Overview on the Guide to Physical Therapist Practice and its implications for neurologic physical therapy

Neurology Report, Aug 1999 by Harro, Cathy C

What an exciting and vital role physical therapists play in the dynamic health care arena! We have so much to offer the evolving health care system, not only our expertise in the area of rehabilitation but also in the area of disease prevention and health promotion. As we embark on our journey into the 21st century as a profession, we are challenged to clearly define the scope of our practice, the models of delivery for our services, the types of patients/clients we serve, the types of examination measures and interventions we use to remediate and/or prevent impairments and disabilities in our patients. We also are challenged to provide evidence of the efficacy of our interventions and the expected outcomes of our interventions for different groups of patients. In other words, we must clearly define our profession and the benefits of our services, and promote our services for patients/clients. We need to speak as a collective voice and educate physicians, other health care providers, third party payers, managed care providers, health care policy makers and administrators, and the public about our role in the health care system and the services we provide.

For the first time in the history of our profession, we now have a comprehensive and critical document that addresses this need, the Guide to Physical Therapist Practice.' This document, developed by the American Physical Therapy Association and published in November 1997, defines the elements of physical therapist practice. This reference document describes our profession: who we are, what we do, how we think about and classify patients, what interventions we use, and the anticipated goals and outcomes of our interventions.The Guide is an expert consensus document that was developed by panels comprised of expert clinicians and then was extensively reviewed by over 1000 physical therapists across the country.2 Therefore, the Guide to Physical Therapist Practice serves as a foundation document for our profession and represents "best clinical practice." The purpose of this issue of Neurology Report is to promote increased awareness of the components of the Guide and to promote application of the Guide to the practice of neurologic physical therapy. It is only by integrating the Guide (its frameworks, its language, and the practice patterns) into daily clinical practice that we begin to see its potential and begin to take ownership in this important document. In this issue, authors will share examples of application of the Guide in different areas of neurologic practice including case management, clinical decision making, administration, and education to reflect integration into daily clinical practice.

The purpose of this introductory article is to provide an overview of the Guide to Physical Therapist Practice and to highlight specifically the Neuromuscular Patterns and their implications for neurologic physical therapy. The Guide is designed to help physical therapists improve quality of care, enhance patient/client satisfaction, promote appropriate utilization of services, reduce unwarranted variation in provision of services, and promote cost reduction through prevention and wellness initiatives.l The purpose of the Guide is to provide an outline of the profession's body of knowledge, define standardized terminology, and delineate preferred practice patterns based on expert consensus.This document provides boundaries for physical therapist practice but is not intended to be clinical guidelines or protocols for treatment. The Guide is organized in 2 parts: Part One describes the elements of patient/client management and explains the tests and measures and interventions used by physical therapists. Part Two describes preferred practice patterns that provide information about common management strategies for specific patient/client diagnostic groups. The preferred practice patterns are grouped into 4 categories that represent major body systems: musculoskeletal, neuromuscular, cardiopulmonary, and integumentary. The Guide should be viewed as an evolving document as it will systematically be revised as the physical therapy profession evolves reflecting new knowledge base from the scientific literature, outcome research, and clinical practice. A task force and panels of expert clinicians are already hard at work developing Parts Three and Four of the Guide to Physical Therapist Practice. Part Three will describe a minimal data set of tests and measures and attempt to develop a standardized examination for physical therapy. Part four will provide research evidence based practice and compile specific functional outcomes for each of the preferred practice patterns.3 We must actively participate in this evolutionary process of the Guide by analyzing and validating the practice patterns, investigating the efficacy of our interventions for different patient groups, and confirming or challenging the prognosis and expected outcomes of different practice patterns.

Three key conceptual frameworks serve as models for the Guide and are integrated throughout this document: the Disablement Model, the Integration of Prevention and Wellness Strategies into physical therapist intervention, and the Patient/Client Management Model. Application of the Disablement Model is pivotal to understanding the preferred practice patterns and expected outcomes of different patient classification groups. This Disablement Framework rejects the medical model of disease in which the primary emphasis is on diagnosis and treatment of disease and shifts the focus on the functional consequences of disease.4 The disablement process examines the impact of chronic and acute conditions on the functioning of specific body systems (impairments), basic human performance (functional limitations), and people functioning in necessary, usual, expected, and personally desired roles in society (disability).5 Physical therapists evaluate the interrelationships between impairments, functional limitations, and disabilities in order to classify patients, develop a prognosis, and direct interventions to remediate functional limitations. For example, a physical therapist in neurologic practice who receives a referral for evaluation and treatment for a patient with multiple sclerosis has insufficient information to develop a prognosis and plan of care for this patient from the medical diagnosis alone. The therapist must perform an examination, identify the underlying impairments and functional limitations in this patient, and then make judgments regarding which impairments and functional limitations are key factors contributing to the patient's disabilities. Through this evaluation process the physical therapist can determine a prognosis and appropriate plan of care for this patient. The impact of injury, disease, and other conditions on function is the primary focus in this disablement process. Function is defined in the Guide as those activities identified by an individual as essential to support physical, social, and psychological wellbeing and create a personal sense of meaningful living.""n The outcomes of physical therapy intervention then are assessed at this "function" level and include: 1) remediation of functional limitation and disability, 2) optimization of patient/client satisfaction, and 3) prevention, either primary or secondary. Each specific preferred practice pattern has clearly defined expected outcomes based on this disablement framework.