Transcript Therapeutic Exercise - University of Michigan–Flint

Natalia Fernandez, PT, MS, MSc, CCS
University of Michigan Health Care System
Department of Physical Medicine and Rehabilitation.
Clinical Decision Making
 Examination
 Evaluation
 Diagnosis
 Prognosis
 Set up Interventions
Clinical Decision Making
 Med Dx: CAD
Med Dx: COPD
 Use of Hypothesis Testing and Algorithms
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Med Dx and History of Cardiopulmonary Disease
Lab and Diagnostic Test Results
PT Dx
Type of activity, specifics of activity, time
Response to exercise/mobility/ADL
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Vital signs – rest, activity, recovery
EKG changes
Need and time to stop, rest
Observed signs – color changes
 Subjective responses
 Concerns – Fatigue, SOB
 Rate of Perceived Exertion
DeTurk & Cahalin - pg 368-369, Fig 12-4 & pg 370, Fig 12-5
Musculoskeletal, Integument, & Neuromuscular
Considerations
 Musculoskeletal
Osteoporosis & Spinal Deformities
Ankylosing Spondylitis
Idiopathic Scoliosis
Pectus Deformities
Shoulder Hypomobility
 Integument
 Sarcoidosis
 Systemic Lupus Erythematosus
 Scleroderma
 Sjogren Syndrome
 Neuromuscular
 Stroke
 Traumatic Brain Injury
 Spinal Cord Injury
 Multiple Sclerosis
 Parkinsons
 Guillain-Barre Syndrome
 Post Polio Syndrome
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Nagi (Disablement) Model
Disability
Functional limitation
Impairment
Pathology
Inability to shop for family
Limited walking distance
Impaired aerobic capacity
Myocardial Infarction
APTA, Guide PT Practice, 1st ed.1997.
Therapeutic Exercise for Cardiopulmonary
Practice Patterns
 Aerobic capacity/endurance conditioning or
reconditioning
 Balance, coordination, and agility training
 Body mechanics and postural stabilization
 Flexibility exercises
 Gait and locomotion training
 Relaxation
 Strength, power, and endurance training for head,
neck, limb, pelvic-floor, trunk, and ventilatory
muscles
Pattern A: Prevention and Risk
Inclusion Criteria
 Risk Factors or Consequences of Pathology
Diabetes
Family history of heart disease
Hypercholesterolemia or hyperlipidemia
Hypertension
Obesity
Sedentary lifestyle
Smoking
 Impairments, Functional Limitations, or Disabilities
Decreased functional work capacity
Decreased maximum aerobic capacity
Dyspnea on exertion
Sedentary job role
Pattern A: Prevention and Risk
Ther Ex
 Aerobic capacity/endurance activities using ergometers,
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treadmills, steppers, pulleys, weights, hydraulics, elastic
resistance bands, robotics, and mechanical or
electromechanical devices
Aquatic programs
Gait and locomotion training - Walking and
wheelchair propulsion programs
Increased workload over time
Task-specific performance training
Flexibility exercises
Muscle lengthening
Range of motion
Stretching
Body mechanic and ergonomics training
Breathing exercises
Posture awareness training
Pattern A: Prevention and Risk
Ther Ex
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary
exercise approaches
 Strength, power, and endurance training
Active assistive, active, and resistive exercises
(including concentric, dynamic/isotonic,
isometric, and plyometric - manual resistance,
pulleys, weights, hydraulics, elastic resistance
bands, robotics and mechanical or
electromechanical devices)
Aquatic programs
Standardized, programmatic, complementary
exercise approaches
Task-specific performance training
Pattern A: Prevention and Risk
Patient Education
 Disease
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Atherosclerosis
Hyperlipedemia
Hypertension
Diabetes
 Diet
 Exercise
 Smoking
 Health & Wellness
 Fitness
Pattern B: Deconditioning
Inclusion Criteria
 Risk Factors or Consequences of Pathology
Acquired immune deficiency syndrome
Cancer
Cardiovascular disorders
Chronic system failure
Inactivity
Multisystem impairments
Musculoskeletal disorders
Neuromuscular disorders
Pulmonary disorders
 Impairments, Functional Limitations, or Disabilities
Decreased endurance
Increased cardiovascular response to low level work loads
Increased perceived exertion with functional activities
Increased pulmonary response to low level work loads
Inability to perform routine work tasks due to shortness of breath
Pattern B: Deconditioning
Ther Ex
 Aerobic capacity/endurance activities using ergometers, treadmills,
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steppers, pulleys, weights, hydraulics, elastic resistance bands,
robotics, and mechanical or electromechanical devices
Aquatic programs
Gait and locomotion training - Walking and wheelchair
propulsion programs
Increased workload over time
Balance, coordination, and agility training
Developmental activities training
Neuromuscular education or reeducation
Standardized, programmatic, complementary exercise
approaches
Breathing exercises
Body mechanics, ergonomics, and postural stabilization
Body mechanics training
Postural control and awareness training
Flexibility exercises
Muscle lengthening
Range of motion
Stretching
Pattern B: Deconditioning
Ther Ex
 Gait and locomotion training
Developmental activities training
Gait training
Implement and device training
Standardized, programmatic, complementary exercise approaches
Wheelchair training
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary exercise approaches
 Strength, power, and endurance training for head and neck, limb, pelvic-floor,
trunk, and ventilatory muscles
Active assistive, active, and resistive exercises (including concentric,
dynamic/isotonic, isometric, and plyometric - using manual
resistance, pulleys, weights, hydraulics, elastic resistance
bands, robotics)
Aquatic programs
Conditioning and reconditioning - Strengthening or Resistive
Standardized, programmatic, complementary exercise approaches
Pattern C: Airway Clearance
Inclusion Criteria
 Risk Factors or Consequences of Pathology
Acute lung disorders
Acute or chronic oxygen dependency
Bone marrow/stem cell transplants
Cardiothoracic surgery
Change in baseline breath sounds
Change in baseline chest radiograph
Chronic obstructive pulmonary disease (COPD)
Frequent or recurring pulmonary infection
Solid-organ transplants (eg, heart, lung, kidney)
Tracheostomy or microtracheostomy
 Impairments, Functional Limitations, or Disabilities
Dyspnea at rest or with exertion
Impaired airway clearance
Impaired cough
Impaired gas exchange
Impaired ventilatory forces and flow
Impaired ventilatory volumes
Inability to perform self-care due to dyspnea
Inability to perform work tasks due to dyspnea
Pattern C: Airway Clearance
Ther Ex
 Aerobic capacity/endurance conditioning or reconditioning activities using
ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance
bands, robotics, and mechanical or electromechanical devices
Aquatic programs
Gait and locomotion training - Walking and wheelchair propulsion
programs
Increased workload over time
 Body mechanics, ergonomics, and postural stabilization
Posture awareness training
Postural control training
 Flexibility exercises
Muscle lengthening
Range of motion
Stretching
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary exercise approaches
Pattern C: Airway Clearance
Ther Ex
 Strength, power, and endurance training for head and
neck, limb, pelvic-floor, trunk, and ventilatory muscles
Active assistive, active, and resistive exercises
(including concentric, dynamic/isotonic,
isometric,and plyometric – using manual
resistance, pulleys, weights, hydraulics,
elastic resistance bands, robotics and
mechanical or electromechanical devices)
Aquatic programs
Standardized, programmatic, complementary
exercise approaches
Task-specific performance training
 Balance and coordination training
 Developmental activities
 Neuromuscular relaxation, inhibition, and facilitation
Pattern D: CV Pump Dysfunction
Inclusion Criteria
 Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or
Condition)
Angioplasty
Atrioventricular block
Cardiomyopathy
Cardiothoracic surgery
Complex ventricular arrhythmias
Complicated MI (failure); uncomplicated MI (dysfunction)
Coronary artery disease
Decrease in ejection fraction (EF) on exercise testing (EF of 30-50% with
dysfunction; < 30% with failure)
Diabetes
Hypertensive heart disease
Valvular heart disease
 Impairments, Functional Limitations, or Disabilities
Abnormal heart rate response to increased oxygen demand
Abnormal pulmonary response to increased oxygen demand
Decreased ability or the inability to perform activities of daily living (ADL)
because of symptoms
Change in baseline breath sounds with activity
Flat or falling blood pressure response to increased oxygen demand (failure)
Pattern D: CV Pump Dysfunction
Ther Ex
 Aerobic capacity/endurance activities using ergometers, treadmills, steppers,
pulleys, weights, hydraulics, elastic resistance bands, robotics
Aquatic programs
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Gait and locomotion training - Walking and wheelchair propulsion
programs
Increased workload over time
Balance, coordination, and agility training
Developmental activities training
Motor function (motor control and motor learning) training or
retraining
Neuromuscular education or reeducation
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
Breathing exercises
Body mechanics, ergonomics, and postural stabilization
Body mechanics training
Postural awareness training
Flexibility exercises
Muscle lengthening
Range of motion
Stretching
Pattern D: CV Pump Dysfunction
Ther Ex
 Gait and locomotion training
Developmental activities training
Gait training
Implement and device training
Standardized, programmatic, complementary exercise approaches
Wheelchair training
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary exercise approaches
 Strength, power, and endurance training
Active assistive, active, and resistive exercises (including concentric,
dynamic/isotonic, isometric, and plyometric - using manual
resistance, pulleys, weights, hydraulics, elastic resistance
bands, robotics and mechanical or electromechanical
devices )
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
Pattern E: Resp Pump Dysfunction
Inclusion Criteria
 Risk Factors or Consequences of Pathology
Elevated diaphragm and volume loss on chest radiograph
Neuromuscular disorders
Partial or complete diaphragmatic paralysis
Poliomyelitis
Pulmonary fibrosis
Restrictive lung disease
Severe kyphoscoliosis
Spinal cord injury
 Impairments, Functional Limitations, or Disabilities
Abnormal or adventitious breath sounds
Abnormal increased respiratory rate and decreased tidal volume at
rest
Airway clearance dysfunction secondary to ventilatory pump
impairment
Decreased to severely impaired strength and endurance of ventilatory
muscles
Dyspnea with self-care
Dyspnea with work tasks
Dys-synchronous or paradoxical breathing at rest or with activity
Pattern E: Resp Pump Dysfunction
Ther Ex
 Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys,
weights, hydraulics, elastic resistance bands, robotics,
Aquatic programs
Gait and locomotion training - Walking and wheelchair propulsion programs
Movement efficiency and energy conservation training
Increased workload over time
 Balance, coordination, and agility training
Developmental activities training
Motor function (motor control and motor learning) training or retraining
Neuromuscular education or reeducation
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
 Breathing exercises
 Body mechanics, ergonomics, and postural stabilization
Body mechanics training
Postural control training
Postural stabilization activities
Postural awareness training
 Flexibility exercises
Muscle lengthening
Range of motion
Stretching
Pattern E: Resp Pump Dysfunction
Ther Ex
 Gait and locomotion training
Developmental activities training
Gait training
Implement and device training
Perceptual training
Standardized, programmatic, complementary exercise approaches
Wheelchair training
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary exercise approaches
 Strength, power, and endurance training for head and neck, limb, pelvic-floor,
trunk, and ventilatory muscles
Active assistive, active, and resistive exercises (including concentric,
dynamic/isotonic, isometric, and plyometric - using manual
resistance, pulleys, weights, hydraulics, elastic resistance
bands, robotics
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
Pattern F: Respiratory Failure
Inclusion Criteria
 Risk Factors or Consequences of Pathology
Adult respiratory distress syndrome
Abnormal alveolar to arterial oxygen tension differences
Cardiothoracic surgery
Chronic obstructive pulmonary disease (COPD)
Multisystem failure
Pneumonia
Pre- and post-lung transplant or rejection
Rapid rise in arterial carbon dioxide at rest or with activity
Sepsis
Thoracic or multisystem trauma
 Impairments, Functional Limitations, or Disabilities
Abnormal or adventitious breath sounds
Abnormal vital capacity
Airway clearance dysfunction
Dyspnea at rest
Dyssynchronous or paradoxical breathing pattern
Impaired gas exchange
Pattern F: Respiratory Failure
Ther Ex
 Aerobic capacity/endurance activities using ergometers, treadmills, steppers,
pulleys, weights, hydraulics, elastic resistance bands, robotics
Aquatic programs
Gait and locomotion training - Walking and wheelchair propulsion
programs
Movement efficiency and energy conservation training
Increased workload over time
 Balance, coordination, and agility training
Neuromuscular education or reeducation
Posture awareness training
 Body mechanics, ergonomics, and postural stabilization
Body mechanics training
Postural control training
Postural awareness training
 Flexibility exercises
Muscle lengthening
Range of motion
Stretching
Pattern F: Respiratory Failure
Ther Ex
 Relaxation
Breathing strategies
Movement strategies
Relaxation techniques
Standardized, programmatic, complementary exercise
approaches
 Strength, power, and endurance training for head and neck, limb,
pelvic-floor, trunk, and ventilatory muscles
Active assistive, active, and resistive exercises (including
concentric, dynamic/isotonic, isometric, and plyometric
- using manual resistance, pulleys, weights,
hydraulics, elastic resistance bands, robotics and
mechanical or electromechanical devices )
Task-specific performance training
Therapeutic Exercise
 Aerobic capacity/endurance conditioning or
reconditioning
 Aquatic programs
 Gait and locomotion training – Walk or W/C
 Increased workload over time
 Movement efficiency and energy conservation training
Aerobic Capacity/Endurance Conditioning or
Reconditioning
 Activity, specific set up, time
 Improve oxygen demand
 Use of large muscle groups in a rhythmic fashion, over time
 Mode
 Marching, Walking, Bike, Gardening
 Intensity
 Max HR and take age adjusted
 50-70% depending on exercise test, age
 Frequency
 4-5 days per week
 Duration
 5-10 min bouts 3x/day
For Progression,
DeTurkmin
& Cahalin,
447 & 448, Figs 15-7 & 15-8
 Work upsee
to 30-40
in one pg
session
Aerobic Capacity/Endurance -Evidence
 Patient Education on Risk or Disease
 Exercise, Diet
 Deconditioning
 Rate of VO2 max decreases greatest the first week of
bedrest1
 Longer the bedrest the more diminished the VO2 max1
 Use of HR, RPE, and METs
1 Convertinao VA, Med Sci Sports Exer, 1997:29:191
Aerobic Capacity/Endurance -Evidence
 Group-based (8-12 patients) simple aerobic dance
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movements (with music)
2 days a week for 4 months
Each session lasted 50 minutes (including warm-up and
cool-down), followed by 15-30 minutes of counseling
The exercise program included three intervals of high
intensity, during which patients were encouraged to reach
15-18 on the Borg scale for 5-10 minutes.
6 min walk, resistance on bike, bike time, MN Living with
Heart Failure QOL all increased with significance as
compared to the control group for 4 and 12 mn.
Nilsson et al, Long-term effects of a group based high intensity aerobic interval training program in patients with
chronic heart failure, Am J Cardiol 2008; 102(9):1220-1224
Therapeutic Exercise
 Balance, coordination, and agility training
 Developmental activities training
 Posture awareness training
 Standardized, programmatic, complementary exercise
approaches
 Task-specific performance training
Balance, Coordination, and Agility Training
 Mode
 Massery Technique
 Intensity
 Duration
 Frequency
 No set parameters
Balance - Evidence
 Sensory-specific balance classes were held 3 times per week, for 1 hour each
session, over 8-week
 Tasks included
 standing or walking on various support surfaces, such as a rocker board, foam, or
narrow beam
 Standing in a tandem position, a semitandem position, on one leg, or in a feet
together
 Progressions to these tasks included simultaneous alterations of visual and
vestibular inputs
 Instructed to close their eyes, to engage vision with a reading or tracking secondary
task
 Perform balance tasks with a distracting background
 Instructed to tilt their head backward or to quickly move their head side to side and
up and down.
 Results
 Less destabilization within the first 5 seconds following vibration with or without a
secondary task than there was at baseline or in the falls prevention education group
 Training effects were not maintained at the 8-week follow-up.
Westlake & Culham. Sensory-Specific Balance Training in Older Adults: Effect on Proprioceptive
Reintegration and Cognitive Demands Physical Therapy. Oct 2007. Vol. 87, Iss. 10; p. 1274
Therapeutic Exercise
 Body mechanics and postural stabilization
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Body mechanics training
Postural control training
Postural stabilization activities
Posture awareness training
Body Mechanics and Postural Stabilization
 Mode
 Intensity
 Duration
 Frequency
 No set parameters
Body Mechanics -Evidence
 Perfusion study in prone and supine
 Pts were under conditions of
 Normal breathing of room air
 Unassisted breathing of 45% O2
 Assisted PEEP
 Ventral, Middle, Dorsal measurements with
ventral more perfuse in prone and dorsal more
perfuse in supine
Suki et al, Perfusion, Science Letter. Atlanta: Mar 25, 2008. pg. 2580
Body Mechanics -Evidence
 Pt with ischemia of stable and unstable angina
 Valsalva and measured QT of EKG
 With valsalsa showed significant difference of EKG
changes of QT segment
 Authors related to carrying or lifting restrictions of
heavy objects with CAD
Balbay et al, Effects of valsalva maneuver on QT dispersion in patients with
ischemic heart...Angiology; Nov 2001; 52, 11
Therapeutic Exercise
 Flexibility exercises
 Improve motion of the chest wall, lengthen anterior chest wall,
improve hip and knee flexor shortening
 Muscle lengthening
 Range of motion
 Stretching
Flexibility Exercises
 Mode
 Isolate muscle or limited joint
 Intensity
 After warmup
 Duration
 Hold with no pain for 30 sec
 Frequency
 3-5 days/week
Flexibility - Evidence
 Pt with ankylosing spondylosis
 3x/wk for 3 months
 18 stretching exercises of entire spine and extremities
along with aerobic and chest expansion exercises
 Significant improvement in cervical and thoracic spine
movement AND chest expansion
Ince et al , Effects of a Multimodal Exercise Program for People With Ankylosing Spondylitis,
Physical Therapy; Jul 2006; 86, 7
Therapeutic Exercise
 Gait and locomotion training
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Developmental activities training
Gait training
Implement and device training
Standardized, programmatic, complementary exercise approaches
Gait and Locomotion Training
 Mode
 Intensity
 Duration
 Frequency
 No set parameters
Gait and Locomotion - Evidence
 See aerobic exercise
 Massery Pairing
Massery et al, Coordinating transitional movements and breathing in
patients with neuromotor dysfunction, NDTA Network, Nov/Dec 1996
Gait and Locomotion - Evidence
 Case Report of pt with C6 tetraplegia
 Taught breathing strategy and reducing valsalva with
tasks with w/c
 Lean forward
 Put foot on footplate
 Posterior lean for pressure relief
 Able to perform tasks with new breathing strategies
Henderson, Application of Ventilatory Strategies to Enhance Functional
Activities for an...Journal of Neurologic Physical Therapy; Jun 2005; 29, 2
Therapeutic Exercise
 Relaxation
 Breathing strategies
 Movement strategies
 Relaxation techniques
 Standardized, programmatic, complementary exercise approaches
Relaxation
 Mode
 Intensity
 Duration
 Frequency
 No set parameters
Relaxation -Evidence
 Five 60 minute individual treatments with the Papworth
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method from a respiratory physiotherapist
No significant differences were found between the groups
at baseline
SGRQ Symptom mean scores were lower in the Papworth
method group than in the control group after treatment
and at 12 months
The Nijmegen and HADS scores were also significantly
lower in the intervention group than in the control group
Objective respiratory measures did not differ significantly
across the groups, apart from breathing rate.
Holloway and West, Integrated breathing and relaxation training (the Papworth method) for adults with
asthma in primary care: a randomised controlled trial , Thorax 2007; 62(12): 1039-1042
Therapeutic Exercise
 Strength, power, and endurance training for head, neck,
limb, pelvic-floor, trunk, and ventilatory muscles
 More efficient motion
 Active assistive, active, and resistive exercises (including concentric,
dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)
 Aquatic programs
 Standardized, programmatic, complementary exercise approaches
 Task-specific performance training
Strength, Power, and Endurance Training for
Trunk, Extremities and Ventilatory Muscles
 Mode
 AAROM, AROM
 Resistance
 Manual
 Weights
 Intensity
 Incorporate breathing with resistance
 Resistance may start light and work up
 8-12 reps, 1-3 sets
 Resistance of 1 rep max and then calculate
 8-10 reps at 70% of max, 6 reps at 80% of max, 4 reps at 90% of max, 2 reps at 95%
max and finally 1 rep at max
 High weight, low reps for strength
 Low weight, high reps for endurance
 Duration
 Frequency
 Every other day or rotate muscle groups
Strength - Evidence
 Systematic review to determine the effect of inspiratory muscle training (IMT) on
inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of
life for adolescents and adults living with cystic fibrosis.
 Articles were included if:
 (1) participants were adolescents or adults with cystic fibrosis (413 years of age)
 (2) an IMT group was compared to a sham IMT, no intervention or other
intervention group
 (3) the study used a randomized controlled trial or cross-over design
 (4) it was published
 Results: The search strategy yielded 36 articles
 Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced
vital capacity (FVC)
 No difference in effect between the IMT group and the sham and/or control group.
 Individual study results were inconclusive for improvement in inspiratory muscle
strength
 One study demonstrated improvement in inspiratory muscle endurance.
 Conclusion:
 The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of
inspiratory muscle function is supported by weak evidence.
 Its impact on exercise capacity, dyspnoea and quality of life is not clear
Reid et al, Effects of inspiratory muscle training in cystic fibrosis: a
systematic review, Clinical Rehabilitation. London: Oct 2008. Vol. 22, Iss. 10-11
Goals and Outcomes Impact on Pathology
Atelectasis
Joint swelling, inflammation, restriction
Nutrient delivery
Osteogenic effects of exercise
Pain
Physiological response
Soft tissue swelling, inflammation, restriction
Increased oxygen demand symptoms
Tissue perfusion and oxygenation
Goals and Outcomes Impact on Impairments
Aerobic capacity is increased.
Airway clearance is improved.
Balance is improved.
Endurance is increased.
Energy expenditure per unit of work is decreased.
Gait, locomotion, and balance are improved.
Integumentary integrity is improved.
Joint integrity and mobility are improved.
Motor function (motor control and motor learning) is improved.
Muscle performance (strength, power, and endurance) is increased.
Postural control is improved.
Quality and quantity of movement between and across body
segments are improved.
Range of motion is improved.
Relaxation is increased.
Sensory awareness is increased.
Ventilation and respiration/gas exchange are improved.
Weight-bearing status is improved.
Work of breathing is decreased
Goals and Outcomes Impact on Functional Limitations
and Disabilities
 Functional Limitations
Ability to perform physical actions, tasks, or activities
related to self-care, home management, work
(job/school/play), community, and leisure is
improved.
Level of supervision required for task performance is
decreased.
Performance of and independence in ADL and IADL with
or without devices and equipment are increased.
Tolerance of positions and activities is increased.
 Impact on disabilities
Ability to assume or resume required self-care, home
management, work (job/school/play), community,
and leisure roles is improved.
Goals and Outcomes Risk Reduction/Prevention
Health, Wellness, and Fitness
 Risk Reduction/Prevention
Preoperative and postoperative complications are
reduced.
Risk factors are reduced.
Risk of recurrence of condition is reduced.
Risk of secondary impairment is reduced.
Safety is improved.
Self-management of symptoms is improved.
 Impact on Health, Wellness, and Fitness
Fitness is improved.
Health status is improved.
Physical capacity is increased.
Physical function is improved.
Goals and Outcomes Impact on Societal Resources
& Patient Satisfaction
 Societal Resources
Utilization of physical therapy services is optimized.
Utilization of physical therapy services results in efficient use of health
care dollars.
 Patient/client Satisfaction
Access, availability, and services provided are acceptable to
patient/client.
Administrative management of practice is acceptable to patient/client.
Clinical proficiency of physical therapist is acceptable to
patient/client.
Coordination of care is acceptable to patient/client.
Cost of health care services is decreased.
Intensity of care is decreased.
Interpersonal skills of physical therapist are acceptable to
patient/client, family, and
significant others.
Sense of well-being is improved.
Stressors are decreased.