Lectura Analisis

PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2022;102:1–17
https://doi.org/10.1093/ptj/pzab281
Advance access publication date January 5, 2022
Perspective
Updated Integrated Framework for Making Clinical

Decisions Across the Lifespan and Health Conditions
Judith E. Deutsch, PT, PhD, FAPTA1 ,* , Kathleen M. Gill-Body, PT, DPT, NCS, FAPTA2 ,
Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Margaret Schenkman, PT, PhD, FAPTA3
1 Rivers Lab, Department of Rehabilitation and Movement Science, School of Health Professions, Rutgers University, Newark, New Jersey,
USA
2 Rehabilitation Services, Newton-Wellesley Hospital, Newton, Massachusetts, USA
3 Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora,
Colorado, USA
*Address all correspondence to Dr Deutsch at: deutsch@rutgers.edu and @JudithDeutsch
Abstract
The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since
the publication of the first version in 2008. The original framework was proposed for persons with neurological health
conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition,
the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode
of care around the patient’s goals for participation; (3) explicitly describes the role of movement science; (4) reconciles
movement science and International Classification of Function language, illustrating the importance of each perspective to
patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient
management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low
back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female
librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is
proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan.
Keywords: Decision-Making: Clinical, Movement Analysis of Tasks, Movement System, Shared Decision-Making
Received: February 23, 2021. Revised: September 16, 2021. Accepted: October 26, 2021
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For
permissions, please e-mail: journals.permissions@oup.com
2 Clinical Decision-Making Across Health Conditions
Introduction
The Integrated Framework for Clinical Decision Making,
published in 2006,1 innovated clinical reasoning in neurolog-
ical physical therapy by being explicitly patient centered and
combining both enablement2 and disablement3 perspectives
of health, with an emphasis on a person’s role in society.4 It
incorporated the Hypothesis Oriented Algorithm for clinical
decision-making5,6 and was organized using the Patient
Client Management from the Guide to Physical Therapist
Practice.7 The framework was based on knowledge at that

time regarding neural plasticity. Motor learning, included
as a critical component of rehabilitation and task analysis,
was identified as central to the examination process. This
framework has been used over the last 15 years to organize
curricula of selected academic physical therapy programs.8 In
addition, it has been used specifically to teach neurological
content in physical therapy programs and for regional
courses taught by the Academy of Neurologic Physical
Figure 1. The Revised Integrated Framework illustrates the centrality of
Therapy. the shared decision-making and the influence of both movement science
Since 2006, substantive changes have occurred in knowl- and the movement system in the reasoning process. The patient-client
edge, evidence, policy, and practice that make it timely to management organizes the steps of the reasoning process. Hypothesis
update the Integrated Framework for Clinical Decision Mak- generation occurs at each step. An episode of care may follow the steps
ing. First, in 2013, the American Physical Therapy Association of the patient client management sequentially.
(APTA) adopted a new vision for the profession of physical
therapy and identified the human movement system as the This manuscript describes the revised Integrated Frame-
“core of physical therapist practice, education and research.”9 work for Clinical Decision Making (Fig. 1), identifies the
Second, the third edition of the Guide to Physical Therapist emerging concepts and evidence that led to the revisions, and
practice incorporated the International Classification of Func- extends the framework to persons with all health conditions.
tion (ICF).10 Next, APTA, through task forces, academies, Each step in the process is illustrated using 2 case examples:
working groups, and summits, has advanced the definition a bus driver with low back pain and a librarian with postural
and application of clinical reasoning,11–14 the human move- instability and falls. For those aspects of the framework
ment system,15–17 and diagnosis.18,19 These initiatives have that have not changed, the reader is referred to the original
focused the profession to define specific approaches to exam- manuscript for details.1 Specifically, the revised Integrated
ining and managing movement system problems as they relate Framework of Clinical Decision Making:
to activity limitations and participation restrictions for all
individuals across the lifespan. The importance of framing the a) applies to persons with any health condition across the
plan of care to improve the patient’s ability to participate in lifespan,
life roles also has come into sharper focus. b) updates patient-centered concepts with shared clinical
Literature on shared decision-making also has advanced decision-making,
beyond patient-centered practice. In partnership with their c) frames the episode of care around the patient’s goals for
clinician, individuals are encouraged to consider the benefits participation,
and harms of available treatment or management options, d) explicitly describes the role of movement science,
communicate their preferences, and collaborate with clin- e) reconciles movement science and ICF language, illustrat-
icians to choose the course of action that best fits their ing the importance of each perspective to patient care,
preferences.20,21 Taken into consideration are individual f) provides a process for movement analysis of tasks, and
preferences, abilities, self-efficacy, a person’s readiness to g) integrates the movement system into patient manage-
change, and clinicians’ knowledge.22 Implementation of ment.
shared decision-making into health care practice23 has
been adapted for physical therapy24 using evidence-based
strategies around communication, motivational interviewing, History and Interview
and decision aids to increase the person’s knowledge and A key change in this revised framework is a focus on shared
options.25,26 decision-making. This client–therapist partnership begins dur-
Finally, the manner in which physical therapists use ing the history and interview. The questions that the clinician
evidence to guide practice has exploded with the publication asks and the way they are phrased lays the groundwork for
of physical therapy–specific clinical practice guidelines,27–29 collaboration. This approach is informed by the ICF, Gordon-
clinical prediction rules,30,31 the integration of evidence- Quinn’s adaptation of the ICF,42 strategies from motivational
based practice with clinical reasoning,32–35 and the growth interviewing,43–45 and an appreciation of a person’s “readi-
of knowledge translation and implementation efforts across ness to change.”46,47 A major focus is to understand the
the profession.36,37 The availability of synthesis documents patient’s perception of their condition, goals related to the
and resources for practice (eg, EDGE task force materials for episode of care, and meaningful benchmarks of progress. It is
examination,38,39 synthesis and implementation resources40 ) important to gain an appreciation of existing life constraints
has also aided in clinical reasoning.41 or resources such as health insurance, home support, job
Deutsch et al 3
Table 1. Representative Probing Interview Questions to Promote Shared Decision-Making
Category Question
Physical therapist’s questions about why a Why are you seeking care?
patient is seeking care
What would you like to do? When was the last time you were able to do the activities
you desire? What are you able to do? What are you unable to do?
How limiting is the problem for which you are seeking care?
How long have you had this problem?
What do you think is contributing to this problem?
Are there other factors or health conditions that you think I should know about?

Patient’s goals What do you hope to achieve with therapy?
What would you consider as benchmarks (examples) of progress towards your goals?
Patient’s role in society What roles do you play (eg, at home, at work)?
How do the identified problem(s) interfere with your important home, work, and
social activities?
Patient’s resources and constraints What are your prior physical therapy experience, knowledge of your health condition,
and recent physical activity?
What kind of assistance do you get on a daily basis from family and friends?
What additional assistance do you (or your family members, significant others) think
you need from family or others?
How feasible is access to health care—both financially and in terms of accessibility (eg,
distance, transportation, schedule, insurance coverage)?
Patient’s preferences for solutions How do you prefer to learn and remember (eg, verbal, written)?
What barriers might make it difficult for you to do what you need to do to participate
in therapy or reach your goals? What do you consider as facilitators to reach your
goals? How ready are you to assume an active role in managing your care? How
comfortable are you in changing a particular behavior that needs to change in order to
optimize your outcome from this episode of care?
flexibility, and access to health care. Examples of probing The systems review must be tailored to each person and
questions, not recommended in a specific order, guide the includes information obtained from a variety of sources
interview (Tab. 1). (eg, medical record, health history questionnaire, subjective
To fully share decision-making, the clinician needs to report, direct assessment). Targeted questions during the
appreciate the patient’s preferences regarding their roles interview process can identify unknown or unreported
and activities while considering what might be realistic for health conditions as well as signs and symptoms that could
the patient. This exchange of information, which occurs suggest alterations in function in specific body systems. Some
throughout the episode of care, provides contextual insight to examples of such targeted interview questions are provided
the clinician regarding the individual’s specific situation and (Tab. 2, middle column). Other information is obtained by
provides insight to the person regarding likely expectations direct assessment; examples of useful tests/measures are
and time frames. presented (Tab. 2, right column).
In parallel with gathering information during the interview, The clinician determines the combination of targeted ques-
the physical therapist observes the person’s spontaneous tions and screening tests and measures that are useful for each
movement, which can inform tasks and tests/measures to be patient. Because sources of information vary across individu-
included in the systems review and examination. Likewise, als, the order of obtaining information is person specific. On
observations and queries related to cognition, learning completion of the systems review, the clinician can generate
style, and preferences are important for the scope of the an initial hypothesis related to the patient’s movement limita-
intervention. tions and makes preliminary decisions regarding the specific
activities that need to be examined and the tests and measures
Systems Review that will be included in examination. The history and clinical
The second major change in this revised framework is the reasoning during systems review are demonstrated for 2 cases:
organization of the systems review using the 6 body sys- a bus driver with low back pain and a librarian who incurred
tems that comprise the movement system (cardiovascular, a recent fall and injury (Tab. 3).
pulmonary, integumentary, musculoskeletal, endocrine, and
nervous).17 The systems review systematically rules out body
systems with which the physical therapist need not be con- Examination
cerned, identifies those that are resources for the patient, Regarding examination, major changes include the blending
guides choices regarding which aspects of the remaining body of both ICF and movement science terminology and concepts,
systems impact movement, and identifies if referral to another the process of dissecting a participation goal into compo-
health care provider is indicated.10 An existing component of nent activities, and the movement analysis of activities and
the systems review, obtained for all patients, is the minimum tasks. The purposes of the examination are to (1) collect
data set (vital signs [heart rate, blood pressure], height, weight, baseline data on participation and activity that will be used
orientation, attention, communication ability, and learning to determine clinical outcomes of the episode of care and
style).10 (2) obtain data from movement observations-analyses and
Table 2. Sources of Information for a Systems Review That Integrates the Movement Systema
Medical Record Review, Medical Screening Questionnaire,

Body System Screening Tests and Measures
and History and Interview
Cardiovascular Known health condition? Heart rate
Shortness of breath? Blood pressure
Chest pain or pressure? Temperature at hands and feet
Sense of irregular heartbeat? Lower extremity edema
Leg cramps with ambulation? Pedal pulse
Slow healing wounds? 2- or 6-min walk test
Pulmonary Known health condition? Breathing pattern

Shortness of breath? Respiratory rate
Difficulty breathing? Color of nail beds and lips
Cough? Oxygen saturation
Wheezing? 2- or 6-min walk test
Integumentary Known health condition? Skin color, integrity, and pliability
Open or healing wounds? Wound/scar inspection
Musculoskeletal Known health condition? Gross AROM and strength
Joint pain, swelling, or stiffness? Posture and symmetry
Weakness? Joint temperature
FTSTS
Joint alignment
Endocrine Known health condition? FACIT Fatigue Scale
Fatigue? 2- or 6-min walk test
Recent weight loss or gain?
Usual level of blood sugar when checked (diabetes)?
Nervous Known health condition? Gross sensory screen
Numbness or pins and needles? Reflex tests
Weakness? Romberg Test/SLS
Dizziness? Myotome/dermatome tests
Problem with balance/falls? Gait observation or TUG
Headaches? FTSTS
Loss of consciousness? Tandem walk
Visual changes? ABC Scale
Cognition, affect, behavior?
aA standardized approach to systems review involves assessing all 6 body systems that comprise the movement system (left column). The systems review
can be performed by using a combination of medical record/questionnaire review and targeted interview questions that address each body system (middle
column) as well as tests/measures (physical examination elements or self-report measures) administered by the physical therapist (right column). Examples of
commonly used interview questions and examination tests/measures related to the 6 body systems are presented. ABC = Activities-Specific Balance Confidence;
AROM = active range of motion; FACIT = Functional Assessment of Chronic Illness Therapy; FTSTS = Five-Times Sit-to-Stand Test; TUG = Timed “Up &
Go” test.
tests/measures of activity and Body Function Structure (BFS) Movement science terminology provides useful language and
that will inform the evaluation, diagnosis, and prognosis. In tools for physical therapy that are not provided by the ICF. We
this revised integrated framework, we explicitly reconcile the acknowledge the value of both sources. In this version of the
differences in language that exist between the ICF and move- framework, we consider the words “tasks” (motor learning)
ment science and clarify how each perspective contributes to and “activities” (ICF) as synonyms.
clinical decisions. To combine the ICF and movement science concepts into
The World Health Organization proposed the ICF as the the examination of goal-directed motor behavior, we propose
current model of health in 2001.2 ICF concepts and language that clinicians follow this 3-step process (Fig. 2).
were incorporated into the third edition of the Guide to Phys- The clinician’s first step is to dissect the person’s partici-
ical Therapist practice, replacing the previous World Health pation goal into relevant component activities (ICF) or tasks
Organization disablement models and terminology found in (movement science) in the context of their personal factors,
the first edition of the “Guide.”71 identifying what the client is both able and unable to do.
Movement science was proposed as a basis for physical Activities that the clinician identifies as resources (able to do)
therapist practice by Carr and Shepherd72 in 1987 and is need no further examination; those that are not performed
informed by biomechanics, kinesiology, psychology, and neu- successfully or efficiently require movement observation and
roscience.73 Motor control and motor learning are distinct are interpreted through a “movement analysis of tasks”
areas of study within the field of movement science. Many (Step 2).
motor control theories have been described to guide the Consider the person with chronic low back pain who wants
examination of movement. A current theory, the “systems to participate in their role as a bus driver (case example 1,
theory,” frames motor control by examining the relation- Tab. 3). Achievement of this goal requires that the person
ship between internal attributes of the person (eg, cognition, performs the following activities: driving, stopping at the
perception, and action) and how these interact with the envi- required points to collect and deposit passengers, opening
ronment and the attributes of the specific movement or task.74 and closing the bus door, inspecting passengers as they pay,
Table 3. Case Examples Illustrating the Revised Integrated Framework of Clinical Decision-Makinga
Category Case Example 1 Case Example 2

Patient overview
Deutsch et al
Description of patient The patient is a 45-y-old man employed as a New York City bus The patient is a 66-y-old woman employed part time as a librarian.
driver. He has 2 teenage daughters and lives in a second-floor walk-up She has had 3 falls in the last 6 mo. Her last fall was 4 wks ago and
apartment with his wife, who is a guidance counselor at a high school. resulted in a wrist fracture for which she is currently casted. She is
This patient has had intermittent, localized LBP for the past 5 y, but referred for evaluation of her gait and balance. She lives with her
this time, the pain in his back has persisted for 2 mo. He is currently spouse in a 1-level home. The spouse is retired and has assumed
not working and is unable to sleep through the night. household tasks since the fracture. She has been out of work for the
past month and is eager to return.
Walks into appointment at a slow pace. Sits down slowly and shifts Walks into appointment independently, with no device, at a slow pace,
away from right lower extremity. with B foot slap, and carrying purse. Able to walk and talk.
Statements from patient “I know that it is important to lose the weight, but I am really not sure “I need to return to work as soon as I can because we depend on my
that I can do it. I have tried so many times and failed.” “I miss being income.” “I really miss my walking club friends; I haven’t seen them in
more active and playing ball with the guys.” “I want to do it but just a while.”
have to find the time to get it back into my routine.” “I am the sole
breadwinner and really need to get back to work.”
Medications Lipitor, lisinopril, Aleve Insulin, Synthroid, Tylenol PRN, calcium with vitamin D
Patient’s goals
For episode of care Resume full-time bus driver duties (participation) Resume librarian duties (participation)
Play basketball with the neighborhood guys (participation) Avoid future falls (activity)
Benchmark Get a full night of sleep (activity) Resume independent outdoor walking with confidence (activity)
Resume part-time bus driver duties (participation) Resume limited meal preparation (participation)
History and interviewb Sitting for too long (>1 h), especially on the bus, bothers his back. He Falls have mostly occurred outside the home, when she was walking or
has difficulty with prolonged standing and has stopped playing turning on an uneven surface. The most recent fall was the only fall
basketball. He is physically uncomfortable with the size of his gut and with an injury; it occurred when she was reshelving books at work.
weight gain. He went to his primary care physician, who did blood She reports intact hearing and vision. Since her fall, she has
work and ruled out any systemic problems; a spine radiograph showed discontinued daily outdoor walking with friends.
degenerative arthritis.
Systems review
Minimum data set Alert and oriented × 4 (person, place, time, situation); Alert and oriented × 4 (person, place, time, situation);
height = ∼1.7 m [67 in]; weight = ∼90 kg [200 lb]; follows directions height = ∼1.6 m [63 in]; weight = 68 kg [150 lb]; follows directions
well and communicates clearly well and communicates clearly
Medical history High cholesterol, HTN, chronic left ankle sprains Type 2 diabetes, knee OA, and hypothyroidism
Review of body systems
Pulmonary Denies issues Denies issues
Integumentary Denies issues Denies issues
Cardiac HTN Denies issues
Musculoskeletal Ankles feel wobbly sometimes; back is stiff after prolonged sitting Denies pain but reports early-morning knee stiffness that typically is
reduced by midmorning and returns after 30 min of sitting
Endocrine Denies fatigue Blood sugar levels are in range, and patient checks levels every other
day
Neurologic Denies any referred pain or feelings of tingling or numbness Reports numbness, tingling, and heaviness in both feet; denies dizziness
Tests and measures
Rationale for selection of screening Screen for possible: Screen for possible:
tests and measures lower extremity strength deficit Cardiac, pulmonary, or integumentary system deficits
Fear of returning to work Possibility of LE pain or weakness affecting performance of tasks
LE sensory deficit Level of fall risk
Rule out structural deformity
(Continued)
5

6
Table 3. Continued

Tests and Measures Cardiovascular: HR = 76 bpm, BP = 125/75, RR = 12 bpm Cardiovascular: HR = 76 bpm, BP = 126/80, RR = 16 bpm; intact
pedal pulses
Neuromuscular: sensory integrity—B LE WNL for sharp/dull and deep Integumentary: normal skin color and integrity
tendon reflexes
Musculoskeletal: standing posture—posterior pelvic tilt, rounded Musculoskeletal: standing posture—mild B genu varum, ∼10-cm
shoulders (4-in) BOS
Combined system measures: FTSTS = 12 s Combined system measures: FTSTS = 16 s, ∼20.25-cm (8-in) BOS, no
symptoms; TUG (no device) = 15.3 s, slows on turns
Other: FABQW = 10 Other: ABC Scale = 60%
Initial hypotheses
Hypothesis 1 Patient may have a combination of trunk weakness, incoordination, Patient moves slowly and appears hesitant during functional tasks; this
and low endurance coupled with poor posture, resulting in decreased behavior may reflect reduced balance confidence.
tolerance for prolonged sitting while driving, resulting in back pain.
Hypothesis 2 Patient’s sleeping position may influence LBP and decreased tolerance Patient may have reduced distal LE strength and sensation that affects
for standing for playing basketball. her balance and gait.
Hypothesis 3 Patient may have residual balance and force generation deficits in the
ankle that compromise basketball playing.
Further movement observation and analysis are needed for bus driving Further movement observation and analysis are needed for selected
tasks: sitting simulation, sit-to-stand transitions, ascending and core tasks and work-related tasks (reaching to surfaces at various
descending stairs, observation of sitting and sleeping positions, and heights, walking while pushing a cart, stair-climbing, and standing
specific tests of motor control and strength of trunk and LE as well as activities with UE tasks), and specific tests of postural control, LE
neuromuscular endurance of the trunk. flexibility and strength, and sensory integrity (especially in LEs).
Examination Strategy: MCF Strategy: MCF and ANPT Framework
Observation of movement during Sitting in driving simulator: narrow base of support, lumbar spine Sit-to-stand transitions: the patient is hesitant to perform without UE
tasks/activities slides into a posterior tilt of pelvis, resulting in LS flexion, after 2 min support, but with encouragement and close supervision, she can
in the position initiate, execute, and complete the task in a stable manner; execution
(rising to stand) is slow, and the patient reports that it is difficult to
rise without using UEs to assist.
Sit-to-stand transitions related to bus driving: unable to perform Reaching in standing to place an object (book) from a cart to a shelf at
without using UEs, amplitude of trunk extension is decreased during knee, waist, and overhead levels:
execution; trunk does not achieve full extension on termination - Able to reach ∼15.25 cm (6 in) and place an object on a shelf at
waist level in a typical manner without support/difficulty
- Able to reach ∼15.25 cm (6 in) in forward and diagonal directions at
low/high levels before needing UE support; grasping and manipulation
of an object are typical; during execution of reaching in any direction,
reduced weight shift and increased trunk lean are noted
- When reaching more than ∼15.25 cm (6 in) in any direction, the
patient widens the BOS at initiation and requires UE support to
complete the task.
(Continued)
Clinical Decision-Making Across Health Conditions

Table 3. Continued
Deutsch et al

Ascending and descending stairs: alignment and direction of the trunk Walking
show excessive flexion from initial conditions through termination, - Walks forward on a level surface at a slow pace with an ∼15.25 cm
more prominently with descending stairs; asymmetry of movement (6-in) BOS, B feet flat at initial contact, and B short steps; speed
with decreased movement speed and amplitude of the entire right LE decreases further during turning (10 steps to turn), on unlevel surfaces,
while unweighted with ascending stairs or when carrying an object; pauses before stepping over an ∼10-cm
(4-in) box; unsteady (increased trunk lateral movement) when walking
on a narrow (∼10-cm [4 in]) path and uses UE to regain balance
(wall). [Walking while pushing a cart: to be examined later]
Sleeping positions in bed: preferred initial position is supine with knees Stair climbing
bent; rolling to lying on a side occurs without trunk dissociation - Performs with 1 rail and using foot-over-foot pattern at a slow speed
across the spine and pelvis and with the use of UEs; moving from lying - Ascent—steps up with B increased hip flexion and reduced DF
on a side to sitting relies on the use of UEs - Descent—uses UEs for significant weight bearing; performs 1 step at
a time
- Reports fear of falling with the task
Basketball: to be examined later
Tests and measures
Participation Oswestry Disability Index = 13/50 = 26% (moderate disability) Activities-Specific Balance Confidence Scale = 60%
Activity 6-min walk test (500 m) Functional Gait Assessment = 18/30
Gait Speed = 0.8 m/s
TUG manual = 16.3 s, slow on turns
TUG cognitive = 16.7 s
Body structure and function Neuromuscular Musculoskeletal
Balance: SLS = 35 s on right, 15 s on left AROM: hips = WNL; B knees = 5◦ –100◦ ; ankle DF = 5◦ with knee
Posterior lumbar trunk muscle endurance using the Biering-Sorenson extended, 10◦ with knee flexed; PF, inversion, and eversion = WNL
Test: 125 s Muscle performance (MMT): B hips = 5/5; B knee flexion and
extension = 4/5; B ankle DF and PF = 3+/5
Musculoskeletal Neuromuscular
Soft tissue: increased resistance to stroking and skin rolling at B Sensory integrity:
paraspinals, L4–S1 - Impaired response to light touch in B LEs distal to knees (3/5 correct
responses)
- Reduced proprioception in B great toes (2/5 correct responses)
Mobility-ROM Steady-state postural control:
SLR No symptoms 0–65 degrees (−): B - Independent in sitting/standing with self-selected BOS
- Positive Thomas Test: with −10 degrees of hip extension - Standing with feet together and EO/EC = 30 s, minimal sway
- B pectoralis minor length = ∼3.2 cm (1.25 in) - B tandem stand with EO = 4 s; uses UEs to avoid falling
- AROM: hip = WNL throughout - B SLS with EO = 2–3 s
- Lumbar flexion (fingertip to floor) = 12 cm; lumbar extension = 20◦
- Side bending (fingertip to thigh) = 17 cm
Muscle performance (MMT): Anticipatory postural control:
- B UE generally = 5/5, except parascapular muscles = 4/5 - With alternating toe tapping, catches B toes on step in 4/10 trials
- LEs = 5/5, except hip extension = 4/5, hip abduction = 4/5, and right Reactive postural control: During tasks/activities (above), ineffective
ankle = 4/5 stepping responses in forward and backward directions; effective hip
- Lower abdominals = 3/5 strategies; ankle strategies effective 50% of the time
(Continued)
7

8
Table 3. Continued

Evaluation The patient is a 45-y-old man who is a New York City bus driver with The patient is a 66-y-old active woman with a history of falls and
LBP. His goals are to return to work, sleep better, and resume recent fracture. Her goal is to return to work as a librarian. She has a
recreation. He is in the contemplation phase for changing his diet and high degree of motivation but reduced confidence in her ability to
the preparation phase for increasing physical activity. He performs return to her job. She performs tasks that require reaching to high/low
job-related tasks with a flexed posture and a lack of extension in levels, turning, and stair-climbing slowly and hesitantly. For some but
movement termination, impaired sequencing between movements, and not all tasks, she requires UE support to be stable.
some asymmetry in standing tasks.
Standardized tests reveal moderate disability with no fear avoidance Standardized tests reveal that current level of fall risk is high when
behavior. walking without a device on level surfaces, which is her current level
of ambulatory function.
Deficits in trunk strength endurance and coordination result in poor She has deficits in both anticipatory and reactive postural control;
biomechanics when holding positions and moving into positions. Soft factors contributing to her falls likely include impaired sensory
tissue and joint mobility limitations as well as force generation deficits integrity, reduced strength, and limited flexibility in B distal LEs.
interfere with both posture and active movement of the trunk.
Diagnosis Deficits in trunk and LE movement stability and sequencing and Deficits in anticipatory and reactive postural control
asymmetry related to impaired force generation, neuromuscular
endurance, and pain
Prognosis
Related to health condition Recurrent LBP = guarded; chronic LBP recurs and is exacerbated by Falls = guarded; diabetes is a progressive health condition and a major
lifestyle choices; score on Biering-Sorenson Test and weight are risk factor for falls50
predictive of recurrence48,49
Related to goals for episode of care Return to work and recreational basketball = good; there is no fear Return to work = good; balance and gait training, in addition to
avoidance for work,51,52 and there is a high degree of motivation; resistance exercise, can help reduce falls54 and improve balance
motor control, force generation, and endurance deficits are amenable confidence55
to rehabilitation53
Plan of care
Direct intervention Mobility and stretching (joint and muscle length and soft tissue) of Functional task retraining,57 including reaching, gait on various
trunk and LEs56 surfaces, turns, and possible trial of ankle-foot orthoses/assistive
devices
Trunk activation and motor control exercises for the trunk56,58 Reactive59,60 and anticipatory61 balance training during functional
tasks
Work hardening for driving tasks62,63 Resistive exercises for B LEs,64 including repeated sit-to-stand tests
with various BOS values and levels of load/resistance
Force generation practice during LE and trunk activities63,65 Calf-stretching exercises
Prevention, health promotion, and Physical activity for conditioning56,55 and establishing smart goals66 Integumentary management
wellness
Assessment for return to basketball Walking program
Motivational interviewing to progress beyond contemplation phase for
diet and referral to nutritionist67
Education Body mechanics for sitting and driving Fall risk reduction strategies, including environmental factors
Positioning for sleeping Role of exercise in managing diabetes
Self-management and pain science68 Strategies to address low balance confidence69,70
a
ANPT = Academy of Neurologic Physical Therapy; AROM = active range of motion; B = bilateral; BOS = base of support; BP = blood pressure; bpm = beats/min; DF = dorsiflexion; EC = eyes closed; EO = eyes
open; FABQW = Fear Avoidance Beliefs Questionnaire—Work; FTSTS = Five-Times Sit-to-Stand Test; HR = heart rate; HTN = hypertension; LBP = low back pain; LE = lower extremity; OA = osteoarthritis;
MCF = Motor Control Framework; MMT = Manual Muscle Test; PF = plantar flexion; PRN = as occasion requires; RR = respiratory rate; SLR = straight-leg raise; SLS = single-leg stand; TUG = Timed “Up &
b
Go” Test; UE = upper extremity; WNL = within normal limits. History and interview were abbreviated and were related to this episode of care.
Clinical Decision-Making Across Health Conditions

Deutsch et al 9

Figure 2. Examination consists of complementary processes of dissection of the participation goal into relevant activities, movement observation and
analysis of tasks (using 3 frameworks: biomechanics, Motor Control Framework and Academy of Neurologic Physical Therapy [ANPT] Framework),
hypothesis generation related to body function structure (left side), and administration of tests and measures (right side). The influences of International
Classification of Function (icf) with personal factors (orange) and the environment (grey) are represented with dotted circles.
observing behavior on the bus, following a route, ascending have been identified as important by the person and the
and descending the stairs on the bus, walking to and away clinician (Fig. 2, left side). The term “tasks” is used here
from the bus at the start of the shift, and sitting for prolonged from movement science to be consistent with “task analysis”
periods of time. All these tasks take place under different and “task specific training.” Movement Analysis of Tasks
environmental conditions (eg, weather, driving terrain, and begins with movement observation, followed by interpreta-
traffic patterns). The bus driver needs to move and function/analysis of how the task was performed and leads to
tion in both a moving environment as a stationary person the generation of hypotheses of underlying body structure–
while performing some upper extremity manipulation tasks function impairments. This information about the patient’s
and in a stationary environment as a moving person with movement is then analyzed and compared with what is known
upper extremity manipulation tasks. The contribution of the about typical performance of the relevant tasks under vari-
environment is integral to the identification and subsequent ous environmental and contextual conditions to identify the
movement analysis of tasks. For a person to return to driving a specific aspects of movement that are problematic for the
bus, they must be competent in all these component activities. patient.
Similarly, for a person to return to work as a librarian (case In the first iteration of the framework, a simplified version
example 2, Tab. 3), activities such as walking while pushing of Gentile’s taxonomy was offered as a tool to examine
a cart, bending and lifting while holding books, reaching in the patients’ movement (stationary or moving) relative to
various directions to place books on/off shelves at different the environment (stationary or moving); this approach
heights, etc must be performed competently. Table 3 illustrates provided a systematic progression of complexity.1,75 We
how the participation goals for the person with low back now extend the environment construct to incorporate the
pain and the librarian are reflected in the activities that are additional considerations (physical, social, and attitudinal)
examined. included in the ICF. When feasible, movement analysis of
A third example is an adolescent soccer player (mid-fielder) activities-tasks should be examined in the environmental
3 weeks after a grade 2 talofibular sprain whose participation context in which the person executes them. For example, in
goal is to return to play. For this person, the relevant activities the case of the bus driver (Tab. 3), examination of driving
would include sprinting, dribbling, running in multiple direc- could be performed in a simulated driving environment
tions, passing, receiving a pass, shooting on goal, and heading to reproduce all the contextual cues. In the case of the
the ball. These activities need to be examined on surfaces librarian (Tab. 3), locomotion and reaching tasks can be
that resemble the soccer pitch and under weather conditions assessed in the clinic using a mobile cart, shelves, and light
consistent with a game (eg, sun at different angles, rain and objects.
cold, very hot weather). The clinician then generates hypotheses about what
In the second step, the physical therapist performs a move- may interfere with typical movement performance. Several
ment observation and analysis of the relevant tasks that approaches to the movement analysis of the tasks are
available, such as biomechanical analyses across the lifespan the caretaker. The limitations of purposeful active movement
and health conditions,76–81 the Motor Control Framework may lead the clinician to directly assess cognition and range
(MCF),82 and, more recently, the Academy of Neurologic of motion, bypassing a movement analysis of tasks during the
Physical Therapy (ANPT) Framework.83 initial encounter. As the individual recovers, the clinician can
In the first iteration of the integrated framework, we used then assess those activities that the person can attempt and
the MCF described by Hedman and colleagues82 in combi- that are consistent with their participation goals. A second
nation with Gentile’s taxonomy75 to guide movement obser- example is a person with an acute total hip arthroplasty; the
vation and analysis. In this iteration of the integrated frame- clinician may examine range of motion, strength, and edema
work, we expand the movement analysis of the tasks to prior to examining bed mobility, sit-to-stand, and gait.
also include the approach recently recommended by ANPT Throughout the examination process, clinicians continue

Movement System Diagnosis-Movement Analysis Task Forces to refine hypotheses about the relationship between the par-
Framework (ANPT Framework).83 The ANPT Framework ticipation goal, activity requirements, movement analysis of
expands the original taxonomy described by Hedman and tasks, and contributing body function/structure limitations,
colleagues and furthermore defines specific “observable con- all within the context of environmental and personal factors.
structs of movement” that can be analyzed across tasks. These The results of the examination combined with the history
constructs of movement, when considered together, reflect and systems review guide the evaluation and diagnosis. The
what we refer to as “movement control.” Of importance, hypotheses generated throughout the examination process for
this concept of movement control goes beyond the BSF and 2 cases are described in Table 3.
activity categories of the ICF and is integral to the role of the
physical therapist as the movement specialist. Evaluation
To date, the ANPT Framework has been applied to assess In this iteration of the revised framework, we focus on inte-
the performance of 6 core tasks (sitting, sit-to-stand, stand- grating each person’s movement ability into the evaluation
ing, step up/step down, walk and turn, and reach/grasp/- process, an element of decision-making that, to our knowl-
manipulate), but it may also be applied to other tasks (eg, edge, has not been described to date. To achieve this, the
those relevant to examining high-level athletic performance, clinician should first identify which of the 6 identified body
age-appropriate motor development, etc). In the case exam- systems, as components of the movement system, contribute
ples presented in Table 3, the MCF is primarily used for to the patient’s activity/participation limitations, which body
the movement analysis of tasks for the bus driver, while a systems are not involved, and which body systems may be
combination of the ANPT/MCF frameworks is used for the enhancing activity/participation.
librarian. Next, as outlined by the ICF2 and elaborated on by oth-
The third step in the examination process is to identify ers,94 it is imperative for the clinician to identify any rel-
body function/structure limitations that may interfere with evant personal or environmental factors that impact, in a
optimal movement and activity-task performance. To this positive or negative manner, the person’s ability to achieve
end, the clinician generates hypotheses from the movement their stated goal or participate fully in rehabilitation. The
analysis of tasks (Step 2). These hypotheses may be tested assessment of task-activity performance, as described above
by combining movement observations with modification to in examination, adds the movement observation of tasks
the environment as well as conducting relevant tests/mea- to identify underlying movement control limitations. The
sures (right side of Fig. 2). For example, the clinician may movement control factors underlying the person’s difficulty
change the height of the chair during sit-stand to differentiate with performed desired tasks and roles must be specifically
between a force generation deficit or a range of motion identified. Factors proposed by the MCF and the ANPT Task
limitation. Known relationships between body function struc- Force include movement accuracy, symmetry, sequence and
ture limitations and activity-task performance guide this pro- timing, speed, smoothness, and amplitude as well as stability,
cess.84,85 verticality, body alignment, and symptom provocation.81–83
Additional factors that affect task performance may relate
Tests and Measures to body function structure limitations such as the muscu-
The use of tests and measures (right side of Fig. 2) com- loskeletal system (muscle performance,95 joint hyper/hypo-
plements the participation goal dissection and movement mobility) or the cardiovascular or pulmonary systems (activity
analysis of tasks (left side of Fig. 2). APTA and its academies tolerance). It is also important to determine if the person’s
have compiled and recommended standardized tests/measures task performance is consistent or changes across various
across multiple practice areas and clinical settings86–88 environmental conditions. For example, a person post-total
and health condition–specific clinical practice guidelines. knee replacement may demonstrate similar difficulty rising
For example, the case example of a person with low back to stand from a low seat at home or at the barber shop
pain (Tab. 3) demonstrates application of recommendations if the factors underlying task performance are deficits in
regarding activity, participation,89 and physical90,91 and muscle performance and knee flexibility. In contrast, a person
mental body function structure measures92 from the first with Parkinson disease may be able to walk safely within
physical therapy–specific clinical practice guidelines on low a quiet, familiar environment but not in the community if
back pain.93 the key movement-related factors underlying walking are
The proposed sequence of the examination process as decreased movement speed and impaired dual-task ability and
described above is not obligatory. For example, a person endurance.
in the ICU with multiple trauma from a car accident and This evaluation summary linking participation and activity
loss of consciousness may not be able to communicate or restrictions to movement control factors and impairments in
move without maximum assistance. For this person, the body structure/function is discussed with the person, rein-
relevant participation goals may need to be negotiated with forcing the ongoing shared decision-making. Analysis of the
Deutsch et al 11
contribution of the primary movement control and body func- Goals

tion/structure deficits contributing to the person’s limitations Goals for rehabilitation should relate to the person’s partici-
is illustrated by the 2 case examples (Tab. 3). pation in relevant life roles or activities and must be carefully
identified to target their reported concerns and participation
Diagnosis limitations. In this revision of the integrated framework, we
emphasize how to use a shared decision-making approach to
Perspectives related to diagnosis made by physical therapists arrive at agreed on goals, emphasizing meaningful benchmark
have changed substantially since publication of the first frame- goals that indicate progress at participation and activity levels.
work. These changes were driven by the profession arriving In the context of shared decision-making, the clinician and
at a definition of the human movement system, recognition patient should revisit the person’s initially stated goals to

that movement analysis of tasks is a critical component of determine if they are realistic and appropriate. Information
the examination, and ongoing efforts to develop agreed on obtained during the systems review and examination, includ-
movement system diagnoses, referred to as diagnostic labels. ing movement analysis, guides this process along with acuity
To date, only a limited number of diagnostic labels have been and severity of the health condition and other comorbid con-
proposed30,31,96–104 ; further work will be required to arrive ditions. In addition, the clinician and patient together carefully
at useful diagnostic labels that can be used in a consistent consider the main concerns and aspirations as well as environ-
manner by health professionals, for all health conditions, and ments in which the person functions and life circumstances
across the lifespan.105 (eg, relevant personal and environmental factors) that might
Identifying the movement system diagnosis for each patient impact their ability to participate in or respond to rehabilita-
extends the clinical reasoning process because it requires tion. Early in the episode of care, the patient should identify
the clinician to consider all available information about the realistic “benchmark goals” or improvements in activity/par-
person and clearly identify each person’s primary movement ticipation that they consider meaningful progress (Tab. 3).
control problem(s), independent of health condition or age. If a patient does not articulate the goals at the level of
This step in the clinical reasoning process differs from what participation (eg, goal is to walk, without any context), the
is currently reflected in the Guide to Physical Therapist Prac- clinician assists them to relate their stated goals to important
tice, which states that “a diagnosis is typically made at the life activities. If a patient’s stated goals are inappropriate or
impairment, activity and participation levels.”10 In fact, we unrealistic, the clinician assists them to identify additional
are proposing that the movement system diagnosis may reflect goals that are central to improving the person’s desired activ-
both movement control attributes and underlying body struc- ity and participation or are preventative. Taking all these
ture/function impairments. We acknowledge the importance factors into consideration, the clinician and patient may need
of linking together findings related to the person’s impair- to renegotiate goals at this point in the episode of care to
ments, activity, and participation as well as to the patient’s arrive at mutually agreed on, meaningful to the person, and
goals as described in the evaluation section above. In contrast, realistic goals to achieve within the available time frame.
however, our use of the term movement system diagnosis Examples from the cases presented in this article include goals
(label) identifies the primary underlying cause(s) of movement for individuals related to both return to work and return to
dysfunction, which may affect multiple activities. This change recreational activities (Tab. 3).
is important because the step of identifying and labeling To facilitate shared decision-making, the clinician can share
the primary causes of the movement problem focuses the data regarding best practice and typical outcomes related to
intervention clearly on those movement deficits (and their the patient’s condition. In addition, a growing body of health-
underlying contributing factors) that are likely to have the or condition-specific decision aids can assist individuals seek-
greatest impact on participation. ing care to participate in an informed manner. For example,
We envision that movement system diagnoses, as they con- the Ottawa Personal Decision Guide25 may help the person
tinue to be developed, will be best labeled at the level of with low back pain (Tab. 3) prioritize the return to work
movement control and/or at the level of impairments in body and sleep goals before the recreation goal. It should be noted
structure/function, and that each diagnosis will be associated that many decision aids are still being vetted for quality and
with a clear description of the movement control charac- efficacy.106–108
teristics and body structure/function impairments associated
with the diagnosis. The diagnosis we propose for the bus
driver with low back pain identifies deficits in both movement Prognosis
control characteristics (ie, sequencing, asymmetry) and BSF Prognosis is based on the patient’s goals, with an emphasis on
impairments (ie, force generation, neuromuscular endurance, those related to activity and participation. Prognosis should
and pain). In contrast, the diagnosis proposed for the person be specific for each goal (eg, goal of walking in the house may
with frequent falls is solely at the level of movement control have a different prognosis than goal of walking in the commu-
(ie, deficit in anticipatory and reactive postural control). nity). To determine prognosis for activity and participation,
Individuals with the same health conditions may present the clinician synthesizes knowledge from the examination,
with different movement system diagnoses. For example, the health condition, foundational knowledge, theory, evidence,
person with frequent falls (case example 2, Tab. 3) with a and experience.
diagnosis of “deficits in muscle performance” would lead the Consider, for example, a person who sustained a lower limb
clinician to choose intervention strategies primarily aimed at amputation due to dysvascularity (eg, diabetes). The person’s
improving strength. In this example, intervention plans would goal is to return to work within 4 months to a job that requires
be focused differently than what is outlined in Table 3, even walking. Regarding the health condition, consideration is
though the health condition and presenting history may be given to the expected level and rate of recovery based on evi-
the same. dence. Issues to consider include the nature of the pathology
Evidence-based Shared Decision-Making

The shared decision-making conversation in the POC focuses
on the clinician identifying evidence-based options for treat-
ment that are then selected and agreed on with the patient.
Examples of options that can be offered to the patient include
choices among different appropriate interventions, how often
to attend clinic-based visits, and how to best structure a
realistic home exercise program.24
Movement System Diagnosis to Guide Intervention

The shared decision-making conversation also includes the
explanation of the movement system diagnosis and how to
address it. Individuals with the same health condition may
have different movement system diagnoses. We include in
Table 3 possible diagnostic labels for the bus driver and
Figure 3. Plan of care organized at a high-level using the Guide to librarian case examples and then outline an appropriate POC
Physical Therapist Practice. It incorporates the language of the for each example based on the diagnosis. In the low back
International Classification of Function (ICF). Interventions are based on pain case example, the person has a movement system diag-
movement science and physiology principles. The process uses shared nosis of “motor control deficits.” Another individual with the
decision making.
same health conditions could present with a fear-avoidance
movement system diagnosis, and the POC might then include
activities to increase self-efficacy rather than strength and
endurance.
(in this case, dysvascularity) as well as stage, acuity, and tissue
irritability. The clinician draws on substantial information Prevention and Health Promotion-Wellness
about morbidity and mortality associated with lower limb Included in Every POC
amputation.109–112
To determine prognosis with regard to benchmark goals Education complements the direct interventions and is the key
related to activity (walking) and participation (return to strategy for prevention and wellness.119 In the revised frame-
work), the clinician draws on available data such as those work, prevention and health promotion–wellness are recom-
related to likelihood and timing of achieving independent mended in every episode of care. Prevention addresses both
ambulation within 1-year post amputation,113 likely average patient-identified problems and non–patient-identified prob-
daily steps, and114 likely overall level of disability.114–116 lems (Hypothesis Oriented Algorithm for clinical decision-
The clinician keeps these types of data in mind when making) and relies on the clinician’s knowledge of the health
assessing likelihood that this person will have sufficient condition, potential complications, and movement system.
walking capacity at 4 months to return to work but tempers Health promotion–wellness is an addition to this revised
expectations with respect to important modifiers that may framework and reflects the expanded role of the physical
be facilitators or barriers to recovery. These modifiers therapist.66,120 Prevention and health promotion–wellness
may include presurgical activity and endurance, previous are administered through patient education, direct care, or
engagement and success with physical therapy, access to referral and collaboration with colleagues. The transtheo-
rehabilitation services, and support. The clinician also retical model of behavior change uses stages of readiness
considers resources and constraints based on personal factors to guide the wellness intervention.60,61 These elements of
(eg, their social, emotional, and motivational status) and the POC are especially relevant for persons with chronic
environmental factors. Prognosis statements are provided for health conditions.121,122,123 Health promotion and wellness
both case examples in Table 3. and prevention may be delivered as a single intervention; for
example, promotion of physical activity is an intervention that
can address both wellness and prevention.124
Plan of Care Task-Specific Training

The plan of care (POC) focuses on the patient’s participa- Knowledge of movement science is used to organize activity-
tion goals and related activities and body function/structure task–specific training; this includes selection of the task and
requirements and is based on results of the examination, the environment, practice schedule, type and frequency of
evaluation, and movement system diagnosis. Elements that feedback provided to the patient, and dose. Principles of
are new to this revised framework include (1) application of exercise complement movement science. The specificity of the
evidence-based shared decision-making to identify and select intervention (ie, how task-specific training is implemented
options for intervention; (2) use of the movement system diag- for each patient) is derived from the movement analysis of
nosis to guide intervention; (3) recommendation to include tasks and hypotheses about the factors contributing to the
wellness and prevention in every plan of care; (4) application patient’s limitations. Evidence of the relevance of task speci-
of task-specific training for all health conditions and across ficity is extending beyond treating persons with neurological
the lifespan; and (5) intervention at the body function struc- conditions. For example, persons with chronic knee pain
ture level guided by the physiology of tissue healing and the due to osteoarthritis who had task-specific training improved
Frequency, Intensity, Time and Type (FITT) principle117,118 both their trained tasks (sit-stand, floor-to-stand, and stair
(see Fig. 3). negotiation) and had pain reduction.125
Deutsch et al 13
In this revised framework, there is a fundamental assump- that can be examined or simulated in the clinic. Approaches
tion that plasticity occurs across the cardiovascular, neuro- to task dissection and movement observation of tasks are
muscular, integumentary, and musculoskeletal systems and presented as a critical component of examination to enable
plasticity can be augmented with training and stimulation. specific deficits in movement control to be identified, recog-
Evidence supports plasticity across systems126 and requires nizing that these deficits are not included in the ICF concepts
that interventions or training be task specific and of a high of BSF or tasks/activities. Movement and exercise science
enough duration and intensity to achieve both behavioral serve as the theoretical foundation. ICF and movement science
and structural changes.127–129 For this reason, we restate the terminology are integrated to link these distinct bodies of
importance of dose in task-specific training. As an example, knowledge. The human movement system is integrated into
the delivery of rehabilitation using task-specific training at the systems review, evaluation, and diagnosis. Throughout this

the correct dose to achieve improved walking for a person article, case examples are used to illustrate the application of
post stroke is achieved with the use of high-intensity interval the framework across all health conditions. The framework
training on a treadmill.127 The high-intensity interval training is proposed as a tool for physical therapist education and
improves the cardiovascular and neuromusculoskeletal sys- guide for clinical practice for all health conditions across the
tems by improving aerobic capacity,130 balance126 and neuro- lifespan.
muscular endurance,126 all of which contribute to achieving
improved ambulation (activity/task goal) that will enable the
person to return to their job as a security guard. Author Contributions
Concept/idea/research design: J.E. Deutsch, K.M. Gill-Body,
Body Function/Structure–Level Intervention M. Schenkman
Writing: J.E. Deutsch, K.M. Gill-Body, M. Schenkman
Interventions to address relevant alterations in body func-
Project management: J.E. Deutsch
tion/structure are guided by knowledge of physiologic recov-
ery, tissue healing, and the FITT principle. Inflammation and
tissue healing are important to understand in the selection of
Acknowledgments
interventions that may promote optimal restoration. These
approaches are well defined based on the understanding of The authors thank Cory Christiansen, PT, PhD; Gerard Fluet, PT,
DPT, PhD; Dana Judd, PT, DPT, PhD; Laura Plummer, PT, DPT, EdD,
tissue repair phases based on physiology: inflammation, pro-
board-certified clinical specialist in neurologic physical therapy; Susan
liferation, and maturation; and tissue-healing phases based
Paparella-Pitzel, PT, DPT; and Genevieve Pinto Zipp, PT, EdD for
on time acute, sub-acute, and chronic.131,132 Foundational their careful read and thoughtful feedback on an early version of the
knowledge of the physical therapist guides selection of modal- manuscript. The authors also thank Ellen Anderson, PT, PhD, board-
ities and interventions.132 certified clinical specialist in geriatric physical therapy, and Tara Jo
The FITT principle provides a systematic way to dose body Manal, PT, DPT, FAPTA, board-certified clinical specialist in orthopedic
function/structure interventions across health conditions. For physical therapy, for source material on the cases.
example, strengthening guided by FITT principles has been
applied to persons post stroke,133 post lung transplant,134 and
with inflammatory myopathy.135 The movement system diag- Disclosures
nosis guides the intervention of the body function/structure as The authors completed the ICMJE Form for Disclosure of Potential
illustrated by the driver with low back pain (Tab. 3). In this Conflicts of Interest and reported no conflicts of interest.
example, several interventions will directly address the limita-
tions with joint and soft tissue mobility to complement the
trunk and lower extremity strengthening activities. Further, References
interventions aimed at reducing deficits in body structure/-
1. Schenkman M, Deutsch JE, Gill-Body KM. An integrated frame-
function can be performed in the context of the relevant tasks.
work for decision making in neurologic physical therapist prac-
In the example of the librarian, lower extremity strengthen- tice. Phys Ther. 2006;86:1681–1702.
ing can be performed using repeated sit-to-stand tasks from 2. World health Organization.International Classification of Func-
various height surfaces with different foot positions; this task tioning, Disability, and Health: ICF. Geneva, Switzerland; WHO;
could also incorporate holding objects and reaching to place 2001.
them onto surfaces. 3. Nagi S. Some conceptual issues in disability and rehabilitation. In:
Sussman M, ed., Sociology and Rehabilitation. Washington, DC,
USA: American Sociological Association; 1965.
4. Quinn LGJ. Disablement models and the ICF framework. In:
Summary of the Framework and Application Documentation for Rehabilitation: A Guide to Clinical Decision
There is a critical need for a unifying clinical decision-making Making in Physical Therapy. 3rd ed. Maryland Heights, MO,
framework in physical therapy to highlight our expertise USA: Elsevier; 2016: 1–11.
as movement specialists and enhance communication within 5. Riddle DL, Rothstein JM, Echternach JL. Application of the
and outside of the profession. This paper offers a unifying HOAC II: an episode of care for a patient with low back pain.
framework that responds to changes in evidence and practice Phys Ther. 2003;83:471–485.
6. Rothstein JM, Echternach JL, Riddle DL. The hypothesis-oriented
that occurred over the last 15 years. It is organized around the
algorithm for clinicians II (HOAC II): a guide for patient manage-
patient-client management of the Guide to Physical Therapist ment. Phys Ther. 2003;83:455–470.
practice and is framed by shared decision-making between the 7. American Physical Therapy Association. Guide to Physical Ther-
patient and the clinician. Goals that focus on participation apist Practice. 2nd ed. Phys Ther. 2001;81:9–746.
are emphasized as an organizing principle, and guidelines are 8. Christensen N, Black L, Furze J, Huhn K, Vendrely A, Wainwright
provided for dissecting participation goals into activities-tasks S. Clinical reasoning: survey of teaching methods, integration, and
assessment in entry-level physical therapist academic education. 31. Alrwaily M, Timko M, Schneider M, et al. Treatment-based
Phys Ther. 2017;97:175–186. classification system for low back pain: revision and update. Phys
9. House of Delegates APTA. Vision Statement for the Physical Ther. 2016;96:1057–1066.
Therapy Profession. 2013. Accessed April 20, 2020. http://www.a 32. Kamper SJ. Engaging with research: linking evidence with prac-
pta.org/Vision/. tice. J Orthop Sports Phys Ther. 2018;48:512–513.
10. American Physical Therapy Assocation. Guide to Physical Ther- 33. Kamper SJ. Evidence in practice: a new series for clinicians. J
apist Practice. 3rd ed. 2014. Accessed April 20, 2020. https://gui Orthop Sports Phys Ther. 2018;48:429.
de.apta.org/. 34. Kamper SJ. Fundamentals of measurement: linking evidence to
11. Higgs J, Jones MA, Loftus S, N. C. Clinical Reasoning in the practice. J Orthop Sports Phys Ther. 2019;49:114–115.
Health Professions. 3rd ed. London, UK: Elsevier; 2008. 35. Kamper SJ. Generalizability: linking evidence to practice. J
12. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clin- Orthop Sports Phys Ther. 2020;50:45–46.

ical reasoning strategies in physical therapy. Phys Ther. 2004;84: 36. Zidarov D, Thomas A, Poissant L. Knowledge translation in phys-
312–330 Discussion 331–315. ical therapy: from theory to practice. Disabil Rehabil. 2013;35:
13. Huhn K, Gilliland SJ, Black LL, Wainwright SF, Christensen N. 1571–1577.
Clinical reasoning in physical therapy: a concept analysis. Phys 37. Noonan VK, Moore JL. Knowledge translation: the catalyst for
Ther. 2019;99:440–456. innovation of neurologic physical therapy. 2016;40:67–70.
14. Clinical Reasoning Curriculum and Assessment Research 38. Research Ao. Evaluation Database to Guide Effectiveness (EDGE)
Consortia A. What is clinical reasoning in physical therapy? Task Force. Accessed April 20, 2020. https://www.ptresearch.org/
Accessed April, 5, 2020. https://acapt.org/docs/default-source/co home/edge-task-force/.
nsortium-(crcac)/consortia-fact-sheet-on-clinical-reasoning.pdf? 39. Academy of Neurologic Physical Therapy. EDGE Task Force:
sfvrsn=557688d8_0. recommendations for outcome measures for persons post-
15. House of Delegates APTA. Physical therapist practice and the stroke. Choose PT Resources. 2011. Accessed April 20,
movement system. 2015. Accessed March, 20 2020. http://www.a 2020. https://www.neuropt.org/practice-resources/neurology-se
pta.org/MovementSystem/. ction-outcome-measures-recommendations/stroke.
16. House of Delegates APTA. Guiding Principles to Achieve the 40. American Physical Therapy Association. CPG + Collection.
Vision. Alexandria, VA: APTA; 2013. Accessed April 4, 2020. https://www.ptnow.org/cpgplus.
17. Sahrmann SA. The human movement system: our professional 41. Deutsch JE, Romney W, Reynolds J, Manal TJ. Validity and
identity. Phys Ther. 2014;94:1034–1042. usability of a professional association’s web-based knowledge
18. Norton BJ. "Harnessing our collective professional power": diag- translation portal: American Physical Therapy Association’s
nosis dialog. Phys Ther. 2007;87:635–638. PTNow.Org. BMC Med Inform Decis Mak. 2015;15:79.
19. Vansant AF. Diagnosis and the human movement system. Pediatr 42. Gordon J. A top-down model for neurologic rehabilitation. In:
Phys Ther. 2007;19:265. Presentation at the III STEP Symposium on Translating Evidence
20. Polaris JJ, Katz JN. "Appropriate" diagnostic testing: supporting Into Practice: Linking Movement Science and Intervention. Salt
diagnostics with evidence-based medicine and shared decision Lack City, UT, USA, July 15–21; 2005.
making. BMC Res Notes. 2014;7:922. 43. Fortune J, Breckon J, Norris M, Eva G, Frater T. Motivational
21. Vivanathan ADM, Mead G, Whiteley W, Lawton J, Doubal F. interviewing training for physiotherapy and occupational therapy
Shared decision making after severe stroke-how can we improve students: effect on confidence, knowledge and skills. Patient Educ
patient and family involvement in treatment decisions? Int J Couns. 2019;102:694–700.
Stroke. 2017;12:920–922. 44. Norris M, Eva G, Fortune J, Frater T, Breckon J. Educating
22. Makoul G, Clayman ML. An integrative model of shared decision undergraduate occupational therapy and physiotherapy students
making in medical encounters. Patient Educ Couns. 2006;60: in motivational interviewing: the student perspective. BMC Med
301–312. Educ. 2019;19:117.
23. Elwyn G, Frosch D, Thomson R, et al. Shared decision mak- 45. O’Halloran PD, Blackstock F, Shields N, et al. Motivational
ing: a model for clinical practice. J Gen Intern Med. 2012;27: interviewing to increase physical activity in people with chronic
1361–1367. health conditions: a systematic review and meta-analysis. Clin
24. Moore CL, Kaplan SL. A framework and resources for shared Rehabil. 2014;28:1159–1171.
decision making: opportunities for improved physical therapy 46. Prochaska J, DiClemente C. Transtheoretical therapy: toward a
outcomes. Phys Ther. 2018;98:1022–1036. more integrative model of change. Psychother Theory Res Pract.
25. Institute TOHR. Ottawa Personal Decision Guide. Patient deci- 1982;19:276–288.
sion aids. 2020. Accessed October 5, 2020. https://decisionaid.o 47. Plotnikoff R, Lippke S, Johnson S, Courneya K. Physical activity
hri.ca/docs/das/OPDG.pdf. and stages of change: a longitudinal test in types 1 and 2 diabetes
26. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing samples. Ann Behav Med. 2010;40:138–149.
health treatment or screening decisions. Cochrane Database Syst 48. Demoulin C, Vanderthommen M, Duysens C, Crielaard JM.
Rev. 2017;4:CD001431. Spinal muscle evaluation using the Sorensen test: a critical
27. Rutten GM, Degen S, Hendriks EJ, Braspenning JC, Harting J, appraisal of the literature. Joint Bone Spine. 2006;73:43–50.
Oostendorp RA. Adherence to clinical practice guidelines for low 49. Russ DW, Amano S, Law TD, Thomas JS, Clark BC. Multiple
back pain in physical therapy: do patients benefit? Phys Ther. measures of muscle function influence Sorensen test performance
2010;90:1111–1122. in individuals with recurrent low back pain. J Back Musculoskelet
28. American Physical Therapy Association. Clinical practice guide- Rehabil. 2021;34:139–147.
lines developed by APTA. EBP tools. Accessed April 20, 2020. 50. Roman de Mettelinge T, Cambier D, Calders P, Van Den Noort-
https://www.apta.org/EvidenceResearch/EBPTools/CPGs/APTA/. gate N, Delbaere K. Understanding the relationship between type
29. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guide- 2 diabetes mellitus and falls in older adults: a prospective cohort
line recommendation for active treatments improve the quality of study. PLoS One. 2013;8:e67055.
care for patients with acute low back pain delivered by physical 51. Cleland JA, Fritz JM, Brennan GP. Predictive validity of initial
therapists? Med Care. 2007;45:973–980. fear avoidance beliefs in patients with low back pain receiving
30. Alrwaily M, Timko M, Schneider M, et al. Treatment-based clas- physical therapy: is the FABQ a useful screening tool for identi-
sification system for patients with low back pain: the movement fying patients at risk for a poor recovery? Eur Spine J. 2008;17:
control approach. Phys Ther. 2017;97:1147–1157. 70–79.
Deutsch et al 15
52. Beneciuk JM, Robinson ME, George SZ. Low back pain sub- 72. Carr J, Shepherd R, Gordon J. Movement Science: Foundations
groups using fear-avoidance model measures: results of a cluster for Physical Therapy in Rehabilitation. Rockville, MD, USA:
analysis. Clin J Pain. 2012;28:658–666. Aspen Publishers Inc.; 1987.
53. Skelly AC, Chou R, Dettori JR, et al. AHRQ comparative effec- 73. Winstein CJ, Knecht HG. Movement science and its relevance to
tiveness reviews. In: Noninvasive Nonpharmacological Treatment physical therapy. Phys Ther. 1990;70:759–762.
for Chronic Pain: A Systematic Review Update. Rockville, MD, 74. Shumway-Cook A, Woollacott MH. Motor Control: Translating
USA: Agency for Healthcare Research and Quality; 2020. Research into Clinical Practice. 5th ed. Philadelphia, PA, USA:
54. Allet L, Armand S, de Bie RA, et al. The gait and balance of Lippincott Williams and Wilkins; 2016.
patients with diabetes can be improved: a randomised controlled 75. Gentile A. Skill acquisition:action, movement and neuromotor
trial. Diabetologia. 2010;53:458–466. processies. In: Carr J, Shepherd R, eds., Movement Science:
55. Hewston P, Deshpande N. Fear of falling and balance confidence Foundations for Physical Therapy in Rehabilitation. 2nd ed.

in older adults with type 2 diabetes mellitus: a scoping review. Gaithesburg, MD, USA: Aspen; 2000: 111–187.
Can J Diabetes. 2018;42:664–670. 76. Perry J. Gait Analysis: Normal and Pathological Function. San
56. George SZ, Fritz JM, Silfies SP, et al. Interventions for the Francisco, CA, USA: SLACK; 1993.
management of acute and chronic low back pain: revision 2021. 77. Schenkman M, Berger RA, Riley PO, Mann RW, Hodge WA.
J Orthop Sports Phys Ther. 2021;51:CPG1–CPG60. Whole-body movements during rising to standing from sitting.
57. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. Phys Ther. 1990;70:638–648 Discussion 648–651.
The effect of fall prevention exercise programmes on fall 78. Ounpuu S. The biomechanics of walking and running. Clin Sports
induced injuries in community dwelling older adults: systematic Med. 1994;13:843–863.
review and meta-analysis of randomised controlled trials. BMJ. 79. Yılmaz Topçuoğlu MS, Krautwurst BK, Klotz M, Dreher T, Wolf
2013;347:f6234. SI. How do children with bilateral spastic cerebral palsy manage
58. Ford JJ, Bower SE, Ford I, et al. Effects of specific muscle walking on inclines? Gait Posture. 2018;66:172–180.
activation for low back pain on activity limitation, pain, work 80. O’Sullivan R, Leonard J, Quinn A, Kiernan D. The short-
participation, or recurrence: a systematic review. Musculoskelet term effects of selective dorsal rhizotomy on gait compared to
Sci Pract. 2020;50:102276. matched cerebral palsy control groups. PLoS One. 2019;14:
59. Hu MH, Woollacott MH. Multisensory training of standing e0220119.
balance in older adults: II. Kinematic and electromyographic 81. McCoy JO, VanSant AF. Movement patterns of adolescents rising
postural responses. J Gerontol. 1994;49:M62–M71. from a bed. Phys Ther. 1993;73:182–193.
60. Bayouk JF, Boucher JP, Leroux A. Balance training following 82. Hedman L, Rogers MW, Hanke TA. Neurologic professional
stroke: effects of task-oriented exercises with and without altered education: linking the foundation science of motor control with
sensory input. Int J Rehabil Res. 2006;29:51–59. physical therapy interventions for movement dysfunction. Neurol
61. Jagdhane S, Kanekar N, Aruin AS. The effect of a four-week Rep. 1996;20:9–13.
balance training program on anticipatory postural adjustments 83. Quinn L, Riley N, Tyrell C, et al. A framework for movement
in older adults: a pilot feasibility study. Curr Aging Sci. 2016;9: analysis of tasks: recommendations from the Academy of Neuro-
295–300. logic Physical Therapy Movement System Task Force. Phys Ther.
62. Hesselstrand M, Samuelsson K, Liedberg G. Occupational ther- 2021;101:pzab154.
apy interventions in chronic pain–a systematic review. Occup 84. Schiefelbein ML, Salazar AP, Marchese RR, et al. Upper-limb
Ther Int. 2015;22:183–194. movement smoothness after stroke and its relationship with mea-
63. Corp N, Mansell G, Stynes S, et al. Evidence-based treatment sures of body function/structure and activity—a cross-sectional
recommendations for neck and low back pain across Europe: a study. J Neurol Sci. 2019;401:75–78.
systematic review of guidelines. Eur J Pain. 2020;25:275–295. 85. Davis AM, Perruccio AV, Ibrahim S, Hogg-Johnson S, Wong R,
64. Goodwin VA, Abbott RA, Whear R, et al. Multiple component Badley EM. Understanding recovery: changes in the relationships
interventions for preventing falls and fall-related injuries among of the international classification of functioning (ICF) compo-
older people: systematic review and meta-analysis. BMC Geriatr. nents over time. Soc Sci Med. 2012;75:1999–2006.
2014;14:15. 86. Rose D, Genevieve P-Z, Anderson H, et al. Stroke Edge II
65. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treat- outcome measures: acute care. Academy of Neurologic Physical
ments for acute, subacute, and chronic low back pain: a clinical Therapy. 2018. Accessed January 5, 2020. http://neuropt.org/do
practice guideline from the American College of Physicians. Ann cs/default-source/edge-documents/strokedge-ii-acute-care.pdf?
Intern Med. 2017;166:514–530. sfvrsn=14fc5443_2.
66. Bezner JR. Promoting health and wellness: implications for phys- 87. Rose D, Genevieve P-Z, Anderson H, et al. Stroke Edge II
ical therapist practice. Phys Ther. 2015;95:1433–1444. Outcome Measures: Inpatient and Outpatient Rehabilitation.
67. Berner P, Bezner JR, Morris D, Lein DH Jr. Nutrition in physical Academy of Neurologic Physical Therapy. Accessed January 5,
therapist practice: tools and strategies to act now. Phys Ther. 2020. http://neuropt.org/docs/default-source/edge-documents/
2021;101:pzab061. strokedge-ii-inpatient-and-outpatient-rehabilitation.pdf?sfvrsn=
68. Gardner T, Refshauge K, McAuley J, Hübscher M, Goodall S, cfc5443_2.
Smith L. Combined education and patient-led goal setting inter- 88. Rose D, Genevieve P-Z, Anderson H, et al. Stroke Edge II
vention reduced chronic low back pain disability and intensity Outcome Measures. Academy of Neurologic Physical Therapy.
at 12 months: a randomised controlled trial. Br J Sports Med. 2018. Accessed January 5, 2020. http://neuropt.org/docs/defau
2019;53:1424–1431. lt-source/edge-documents/strokedge-ii-student.pdf?sfvrsn=17
69. Liu TW, Ng GYF, Chung RCK, Ng SSM. Cognitive behavioural fc5443_2.
therapy for fear of falling and balance among older people: 89. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain
a systematic review and meta-analysis. Age Ageing. 2018;47: screening tool: identifying patient subgroups for initial treatment.
520–527. Arthritis Rheum. 2008;59:632–641.
70. Rand D, Miller WC, Yiu J, Eng JJ. Interventions for addressing 90. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability
low balance confidence in older adults: a systematic review and of clinical examination measures for identification of lumbar seg-
meta-analysis. Age Ageing. 2011;40:297–306. mental instability. Arch Phys Med Rehabil. 2003;84:1858–1864.
71. American Physical Therapy Assocation. Guide to Physical Ther- 91. Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental
apist Practice. Phys Ther. 1997;75:1163–1650. mobility assessment: an examination of validity for determining
intervention strategies in patients with low back pain. Arch Phys major amputation for critical limb ischemia. J Vasc Surg. 2011;54:
Med Rehabil. 2005;86:1745–1752. 1374–1382.
92. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. 110. Stone PA, Flaherty SK, Aburahma AF, et al. Factors affecting peri-
A fear-avoidance beliefs questionnaire (FABQ) and the role of operative mortality and wound-related complications following
fear-avoidance beliefs in chronic low back pain and disability. major lower extremity amputations. Ann Vasc Surg. 2006;20:
Pain. 1993;52:157–168. 209–216.
93. Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop 111. Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation
Sports Phys Ther. 2012;42:A1–A57. in diabetic patients stratified by limb and level of amputation: a
94. Jette AM. Toward a common language for function, disability, 10-year observation. Diabetes Care. 2006;29:566–570.
and health. Phys Ther. 2006;86:726–734. 112. Pauley T, Devlin M, Heslin K. Falls sustained during inpatient
95. Scheets PKSS, Norton JB. Diagnosis for physical therapy for rehabilitation after lower limb amputation: prevalence and pre-

patients with neuromuscular conditions. Neurol Rep. 1999;23: dictors. Am J Phys Med Rehabil. 2006;85:521–532 quiz, 533-
158–159. 525.
96. Azevedo DC, Ferreira PH, Santos HO, Oliveira DR, de Souza JVL, 113. Czerniecki JM, Turner AP, Williams RM, Hakimi KN, Norvell
Costa LOP. Movement system impairment-based classification DC. Mobility changes in individuals with dysvascular amputation
treatment versus general exercises for chronic low back pain: from the presurgical period to 12 months postamputation. Arch
randomized controlled trial. Phys Ther. 2018;98:28–39. Phys Med Rehabil. 2012;93:1766–1773.
97. Henry SM, Van Dillen LR, Trombley AR, Dee JM, Bunn JY. 114. Paxton RJ, Murray AM, Stevens-Lapsley JE, Sherk KA, Chris-
Reliability of novice raters in using the movement system impair- tiansen CL. Physical activity, ambulation, and comorbidities in
ment approach to classify people with low back pain. Man Ther. people with diabetes and lower-limb amputation. J Rehabil Res
2013;18:35–40. Dev. 2016;53:1069–1078.
98. Kajbafvala M, Ebrahimi-Takamjani I, Salavati M, et al. Valida- 115. Desveaux L, Goldstein RS, Mathur S, et al. Physical activity in
tion of the movement system impairment-based classification in adults with diabetes following prosthetic rehabilitation. Can J
patients with knee pain. Man Ther. 2016;25:19–26. Diabetes. 2016;40:336–341.
99. Kajbafvala M, Ebrahimi-Takamjani I, Salavati M, et al. Intratester 116. Tudor-Locke C, Craig CL, Aoyagi Y, et al. How many steps/day
and intertester reliability of the movement system impairment- are enough? For older adults and special populations. Int J Behav
based classification for patients with knee pain. Man Ther. Nutr Phys Act. 2011;8:80.
2016;26:117–124. 117. Chen FT, Hopman RJ, Huang CJ, et al. The effect of exercise
100. Lehtola V, Luomajoki H, Leinonen V, Gibbons S, Airaksinen O. training on brain structure and function in older adults: a system-
Sub-classification based specific movement control exercises are atic review based on evidence from randomized control trials. J
superior to general exercise in sub-acute low back pain when both Clin Med. 2020;9:914.
are combined with manual therapy: a randomized controlled trial. 118. Lemos JR, da Cunha FA, Lopes AJ, Guimarães FS, do Amaral Vas-
BMC Musculoskelet Disord. 2016;17:135. concellos FV, Dos Santos Vigário P. Respiratory muscle training
101. Taddeo J, Santaguida L. Evaluation of classifications of neck in non-athletes and athletes with spinal cord injury: a systematic
pain: a scoping review of diagnostic and prognostic classification review of the effects on pulmonary function, respiratory muscle
systems. Man Ther. 2016;25:e69. strength and endurance, and cardiorespiratory fitness based on
102. Van Dillen LR, Norton BJ, Sahrmann SA, et al. Efficacy of the FITT principle of exercise prescription. J Back Musculoskelet
classification-specific treatment and adherence on outcomes in Rehabil. 2020;33:655–667.
people with chronic low back pain. A one-year follow-up, 119. Engers A, Jellema P, Wensing M, van der Windt DA, Grol R,
prospective, randomized, controlled clinical trial. Man Ther. van Tulder MW. Individual patient education for low back pain.
2016;24:52–64. Cochrane Database Syst Rev. 2008;2008:Cd004057.
103. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDon- 120. Magnusson DM, Rethorn ZD, Bradford EH, et al. Population
nell MK, Bloom NJ. Movement system impairment-based cate- health, prevention, health promotion, and wellness competencies
gories for low back pain: stage 1 validation. J Orthop Sports Phys in physical therapist professional education: results of a modified
Ther. 2003;33:126–142. Delphi study. Phys Ther. 2020;100:1645–1658.
104. Clinton SC, Newell A, Downy PA, Ferriera K. Pelvic girdle pain 121. Uusitupa M, Khan TA, Viguiliouk E, et al. Prevention of type
in the antepartum population: physical therapy clinical practice 2 diabetes by lifestyle changes: a systematic review and meta-
guidelines linked to the international classification of function- analysis. Nutrients. 2019;11:2611.
ing, disability, and health from the Section on Women’s Health 122. Heinemann AW, Wilson CS, Huston T, et al. Relationship of
and the Orthopaedic Section of the American Physical Therapy psychology inpatient rehabilitation services and patient charac-
Association. J W Health Phys Ther. 2017;41:102–125. teristics to outcomes following spinal cord injury: the SCIRehab
105. Gill-Body KM, Hedman LD, Plummer L, et al. Movement system project. J Spinal Cord Med. 2012;35:578–592.
diagnoses for balance dysfunction: recommendations from the 123. van Netten JJ, Raspovic A, Lavery LA, et al. Prevention of foot
Academy of Neurologic Physical Therapy Movement System Task ulcers in the at-risk patient with diabetes: a systematic review.
Force. PTJ. 2021;101:pzab153. Diabetes Metab Res Rev. 2020;36:e3270.
106. Fajardo MA, Durayb B, Zhong H, Trevena L, Traeger A, Bonner 124. Ramamoorthi R, Gahreman D, Skinner T, Moss S. The effect of
C. Online decision aids for knee osteoarthritis and low back pain: yoga practice on glycemic control and other health parameters in
an environmental scan and evaluation. Med Decis Mak. 2019;39: the prediabetic state: a systematic review and meta-analysis. PLoS
327–334. One. 2019;14:e0221067.
107. Patel S, Brown S, Friede T, et al. Study protocol: improving patient 125. Bove AM, Baker N, Livengood H, et al. Task-specific training for
choice in treating low back pain (IMPACT-LBP): a randomised adults with chronic knee pain: a case series. J Orthop Sports Phys
controlled trial of a decision support package for use in physical Ther. 2017;47:548–556.
therapy. BMC Musculoskelet Disord. 2011;12:52. 126. Wiener J, McIntyre A, Janssen S, Chow JT, Batey C, Teasell
108. Wieringa TH, Rodriguez-Gutierrez R, Spencer-Bonilla G, et al. R. Effectiveness of high-intensity interval training for fitness
Decision aids that facilitate elements of shared decision making and mobility post stroke: a systematic review. PM R. 2019;11:
in chronic illnesses: a systematic review. Syst Rev. 2019;8:121. 868–878.
109. Hasanadka R, McLafferty RB, Moore CJ, Hood DB, Ramsey 127. Crozier J, Roig M, Eng JJ, et al. High-intensity interval training
DE, Hodgson KJ. Predictors of wound complications following after stroke: an opportunity to promote functional recovery,
Deutsch et al 17
cardiovascular health, and neuroplasticity. Neurorehabil Neural 132. Cameron M. Inflammation and tissue repair. In: Physical Agents
Repair. 2018;32:543–556. in Rehabilitation, From Research to Practice. 5th ed. Amsterdam,
128. Boyne P, Meyrose C, Westover J, et al. Effects of exercise intensity the Netherlands: Elsevier; 2018.
on acute circulating molecular responses poststroke. Neuroreha- 133. Ammann BC, Knols RH, Baschung P, de Bie RA, de Bruin
bil Neural Repair. 2020;34:222–234. ED. Application of principles of exercise training in sub-acute
129. Boyne P, Meyrose C, Westover J, et al. Exercise intensity affects and chronic stroke survivors: a systematic review. BMC Neurol.
acute neurotrophic and neurophysiological responses poststroke. 2014;14:167.
J Appl Physiol (1985). 2019;126:431–443. 134. Knols RH, Fischer N, Kohlbrenner D, Manettas A, de Bruin ED.
130. Boyne P, Welge J, Kissela B, Dunning K. Factors influencing the Replicability of physical exercise interventions in lung transplant
efficacy of aerobic exercise for improving fitness and walking recipients; a systematic review. Front Physiol. 2018;9:946.
capacity after stroke: a meta-analysis with meta-regression. Arch 135. Baschung Pfister P, de Bruin ED, Tobler-Ammann BC, Maurer

Phys Med Rehabil. 2017;98:581–595. B, Knols RH. The relevance of applying exercise training princi-
131. Catharine Goodman KF, ed.. Injury, inflammation, healing and ples when designing therapeutic interventions for patients with
repair. In: Pathology Implications for Physical Therapy. 4th ed. inflammatory myopathies: a systematic review. Rheumatol Int.
Amsterdam, the Netherlands: Elsevier; 2018. 2015;35:1641–1654.

Lectura Analisis

Uploaded by

Copyright:

Available Formats

Lectura Analisis

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lectura Analisis

Uploaded by

Copyright:

Available Formats

PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2022;102:1–17

Updated Integrated Framework for Making Clinical

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Table 1. Representative Probing Interview Questions to Promote Shared Decision-Making

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Medical Record Review, Medical Screening Questionnaire,

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Category Case Example 1 Case Example 2

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Category Case Example 1 Case Example 2

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Category Case Example 1 Case Example 2

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Category Case Example 1 Case Example 2

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

contribution of the primary movement control and body func- Goals

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Evidence-based Shared Decision-Making

Movement System Diagnosis to Guide Intervention

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Plan of Care Task-Speciﬁc Training

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

Downloaded from https://academic.oup.com/ptj/article/102/3/pzab281/6497836 by APTA Member Access user on 24 August 2024

You might also like