The Role of the Physical Therapist in Life Care Planning

Physical therapists serve as facilitators of health. They treat patients with a broad range of potential participation from other professionals, family, and friends. An open mind-set to any given patient and situation is crucial to the enhancement and facilitation of health. The treatment of signs and symptoms, pain, irritation, lesions, catastrophic injury, and dysfunction are given viable solutions from the unique perspective of balanced deliverance of effective physical therapy skills. This cre­ates a synergistic application of physical therapy with the patient’s willingness to be responsible toward maximizing health and function.

Cooperation with all professionals, financial supporters, family members, and friends contributes to the overall facilitation of health. Insight to innovative and new techniques as applied to a specific patient’s needs is an opportunity to promote physical therapy skills with positive participation by the patient. It is vitally important that the well-being of each patient be considered in long-term and short-term care.

In dealing with life care issues, there are fundamental questions and paradigms of thinking to be asked of the physical therapist and others involved in the care of the patient or client, such as the following:

¦     What was the level of health, function, and lifestyle before the injury, disease, lesion, or dysfunction?

¦     What level of health, function, and lifestyle can be achieved given the present status of the patient and his or her physiological, social, psychological, financial, and spiritual environment?

¦     What are the ideal, hopeful goals and plans, balanced with the real goals and plans?

¦     What are the integrated thoughts on parameters and boundaries of the patient’s thinking in relationship to the process of healing and health?

The physical therapist and all persons involved in life care planning should integrate their plans with the following concepts being interwoven in their health care delivery process:

¦     “Seek first to understand, before you are understood.” (Covey, 1989, p. 239)

¦     “Walk a mile in my shoes.” (Song performed by Joe South)

¦     “Do unto others as you would have them do unto you.” (Matthew 22:39 paraphrased, KJV)

¦     “Understand the patient’s languages of love—care and receiving”. (Chapman, 1995)

As we examine life care goals and priorities for the patient, we are building a foundation of true principles to develop our skilled delivery of physical therapy. Therefore, we return the patient, as much as possible, to full health and function with basic human dignity, rights, and privileges. If
full health and function are not attainable, then at the very least we should create a plan, delivery, and environment of highest quality and dignity of life, minimizing suffering and creating a door of hope for tomorrow. This also allows us to participate in one of the greater values of life, the opportunity for fellowship and to relate to a person’s unique experience of life, a form of shared enlightenment.

Again, the attitude for delivery is based on how we would want to be treated in any given situation. This attitude counteracts selfish goals and stirs physical therapists to strive for the best scenario and outcome, for the goal is quality of life. This way of life care planning requires com­mitment to the process. It includes active responsibility and participation of both the physical therapist and the patient.

The physical therapist has the unique capability of providing a large spectrum of evaluative techniques as well as evaluative protocol. The evaluation process is a multilevel course of action. Full detailed evaluation processes can occur on various levels or may be specific parameters, as well as being appropriate to special situations.

In the general areas of medical studies and patient situations, a physical therapist is presented with a variety of evaluative techniques. These include the areas of orthopedics, neurology, soft tissue dysfunction, wound care, sports medicine, hand therapy, industrial medicine, and cata­strophic injury to specific or multiple areas. The physical therapist can also specify evaluative techniques by age groups, including pediatric, youth, adult, and geriatric populations. Besides the areas of physical dysfunction and areas of given diagnostic diseases, lesions, or injury, a compara­tive evaluation and preparation for return to life evaluations can be delivered. Evaluations that involve return to life skills, including activities of daily living (ADL), function, work-related skills, ergonomic analysis, sports-related skills, and overall total life skills can be offered with the appro­priate parameters in order to be specific or holistic in nature.

The evaluation process involves consideration of the adaptability of the patient and the circum­stances in which the patient is placed. Evaluations can involve specific areas of spine, extremities, and body systems, as well as specific areas of dysfunction and injury. General areas of consider­ation and evaluation involve the following.

Review the existing medical history and subjective information.Interview the patient. This involves a general subjective overview, including verbal con­tributions from the patient, type of injury, surgical history, disease process, and dysfunc­tion. Other areas involved in subjective information include present job situation, activity level before and after injury, previous types of physical therapy received, and medical care received.Consider psychosocial questions and interview as they relate to the present dysfunction. Other professionals may have covered psychosocial issues, but it is always appropriate to establish a baseline of understanding of other involved issues in the patient’s dysfunction.As appropriate, communicate with family and friends about observed subjective and objec­tive information.

The subjective information and input obtained from the client are established as the baseline for other evaluation considerations. Pain evaluations using standardized questionnaires as well as various tests have benefits for cross-correlation and reliability of subjective information. These essential baseline data of pain characteristics assist in leading the therapist toward establishing present dysfunction and potential for further dysfunction and other complicating factors.

General characteristic complaints of pain are to be established, such as:

¦     The location, duration, and frequency of the pain.

¦     The specific qualities of the pain—constant, intermittent, diffused, localized, sharp, numb, burning, dull, tingling, radiating, quick, or sustained.

¦     Examples of specific pain (e.g., night pain, pain upon arising in the morning, pain with activity, or pain throughout the day).

¦     Clarifying the pain intensity by using a scale—0 being no pain and 10 being acute pain.

¦     Examples of activities that increase pain and activities that decrease pain (e.g., sitting, stand­ing, walking, lying, bending, massage, ice, or heat).

¦     Is the pain getting better, getting worse, or remaining the same?

¦     What is the maximum length of time the patient can perform any particular function, such as sitting, standing, walking, and driving?

Pain questionnaires should also reveal relationships between how much function the patient can perform and at what level the pain occurs, such as how much can the patient lift and carry? What provides relief? What positions and body ergonomics or equipment assist in decreasing pain and promoting function? Pain drawings and various standard pain scales are other informative tools to be utilized for comparative information, with coordination of other data.

Past medical history and personal information also are important to understanding the direc­tion of evaluation, treatment, and plans for function and health care. The new standards and parameters established under the Health Insurance Portability and Accountability Act (HIPAA) have to be considered in all aspects of care and planning.

Referral questions such as return to work, work duty load, time load, consistency testing, and impairment ratings are also directional in the evaluative and care process.

An objective evaluation will analyze basic functional activities, such as the patient’s gait; sitting, standing, and rolling activities; and appropriate supportive devices.

Observation of the basic structure of the anatomy, weight-bearing capabilities, and appropriate body landmarks is an essential part of this examination. One should note appropriate posture, compared to the correct anatomical position, and specific noted deviations. Considerations for historical body habits, adaptive shortening, and contractures are important data. Also note the self-limiting or compensated functions and adaptations the patient has made. These can occur voluntarily or involuntarily.

Other observations should include:

¦     Basic soft tissue evaluation

¦    Appropriate understanding of joint position

¦     Intervertebral movement

¦     Normal joint movement

¦     Range of motion (ROM), including cardinal and diagonal planes

¦     Gait analysis

¦     Flexibility

¦     Manual muscle testing

¦     Strength testing with technologies and instruments

¦     Functional test

¦     Sensory tests

¦     Special tests

Special tests can target specific examination of any given extremity or body part. These tests rule out various complications and evaluate appropriate function and dysfunction.

Other appropriate evaluations include:

¦     A neurological exam would include basic reflexes as well as appropriate strength measuring, with manual muscle testing and sensory examination. It should be noted that during the evaluation any cross-correlation with a basic generalized assessment can be made with more specific evaluations, including functional aspects of a work capacity assessment (WCA), functional capacity assessment (FCA), and isokinetic, neurological, and balance testing and sensation tests.

¦    Joint mobility evaluations include the normal ROM, correct anatomical position, appropriate accessory movements, and physiological movements.

¦     Soft tissue evaluations include palpation of tissue, noting restrictions, trigger points, pliabil­ity, and plastic and elastic responsiveness. The evaluation of soft tissue and tender points should include restrictive qualities and tenderness nature and the response of the tissue (Jones et al., 1995). The evaluation of articular structures should include pain, irritation, and inflammation status as well as movement patterns being evaluated. The functioning of soft tissue and joint structures as a synergistic pattern should be noted. Functioning activities such as sit to supine and return, rolling to supine, side lying and return, and overhead reach are part of the evaluation. The evaluation of functional positions and assuming positions, including the quality of movement as well as any centralization or peripheralization of pain, signs, and symptoms should be considered in this process.

¦     Other palpation skills include evaluating muscle play, restriction, guarding, reflex contractions, soft tissue restrictions, trigger point, and referred pain. Intervertebral movement evaluation is based on a numerical scale set between 0 and 6, with 0 being ankylosed and 6 being unstable; 3/6 is normal. The intervertebral movement can also be classified as hypomobile, hypermobile, and painful. The general evaluation can be broad or specific.

The terms work capacity assessment and functional capacity assessment are sometimes used synonymously (Polinsky, 1983; Blankenship, 1989). They can also be more definitive, with WCA being an evaluation used for baseline of work capacities. The FCA would involve a more direct study of basic, functional activities of daily living, with the potential of also evaluating work-related activities. The WCA/FCA can be done at the beginning, middle, or end of any
treatment evaluation process, or as part of a total perspective of life care planning depending on what is needed. There can also be varying degrees of specific details in the WCA, since the parameters are determined by the physical therapist’s understanding of the goals of the evaluation process. The WCA/FCA can occur during the initial stages of the life care planning process or can be extended throughout the span of the life care plan. Follow-up assessments are to upgrade and adjust the goals and plans for the patient, as well as to update the baseline data for reevaluation. All physical therapy evaluations are done in coordination with other professionals and their evaluations. Integrating the results of other health professionals’ assessments into the physical therapy plan allows for a more holistic approach in achieving the goals for the individual patient.

There are a number of evaluative techniques in the areas of WCA and FCA that are effective and appropriate for any given situation in the life care planning process. According to Blankenship (1989, p. 122), “the WCA or the FCA is an evaluation of physical capabilities and limitations as they relate to work, recreation, and ADL. It describes the optimum and maximal capabilities in terms of strength, endurance, related joint problems, fine and gross motor coordination, limiting factors and methods of functional and task performance.” Therefore, in order to make a more accurate assessment, the WCA/FCA should involve measurements of different activities.

General areas tested in basic functioning include:

¦     Lifting, which includes level lift, floor to table, and carrying

¦     Pushing to maximum tolerance

¦     Pulling to maximum tolerance

¦     Standing, sitting, and kneeling tolerance

¦     Bending, stooping, and squatting

¦    Walking, climbing, and balance

¦    Coordination activities, including the upper and lower extremities with gait analysis and gait function

¦     Pivots, forward reach, overhead reach, etc.

The evaluation often requires an assessment of time and repetitive parameters specifically defined as not required, occasional (up to one-third of the time), frequent (one-third up to two- thirds of the time), and constant (over two-thirds).

These tests can take on specific work or functional aspects. Various lifting tests have been developed to improve consistency, reliability, validity, and standardization of data to be applied to evaluation and supportive conclusions, results, and directions of rehabilitation.

Isometric lift test, strength test with one repetition, repetitive loads, dynamic and static, grip test, and other integrated techniques utilizing new technologies, programs, and standardized tech­niques and databases are part of the evaluative tools available. These tests are also cross-correlated often to arrive at reliability, validity, and consistency of effort parameters. Many tests, for example, EPIC (Employment Potential Improvement Corporation, developed by Matheson, available at www.epicrehab .com), have criteria and standards for application, databasing, and analysis.

Establishment of proper body ergonomics and posture during functional ADL, as well as work- related activities, is important not only in establishing and facilitating present health, but also in preventing further dysfunction and injury. It is important that ergonomics be applied in the evaluation process as a tool to determine the patient’s capabilities (physically and mentally) in comprehending the issues of proper body mechanics. In the evaluative functional capacity/work capacity arena, proper ergonomics and posture will need modifications based on equipment handling capabilities and the use of adaptive equipment.

Functional aspects of ADL, such as personal grooming, hygiene, and dressing, are issues that are often considered in the FCA (also see this post on the occupational therapist’s role). Areas of nutrition and speech can also be evaluated by a qualified physical therapist with appropriate training. Some aspects of the FCA, as well as other aspects of WCA, are often overlapped in the expertise area with the occupational therapist, speech therapist, recreational therapist, ergonomic specialist, and appropriate physician specialist. In any evaluative process, standard body mechanics are to be evaluated by the therapist during the lifting task portion, as well as basic functional activities task, in order to ensure the most advantageous body mechanics for handling basic ADL functions and work functions.

Evaluation for sports and other specific recreational skills needs to be considered in the evaluative process. There is a correlation between functional skills, work skills, and sports or recreation skills. Collating these concepts provides for efficiency of movement, as well as promoting correct body function and health, within the parameters of the given dynamics of the patient’s physical challenges.

Evaluation of body mechanics is crucial to determine potential for wear and tear on the patient. Appropriate alternatives, suggestions, and varying procedures and skills for handling any given dysfunction should be understood. Full comprehension of these procedures and skills will enhance the development of proper use of strength, as well as minimize irritation and pain. Also, with proper evaluation of the patient’s present knowledge and skill, the need for further training or education can be developed. The role of the physical therapist from the basic evaluative process or WCA/FCA can essentially be refined or specified for any catastrophic impairment.

When performing the evaluative process and listing objective findings, substantial data are important to assist the delivery of health care to the patient. Gathering of data and information in the objective format also plays an important role in defending the patient’s present situation and in presenting the plan for future services. Skilled assessment is vital in giving direction for the best possible outcome for the patient’s return to health, as well as providing long-term care. It is appropriate to develop parameters allowing for changes in the patient’s function and health and in the patient’s environmental situation and basic home lifestyle. Adaptability and changes in preparing the patient for return to work or work activities are crucial in understanding the format for performing the evaluative FCA or WCA.

Isokinetic testing provides a technologically advanced approach to human performance testing, rehabilitation, and exercise. The test allows all major joints of the body, including the upper extremities, lower extremities, and trunk, to be evaluated and compared. Bilateral testing, as well as comparative testing, can differentiate between muscle groups in the isokinetic test. Isokinetic exercise is performed at a constant speed throughout the range of motion. As the muscle applies
force, it is resisted by appropriate proportional opposing force. Therefore, the speed of movement is kept constant. The isokinetic evaluation process or exercise provides an excellent means of qualifying many aspects of movement and function, including muscle torque, work, fatigue, ROM, and peak torque levels. As the sophistication of technology improves, more accurate and appropriate measuring devices will allow for basic data and parameters in which to assess body function. The isokinetic test can also be used in a cross-correlation with functional measurements being taken, as well as manual muscle testing and basic lifting capabilities. This cross-correlation can help define the patient’s present level of activity and assist in determining symptom magnification and inappropriate illness behavior parameters.

As in the general evaluation given earlier, the neurological examination can be an expanded appraisal involving specific parameters. It involves specific emphasis on neurological and neu­romuscular mechanisms of the body, including muscle test and evaluations, sensory tests, functional and neuromuscular developmental sequencing and evaluations, and specific injury evaluations to the central nervous system or peripheral nervous system. Associated dysfunction as in gait, transfers, dressing, grooming, hygiene, sports, and work can also be neurologically evaluated.

Cardiovascular fitness evaluations incorporate a range of specifically applied stress testing under the supervision of the physician and appropriate professionals, including a physical therapist. The cardiovascular appraisal is often involved in the FCA/WCA, which establishes a minimal level of conditioning protocol that could include treadmill, bicycle ergometer, or step-climbing evalua­tions. All these tests have basic guideline parameters. Often a cardiovascular clearance evaluation is needed before other evaluations, WCA, and FCA can be performed. The pertinent physician or professional may give appropriate parameters under which the cardiovascular system may be stressed or tested.

The neuromuscular skeletal function is evaluated in specific areas or systems and holistic body systems and functions. This evaluation can involve the study of the balance system of the body in relationship to gait and functional activities. Proper consideration for a proprioceptive feedback system in static and dynamic functional activities is measured. This evaluation can involve specific job activities, sports activities, and ADL, with coordination, balance, and skill being integrated into foundation data. The criteria involve general standardized tests, as well as specific tests designed by the physical therapist to the given situation based on age, developmental sequencing, and specific goals of the functional or life care demands.

Gait evaluation involves specific or general evaluations of the patient’s ambulatory status in a variety of environment situations. Consideration for adaptive equipment, tools, and prosthetics is part of this evaluative process.

Return to work and physical demand categories as published by the Department of Labor, in combination with consistency of performance, positional tolerances, and lifting tests and other evaluative procedures, create a viable tool to have a “systematic process of measuring and develop­ing an individual’s ability to perform meaningful tasks on a safe and dependable basis” (Hanoun Medical, 2002).

The role of the physical therapist as a facilitator in health care is to treat, train, condition, and assist in the direct structure and setting of goals for the patient. Basic communication to the patient, family, professionals, and financial parties serves as a primary directive of achieving the life care planning process. It should be understood from the physical therapist’s point of view that his or her establishment of feedback into the life care planning process is crucial in developing a long­term solution for the patient’s care. Proper structured treatment, evaluation, follow-up physical therapy, and training involve clear communications among the professionals involved so that all forms of facilitation to functioning are utilized.

An attitude of openness and understanding should be the goal while preparing the patient for the highest level of independence. This same directive should be applied when providing options for those who will need long-term or lifelong physical therapy. Examples of this attitude and structure are as follows: a patient who is in need of a wheelchair and is dependent upon the wheelchair for most of her life will develop other dysfunctions. Typically there is greater wear and tear on the upper extremities, cervical, neck, thoracic, and spine, due to having to handle a greater load of total body function in the upper extremities and upper trunk and neck areas. It is important to understand that lower extremities that are not functioning do not provide support and therefore cannot be used in functional skills. This greater demand of activity and function is placed on the remaining working cardiovascular, neuromuscular, and skeletal systems. These patients or clients are susceptible to greater breakdown of all involved systems and structures. Effective planning involves addressing the immediate dysfunction in preparing the patient to develop a higher level of independence and future preparation. It should also be understood that the patient would in all probability have an increased ratio of wear-and-tear factors and greater susceptibility to further lesions and insult in his remaining systems and structures.

The dysfunctional areas of the body and mind will still need suitable care and support. These would include areas of strength, ROM, hygiene, wound care, tissue function, and basic vascular and neurological functional considerations. Sometimes injured areas become hypersensitive, even though not functional. Phantom and referred pain can occur in the dysfunctional area.

As in any treatment or evaluation process, the therapist should be open-minded and aware of any new studies or opportunities to increase the function and promote the facilitation of health in the injured area. This especially applies for adaptive equipment. The progressive use of equip­ment, awareness of advanced technology, and foresight to predict need are essential. For example, a lower-level tetraplegic patient would commonly require a primary power wheelchair for basic ambulating. However, there are occasions in which an additional manual wheelchair would pro­vide the patient with a variety of sitting postures, backup to the power chair, and an opportunity for the wheelchair to be used as a piece of exercise equipment. The manual wheelchair provides an
excellent source of exercise potential and opportunity for the patient to develop some control and direction in ambulating.

Thoughtful modifications and supplements to the patient and the given situation, with appro­priate equipment, should be considered for both short-term and long-term care. This allows the physical therapist and the life care planning team to develop a full perspective in returning the patient to the highest level of independence and an appropriate, dignified lifestyle. Motivating, encouraging, and challenging the patient to use equipment and supportive devices are part of the evaluative, training, and treatment process.

Financial considerations include original equipment, maintenance, modifications, and replace­ment equipment. All these factors are to be considered over the patient’s life span. As the patient changes and various challenges are presented, considerations for equipment should be appropriate to the life care plan and goals. Financial support for equipment and the evaluative process should be based on the highest goals and principles presented.

In the life care planning process, an evaluation establishes the baseline for treatment through­out the process. In many situations, specific treatment by the physical therapist is required and involves not only therapy, but also ongoing evaluation. Physical therapy treatment may involve eight basic categories:

EducationConditioningPhysical medicine treatmentFunction-specific and ADL-specific treatmentOccupational and industrial physical therapySports physical therapyTotal life relationship skills and integration treatmentBoundaries and communication skills

Education involves an emphasis on ergonomic principles applied to posture and body mechanics, and essential principles for carrying out assisted or independent programs of conditioning, strengthening, ROM, and functional care. Education in ADL, functional, sports, and work- related skills is delivered to all parties involved. It is important that these skills are developed in the patient’s real-world setting and that there is ample opportunity to implement them in an appropriate manner—with supervision, leading toward independence as a baseline goal. The appropriate support of professionals and family members in the real-world setting will require adaptive thinking.

Establishment of specific patient potential in any given area needs to be determined and understood by the patient and team members. An understanding of the patient’s situational life­style, critical work demands, task analysis, functional activities, and recreational plans is impor­tant. The patient’s understanding of educational information presented and the development of a functional delivery by the patient in handling basic nonmaterial ergonomics and essential material ergonomics should be considered. Material handling and nonmaterial handling ergo­nomics are matters not just of work-related issues, but also of functional ADL and the total environment.

Integration into the whole aspect of the patient’s life care with the life care planning team on an as-needed and program-developmental basis will be required. This will probably require the physical therapist to coordinate with the patient/client, other professionals, and family members to follow through with essential concepts of physical therapy education.

Conditioning involves aerobics, cardiovascular, and physiological conditioning. It should be noted that in conditioning, appropriate adaptations to the patient’s/client’s needs will be made and evaluated, as well as developed into a working solution by the physical therapist. Strengthening, which will incorporate specific muscle dynamics, will be used to increase strength levels for performing functional activities, work activities, sports activities, and ADL. Specific areas of strengthening can involve techniques in cardinal and diagonal planes, which can involve singular movements or multidirectional movements. The physical therapist has at his disposal the use of many strengthening techniques, including isometrics, isotonics, isokinetics, plyometrics, and proprioceptive neuromuscular facilitation (PNF). Strengthening could involve rotational, multidirectional facets to prepare the patient for a variety of lifestyle situations. Mobility, stretching, and flexibility categories are used synonymously to describe appropriate mobility exercises to ensure basic principles of full functional ROM in both physiological and accessory patterns. Using balanced concepts of strengthening without strain or further injury is of vital importance in designing a program specific to the individual patient and situation.

The integration of all conditioning factors with functional skills, ADL skills, work skills, and sports skills should be considered and integrated into life care planning. Specific neuromuscular, balance, and coordination activities allow the integration of the central nervous system and the peripheral nervous system to handle ADL, functional, work, and sports activities. Ballistics and dynamics are stresses to be applied to prepare the patient to handle a variety of velocity forces and changes that occur in any lifestyle situation. This can involve specificity of training at various speeds and various levels of physical performance.

Physical medicine treatment includes the use of appropriate medications, modalities, manual therapy, and specific exercises. Physical therapy medicine is used for basic signs and symptoms, which may include pain management, wound care, and improving function. Physical medicine includes the areas of specialized program development or treatment, which could include relaxation techniques, weight control, and appropriate uses of supportive devices, equipment, and braces.

Function-specific and ADL-specific treatment are specific treatment programs the physical therapist can use to encourage increased functional capabilities, such as in gait, transfers, personal hygiene and grooming, speech, and general ADL.

Occupational and industrialphysical therapy involves the process of creating a situation in which a patient/client may progress from a beginning level of handling any job task to the actual per­formance of the job. The job-specific program can involve a program starting in the clinic and being transferred to the on-site job location. Work hardening, work conditioning, and work start are synonymous terms to describe this process.

Sports physical therapy involves the direct relationship of physical therapy in establishing appro­priate conditioning and training, structure, and protocol. This skilled development of parameters and goals creates an atmosphere that develops independent training techniques, as well as inde­pendence to continue higher levels of sport or sports-specific performance.

Total life relationship skills and integration treatment involves the physical therapist working with the patient, family, and total environmental in developing a workable plan structured for assisting the patient in facilitating her full health at the highest level possible. This total life care integration involves a coordination of all previous physical therapy treatments and evaluations with the potential for upgrading, changing, and adapting any given treatment plan and program.

Boundaries and communication skills involve personal and relationship effort and education, utilizing appropriate psychological consultation and study. The skills and techniques gained will enhance the positive effectiveness of a caring serving professional.

Preparing the exit program involves a combination of compiling all previous evaluations, treat­ment, data, and observation processes in communication with the associated team members to arrive at a conclusion of the involvement process in the patient/client. During the exit program, appropriate recommendations and postdischarge plans are made from the physical therapist’s point of view with preferred sequencing, as well as postdischarge plans for status to returning to full lifestyle situations. Options and variations of any program, as well as reentry into a program, are open for consideration, as is proper application of newly found situations.

Follow-up care resolution is a broad category involved in interpreting the appropriateness and efficacy of the evaluative and treatment process from the patient’s perspective. It also involves the physical therapist’s perspective in the areas of physical ergonomic integration into basic life, con­cepts of preventative physical medicine, appropriate concerns for future update and recheck, and any issue of compliance. This involves a process of communication between the patient and all team members in restoring the patient to the highest level of function and a dignified lifestyle.

Symptom magnification or inappropriate illness behavior is an issue that can be present in the life care process and involves many complications and issues. Physical therapists, as well as other professionals, have attempted to arrive at appropriate systems, tests, and evaluative procedures for giving suitable feedback and baseline data to establish appropriate behavior in any given situ­ation. General considerations for inappropriate illness behavior and symptom magnification are behaviors that are out of proportion to the impairment. It should be understood that symptom magnification is a behavior that is improper but does not implicate a reason or motive for that behavior. Furthermore, it should also be understood that there could be a psychosocial basis for some behaviors that do not necessarily originate from a physiological or organic basis.

In determining symptom magnification or inappropriate illness behavior it should be under­stood that there are often degrees and levels at which it is expressed. Some of these levels are extreme and can impede the appropriate fair process of assisting a person to achieve a healthy lifestyle. In addition, there are forms of symptom magnification that exist on a low level that are intrinsic to basic lifestyle teachings. Therefore, appropriate considerations for establishing objec­tive information, as well as objective treatment, require skill and fitting consultation from the team of life care planners and associated professionals.

If the physical therapist is involved in the identification of the type of symptom magnifier, which could be classified in the areas of an experimenter, a refugee, a game player, and a psychogenic type of magnification, consultation with the appropriate professional should be performed and used (Blankenship, 1989). Appropriate test questionnaires and scales administered by the physical therapist, or previously by associated professionals, can be considered as part of the evaluative
process. It should also be noted that in understanding, evaluating, and commenting on appropriate and inappropriate illness behavior, one should have an open mind and be alert to cross-correlation factors in the evaluative and treatment processes.

An example of this would be a patient being asked to perform a cardinal plane ROM by lifting his arm over his head, but the patient states or demonstrates that he cannot lift his arm above 70° of shoulder flexion. Then when asked to take off his shirt, he is able to demonstrate taking his shirt off over his head, thus demonstrating his ability to flex his shoulders above 100° or more of shoul­der flexion. Cross-correlation of specific evaluative techniques and functional techniques assists in determining the reliability and validity of the patient’s status. In communicating this information, the physical therapist should use the expression “The data presents itself.” Another way to express performance is to use the phrase “The patient demonstrated (this or that).” Therefore, the therapist avoids conjecture and judgment when communicating.

Basic rates in physical therapy for services rendered are wide and varied. Each profession and professional has his or her requirements and specific insights into delivery of any evaluation and treatment process. The following numbers are given as a broad perspective and are estimates for considering lifelong life care planning issues and are subject to change with all basic life situational economics, as well as specific professional demands.

¦     Basic physical therapy treatment and conditioning range from $65 to $200 per hour.

¦    General evaluative techniques, depending on the extensiveness of the techniques, range from $60 to $1000.

¦    These techniques could involve anything from a beginning basic physical therapy evaluation of $65 (average charge) to more specific exams running $200.

¦    WCAs and FCAs range from a modified WCA/FCA costing $200 to a more extensive WCA/FCA costing $1000.

Again, there is such a wide variety in pricing that it is best to be specific to the physical thera­pist involved in the analysis, evaluation, and treatment processes to determine the best life care planning situation. As in other life care planning areas, considerations for “how I would like to be treated” and what is fair should be a basis for appropriate structuring for financial reimbursement.

The physical therapist should establish an appropriate information system in order to accomplish the following:

Provide a means of examining the specific case issues as a professional.Establish appropriate correlations between injury and patient types. Establish appropriate protocol for returning the patient to his or her lifestyle and life situation.Establish appropriate modifications for further patient assistance and study.