outcomes that have an impact on a patient's ability to function at work, in the home, or in the community in ways that have been identified as important by the patient, family, significant others, caregivers, or employers are considered meaningful. If the formulation of anticipated goals and expected outcome has been a collaborative effort between patient and therapist, the outcomes will be meaningful to the patient. The practical aspect of functional outcomes implies that improvements in function have been achieved in an efficient and cost-effective manner. Improvements in function that are maintained over time after discharge from treatment (to the extent possible given the nature of the health condition) are considered sustainable.

Measuring Outcomes

The expected outcomes identified in a physical therapy plan of care must be measurable. More specifically, changes in a patient's status over time must be quantifiable. As noted in the previous discussion of the examination component of the patient management model, many of the specific tests and measures used by physical therapists traditionally have focused on measurement of impairments (i.e., ROM, muscle performance, joint mobility/stability, balance). The reduction of impairments may reflect the impact of interventions on the pathological condition but may or may not translate into improvements in a patient's health-related quality of life, such as safety and functional abilities. Hence, there is the need for measurement not only of impairments but also of a patient's levels of physical functioning and perceived disability to assess accurately patient-related outcomes that include but are not limited to the effectiveness of physical therapy interventions, such as therapeutic exercise.

Impact of interventions on patient-related, functional outcomes. In response to the need to produce evidence that supports the effectiveness of physical therapy interventions for reducing movement dysfunction, a self-report instrument called OPTIMAL (Outpatient Physical Therapy Improvement in Movement Assessment Log) has been developed for measuring the impact of physical therapy interventions on function and has been tested for validity and reliability.⁵⁵ The instrument measures a patient's difficulty with or confidence in performing a series of actions, most of which are related to functional mobility, including moving from lying to sitting and sitting to standing, kneeling, walking, running, and climbing stairs, reaching, and lifting. In addition, to assist the therapist with setting goals for the plan of care, the patient is asked to identify three activities that he or she would like to be able to do without difficulty.

A number of studies that have investigated the benefits of exercise programs for individuals with impaired functional abilities^79,88,141 reflect the trend in research to include an assessment of changes in a patient's health-related quality of life as the result of interventions. Assessment of outcomes related to the reduction of risks of future injury or further impairment, prevention of further functional limitations or disability, adherence to a home program, or the use of knowledge that promotes optimal health and fitness may also help determine the effectiveness of the services provided. To substantiate that the use of physical therapy services for prevention is cost-effective, physical therapists are finding that it is important to collect follow-up data that demonstrate a reduced need for future physical therapy services as the result of interventions directed toward prevention and health promotion activities.

Patient satisfaction. Another area of outcomes assessment that has become increasingly important in physical therapy practice is that of patient satisfaction. An assessment of patient satisfaction during or at the conclusion of treatment can be used as an indicator of quality of care. Patient satisfaction surveys often seek to determine the impact of treatment based on the patient's own assessment of his or her status at the conclusion of treatment compared to that at the onset of treatment.¹⁴⁰ Instruments, such as the Physical Therapy Outpatient Satisfaction Survey (PTOPS)¹⁴⁰ or the MedRisk Instrument for Measuring Patient Satisfaction with physical therapy (MRPS),^8,9 also measure a patient's perception of many other areas of care. An important quality of patient satisfaction questionnaires is their ability to discriminate among the factors that influence satisfaction. Identification of factors that adversely influence satisfaction may enable the clinician to take steps to modify these factors to deliver an optimal level of services to patients.⁹

Factors that may influence the extent of patient satisfaction are noted in Box 1.16.^8,9,20,140

Discharge Planning

Planning for discharge begins early in the rehabilitation process. As previously noted, criteria for discharge are identified in a patient's plan of care. Ongoing assessment of outcomes is the mechanism by which a therapist determines when discharge from care is warranted. A patient is discharged from physical therapy services when the anticipated goals and expected outcomes have been attained.³ The discharge plan often includes some type of home program, appropriate followup, possible referral to community resources, or re-initiation of physical therapy services (an additional episode of care) if the patient's needs change over time and if additional services are approved.

Discontinuation of services is differentiated from discharge.³ Discontinuation refers to the ending of services prior to the achievement of anticipated goals and expected outcomes. Several factors may necessitate discontinuation of services, which may include a decision by a patient to stop services, a change in a patient's medical status such that progress is no longer possible, or the need for further services cannot be justified to the payer.

In conclusion, the patient management model discussed in this section establishes a comprehensive, systematic approach to the provision of effective and efficient physical therapy care and services to patients and clients. The model is a mechanism to demonstrate the interrelationships among the phases of the continuum of patient care set in a conceptual framework of functioning and disability; it is aimed at improving a patient's function and health-related quality of life. The management model also places an emphasis on reducing risk factors for disease, injury, impairments, or disability and promoting health and well-being in patients and clients seeking and receiving physical therapy services.

As discussed in the previous section of this chapter, patient-related instruction is an essential element of the intervention phase of patient management. As a patient educator, a therapist spends a substantial amount of time teaching patients, their families, or other caregivers how to perform exercises correctly and safely. Effective strategies founded on principles of motor learning that are designed to help patients initially learn an exercise program under therapist supervision and then carry it out on an independent basis over a necessary period of time contribute to successful outcomes for the patient. Box 1.17 summarizes some practical suggestions for effective exercise instruction.

Preparation for Exercise Instruction

When preparing to teach a patient a series of exercises, a therapist should have a plan that will facilitate learning prior to and during exercise interventions. A positive relationship between therapist and patient is a fundamental aspect for creating a motivating environment that fosters learning. A collaborative relationship should be established when the goals for the plan of care are negotiated. This, of course, occurs before exercise instruction begins. Effective exercise instruction is also based on knowing a patient's learning style—that is, if he or she prefers to learn by watching, reading about, or doing an activity. This may not be known early in treatment, so several methods of instruction may be necessary.

Identifying a patient's attitudes toward exercise helps a therapist determine how receptive a patient is likely to be about learning and adhering to an exercise program. Answers to the following questions may help a therapist formulate a strategy for enhancing a patient's motivation to exercise:

• Does the patient believe exercise will lessen symptoms or improve function?

• Is the patient concerned that exercising will be uncomfortable?

• Is the patient accustomed to engaging in regular exercise?

One method for promoting motivation is to design the exercise program so the least complicated or stressful exercises are taught first, thus ensuring early success. Always ending an exercise session with a successful effort also helps maintain a patient's level of motivation. Additional suggestions to enhance motivation and promote adherence to an exercise program are discussed in this section following an overview of the concepts of motor learning and acquisition of simple to complex motor skills.

Concepts of Motor Learning: A Foundation for Exercise and Task-Specific Instruction

Integration of motor learning principles into exercise instruction optimizes learning an exercise or functional task. An exercise is simply a motor task (a psychomotor skill) that a therapist teaches and a patient is expected to learn.

Motor learning is a complex set of internal processes that involves the acquisition and relatively permanent retention of a skilled movement or task through practice.^{118,148,149,174,178} In the motor-learning literature a distinction is made between motor performance and motor learning. Performance involves acquisition of the ability to carry out a skill, whereas learning involves both acquisition and retention.^48,140,148 Therefore, a patient's ability to perform an exercise or any skilled movement early in the motor-learning process is not necessarily representative of having learned the new exercise or skill.

It is thought that motor learning probably modifies the way sensory information in the central nervous system is organized and processed and affects how motor actions are produced. In addition, because motor learning is not directly observable, it must be measured by observation and analysis of how an individual performs a skill.

Types of Motor Tasks

There are three basic types of motor tasks: discrete, serial, and continuous.^148,149

Discrete task. A discrete task involves an action or movement with a recognizable beginning and end. Isolating and contracting a specific muscle group (as in a quadriceps setting exercise), grasping an object, doing a push-up, locking a wheelchair, and kicking a ball are examples of discrete motor tasks. Almost all exercises, such as lifting and lowering a weight or performing a self-stretching maneuver, can be categorized as discrete motor tasks.

Serial task. A serial task is composed of a series of discrete movements that are combined in a particular sequence. For example, to eat with a fork, a person must be able to grasp the fork, hold it in the correct position, pierce or scoop up the food, and lift the fork to the mouth. Many functional tasks in the work setting, for instance, are serial tasks with simple as well as complex components. Some serial tasks require specific timing between each segment of the task or momentum during the task. Wheelchair transfers are serial tasks. A patient must learn how to position the chair, lock the chair, possibly remove an armrest, scoot forward in the chair, and then transfer from the chair to another surface. Some transfers require momentum, whereas others do not.

Continuous task. A continuous task involves repetitive, uninterrupted movements that have no distinct beginning and ending. Examples include walking, ascending and descending stairs, and cycling.

Recognizing the type of skilled movements a patient must learn to do helps a therapist decide which instructional strategies will be most beneficial for acquiring specific functional skills. Consider what must be learned in the following motor tasks of an exercise program. To self-stretch the hamstrings, a patient must learn how to position and align his or her body and how much stretch force to apply to perform the stretching maneuver correctly. As flexibility improves, the patient must then learn how to safely control active movements in the newly gained portion of the range during functional activities. This requires muscles to contract with correct intensity at an unaccustomed length. In another scenario, to prevent recurrence of a shoulder impingement syndrome or back pain, a patient may need to learn through posture training how to maintain correct alignment of the trunk during a variety of reaching or lifting tasks that place slightly different demands on the body.

In both of these situations, motor learning must occur for the exercise program and functional training to be effective. By viewing exercise interventions from this perspective, it becomes apparent why applications of strategies to promote motor learning are an integral component of effective exercise instruction.

Conditions and Progression of Motor Tasks

If an exercise program is to improve a patient's function, it must include performing and learning a variety of tasks. If a functional training program is to prepare a patient to meet necessary and desired functional goals, it must place demands on a patient under varying conditions. A taxonomy of motor tasks, proposed by Gentile,⁴⁸ is a system for analyzing functional activities and a framework for understanding the conditions under which simple to complex motor tasks can be performed. Figure 1.8 depicts these conditions and the dimensions of difficulty of motor tasks.

An understanding of the components of this taxonomy and the interrelationships among its components is a useful framework for a therapist to identify and increase the difficulty of functional activities systematically for a patient with impaired function.

There are four main task dimensions addressed in the taxonomy: (1) the environment in which the task is performed; (2) the inter-trial variability of the environment that is imposed on a task; (3) the need for a person's body to remain stationary or to move during the task; and (4) the presence or absence of manipulation of objects during the task. Examples of simple to complex everyday activities characteristic of each of the 16 different but interrelated task conditions are shown in Figure 1.9.

Closed or open environment. Environmental conditions of a task address whether objects or people (around the patient) are stationary or moving during the task and if the surface on which the task is performed is fixed or moving. A closed environment is one in which objects around the patient and the surface on which the task is performed do not move. When a functional task is performed in this type of environment, the patient's complete attention can be focused on performing the task, and the task can be self-paced. Examples of tasks performed in a closed environment are drinking or eating while sitting in a chair and maintaining an erect trunk, standing at a sink and washing your hands or combing your hair, walking in an empty hallway or in a room where furniture placement is consistent.

A more complex environment is an open environment. It is one in which objects or other people are in motion or the support surface is unstable during the task. The movement that occurs in the environment is not under the control of the patient. Tasks that occur in open environments include maintaining sitting or standing balance on a movable surface (a balance board or BOSU^®) (Fig. 1.10), standing on a moving train or bus, ascending or descending stairs in a crowded stairwell, crossing a street at a busy intersection, or returning a serve in a tennis match or volleyball game. During tasks such as these, the patient must predict the speed and directions of movement of people or objects in the environment or must anticipate the need to make postural or balance adjustments as the support surface moves. Consequently, the patient must pace the performance of the tasks to match the imposed environmental conditions.

Inter-trial variability in the environment: absent or present. When the environment in which a task occurs is constant (unchanging) from one performance of a task to the next, inter-trial variability is absent. The environmental conditions for the task are predictable; therefore, little attention to the task is required, which often enables a patient to perform two tasks at one time. Some examples of tasks without inter-trial variability are practicing safe lifting techniques using a box of the same dimensions and weight, practicing the tasks of standing up and sitting down from just one height or type of chair, or walking on just one type of surface.

A task becomes more complex when there is inter-trial variability in the environmental conditions—that is, when the demands change from one attempt or repetition of a task to the next. With such variability, the patient must continually monitor the changing demands of the environment and adapt to the new circumstances by using a variety of movement strategies to complete the task. Lifting and carrying objects of different sizes and weight, climbing stairs of different heights, or walking over varying terrain are tasks with inter-trial variability.

Body stable or body transport. In addition to environmental conditions, tasks are analyzed from the perspective of the person doing the task. Tasks that involve maintaining the body in a stable (stationary) position, such as maintaining an upright posture, are considered simple tasks, particularly when performed under closed environmental conditions. When the task requirements involve the patient moving from one place to another (body transport), such as performing a transfer, walking, jumping, or climbing, the task is more complex. When a body transport task is performed in an open environment with inter-trial variability, such as walking in a crowded corridor or on different support surfaces, such as grass, gravel, and pavement, the task becomes even more complex and challenging.

Manipulation of objects—absent or present. Whether performing a task does or does not require upper extremity manipulation activities also affects the degree of difficulty of the task. When a task is performed without manipulating an object, it is considered less complex than if manipulation is a requirement of the task. Carrying a cup of coffee without spilling it while at home alone and walking from one room to another is a more complex task than walking with hands free. Doing the same task in a busy hallway further increases the complexity and difficulty of the task.

In summary, Gentile's taxonomy of motor tasks can be used to analyze the characteristics of functional tasks in the context of the task conditions. The taxonomy provides a framework to structure individual treatment sessions with a patient or to progress the level of difficulty of motor tasks throughout a functional training program.

Stages of Motor Learning

There are three stages of motor learning: cognitive, associative, and autonomous.^{37,41,119,148,149} The characteristics of the learner are different at each stage of learning and consequently affect the type of instructional strategies selected by a therapist in an exercise and functional training program.

Cognitive Stage

When learning a skilled movement, a patient first must figure out what to do—that is, the patient must learn the goal or purpose and the requirements of the exercise or functional task. Then the patient must learn how to do the motor task safely and correctly. At this stage, the patient needs to think about each component or the sequencing of the skilled movement. The patient often focuses on how his or her body is aligned and how far and with what intensity or speed to move. In other words, the patient tries to get the "feel" of the exercise.

Because all of the patient's attention is often directed to the correct performance of the motor task, distractions in the environment, such as a busy, noisy exercise room (an open environment), may initially interfere with learning. During this stage of learning, errors in performance are common, but with practice that includes error correction, the patient gradually learns to differentiate correct from incorrect performance, initially with frequent feedback from a therapist and eventually by monitoring his or her own performance (self-evaluation).

Associative Stage

The patient makes infrequent errors and concentrates on fine-tuning the motor task during the associative stage of learning. Learning focuses on producing the most consistent and efficient movements. The timing of the movements and the distances moved also may be refined. The patient explores slight variations and modifications of movement strategies

while doing the task under different environmental conditions (inter-trial variability). The patient also uses problem-solving to self-correct errors when they do occur. At this stage, the patient requires infrequent feedback from the therapist and, instead, begins to anticipate necessary adjustments and make corrections even before errors occur.

Autonomous Stage

Movements are automatic in this final stage of learning. The patient does not have to pay attention to the movements in the task, thus making it possible to do other tasks simultaneously. Also, the patient easily adapts to variations in task demands and environmental conditions. Little, if any, instruction goes on in this phase of learning unless the patient encounters a recurrence of symptoms or other problems. In fact, most patients are discharged before reaching this stage of learning.

Variables That Influence Motor Learning—Considerations for Exercise Instruction and Functional Training

Motor learning is influenced by many variables, some of which can be manipulated by a therapist during exercise instruction or functional training to facilitate learning. Some of these variables include pre-practice considerations, physical or mental practice, and several forms of feedback. An understanding of these variables and their impact on motor learning is necessary to develop strategies for successful exercise instruction and functional training. A brief overview of these key variables that influence the acquisition and retention of skilled movements during each stage of motor learning is presented in this section. Because concepts and principles of motor learning encompass an extensive body of knowledge, the reader is referred to a number of in-depth resources for additional information.^{38,41,48,101,117,118,119,148,149,174}

Pre-Practice Considerations

A number of variables can influence motor learning during an exercise session even before practice begins. A patient's understanding of the purpose of an exercise or task, as well as interest in the task, affects skill acquisition and retention. The more meaningful a task is to a patient, the more likely it is that learning will occur. Including tasks the patient identified as important during the initial examination promotes a patient's interest.

Attention to the task at hand also affects learning. The ability to focus on the skill to be learned without distracting influences in the environment promotes learning. Instructions given to a patient prior to practice about where his or her attention should be directed during practice also may affect learning. There is evidence in studies of nonimpaired individuals that learning is enhanced if a person attends to the outcomes of performing a task rather than to the details of the task itself.^106,181 This finding is addressed in more detail in a later discussion of feedback as it relates to motor learning.

Demonstration of a task prior to commencing practice also enhances learning. It is often helpful for a patient to observe another person, usually the therapist or possibly another patient, perform the exercise or functional task correctly and then model those actions. Pre-practice verbal instructions that describe the task also may facilitate skill acquisition, but they should be succinct. Extensive information about the task requirements early in the learning process may actually confuse a patient rather than enhance the learning process.

Practice

Motor learning occurs as the direct result of practice—that is, repeatedly performing a movement or series of movements in a task.^90,148,149 Practice is probably the single most important variable in learning a motor skill. The amount, type, and variability of practice directly affect the extent of skill acquisition and retention.^117,148,149 In general, the more a patient practices a motor task, the more readily it is learned. In today's health-care environment, most practice of exercises or functional tasks occurs at home, independent of therapist supervision. A therapist often sets the practice conditions for a home program prior to a patient's discharge by providing guidelines on how to increase the difficulty of newly acquired motor skills during the later stages of learning.

The type of practice strategy selected also has a significant impact on how readily a motor task is learned.^{90,101,117,119,148,149,178} Common types of practice are defined in Box 1.18. The type of skill to be learned (discrete, serial, or continuous) and the patient's cognitive status and stage of motor learning determine which practice strategies are more appropriate than others.

Part versus whole practice. Part practice has been shown to be most effective in the early stage of learning for acquisition of complex serial skills that have simple and difficult components. Depending on the patient's cognitive status, it is usually necessary to practice only the difficult dimensions of a task before practicing the task as a whole. Whole practice is more effective than part practice for acquiring continuous skills, such as walking and climbing stairs, or serial tasks in which momentum or timing of the components is the central focus of the learning process. Whole practice is also used for acquisition of discrete tasks, such as an exercise that involves repetitions of a single movement pattern.

Practice order—blocked, random, and random/blocked. During the initial phase of rehabilitation, practice usually is directed toward learning just a few exercises or functional motor tasks. During the initial (cognitive) stage of learning in which a new motor skill is acquired, blocked-order practice is the appropriate choice because it rapidly improves performance of skilled movements. A transition to random-order or random/blocked-order practice should be made as soon as possible to introduce variability into the learning process. Variability of practice refers to making slight adjustments (variations) in the conditions of a task—for example, by varying the support surface or the surroundings where a task is performed.^48,148,149

Although blocked-order practice initially improves performance at a faster rate than random-order practice, random practice leads to better skill retention and generalizability of skills than blocked practice.¹¹⁷ It is thought that varying tasks just slightly, as is done with random-order practice, requires more cognitive processing and problem-solving than blocked-order practice and, hence, culminates in greater retention of a newly acquired skill after practice has ceased. However, blocked-order practice may be preferable for patients with cognitive deficits, because random-order practice may pose too great a challenge for the patient and subsequently interfere with the learning process.⁹³

Random/blocked-order practice results in faster skill acquisition than random-order practice and better retention than blocked-order practice. Because random/blocked-order practice enables a patient to perform a task at least twice before changing to another variation of the task, this form of practice gives a patient the opportunity to identify and then immediately correct errors in a movement sequence before proceeding to the next variation of the task.^48,148

Physical versus mental practice. Physical practice has long been a hallmark of exercise instruction and functional training in physical therapy, whereas mental practice (motor imagery practice) has its roots in sports psychology and sport-related training.^149,156 About two to three decades ago, the applicability of mental practice as a treatment tool in the rehabilitation of patients with movement impairments began to be investigated for its potential.¹⁷⁷ It is thought that mental rehearsal of a motor task reinforces the cognitive component of motor learning—that is, learning what to do when performing a task and refining how it is executed.

Most studies support the finding that physical practice of motor skills by overtly performing the task is superior to mental practice alone for learning motor tasks.^148,149 However, in sports training and rehabilitation, mental practice, when used in conjunction with physical practice, has been shown to enhance motor skill acquisition at a faster rate than use of physical practice alone.^{101,102,117,121}

Feedback

Second only to practicing a motor task, feedback is considered the next most important variable that influences motor learning.¹¹⁷ Feedback is sensory information that is received and processed by the learner during or after performing or attempting to perform a motor skill.^{48,117,118,148,149} There are a number of descriptive terms used to differentiate one type of feedback from another. The terms used to describe feedback are based on the source of feedback (intrinsic or augmented/extrinsic), the focus of feedback (knowledge of performance or knowledge of results), and the timing or frequency of feedback (the feedback schedule). Boxes 1.19 and 1.20 identify and define the various terms associated with the types and scheduling of feedback.

Several factors influence the types of feedback that can occur during exercise instruction or functional training and the effectiveness of feedback for skill acquisition (performance) and skill retention (learning). For example, a patient's physical and cognitive status and the stage of motor learning have a significant impact on the type of feedback that is most effective and the timing and frequency of augmented feedback implemented during practice sessions. It has also been suggested that a therapist should encourage a patient to provide input about his or her receptiveness to the type of feedback or feedback schedule used during practice, particularly once the patient has achieved a beginning level of skill acquisition. This active participation may promote a sense of self-control in the patient and is thought to have a positive impact on learning.¹⁰⁶

In order to provide the most effective forms of feedback during exercise instruction and functional training, it is useful for a therapist to understand the benefits and limitations of several types and schedules of feedback for skill acquisition and skill retention.

Intrinsic feedback. Intrinsic feedback comes from all of the sensory systems of the learner, not from the therapist, and is derived from performing or attempting to perform any movement. Intrinsic feedback is inherent in the movement itself—that is, it occurs naturally during or after a task is performed.^48,117,148 It provides ongoing information about the quality of movement during a task and information about the outcomes (results) of a task, specifically if the goal of a task was achieved. In everyday life, intrinsic feedback is a continuous source of information that provides knowledge of performance (KP) and knowledge of results (KR) as a person performs routine activities or tries to learn new motor skills.

Augmented feedback. Information about the performance or results of a task that is supplemental to intrinsic feedback is known as augmented feedback.^{117,148,149,180} It is also referred to as extrinsic feedback.^48,119 Unlike intrinsic feedback, a therapist has control of the type, timing, and frequency of augmented feedback a patient receives during practice. Augmented/extrinsic feedback can be provided during or at the conclusion of a task to give information about the quality of the performance (KP) or the quality of the outcome of a task (KR).

NOTE: Although augmented feedback is a commonly used instructional tool to facilitate motor learning in healthy individuals, it is thought to be particularly necessary when teaching motor skills to patients who may receive inadequate or inaccurate intrinsic feedback as the result of impaired sensory systems from injury or disease.^48,117

Therapists have many forms of augmented/extrinsic feedback from which to select for exercise instruction and functional training.^{48,61,118,180} Some examples include verbal or tactile feedback directly from a therapist who is interacting with a patient during practice and visual or auditory feedback from a rehabilitative ultrasound imaging device (Fig. 1.11) or an electromyography (EMG) biofeedback unit. A videotaped replay of a previous performance is another source of augmented visual feedback.

Knowledge of performance versus knowledge of results. Over the past two to three decades, the selection and application of feedback have changed in the clinical setting. Traditionally, a therapist would have a patient focus on sensory information inherent in a motor task (intrinsic feedback) to "get the feel" of movements in the task, such as how it felt to weight shift from side to side while controlling the knees and maintaining standing balance. At the same time the therapist would provide ongoing feedback—usually verbal—about the quality of the patient's posture or knee control (knowledge of performance) during the weight-shifting activity.

However, research, primarily with nonimpaired subjects, has shown that directing a person's attention to the outcomes of movements (knowledge of results) rather than to the details of the movements themselves enhances learning (retention of a motor skill) more effectively.¹⁸¹ Consequently, therapists now tend to place greater emphasis on providing feedback about the outcomes (results) of performing a motor skill.¹⁸⁰

Going back to the weight-shifting example—to employ knowledge of results during functional training, a therapist should have a patient perform weight shifts by reaching for objects placed in various positions just outside the patient's base of support. By giving the patient a target, the task becomes goal-directed as the patient focuses on the intended results of the movement. The patient, therefore, learns to judge the effectiveness of his or her movements based on feedback received from external cues.^106,181

The feedback schedule—timing and frequency of augmented feedback. The scheduling of feedback during practice sessions (see Box 1.18) involves the timing and frequency with which augmented/extrinsic feedback is provided. Feedback schedules affect motor skill acquisition and retention and should be adjusted during the learning process.

Concurrent feedback is a form of augmented feedback that occurs in "real-time" as a patient is performing or attempting to perform a motor task. Visual feedback from a rehabilitative ultrasound-imaging unit (see Fig. 1.11) is an example of concurrent feedback and is useful when a patient is first learning how to perform an isometric contraction of the trunk stabilizing muscles, because no observable movement of the body occurs.

Another form of concurrent feedback, the use of manual guidance, which provides tactile cues to the patient, may be necessary for patient safety and may help a patient understand the required movements of an exercise or functional task. However, excessive or long-term use of manual guidance may hamper motor learning, in that it may not allow a patient to make "safe mistakes" while figuring out how to perform a movement. As mentioned in the discussion of the stages of motor learning, self-detection and self-correction of errors are absolutely necessary for learning to occur. The key is to use the least amount of concurrent feedback for the shortest time possible, so the patient does not become reliant on it to carry out a task.⁴⁸

Immediate, postresponse feedback is another form of augmented/extrinsic feedback often used during the initial stage of learning. The therapist provides information, often verbally, about the outcome of the task (KR) immediately after each trial. Although immediate feedback after each trial may enhance early skill acquisition, it too does not allow time for problem-solving by the patient and detection of errors without input from the therapist. Consequently, although initial skill acquisition may occur rather quickly, learning, which includes retention, is delayed.¹⁴⁸

As alternatives to immediate feedback, delayed feedback from the therapist after each repetition of a task or exercise or summary feedback after several trials have been completed gives the patient time for self-evaluation and problem-solving as to how the task was performed during practice, which in turn, promotes retention and generalizability of the learned skills. Although use of delayed or summary schedules of feedback is associated with slower skill acquisition than concurrent or immediate feedback after every trial, it is thought that delaying the timing of feedback makes the patient pay attention to intrinsic feedback inherent in the task.^48,148,179

The frequency with which a therapist provides augmented feedback also should be considered. A basic principle about augmented feedback is that "less is better." Although the greatest frequency of feedback is necessary during the cognitive (initial) stage of learning when a patient is first learning how to perform an exercise or a functional task, excessive or extended use of any form of augmented feedback can create dependence on the feedback and can be a deterrent to self-detection and correction of errors.^48,148,149 Excessive verbal feedback, for example, provided by a therapist after every trial also can be distracting and may interrupt a patient's attention to the task.

Rather than providing feedback after each repetition of an exercise, a therapist may want to consider varying the frequency of feedback (a variable feedback schedule) by giving the patient input following more than a single repetition and on a variable, less predictable basis. Variable (intermittent) feedback during practice has been shown to promote retention of a learned motor skill more effectively than constant (continuous) feedback given during or after each repetition.⁶¹ A therapist must keep in mind, however, that constant (continuous) feedback improves skill acquisition (performance) more quickly during the initial stage of learning than variable (intermittent) feedback.⁴⁸

It is also important to fade (decrease) the frequency of feedback over time to avoid the extended use of feedback. Summary feedback, particularly during the associative stage of learning, is an effective strategy to reduce the total amount of feedback given in a practice session. As augmented feedback is faded, a patient must explore slight modifications of a movement strategy and analyze the results. This promotes problem-solving, self-monitoring, and self-correction, all of which enable a patient to perform tasks independently and safely and to transfer learning to new task conditions.

Application of Motor-Learning Principles for Exercise Instruction Summarized

Box 1.21 summarizes the information discussed in this section with regard to qualities of the learner and effective strategies for exercise instruction and functional training founded on the principles and stages of motor learning.

Adherence to Exercise

Effective patient-related instruction for a functionally oriented exercise program must include methods to foster adherence. This is particularly challenging when a patient is unaccustomed to regular exercise or when an exercise program must be carried out for an extended period of time. Positive outcomes from treatment are contingent not so much on designing the "ideal" exercise program for a patient, but rather, on designing a program that a patient or family will actually follow.^73,74,170

NOTE: Although the terms adherence and compliance are often used interchangeably by clinicians and in the literature, the term adherence has been selected for this discussion because it has a stronger connotation of active involvement of the patient and patient-therapist collaboration. In contrast, compliance tends to imply a more passive connotation with respect to a patient's behavior.

Factors that Influence Adherence to an Exercise Program

Many factors influence adherence to an exercise program.^{21,52,57,73,74,100,106,116,153,170} These factors can be grouped into several categories: a patient's characteristics, factors related to a patient's health condition or impairments, and program-related variables.

Patient-Related Factors

The following patient-related factors can have a positive or negative impact on adherence: understanding the health condition, impairments, or exercise program; level of motivation, self-discipline, attentiveness, memory, and willingness and receptivity to change; degree of fatigue or stress; the availability of time to devote to an exercise program; the patient's self-perception of his or her compatibility with the therapist or the degree of control in the exercise program; socioeconomic and cultural background; the beliefs and attitudes about exercise and the value the patient places on the exercise program; and the patient's access to resources. The patient's age and sex also influence adherence to an exercise program, with men having higher adherence rates than women. The association between age and adherence is less clear.

Factors Related to the Health Condition or Impairments

The acuity, chronicity, severity, or stability of the primary health condition and related impairments and presence of comorbidities all have an impact on adherence. Pain is obviously a deterrent to adherence and, therefore, must be minimized in an exercise program. When impairments are severe or long-standing, setting short-term goals that can be achieved regularly fosters adherence to an exercise program that must be followed over a long period of time.

Program-Related Variables

The complexity and necessary duration of an exercise program; the adequacy of instruction, supervision, and feedback from the therapist; whether the patient has had input into the plan of care; and the continuity of care from an inpatient to a home setting all can have an impact on adherence. Programs that address the interest level and motivational needs of a patient have higher adherence rates. In the outpatient setting, logistics, such as location and scheduling, the program's atmosphere created by the therapist/exercise instructor, as well as the availability of social support and individualized attention or counseling from personnel also are important factors that foster adherence.

Strategies to Foster Adherence

A therapist should expect that most patients will not dutifully adhere to any treatment program, particularly if regular exercise has not been a part of the patient's life prior to the occurrence of disease or injury. The most a therapist can hope to do is implement strategies that foster adherence. Some suggestions from a number of resources in the literature are noted in Box 1.22.^{21,52,57,73,74,89,106,116,153,170}

Critical Thinking and Discussion

1. Critically analyze your own, an acquaintance's, or a family member's exercise history. Then identify how a regular regimen of exercise could improve your quality of life or theirs.

2. Research four health conditions (diseases, injuries, or disorders) that result in primary impairments of the (1) musculoskeletal, (2) neuromuscular, (3) cardiovascular/pulmonary, and (4) integumentary systems. Identify characteristic impairments (signs and symptoms) associated with each health condition and hypothesize what activity/functional limitations and participation restrictions are most likely to develop.

3. Why is it essential for a physical therapist to understand and be able to articulate (verbally or in written form) the interrelationships among impairments typically exhibited by patients with various health conditions, activity/functional limitations, participation restrictions, and disability?

4. Last month, you sprained your ankle (inversion sprain). You had to use crutches for several days, but since then you have been walking independently. Pain and swelling still return after vigorous activity, and your ankle feels unstable on uneven terrain. Using a model of functioning and disability as your frame of reference, identify specific activity limitations that would most likely develop in your life as the result of your history and current problems.

5. Using your current knowledge of examination procedures, develop a list of specific tests and measures you would most likely choose to use when examining a patient whose primary impairments affect the (1) musculoskeletal, (2) neuromuscular, (3) cardiovascular and/or pulmonary, and (4) integumentary systems.

6. You have been asked to make recommendations for the adoption of one or more new measurement instruments to be used at your facility for data collection and analysis of patient-centered functional outcomes. Review the literature on musculoskeletal assessment and identify and summarize key features of five instruments that measure activity limitations associated with musculoskeletal impairments of the extremities, neck, or trunk. In addition, identify and summarize key features of five measurement instruments that assess a patient's perceived level of disability.

7. Three individuals just recently sustained a similar fracture of the hip. All underwent an open reduction with internal fixation. The patients are an otherwise healthy 19-year-old college student who was in an automobile accident and wants to return to campus after discharge from the hospital; a 60-year-old person with a somewhat sedentary lifestyle who plans to return home after postoperative rehabilitation and wishes to return to work in an office as soon as possible; and an 85-year-old individual with severe age-related osteoporosis who has been residing in an assisted living facility for the past year. What issues must be considered when identifying anticipated goals and expected outcomes and determining appropriate interventions in the plans of care for these patients? In what ways would goals and expected outcomes differ for these patients?

8. Identify the key components of the patient management model described in this chapter and discuss how each of those components relates to the potential use of therapeutic exercise interventions.

9. Using the taxonomy of motor tasks discussed in this chapter, identify simple to complex activities that are necessary or important in your daily life. Identify at least three activities that fall within each of the 16 condition variables described in the taxonomy.

10. You are seeing a patient in the home setting for follow-up of a postoperative exercise program and progression of functional activities initiated in the hospital. The patient is a 55-year-old computer analyst who had a (L) total knee arthroplasty 10 days ago. You have completed your examination and evaluation. Other than a long-standing history of degenerative arthritis of the (L) knee, the patient has no other significant health-related problems. As you would expect, the patient has pain and limited range of motion of the (L) knee and decreased strength of the (L) lower extremity. The patient is currently ambulating with axillary crutches, weight bearing as tolerated on the (L) lower extremity. (a) Identify the musculoskeletal diagnostic classification (as described in the Guide to Physical Therapist Practice³) that best describes this patient's impairments. (b) As the patient recovers strength and ROM, design a series of progressively more challenging functional motor tasks the patient could practice with your supervision or independently at home based on the taxonomy of motor tasks described in this chapter.