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.

Life Care Planning for Acquired Brain Injury – Case study and Conclusion (III)

A 32-year-old client was riding a motorcycle that was hit by a car. At the time of the interview, 3 years postinjury, he stated that he did not remember the incident or anything a couple of weeks prior to the incident. Following the incident, his first consistent memory is approximately 2 to 3  months later. He was treated for 2 months in an acute care hospital and then for 5 months in a brain injury rehabilitation hospital. The client was diagnosed with severe TBI with physical and cognitive deficits, including ventriculoperitoneal shunt and orthopedic injuries requiring extensive care.

Neuropsychological testing results concluded that the client had sustained a very severe TBI. Testing revealed reduced intellectual capacity of one standard deviation, perhaps slightly more, below preinjury levels. His primary deficit is in visual/motor problem solving. He is able to sight read beyond a high school level. He has significant deficits in mathematical calculations, with overall performance at a level much lower than expected given his preinjury educational level. No anomia was noted, and he is able to mildly retrieve words without perseveration or intrusive errors. He has significant difficulty with fine motor coordination, with reduced range in the left upper extremity. He has significantly improved executive function from prior testing, which is the most promising part of the overall evaluation, although he continues to exhibit occasions of temper outbursts. He has moderately to severely impaired short-term memory, especially with verbal short-term memory given the absence of consolidation of information. He has a positive affect, although he has times of unhappiness/frustration, and is basically functioning in a more adaptive manner.

He has a young daughter and must be supervised when with her. His wife is supportive and has quit work to be his caregiver. He must have someone available for assistance with judgment, safety, food preparation, and financial commitments. Work is not a reasonable goal, although volunteer activities part-time would be therapeutic.

LIFE CARE PLAN

Note: For purposes of this plan, the following initials are placed in parentheses according to their respective recommendations:

JP   = Jeffrey Preston, MD, physiatrist

MC = Michael Cathy, MD, psychiatrist

RH  = Robert Hampton, MD, ophthalmologist

IR   = Ian Raston, MD, hand surgeon

WW = William White, MD, internist

AP  = Amy Passy, PT, physical therapist

JH   = John Hurry, PsyD, neuropsychologist

RW = Roger Weed, PhD, life care planner

Routine Future Medical Care—Physician Only

Physiatrist (JP)

X-rays: left hip, knee, or shoulder (JP)

Head CT scan (JP) Head MRI (JP)

EEC (JP)

4  times/year to life expectancy 3 times/year to life expectancy 1 time/year to life expectancy Every 5 years to life 1 time/year to life expectancy

Monitor overall rehabilitation program and prevent/reduce complications, etc. Monitor development of expected degenerative joint disease Assess integrity of shunt Monitor structural changes to brain Assess brain wave activity due to high risk for seizures

$276-320/year at $69-$80/ visit (see Note 1)

Range: $609-1365/year at $203-455 each, 3 times/ year to life

CT scan: $2173-2296/year to life

MRI: $3016-4370 every

5 years to life

EEC: $854/year to life

Note 1: Dr. Preston states in his deposition that a personal computer is medically indicated for the client to include possible access for environmental control unit (ECU) or adaptive devices integration in the future.

Note 2: A one-time-only replacement cost for computer and related equipment/supplies is included in plan. Replacement after that is presumed to be consistent with use of a personal computer by the general population.

Note: The client has no competitive vocational potential. Volunteer activity is a best option for him to increase his sense of productivity and self-worth, and provide a sense of purpose. If professional services are required in the future to develop or cultivate an alternate volunteer program for the client, expect 20 to 40 hours for vocational counseling and related services, including vocational evaluation, labor market research, job site analysis, etc., at $75 to $89/hour. However, costs for these services are not included in the plan.

Architectural Considerations

(List considerations for home accessibility and modifications.)

The client currently lives with his wife and 2-year-old daughter in a ranch-style house that has been modified to accommodate him and generally appears appropriate for his current needs. A ramp has been constructed to the back door, which is the entrance the client uses to enter and exit the home, and grab bars have been installed in the bathroom. The front entrance has steps leading to the front door, although no handrail is available and the client demonstrates he generally is able to ascend and descend the stairs with difficulty in a modified fashion and with altered gait.

The client requires a one-story home with accessibility features and minimal, if any, stairs. If stairs, he requires handrails. See also home accessibility evaluation for one-time-only evaluation to assure the home is accessible both now and for the future as he ages and experiences an expected reduction in his physical capabilities.

Left total knee replacement (JP)

Left knee revision (JP) 2020 (age 50) Approximately 2030-2032 and every 10-12 years (average) thereafter to life expectancy

Initial knee replacement in 2020, then every 10-12 years (average) knee revision to life expectancy

Replacement in approximately 2020: $30,948

1st revision: $35,608 2nd revision: $34,378

Left total hip replacement (JP)

Left hip revision (JP) 2020 (age 50) Approximately 2030-2032 and every 10-12 years (average) thereafter to life expectancy

Initial hip replacement in 2020, then every 10-12 years (average) hip revision to life expectancy

Replacement in approximately 2020: $31,568

1st revision: $39,811 2nd revision: $37,479

*Expected cost for knee and hip replacement/revision includes surgeon fee and average hospital charges and does not include surgeon assistant fee, if applicable, anesthesiologist fee, or sub­acute or rehab unit stay. One case of a client similar in age to this client with diagnosis of degen­erative joint disease required total knee replacement at a cost of $40,733, inclusive.

Note 1: The physiatrist states he expects the client to require joint replacement in both left hip and left knee due to altered gait and increased wear and tear on his lower-extremity joints as well as expected degenerative joint disease. He states the severity of the degenerative joint disease depends on maintenance of the client’s weight and overall health and fitness.

Note 2: According to one orthopedic surgeon who performs knee and hip replacement surger­ies, knee and hip prostheses last on average 10 to 12 years (based on geriatric popula­tion); however, the client may require more frequent revision due to his young age at time of projected initial replacement and expected increased activity level (more so than geriatric activity level). See also Potential Complications.

Note 3: For purposes of future care planning and based on the physiatrist’s recommendation for initial hip and knee joint replacement at approximately age 50, presume two hip and knee revisions over the client’s lifetime at approximately age 60 to 62 and age 72 to 74.

Note 4: The orthopedic surgeon states joint revision surgeries are more difficult than the initial replacement surgery and each subsequent revision is more difficult than the previous one. Recovery also tends to take longer. However, no additional cost for extended recovery is included in plan totals for revision surgeries.

Note 5: Pain medication is expected to be needed following each joint revision surgery as well as probable anti-inflammatory medication. Exact kind, dose, and duration of medica­tion are unknown and no additional cost for medications is included in plan totals.

Note 6: Orthopedic visits following joint replacement/revision generally include one post-op visit (at no cost) plus three other visits at 3, 6, and 12 months postreplacement/postrevi­sion at $60 to $80/visit. Routine follow-up also includes AP and lateral x-rays of hip at $174.25/x-ray and knee at $261.25/x-ray at each post-op visit. Additional medical needs following joint replacement/revision likely include postoperative physical therapy and

probable long-term need for cane or walker for mobility assistance. Aqua therapy also may be indicated following joint replacement/revision.

Ventriculoperitoneal (VP) shunt revision (JP)

Approximately 2011 (15 years after initial shunt placement)

1  time only, assuming no complications

Neurosurgeon evaluation: $286 Revision surgery: $28,927

Note 1: The client was released from the care of his neurosurgeon in February 1998 to be fol­lowed by the physiatrist and return as needed if there were complications with his shunt or changes in his neurologic status. The physiatrist states it is probable the client will require at least one shunt revision over his lifetime due to expected complications.

Note 2: Expected cost for VP shunt revision includes surgeon fee and hospital charges only and does not include diagnostic studies that may be needed such as abdominal x-rays or head CT scan, or anesthesiology charges. See head CT scan, which may be used for diagnostic purposes at time of shunt revision.

Note: Potential complications are included for information only. No frequency or duration of complications is available. No costs are included in the plan.

The Role of the Speech-Language Pathologist and Assistive Technology in Life Care Planning

The purpose of a life care plan is to identify the comprehensive and individualized needs of a person as they relate to a disability or chronic illness with relevant associated cost consider­ations. These needs are the operational components of a life care planning process. They should never be compromised or manipulated. The costs assigned to these needs are determined by the geographical consumer rate for the identified services and equipment. The costs can be developed through understanding the range of available funding streams, creative and innova­tive ways of negotiating, available resources, and the cost projection analyses that accompany such planning.

The SLP must be well grounded in the theory of normal development in all ages, in any previ­ous learning or developmental problems affecting the individual, and in the current status of the individual, and must be able to predict future functioning of the individual. Many times SLPs will practice in the treatment of either the pediatric or the adult population. This frequently precludes the SLP from being able to look backward or beyond to make accurate recommendations about future functioning needs.

It is always useful for the SLP, who is consulting in the life care planning process, to be able to actively engage in the clinical treatment of individuals and their families. This enhances the SLP’ credibility, because the SLP should have realistic estimates of current needs and prognostic predictions. However, it is also imperative that the consulting SLP have a fluid understanding of the current literature and research that directly or indirectly impacts the area of communication
sciences and disorders. This includes knowledge of the most current assessment procedures, state- of-the-art assistive technology, trends in pharmacology and medical care, and possible needs in the areas of residential and geriatric care (ASHA, 1993).

The generally accepted national standard for practice in speech-language pathology (communica­tion sciences and disorders) is the American Speech-Language-Hearing Association (ASHA) cer­tificate of clinical competence in speech-language pathology (CCC-SLP). The ASHA CCC-SLP requires a master’s degree in speech-language pathology, completion of a 1-year clinical fellowship, and successful passage of the national examination. For states with licensure (50 for audiology and 47 for speech-language pathology), the legal right to practice will vary with the individual licensing acts. Most licensure laws were modeled after the ASHA CCC standard (ASHA, 1996). Licensure, unlike certification, is mandatory for those states that regulate the practice of audiology and speech-language pathology. In many states, licensure requirements parallel those of ASHA certification. Further, ASHA certification will satisfy many of the requirements of state licensure when you apply for reciprocity. Table 9.1 shows the states with licensure of SLPs and audiologists.

 State Licensure for SLPS and Audiologists

a Does not regulate the profession of speech-language pathology.These individuals may hold additional credentials through their state education agency. Often, the state education agency requirements do not equate to the national standard, requiring only a bachelor’s degree and education certification in a state to practice. Twelve states require school-based audiologists and SLPs to be licensed (Connecticut, Delaware, Hawaii, Kansas, Indiana, Louisiana, Massachusetts, Montana, New Mexico, Ohio, Texas, and Vermont). SLPs with specific interests may hold additional certifications determined by societies and organizations interested in develop­ing credentials to define expertise in a particular area, such as the Rehabilitation Engineering and Assistive Technology Society of North America (also known as RESNA) or the special-interest divisions of ASHA.

Codes of ethics for all organizations in which an individual holds membership must be acknowledged and followed. Ethics is defined as “the study of standards of conduct and moral judgment … and the system or code of morals of a particular profession” (ASHA, 2003). When applied to a field or professional area, such as augmentative communication, or a profession, such as audiology or speech-language pathology, the ethical conduct of practitioners is embodied both in a code (or canons) of ethics and in standards of practice. SLPs and audiologists must comply with the code of ethics for their discipline. The code of ethics for a discipline is typically developed by the professional association serving it. The ASHA code of ethics sets forth the fundamental principles and rules considered essential to the preservation of the highest standards of integrity and ethical conduct to which members of the profession of speech-language pathology and audiol­ogy are bound. All professional activity must be consistent with the code of ethics. The Principle of

 ASHA Special Interest Divisions Language learning and educationNeurophysiology and neurogenic speech and language disordersSpeech science and orofacial disordersHearing and hearing disorders: research and diagnosticsAural rehabilitation and its instrumentationHearing conservation and occupational audiologyAdministration and supervisionAugmentative and alternative communicationSwallowing and swallowing disorders (dysphagia)Communication disorders and sciences in culturally and linguistically diverse populations

Ethics II, Rule B, especially important in the area of assistive technology, states “individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education and training” (ASHA, 2003a).

When funding is available, third-party intermediaries in most instances require the ASHA CCC and licensure. The national certification standards are generally tied to the ASHA CCC for both funding by third-party intermediaries and for service delivery. On the other hand, other certifications in existence, such as the education agency certification, traditionally do not equate to the CCC. If you are not familiar with an individual and his or her credentials, it is wise to contact ASHA and the state licensing board to determine his credentials. It is also important to note that licensing laws usually relate to direct patient assessment and treatment in the state where the service is provided, but do not address review of records or expert testimony. The national certification is a generic certification whereby the individual has met the minimum entry-level requirements across a broad spectrum of knowledge areas in communication sciences and disor­ders. When funding is available, third-party intermediaries use as a guideline the requirements for service delivery established by Medicare and Medicaid (i.e., ASHA CCC-SLP) and, where applicable, a current state license.

SLPs who have the expertise to provide information in their area must also understand and participate in transdisciplinary integrated assessment and treatment models; have knowledge of funding streams and creative funding; be knowledgeable about state and federal policy, laws, and changes in these laws and policies; and be knowledgeable of collaborative sources and how to build them. They must also be able to provide clear, concise, understandable documenta­tion that is written in a defensible but understandable format with functional milestones and goals available. For a complete communication assessment and many of the services related to delivery of care for individuals exhibiting communication and swallowing difficulties described in this post, it is advisable that the consulting SLP hold a doctoral degree with emphasis in the areas of assistive technology.

The competent SLP has received preparation in the following areas, as they relate to human com­munication, swallowing, and development across the life span:

¦     Theories and processes of normal development and aging, including motor, cognitive, social- emotional, and communication

¦     Physiology of speech production and swallowing, including respiration, phonation, articula­tion, resonance, and the vocal/aerodigestive tract

¦     Embryological, genetic factors in development, including the development of craniofacial structures and the nervous system

¦     Anatomic structures, neuroanatomy, and neurophysiology supporting speech, language, hearing, swallowing, and respiration

¦     Organic etiologies of disorders of communication and swallowing

¦     Psychological and psychosocial influences on communication and swallowing

¦     Neurolinguistic, linguistic, cultural, and social influences on communication

¦     Theories of speech perception and production, language development, and cognition

¦     Ethics related to diagnosis, treatment, and professional conduct

Voice Disorders Addressed by the SLP Hyperkinetic (spasmodic dysphonia, essential tremor)Hypokinetic (Parkinson’s disease)Mixed (amyotrophic lateral sclerosis, TBI, multiple sclerosis)Upper motor neuron (UMN) Vocal fold paralysis

¦     Basic computer theory and systems applications, including frequently used software and input and output devices, as they relate to evaluation and treatment of language, cognitive communication, augmentative and alternative communication (AAC), swallowing, voice disorders (see Table 9.3), and central auditory processing disorders

The SLP who is consulting on a life care plan should demonstrate an advanced knowledge and understanding of health care and educational facility practices; the common diseases and condi­tions affecting human communication, swallowing, and development across the life span; and medical, educational, surgical, and behavioral treatment as they relate to communication dis­orders, including knowledge of:

¦     Medical terminology

¦     Physicians’ orders, confidentiality, legal issues in medical practices, and information and data systems management

¦     Elements of the physical examination and vital sign monitors

¦     Medical and laboratory tests and their purposes

¦     Medical record documentation practices

¦     Pharmacologic factors affecting communication and cognitive processes, development, and behavior

¦     AT, AAC approaches, and the range of bioengineering adaptations used in medical settings

¦     Concepts of quality control and risk management

¦    Concepts in medical setting environmental safety (such as universal precautions, proce­dures, and infection control principles; radiation exposure precautions; and the Safe Medical Devices Act)

¦     Team processes

¦     Performance improvement processes

¦    Theories, concepts, and practices in outcomes measures

¦    Theories and concepts related to the impact of psychosocial and spiritual needs and the individual’s cultural values on health care services

¦    Voice and laryngeal health and disorders

¦     Respiratory functions, tracheostomy tubes, and respiratory support requirements

¦    Neuroanatomy, neuropathology, and the neurophysiological support of swallowing, speech, language and related cognitive abilities (Table 9.4), and the effects of diseases and disorders of the nervous system

¦     Concepts in human nutrition and hydration needs and their disorders

¦     Methods and interpretations in neuroimaging and other forms of anatomic imaging

¦     Esophageal, oropharyngeal, laryngeal, and neurologic tumors

¦     Concepts in neuropsychology and psychiatric and psychosocial disorders

¦     Common medical conditions

¦     Educational terminology

¦     Federal mandates related to education

¦     Broad understanding of curricula and literacy

¦     Educational philosophy of state education agencies

¦     Medical and surgical management of communication and swallowing

The SLP should be able to demonstrate advanced skills and abilities in diagnostics, treatment, and service delivery. The SLP should be able to review medical records and conduct succinct clinical case histories and interviews to gather relevant information related to communication and swallowing, and to select and administer appropriate diagnostic tools and procedures and treat­ment for communication and swallowing disorders that are functionally relevant, family centered, culturally sensitive, and theoretically grounded.

Table 9.4 Language versus Cognition

Note: This table lists the areas of language and cognition the SLP assesses and treats.

The SLP should be able to:

¦     Conduct reliable and accurate modified barium swallow procedures following a standard protocol that includes identification of structural abnormalities; swallowing motility dis­orders; presence, time, and etiology of aspiration; and appropriate treatment techniques (posture, maneuvers, bolus modification).

¦     Determine patient management decisions regarding oral/nonoral intake, diet, risk precautions, candidacy for intervention, and treatment strategies.

¦     Select and appropriately apply aided and unaided communication, including both linguistic and nonlinguistic modes and methods.

¦     Locate and access assistive technology (AT), services, and funding sources.

¦    Work effectively with interpreters and translators and use assistive listening devices when needed for patient care.

¦     Communicate findings and treatment plans in a manner that is fitting and consistent with health care facility procedures.

¦     Counsel and educate patients and families and work within family systems to elicit parti­cipation in the treatment plan and work as a member of a health educational care team. (See also Table 9.5 for a description of the types of physical and communication impairments that may need AAC or AT evaluation by a SLP.)

Progressive deteriorating central and peripheral nervous system diseases (Parkinson’s disease, ALS, multiple sclerosis, Guillain-Barre syndrome, dementias, and Alzheimer’s)

The SLP will need to consider all of the following categories, regardless of the age of the indi­vidual, in the development of information for the life care plan: an oral and pharyngeal swallow­ing (dysphagia) assessment to include modified barium swallows, videostroboscopy evaluation, prostodontic intervention, and palatal prostheses; cognitive commu­nication information; auditory processing information to include central auditory processing, augmentative communication assessment information, AT assessment information, voice and vocal information including vid­eostroboscopy, and Botox assessment information; oral peripheral motor information; hearing acuity informa­tion; assistive listening device; and cochlear implant information.

The critical information obtained from a thor­ough communication sciences and disorders assessment must be considered within all the parameters of the life care plan itself. In other words, any and all areas that are impacted by deficits in communication and swal­lowing must be addressed with recommendations, if deemed appropriate by the evaluating SLP. These param­eters include projected evaluation, projected therapeutic modalities, diagnostic testing and educational assess­ment, mobility (including accessories and maintenance of mobility technology), aids for independent functioning, orthotics and prosthetics, home furnishing and acces­sories, pharmacology needs, home/facility care, future medical care, transportation, health and strength mainte­nance, architectural renovations, potential complications, orthopedic equipment needs, vocational/educational planning, AT in the areas of sensory deficits, cognitive challenges, and communication disorders (including
hearing and processing difficulties needing assistive listening devices).

Jenny Craig, the well-known cofounder of weight-loss centers, had a bizarre accident in 1995. She was watching television while sitting on a couch with no headrest. She fell asleep and her head fell forward with her chin on her chest. A loud noise from the TV startled her and her head jerked up, causing the mandible to snap over her maxilla. She had to pry her teeth apart, and began to speak with a lisp as a result of trying to keep her lower teeth from hitting her upper teeth. She immediately saw her dentist, who referred her to a tempo­ral mandibular joint (TMJ) specialist who told her that she had dislocated her jaw. The TMJ specialist recommended she try dental appli­ances, none of which helped. Her speech problem became worse and chronic. She was diagnosed with focal dystonia of the mandible (involuntary muscle contractions that induce abnormal movements and postures caused by the trauma of the sudden jerking of her man­dible). She received Botox injections in her cheeks, which had no beneficial effect on her speech. Three years after the accident, she saw a reconstructive surgeon who specialized in cleft lip and palate and was able to repair some of the damaged muscle tissue that had been caused by the years of abnormal man­dibular movements. In addition, the surgeon was the first person to recommend speech therapy. Craig began working with an SLP 5 days a week, 1 hour per day plus speech exer­cises in between appointments. Although her speech is not the same as it had been before the unusual accident, Craig is thankful she can communicate with people. (Fogle, 2008)

The importance of terminology relative to our communication with other professionals and the general public, as well as the very special needs of international and transdisciplinary communi­cation and development, has become increasingly apparent. In addition to improved consistency in the use of terms, there is the need to carefully examine what meanings the developing jargon may have to other individuals who rely primarily on a dictionary and common sense. Although many people in the field may know what is meant by a given term, others may not share the same meaning. Some terms used by many people in one country may not easily translate into other languages. Even more apparent, with the diversity of people in the world today, care must be exercised to consider multiple interpretations of a term, sometimes affected by the perspective of one’s culture.

Because of the transdisciplinary nature of the medical-legal-clinical world, there are also problems of various disciplines using other jargon to describe essentially the same phenomenon, act, or characteristic. These problems reflect the need for an emerging field like life care planning to develop an internally consistent and logical terminology that will facilitate the international and transdisciplinary development of the field. It is important to actively educate individuals on the life care planning team concerning specific terminology that defines and describes areas of assessment and treatment within the field of communication sciences and disorders.

The SLP must perform his own case intake, consisting of talking with the referral source, determin­ing the time frames needed to complete testing, arranging the financial and billing agreements, and arranging for a release of all pertinent information. Additional testing needed may be identified at this time or during the initial interview arrangements.

The SLP will then review a copy of the medical records to include:

¦    Nursing notes

¦     Doctor’s orders

¦     Other services’ reports

¦     Educational information

¦    Vocational information

¦     Day-in-the-life videos

¦     Other relevant documentation, depending on the etiology and diagnosis

A thorough assessment battery is then administered, gathering information from the spouse, family, or other relatives, including the clients themselves. This step may also include the oppor­tunity for the SLP to consult and interview other team members whose information may have a bearing on final recommendations of the SLP. At this time, if additional medical, clinical,
vocational, or educational information or evaluations are needed, requests for these additional information-gathering steps should be submitted to the referral source. A letter may be composed outlining the correct questions with supporting data to ensure that the SLP has the opportunity to solicit the needed information.

At the completion of the assessment, the SLP must be able to provide a written report, documenting the test results, observations, and conclusions with clear recommendations. These recommendations must be detailed to include a projection of future care costs, frequency of service or treatment, duration, base cost, source of information, and recognized vendors or manufacturers, current prices, collaborative sources, and categories of information. It is recommended that the consulting SLP be knowledgeable about the local sources and costs of these recommendations, either through direct contact with suppliers or through catalog and desktop/ computerized research. Recommendations from the SLP should be discussed with the client and family, treatment team members, and other life care team members if they directly impact the final recommendations and the cost analysis of the plan by the economist. Any coordination and agreement needed between team members including the economist should occur at this time. A draft of the communication sciences and disorders assessment and recommendations report should be written and distributed to the life care planner for review relative of the accuracy and completeness of the information. The SLP must be able to explain, from a life care planning perspective, the reasons and rationales that are relative to their recommendations. These must be lifelong recommendations and objectives, developed in an integrated format. Once the document is correct and complete, a final draft should be compiled and distributed to the life care planner and the referral source. It should be determined, by these two parties, whether the written documentation should be sent to other internal life care planning team members, including the family and client, and to external individuals.

There are four methods of gathering and interpreting quantitative and qualitative information about the client that should be used in the communication sciences and disorders assessment pro­cess by the SLP. These four measures are a collection of the initial database, interview procedures, clinical assessment, and formal assessment procedures (Dunn & Dunn, 1991). Often more than one method is used to gather information about the same aspect of a client’s skills and abilities, the context, the activity, or the use of technology or equipment. Information collected should include the reason and need for referral, medical diagnosis, and educational and vocational background information. This information is collected during the referral and intake phase, and its purpose is to provide preliminary data for planning the assessment. The interview takes place during the identification phase as a means of gathering information regarding the consumer and her needs. It is important that the consumer, family members, rehabilitation or education professionals, and other care providers be interviewed.

Formal assessment procedures are administered in a prescribed way and have set methods of scoring and interpretation. Therefore, they can be duplicated and analyzed. They may or may not be standardized. Clinical assessment techniques involve skilled observation of the consumer and are used throughout the assessment process. These techniques may be structured so that a series of steps is followed to determine specific skills, or they may be intentionally left unstructured to see what takes place. Observation can be done during a simulated task in a clinic setting or in a context familiar to the consumer such as a classroom or workplace. Differential diagnosis is an
ongoing and essential component of the assessment process and one that requires an advanced level of understanding and perspective about the trauma or injury.

Evaluating children (pediatric and adolescent) presents complex and challenging issues, compli­cated by the catastrophic nature of the disease, disability, or trauma and frequently challenged by the almost insurmountable task of planning a child’s life. For these reasons, it is critical to make accurate and thorough projections and careful analysis of the disability, educate team members and caregivers about the pediatric disabilities, and develop a differential diagnostic therapeutic approach to service delivery to the child. The list of pediatric and adolescent considerations in the communication sciences and disorders assessment is lengthy, detailed, and can be complex. It is important to disclose that the list is not all-inclusive, because changes occur as research and science enhance the process.

There are areas that warrant consideration when performing a communication evaluation for a pediatric or adolescent individual that are not considered, or at least not in the same detail, when evaluating an adult. Chronological age and pretrauma development are used as the normal bench­marks against which to measure the disability issues. Routine medical needs must be addressed to the pediatric specialists who would provide the information that impacts a child’s communication development. These include pediatric physiatry, otolaryngology, pediatric neurology, developmen­tal medicine, audiology, dental/orthodontic, prosthodontist, and pediatric neuro-ophthalmology and ophthalmology. It should be noted here that there is a trend in the medical specialty fields to identify specialists who work solely with adolescents. Additional cognitive and educational infor­mation is gathered from the following sources:

¦     Educational consultants to private and public educational programs

¦     Personal caregivers and attendants

¦     Pediatric neuropsychological assessment

¦     Occupational and physical therapy

¦    Vision and hearing specialists

¦     Evaluators of driving

¦     Programs for the development of social and pragmatic skills

¦     Prevocational and vocational training programs

One area receiving an increased amount of attention at this time is autism. Autism (autistic disor­ders) is within the broader diagnostic category of autism spectrum disorder (ASD). Other diagnoses in the category include Asperger’s syndrome, pervasive developmental disorder (PDD) (sometimes referred to as PDD-NOS), and childhood disintegrative disorder. All of these disorders occur in males approximately four times more often than in females. In earlier years, autism affected 1 in 500 children; however, with the explosive increase in the United States (and apparently in other countries), whether because of better diagnoses or actual increases in cases, it is now estimated that

1   in 150 children ages 10 and younger are classified as having some form of ASD (Bishop, 1989; Gillberg, 1991; Tonge, 2002; Owens, 2004). SLPs are aggressively involved in treating children and adolescents with ASD.

The SLP, as an outcome of the assessment results, frequently provides AT or augmentative and alternative communication (AAC) recommendations. AT is defined as any technology used to enable individuals to perform tasks that are difficult or impossible due to disabilities (Lloyd et al., 1997). AAC itself is defined as the supplement or replacement of natural speech or writing using aided or unaided symbols, and the field is referred to as the clinical/educational practice to improve the communication skills of individuals with little or no functional speech (Lloyd et al., 1997). It is important to be knowledgeable about the laws and policies that support the use of AT or AAC. The list of federal mandates that relate to the use of AT, the development of AT services (evaluation and therapy), and the integration of AT devices and services into medicine, education, independent living, and vocational arenas is lengthy. The partial list of mandates as shown in Table 9.6 continues to change (and improve) and is not considered to be inclusive. It is included to give readers an idea of the growing list of political directives that acknowledge the consumer’s need for AT devices and services.

Industrial advancements and competition have driven the recent development of AT devices, but the development of services and service delivery in the United States has been influenced significantly by federal legislation. Over the last 40 years, the federal government has enacted a series of bills and initiatives requiring federal agencies, states, and private industry to support the employment of people with disabilities. Milestones over the 40 years include the following most recent legislation.

The Rehabilitation Act of 1973 mandates reasonable accommodation in federally funded employment and higher education for AT and services. This act has established several important principles upon which subsequent legislation has been based. These include reasonable accommodations in employment and in secondary education. The act mandates that employers and institutions of higher education receiving federal funds seek to accommodate the needs of employers

Federal Mandates

Section 504 of the Rehabilitation Act of 1973

Rehabilitation Act of 1973, reauthorization and amendments of 1993 and 1998 Individuals with Disabilities Education Act (IDEA), PL 101-476

Technology-Related Assistance for Individuals with Disabilities Act of 1988, PL 100-407

Technology-Related Assistance for Individuals with Disabilities Act Amendments, PL 103-218

Americans with Disabilities Act (ADA) of 1990, PL 101-336

Goals 2000: Educate America Act, PL 103-85

Improving America’s Schools Act, PL 103-382

Telecommunications Act of 1996, PL 104-104

Telecommunications for the Disabled Act of 1982

Telecommunications Accessibility Enhancement Act of 1988

Rehabilitation Act, Section 508

Decoder Circuitry Act
and students who have disabilities. It specifically prohibited discrimination in employment or admission to academic programs solely on the basis of a handicapping condition. Sections 503 (educational institutions) and 504 (employers receiving federal funds) of this act describe both reasonable accommodations and least restrictive environment (LRE), a term relating to the degree of modification in a job or academic program that is acceptable. Many of the efforts to achieve accommodations in the least restrictive environment involved the use of assistive technologies.

The Education for All Handicapped Children Act (EHA) of 1975 extends reasonable accom­modations for students from ages 5 to 21, providing a free, appropriate public education (FAPE). This act initiated procedures to ensure that each public school system identifies and provides all children with disabilities with an education. States were also mandated to establish procedures for enforcement. AT plays a more significant role in gaining access to educational programs. The act created the individual education plan (IEP) to be made for all students with disabilities. This act, also known as PL 94-142, established the right of all children to a free and appropriate education, regardless of handicapping condition. When PL 94-142 passed, children with disabilities who were not in school programs or those who were but who were not receiving services began individual education plans (IEPs) with measurable goals, AT, and services. Lack of local services or lack of funding was not a reason to deny services. The impact of this law has been far reaching. Devices ranging from sensory aids (visual and auditory) to augmentative communication devices to spe­cialized computers have been utilized to provide access to educational programs for children with disabilities. Several additional acts leading up to PL 94-142 gave the foundation for the passage of this act.

The passage of the Elementary and Secondary Education Act (PL 89-10) in 1965 to improve quality of education for individuals and the passage of Elementary and Secondary Education Amendments for Children with Handicaps (PL 89-313) established the foundation for future legislation dealing with children with handicaps. The zero reject principle is the principle developed out of EHA, stating that all children, regardless of the severity of their disability, have a right to special education services. These services are provided by the local education agency (LEA) in the LRE. The Handicapped Infants and Toddlers Act of 1986 extended the preceding act to children ages 5 and under, expanding emphasis on educationally related AT.

Assistive technology (AT) includes both devices and services. The Individuals with Disabilities Education Act (IDEA) (reauthorized in 2004) defines an AT device as any item, piece of equip­ment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Devices can replace a missing limb, help prevent the worsening of a condition, improve physical functioning, increase a person’s capacity to learn, or strengthen a physical or other weakness. AT services support people with disabilities or their caregivers to help them select, acquire, or use AT devices. Such services also include functional evaluations, training on or demonstration of devices, and purchasing or leasing devices. Specifically, AT services include the following:

¦    Evaluating the needs of an individual with a disability, including a functional evaluation of the individual in the individual’s customary environment

¦    Purchasing, leasing, or otherwise providing for the acquisition of AT devices by individuals with disabilities

¦    Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing of AT services

¦    Coordinating and using other therapies, interventions, or services with AT devices, such as those associated with existing education and rehabilitation plans and programs

¦     Training or technical assistance for an individual with disabilities or family of an individual with disabilities

¦     Training or technical assistance for professionals (including individuals providing educa­tion and rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of individuals with disabilities

AT can help people learn, compete in the work environment, achieve independence, or improve quality of life. Although the use of AT is not an end in itself, it is part of an ongoing therapeutic process to improve functional capabilities.

Aids for Daily Living: Self-help aids for use in activities such as eating, bathing, cooking, dress­ing, toileting, home maintenance, and so on. Examples include modified eating utensils, adapted books, pencil holders, page turners, dressing aids, and adapted personal hygiene aids.

Aids for Hearing Impaired: Aids for specific populations including assistive listening devices (infrared, FM loop systems), hearing aids, TTYs, visual and tactile alerting systems, and so on.

Aids for Vision Impaired: Aids for specific populations including magnifiers, Braille or speech output devices, large-print screens, closed-circuit television for magnifying documents, and so on. Augmentative and Alternative Communication (AAC): Electronic and nonelectronic devices that help persons with speech and/or hearing disabilities communicate: communication boards, speech synthesizers, modified typewriters, head pointers, and text-to-voice software.

Computer Access Aids: Headsticks, light pointers, modified or alternate keyboards, switches acti­vated by pressure, sound or voice, touch screens, special software, and voice-to-text software that enable persons with disabilities to use a computer. This category includes speech recogni­tion software.

Environmental Controls: Electronic systems that help people control various appliances, switches for telephone, TV, or other appliances activated by pressure, eyebrows, or breath. Home/Workplace Modifications: Structural adaptations that remove or reduce physical barriers: ramps, lifts, bathroom changes, automatic door openers, and expanded doorways.

Mobility Aids: Devices that help people move within their environments: electric or manual wheelchairs, modifications of vehicles for travel, scooters, crutches, canes, and walkers.

Prosthetics and Orthotics: Replacement or augmentation of body parts with artificial limbs or other orthotic aids such as splints or braces. There are also prosthetics to assist with cognitive limitations or deficits, including audiotapes or pagers (that function as prompts or reminders).

Recreation: Devices to enable participation in sports, social, cultural events. Examples include audio description for movies, adaptive controls for video games, adaptive fishing rods, cuffs for grasping paddles or racquets, and seating systems for boats.

Seating and Positioning: Adapted seating, cushions, standing tables, positioning belts, braces, cushions and wedges to maintain posture, and devices that provide body support to help people perform a range of daily tasks.

Service Animals: The Americans with Disabilities Act defines a service animal as any guide dog (for visually impaired and blind individuals), signal dog (for hearing impaired or deaf individuals), or other animal individually trained to provide assistance to an individual with a disability.

Vehicle Modifications: Adaptive driving aids, hand controls, wheelchair and other lifts, modified vans, or other motor vehicles used for personal transportation.

The 1986 amendment to the Rehabilitation Act of 1973 required all states to include provision for AT services in the rehabilitation plans of the state vocational rehab agencies. Section 508 man­dates equal access to electronic office equipment for all federal employees. Technology-Related Assistance for Individuals with Disabilities Act (Tech Act) of 1988 mandates consumer-driven AT services and system changes in the states. This act created the development of the Tech Act programs throughout the country. The act was reauthorized in 1994. This legislation authorized funds for states to establish and implement a consumer-responsive, statewide program of technolo­gy-related assistance for individuals with disabilities, including identification of barriers to admin­istering this assistance.

The Americans with Disabilities Act (ADA) (PL 101-336) of 1990 (reauthorized in 2002) pro­hibits discrimination based on disability in employment, transportation, and telecommunications. The ADA furthers the goal of full participation of people with disabilities by giving civil rights protection to individuals with disabilities that are like those provided to individuals on the basis of race, sex, national origin, and religion. It guarantees equal opportunity for individuals with disabilities in employment, public accommodations, transportation, state and local government services, and telecommunications. President George H. W. Bush signed the ADA into law on July 26, 1990. Copies of the full Americans with Disabilities Act of 1990 may be obtained at no cost from the U.S. Subcommittee on Disability Policy, 113 Hart, Senate Office Building, Washington, DC 20510. The ADA Private Transportation hotline is (202) 224-6265.

The IDEA of 1991 (Public Law 105-17 and the reauthorization of PL 94-142), which became the Individuals with Disabilities Improvement Act (IDIA) of 2003, mandates that all local educational agencies provide AT devices and services to benefit students with disabilities. The IDEA mandate includes that local educational agencies be responsible for providing AT devices and services if these are required as part of the child’s educational or related services or as a supple­mentary aid or service. AT devices are identified in the IDEA as “any item, piece of equipment

Tech Act Priorities

To promote public awareness of AT at the national level

To provide training and education about AT on a national basis for stakeholders, including other national social service and business organizations, members of the insurance and health care industry, and public office holders/policy makers

To develop positions on a full range of national AT- and disability-related issues and to share these positions with other organizations or policy makers, as needed, to ensure that the views of the states and territories and their consumers with regard to AT service delivery are adequately represented

To provide a forum for exchanging information and promoting the system change accomplishments and activities of the Tech Act projects

To identify the need and opportunities for the development of nationally conducted activities to increase access to AT

To develop and promote a national agenda or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of children with disabilities” (Section 300.5). The IDIA was also aligned with the No Child Left Behind (NCLB) Act of 2001. Refer to www.asha .org for additional information on IDEA, IDIA, and NCLB.

The definition of an AT device, as provided in the IDEA, is very broad and gives IEP teams the flexibility that they need to make decisions about appropriate AT devices for individual students. AT includes a range of low and high technology, hardware and software, and technology solutions that are generally considered instructional technology tools if they have been identified as educationally necessary and documented in the student’s IEP. The need for AT is determined by the student’s IEP committee as educationally necessary. AT service is any service that directly assists a child with a disability in the selection, acquisition, and use of an AT device. The term includes (1) the evaluation of the needs of a child with a disability, including a functional evaluation of the child in the child’s customary environment; (2) purchasing, leasing, or otherwise providing for the acquisition of AT devices by children with disabilities; (3) selecting, designing, fitting, customiz­ing, adapting, applying, retaining, repairing, or replacing AT devices; (4) coordinating and using other therapies, interventions, or services with AT devices, such as those associated with existing education and rehabilitation plans and programs; (5) training and technical assistance for a child with a disability or, if appropriate, that child’s family; and (6) training or technical assistance for professionals (including individuals or rehabilitation services), employers, or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of children with disabilities (Section 300.6). The rules and regulations for special education in each state may also address the provision of assistive devices and services in various sections of the state’s educational policy and regulations, including the definition of assistive devices, the definition of service, within what parts of the IEP AT may be included (related services, supplemental aids and services, etc.), whether AT is needed to provide the student a FAPE, whether an AT assessment is needed, if AT is needed for the student to participate in local or state testing, and whether the technology is needed in a nonschool setting.

The reauthorization of the Rehabilitation Act of 1973 (1992) (1997) mandates rehabilitation technology to be a primary benefit to be included in the rehabilitation plan for the state rehabilitation agencies. The rehab plan was required to include how AT will be used in the rehabilitation process of each individual client. In 1992, Congress passed the reauthorization of the Rehabilitation Act of 1973. This legislation (PL 102-569 in 1992 and PL 105-17 in 1997) makes the rehabilitation act consistent with the principles of self-determination of the ADA, and it is more consumer responsive than the original version. Rehabilitation technology is defined in this law to include rehabilitation engineering and AT devices and services. Under this legislation each state must specify how AT devices and services or work site assessments are to be provided. The individualized written rehabilitation plan (IWRP, but now referred to as the Individual Work Plan, or IWP) must include the provisions of rehabilitation technology services to assist in the implementation of intermediate and long-term objectives, and rehabilitation technology is exempt from what are termed comparable benefits funding considerations. The latter concept means that vocational rehabilitation monies are considered to be the first source of funding for purchase of AT regardless of whether the individual has other funding sources. Also included within the mandate of this legislation was the continuation of rehabilitation engineering research centers, which focus on one or more core areas of research and development.

The Ticket to Work and Work Incentive Improvement Act of 1999 provides consumer choices for the provision of vocational rehabilitation and job training and other support services. The Ticket to Work and Work Incentive Improvement Act of 1999 has a number of incentives that can
be offered to benefit recipients to help them reintegrate into the workplace. Agencies that provide employment training and job placement to people with disabilities will receive a fixed portion of that person’s prospective Social Security case benefit when the individual goes back to work and in the first few years during the individual’s employment.

The New Freedom Initiative (February 2001) increases funding for research and development of AT resources nationwide. Although not legislation, this initiative also promotes full access to the community for people with disabilities through expanded transportation options, educational opportunities, and greater integration into the workforce.

SLPs (and audiologists) must address the unique privacy concerns, both ethical and regula­tory, that confront individuals who rely on AT and the SLPs and other practitioners who provide them with services (Blackstone et al., 2002). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created by Congress to provide guidelines for the protection of health care information and to establish standard formats for the electronic transmission of clinical data such as claims, referrals, explanation of benefits (EOB), remittance advices (RAs), and others. Although there are nine separate elements to the HIPAA legislation, the Department of Health and Human Services (DHHS) has thus far promulgated three in the form of final regulatory rules, the privacy rule and the transaction and code set rules, and the security of health care data as they are generated and stored by providers and others who have access to this protected information.

The privacy rule of HIPAA is intended as a federal floor to protect the privacy of individually identifiable health information contained in a patient’s medical record. The protected information includes a patient’s name, address, Social Security number, financial data, or any other identifying information in addition to the medical record itself. The rule creates substantial new compliance issues for covered entities, which include virtually all health care providers, health plans, health information clearinghouses, and those business associates who engage directly or through contractual arrangements with any of those. It also covers paper files containing this pro­tected information that is not yet in electronic form. In short, it covers all information, including both hard and soft files. The compliance date for the privacy rule was April 14, 2003. Substantial civil and criminal penalties, up to and including jail time, can be assessed for noncompliance.

The final HIPAA privacy rule covers all individually identifiable health care information in any form, electronic or nonelectronic, that is held or transmitted by a covered entity such as a health care provider, a third-party payer, or any of their business associates who come into contact with these data. Under HIPAA, there are legal penalties for covered entities that receive or use unauthorized information intentionally. SLPs, by transmitting personal health information (PHI) in electronic form, are regulated by HIPAA. The following points about HIPAA and AT should be followed to remain compliant.

SLPs should consider assistive devices that facilitate the security of PHI by providing essential design features, vocabulary, and training that emphasize the rights to privacy and informed con­sent of individuals who rely on assistive devices, strategies, and techniques. The SLP is responsible for making sure the PHI is not openly accessible. New devices offer both text and audio-data logging. These logs potentially put the user at risk if they are available to others. All AAC users should receive a copy of the provider’s Notice of Privacy Practices. The Notice of Privacy Practices explains how the provider will use the individual’s PHI and outlines the provider’s confidentiality program. SLPs should educate themselves on HIPAA regulations, should conduct a gap analysis of their practice policies and procedures, and should undertake a compliance implementation program. The privacy and safety of individuals using communication boards and AAC devices should be considered when including personal information (name, address, phone number, reli­gion, political affiliation, etc.). Remember that not all AT users understand the privacy issues, either. Eavesdropping, communication partners speaking loudly to interpret the message, and people reading what is on the screen are all potential violations of privacy. AT users need training to learn to protect their privacy and need help selecting vocabulary such as “Please do not read my display.” AT users also need training to coordinate their speech output to conform to public expectations of conversations, help to lower the volume of their device, password protection and encryption of the message buffer and data logging system in the AT device to protect the user’s content, and privacy/confidentiality training for their communication partners.