See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/24425342

Use of the Guide to Physical Therapist Practice by Pediatric Physical

Therapists

Article  in  Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association · February 2009
DOI: 10.1097/PEP.0b013e3181a349b1 · Source: PubMed

CITATIONS READS

102 956

2 authors:

Connie C Johnson Toby Long

Fairfax County Public Schools, USA Georgetown University
6 PUBLICATIONS   291 CITATIONS    28 PUBLICATIONS   402 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Defining work capacity evaluation terms for youth with developmental disabilities View project

All content following this page was uploaded by Connie C Johnson on 13 June 2018.

The user has requested enhancement of the downloaded file.

 R E S E A R C H R E P O R T

Use of the Guide to Physical

Therapist Practice by Pediatric
Physical Therapists
Connie C. Johnson, PT, DScPT, and Toby Long, PT, PhD
Downloaded from http://journals.lww.com/pedpt by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FlQBFFqx6X+n+DiK4smZ3ybY/ByKhSuZeQdDvPqv/6m+ua0ZOjUg4Q== on 06/13/2018

Fairfax County Public Schools (C.C.J.), Falls Church, Virginia; and Division of Physical Therapy, Center for Child and
Human Development, Georgetown University (T.L.), Washington, DC

Purpose: Physical therapists are encouraged to use the Guide to Physical Therapist Practice (Guide) in their
practice. The purpose of this study was to determine whether and how pediatric physical therapists (PTs) use
the Guide. Subjects and Methods: A nationwide electronic survey was sent to pediatric physical therapists.
Four hundred seventy-five members returned the survey yielding a 9.6% response rate. Results: Respondents
reported that they practice consistently with the Guide’s patient/client management model but that they do
not find the Guide useful. Respondents made recommendations for a future edition of the Guide. Conclusions:
Pediatric PTs value the Guide as a reference, resource, and teaching tool. When the Guide is revised, the following
should be considered: pediatric content, format, and utility of the Guide; educational needs of pediatric PTs about
the Guide; and how stakeholders and PTs with other specialties view and use the Guide. (Pediatr Phys Ther 2009;21:
176 –186) Key words: pediatric physical therapy, practice guidelines as topic, survey research

INTRODUCTION tice.2,3 However, it is unclear whether pediatric physical ther-

The purpose of the Guide to Physical Therapist Practice
(Guide), 2nd edition1 is to define and describe physical ther-
apy practice. The American Physical Therapy Association
(APTA) encourages use of the Guide by all physical therapists
and student physical therapists; however, it is unclear
whether practitioners use the Guide on a regular basis. The
Section on Pediatrics also encourages pediatric physical ther-
apists to use the Guide. The Section has fact sheets available
describing the Guide and its application to pediatric prac-
0898-5669/109/2102-0176
Pediatric Physical Therapy
Copyright © 2009 Section on Pediatrics of the American Physical
Therapy Association.
Address correspondence to: Connie C. Johnson, PT, DScPT, 14516 South
Hills Court, Centreville, VA 20120. E-mail: Conniecjohnson@gmail.com
Supported by a grant to the first author from the Section on Pediatrics,
American Physical Therapy Association.
This study was completed by C.C. Johnson in partial fulfillment of DScPT
program requirements at University of Maryland, School of Medicine,
Physical Therapy and Rehabilitation Sciences Program.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text, and links to the digital files are provided in the
HTML text of this article on the journal’s Web site (www.pedpt.com).
DOI: 10.1097/PEP.0b013e3181a349b1
apists use the Guide in their practice.
The Guide is based on the following three constructs:
(1) an adapted version of the Disablement Model by Nagi,
(2) the continuum of care perspective, and (3) five ele-
ments of patient/client management. See Table 1 for a de-
scription of these constructs. The Guide is organized into
three major components: Part 1: a description of patient/
client management; Part 2: preferred practice patterns; and
Part 3: an interactive guide to physical therapist practice,
with a catalog of tests and measures, Version 1.1. Parts 1
and 2 were mailed to APTA members as the January, 2001
issue of Physical Therapy. Part 3 is available for purchase by
APTA members and includes all of the print material and
the catalog of tests and measures on CD-ROM. See Table 2
for a description of these parts.
The profession advocates use of the elements of the pa-
tient/client management model,2–9 but it is unclear whether
pediatric physical therapists have incorporated the Guide into
their practice. The purpose of this survey was to determine in
what way pediatric physical therapists use the Guide.1 Our
specific research questions were (1) How do pediatric physi-
cal therapists use the Guide? (2) Do pediatric physical thera-
pists perceive that they practice consistently with the Guide? (3)
Do pediatric physical therapists find the Guide useful? (4) Which
factors influence pediatric physical therapists’ use of the Guide?
and (5) Do pediatric physical therapists want the Guide changed?

176 Johnson and Long Pediatric Physical Therapy

 TABLE 1
Constructs of the Guide
Construct Description
Disablement model 1. Describes the impact a health condition
has on an individual’s activities and
participation in societally defined roles.
2. Uses the terms pathology, impairment,
functional limitation, and disability.
Continuum of care 1. Physical therapy needs addressed in a
variety of settings.
2. Promotes health, wellness, and fitness.
Patient-client A 5-component model that includes:
management model 1. Examination: screening, history, and
systems review, administration of
objective tests and measures.
2. Evaluation: synthesis of the information
gathered from the examination.
3. Diagnosis: selection of labels or
diagnostic categories that assist with
determining prognosis (including plan
of care) and selecting interventions.
4. Prognosis: determination of the level of
improvement, amount of intervention
required to achieve that level, the plan
of care, anticipated goals and outcomes,
and discharge plan.
5. Intervention: coordination,
communication, and documentation;
patient/client related instruction;
procedural interventions.
METHODS
Survey Instrument
The study methodology was approved by the Institu-
tional Review Board of the University of Maryland at Balti-
more. A 40-item questionnaire was developed using the Tai-
lored Design Method.10 The survey consisted of 4 parts. Part 1
requested demographic information about the respondent
and was based on APTA demographic profile questions
(Sarah Miller, e-mail communication, March 5, 2007).
Parts 2, 3, and 4 asked questions about the patient/client
management model, the disablement model, and overall
usefulness of the Guide, respectively. Content validity
was established by developing questions based on the 3
constructs of the Guide: the disablement model, contin-
uum of care, and the 5 elements of patient/client man-
agement. Questions included forced-choice (multiple
choice, yes/no), Likert scale items, and open-ended
responses. The survey included definitions of Guide
terminology.
To enhance face validity, the instrument was reviewed
by expert physical therapists, including members of the
Section on Pediatrics Practice Committee, and individuals
from the APTA Departments of Research and Practice. Re-
viewer recommendations were incorporated into the final
version of the survey. The instrument was pilot tested on
15 pediatric physical therapists for clarity, ease of use, and
time of administration. The survey may be viewed online at
http://links.lww.com/A996.
Pediatric Physical Therapy
TABLE 2
Organization of The Guide to Physical Therapist Practice
Part 1: A description of 1. Description of who physical therapists
patient/client are and their role:
Education, qualifications, practice
management
settings, scope of practice,
Roles in primary, secondary and tertiary
care, prevention, and promotion of
health, wellness, and fitness,
Elements of patient client management:
examination, evaluation, diagnosis,
prognosis, intervention,
Re examination, outcomes, episode of
care, criteria for termination of
services, other roles of the physical
therapist.
2. Description of tests and measures
organized by category measured.
3. Description of types of interventions that
physical therapists provide.
Part 2: Preferred 1. Categorized by musculoskeletal,
practice patterns neuromuscular, cardiovascular/
pulmonary, and integumentary systems
2. Each category contains practice patterns
that include medical diagnoses, possible
impairments, functional limitations, or
disabilities
3. Information regarding the examination,
evaluation, diagnosis, interventions,
outcomes, and criteria for termination of
services
Part 3: (Available on Tests and measures linked to practice
CD-ROM) patterns
CD-ROM also includes Parts One and Two
and Appendixes
Appendices additional Glossary of terms
information Standards of practice for physical therapy
Code of ethics, Guide for professional
conduct, standards of ethical conduct for
the physical therapy assistant, Guide for
conduct of the affiliate member
Guidelines for physical therapy
documentation
Documentation templates for physical
therapist patient/client management
Patient/client satisfaction questionnaire
Sample
Surveys were emailed to members of the Section on Pe-
diatrics (n ⫽ 4053) and non Section APTA members who
indicated pediatrics as an area of practice (n ⫽ 914); the total
number of surveys emailed was 4967. Response rate was 9.6%
(n ⫽ 475). Surveys were completed anonymously.
Data Collection and Analysis
The survey was conducted from November 30, 2007, to
January 2, 2008. Respondents received an email invitation
with an electronic link to the survey. A reminder notice was
sent out on December 14, 2007. A reminder and an electronic
link were also included in the Section on Pediatrics electronic
newsletter sent out in December, 2007. The response rate for
this study was 9.6%, meeting the criteria for the 95% confi-
dence level at ⫾5% sampling error.10
Use of the Guide to PT Practice by Pediatric PTs 177
 Statistical analyses were performed using SPSS 16.0 for
Windows.11 Descriptive statistics documented the character-
istics of the survey respondents including frequencies for cat-
egorical variables (ie, type of graduate training). Additional
analyses addressed our five research questions. A chi square
goodness-of-fit test was used to compare selected demograph-
ics (sex, race, highest degree earned, entry level degree, and
practice setting) of the sample with the APTA, Section on
Pediatrics. Selected questions (those pertaining to use and
usefulness of the Guide) and demographics (age, years of
practice, years of practice in pediatrics, entry level degree,
highest degree attained) were analyzed using SPSS 10 for
Windows.12 The Kruskal-Wallis test, appropriate for non-
parametric ordinal data, was used to examine whether there
was an association between selected questions implying use of
the Guide and demographic variables. A Spearman rank corre-
lation coefficient was used for post hoc analysis to determine the
strength and nature of the relationship between questions imply-
ing use of the Guide and demographic variables.
Qualitative data were analyzed by the hermeneutical
perspective, focusing on interpretation of information from
textual sources and placing the information within a histori-
cal and cultural context.13 Qualitative data were analyzed by 2
pediatric physical therapists using thematic analysis, from an
etic perspective. In an etic perspective, the researcher main-
tains objectivity when dealing with the data. Each coder sep-
arately analyzed the data for themes. Coders compared
themes. Where inconsistencies existed, the coders recoded
data until consistent themes were obtained. The process was
repeated until the coders were in 100% agreement. Data anal-
ysis included theory and investigator triangulation.13
RESULTS
Respondent Characteristics
Table 3 describes the 475 therapists who responded to
the survey. The mean age of the respondents was 43 years
(range, 23–78 years), and mean experience level was 18.5
years (range, 0 – 47 years). Most entered the profession
with a baccalaureate degree (52.2%) and the highest level
of education that they earned was a master’s degree

TABLE 3
Characteristics of the Sample Compared to Members of APTA, Section on Pediatrics (%)

Chi Squared Test of Goodness-of-Fit

Sample Section on Pediatrics
(n ⫽ 475) (n ⫽ 4177)* ␹2 Critical (0.01) ␹2 Computed
Sex 6.34 0.24
Female 92.6 92.0
Male 7.4 8.0
Age (mean), range 23–78 yrs 43.0 46.5 6.34 0.26
Race
White 92.3 90.5 11.34 8.5
Asian 1.5 3.6
Hispanic/Latino 2.3 2.6
Other 3.9 2.9
Highest degree earned
Baccalaureate 19.6 38.7 15.08 935.8†
Master’s 45.5 46.2
DPT/tDPT 22.6 6.6
PhD 9.1 6.4
PhD and DPT/tDPT 0.8 0.1
Other 2.3 2.1
Entry Level PT degree 11.34 7.15
Baccalaureate 52.2 53.6
Master’s 32.2 30.1
DPT 9.4 8.9
Other (including postbaccalaureate certificate) 6.2 7.5
Employment status 15.08 0.05843
Full-time salaried 56.6 56.9
Part-time salaried 11.9 15.5
Full-time self employed 8.7 12.3
Part-time self employed 3.8 9.6
Retired 1.1 2.2
Unemployed 1.2 3.3
Practice setting 24.725 68.2†
Hospital setting: acute care or sub-acute rehab 9.3 11.5
Health system or hospital based outpatient facility 17.4 12.9
Private out-patient office or group practice 8.3 15.3
Patient’s home/home care 10.7 12.4
School system 31.7 31.8
Academic institution (postsecondary) 12.0 7.0
Other 10.0 9.2
*Data from member database (S. Miller, written communication, January 14, 2008).
†Significant results, ␹2 (5, N ⫽ 935.8) ⫽ 16.8, p ⬍ 0.05, ␹2 (6, N ⫽ 68.2) ⫽ 24.725.

178 Johnson and Long Pediatric Physical Therapy

(45.5%). The sample had more respondents with the high-
est degree earned as a DPT/tDPT (22.6%) and fewer with a
baccalaureate degree (19.6%) than the Section as a whole.
Most respondents are employed full time, with a similar
distribution to the Section. Respondents provide services
in school systems (31.7%), private out-patient offices
(8.3%), health system/hospital-based outpatient facilities
(17.4%), and patient’s home/home care (10.7%). The sam-
ple contained more therapists employed by academic set-
tings (12% versus 7%), more working in health system/
hospital-based outpatient facilities (17.4% versus 12.9%),
and fewer in private office settings (8.3% versus 15.3%)
compared with the Section on Pediatrics.
A chi square test of goodness-of-fit was performed on
demographic variables to determine if the sample and the
Section on Pediatrics were similar. All variables were
equally distributed in the population except highest degree
earned and practice setting, ␹2 (5, n ⫽ 935.8) ⫽ 16.8, p ⬍
0.05, ␹2 (6, n ⫽ 68.2) ⫽ 24.725 (Table 3).
How Do Pediatric Physical Therapists Use the Guide?
To determine whether pediatric physical therapists
use the Guide, the respondents were asked how and in what
ways they use the Guide. Most respondents (81.8%) re-
ported that they never or rarely consult the Guide on a
regular basis, and a majority of the respondents (68.5%) do
not or rarely consult the Guide when confronted with a new
or unusual situation. Most (89.3%) never or rarely consult
the Guide to select interventions. Most respondents indi-
cated that they do not use Part 3 of the Guide (90.7%) to
identify tests or measures for use with a client. Of those
who did not use the Guide, most had not seen the CD ROM
(74.4%); many respondents (43.5%) indicated that cost
was a reason. Respondents (66.9%) indicated that they
would be “somewhat likely,” “likely,” or “extremely likely”
to use Part 3 if it was available in a different format.
Respondents reported using the Guide as a resource
(48.4%) or as a reference to answer a specific question
(27.8%); fewer use the Guide to aid decision making (13.7%)
or to justify treatment (11.4%). When asked to indicate
“other” uses, themes included use as a teaching tool (26%)
and as a reference for postprofessional learning (13%); sixty-
one percent reported that they do not use the Guide at all.
Barriers to use of the Guide included the size of the
book (30.3%), lack of relevance to their practice (23.2%),
and missing information relevant to practice (21.5%, Table
4). When asked about other barriers to use of the Guide,
respondents expressed a lack of knowledge in use of the
Guide. They expressed the need for documents on how to
use the Guide, including documents that were practice set-
ting specific and diagnosis specific. Several respondents
suggested that a lack of knowledge of the use of the Guide
could be fulfilled by web/class-based seminars.
Do Pediatric Physical Therapists Practice Consistently
With the Guide?
Although most therapists (81.8%) reported that they did
not consult the Guide on a regular basis, many reported prac-
Pediatric Physical Therapy
TABLE 4
Barriers to Use of the Guide
Response %
The Guide is too big thus not convenient to use. 30.3
I do not find the patient/client management 23.2
model relevant to my practice.
The Guide is missing information that is 21.5
important to my practice.
Other 20
The Guide needs to have parts expanded upon. 19.8
I don’t have a copy of the Guide. 14.1
I don’t understand how to use the Guide. 13.9
I do not agree with use of the Nagi framework. 12
I do not agree with the terminology of the Guide. 10.1
TABLE 5
Relevance of the Disablement Framework to the Patient/Client
Management Model
Not Relevant*(%) Relevant†
Examining 21.3 78.8
Evaluating 20.1 80
Determining physical therapy diagnosis 25.3 74.4
Determining prognosis 30.2 69.7
Selecting and providing interventions 27.6 72.4
*Combined results from 1 (not relevant) and 2 (somewhat relevant).
†Combined results from 3 (relevant), 4 (very relevant), 5 (ex-
tremely relevant).
ticing physical therapy consistent with the 3 constructs of the
Guide: the disablement framework, the continuum of care,
and the 5-element patient/client management model (exami-
nation, evaluation, diagnosis, prognosis, and intervention).
Disablement Model
When asked if they use a specific model to guide their
practice, 38.5% reported using the disablement model and
31.6% use the International Classification of Functioning,
Disability, and Health (ICF) model. One-third of the respon-
dents indicated that they did not use a framework (32.8%). Most
of the respondents found the disablement framework relevant to
the elements of the patient/client management model (Table 5).
Continuum of Care
According to the Guide, the continuum of service ad-
dresses the need of clients across a variety of settings. Services
include consultation, intervention, and promoting health,
wellness, and fitness. The survey did not include specific
questions relating to a therapist’s theoretical foundation regard-
ing the continuum of service. Respondents indicated that they
provide services in a variety of settings with most of the respon-
dents providing services in school systems (31.7%, Table 3).
The Patient/Client Management Model
The survey included questions related to the 5 elements
of the patient/client management model: examination,
evaluation, diagnosis, prognosis, and intervention (Table
1). According to the Guide, examination contains 3 com-
ponents: history, systems review, and tests and measures.
Use of the Guide to PT Practice by Pediatric PTs 179
 TABLE 6
Use and Documentation of Systems Review (% of Respondents)

Routinely
Reviewed? I Review this System by I Document Results
Yes No History Observation Direct Measurement Always Only if Significant Do not Document
Cardiovascular/pulmonary 54.7 45.1 70.5 61.9 29.5 17.3 79.3 3.4
Integumentary 73.9 25.9 56 81.9 18.9 21.2 77.7 1.1
Musculoskeletal 98.1 1.9 73.1 82.5 95.6 95.3 4.5 0.2
Neuromuscular 98.7 1.3 73.3 83.8 89.5 94.9 4.9 0.2
Communication, affect, 89.5 10.5 71.8 92.2 23.6 61.8 36.2 2
cognition, learning style

TABLE 7 the expected level of improvement of function, and selec-

Use of Diagnostic Labels or Classifications (may Indicate More Than
One)
Response
Diagnosis of functional limitations
Diagnosis of impairments
Medical diagnosis
ICD-9 code
Other classification terminology that relates to diagnosis
Physical therapy practice pattern
Other
Evaluation is the synthesis of findings from the examina-
tion and the establishment of a diagnosis, prognosis, and
plan of care. Most respondents perform a history (98.5%),
systems review (92.1%), and selected tests and measures
(97.8%). Of the systems listed in the Guide that should be
examined, over half of the respondents indicated that they
review all systems routinely and document those results.
Respondents rarely chose “do not document” as an answer
for any system (Table 6).
The Guide uses the term diagnostic label and describes
a process of making a diagnosis. The Guide describes the
use of the preferred practice patterns during the diagnostic
process. Most respondents reported that they “always” or
almost always determine a physical therapy diagnosis
(66.4%); and they feel that it is always or almost always
necessary to determine a physical therapy diagnosis
(67.3%). When asked about specific categories of diagno-
sis, most respondents used diagnosis of functional limita-
tions (81.5%), diagnosis of impairments (70.1%), and/or
medical diagnosis (68.2%) (Table 7).
When asked about the use of practice patterns, 20.6%
of respondents indicated that they categorize a child in a
practice pattern. Of those who choose practice patterns
(n ⫽ 98), most “never” or almost never included the prac-
tice pattern in initial examination reports (61.5%) or dis-
charge summaries (68.1%), and never chose more than 1
practice pattern (54.7%). In the context of the patient/cli-
ent management model, most respondents found the prac-
tice pattern “not useful,” lacked use, or were neutral when
examining (82.1%), evaluating (81.4%), determining diag-
nosis (80%), determining prognosis (85.4%), or selecting
interventions (91.9%).
Prognosis includes the development of the plan of
care including frequency and duration of care, determining
tion of interventions. Most respondents (81.7%) reported
that they always or almost always determine the optimal
% level of improvement, 79.8% always or almost always dis-
81.5
cuss prognosis with caregivers, 62.2% document the prog-
70.1 nosis, and 95.1% verbally discuss the plan of care with
68.2 caregivers. Almost all respondents always or almost always
54.7 documented the plan of care (94.6%), including docu-
23.2 menting goals in the plan of care (98.3%), interventions
12.6
7.2
(82.6%), and frequency and duration of treatment
(91.6%). Respondents report including the anticipated
number of visits less often (39.5%).
Respondents indicate that they practice consistently
with the components of intervention [(1) coordination,
communication, and documentation; (2) patient/client-
related instruction; and (3) procedural interventions].
Seventy-two percent provide coordination of care, ex-
change information with other professionals (85.8%), doc-
ument care (89.6%), provide patient/client-related instruc-
tion verbally (89.9%) and in writing (72.3%, Table 8). Few
pediatric therapists refer to the Guide when selecting spe-
cific procedural interventions (10.7%), and less than half
(38.7%) of the respondents report that the Guide reflects
interventions chosen for their practice and 65.5% indicate
that the Guide does not list interventions that they use in
their practice.
When asked to indicate what interventions were miss-
ing from the Guide, respondents listed interventions such
as strength training, airway clearance, therapeutic play,
and partial body weight support treadmill training that
could be categorized in existing Guide categories. When
asked about use of specific procedural interventions, those
most frequently checked included gait and locomotion train-
ing and balance, coordination, and agility training (Table 9).
Fewer than 15% of respondents indicated use of interventions
listed under integumentary repair/protection.
Although outcomes are not considered as an element
of the patient/client management model, they are consid-
ered as the results of patient/client management. When
asked about their use of outcomes many respondents
(49.3%) report that they determine outcomes consistent
with the Guide, but 55.7% report that they do not have a
formal process in their work setting to determine out-
comes. Figure 1 depicts the various ways in which respon-
dents indicated how they determine that outcomes have

180 Johnson and Long Pediatric Physical Therapy

 TABLE 8 TABLE 9
Components of Intervention Procedural Interventions Used by More than 50% of Respondents

Never* Sometimes Always† %

(%) (%) (%)
Therapeutic exercise
Consulted the Guide to 89.3 6.3 4.5 Gait and locomotion training 96.8
select interventions Balance, coordination, and agility training 96.4
Provided coordination of 12.9 15.1 72 Neuromotor development training 92.6
care Flexibility exercises 90.9
Exchanged information with 8.7 5.6 85.8 Strength, power, and endurance training for head, neck, 86.7
another professional limb, pelvic-floor, trunk, and ventilatory muscles
regarding a patient/client Body mechanics and postural stabilization 81.7
Documented care of the 7.8 2.6 89.6 Aerobic capacity/endurance conditioning or 75.2
client. May include reconditioning
progress notes, flow Functional training in self-care and home management
sheets, checklists, Device and equipment use and training 93.1
summations of care Leisure and play activities and training 85.5
Provided patient/client- 7.1 3 89.9 ADL training 76
related instruction to Barrier accommodations or modifications 69.3
patients/clients, families, Manual therapy techniques
and caregivers verbally Passive range of motion 85.5
Provided patient/client- 12.2 15.6 72.3 Mobilization (soft tissue or joint) 64
related instruction to Massage 52.2
patients/clients, families, Prescription, application, and, as appropriate
and caregivers in written fabrication of devices
form Assistive devices 88.8
Orthotic devices 85.7
*Combined results from 1 (never) and 2 (occasionally).
Adaptive devices 80
†Combined results from 4 (frequently), 5 (always).
Supportive devices 62.7
Airway clearance techniques
Positioning ( to alter work of breathing, maximize 57.5
been met. When asked to list other responses, “parent sat- ventilation/perfusion, postural drainage)
isfaction” was cited most often followed by site-specific
documents such as IEP’s, state-mandated outcome collec-
tion systems, and curriculum-based assessments. useful they find the Guide in any element of patient/client
management, no correlations were present with demo-
Do Pediatric Physical Therapists Find the Guide graphic variables.
Useful? Table 12 depicts significant correlations for demo-
Although the respondents reported that they practice graphic variables and questions implying use of the Guide;
consistent with the Guide, when asked about overall use- weak correlations were present.14 Respondents who were
fulness of the Guide, only 11.2% of the respondents re- older, had more experience, or with a higher academic
ported that they found the Guide useful for their practice. degree were more likely to consult the Guide on a regular
Table 10 demonstrates that less than half of the respon- basis. Respondents with a higher entry level degree were
dents find the Guide useful for each of the 5 elements of the less likely to consult the Guide when confronted with a new
patient/client management model. or unusual situation; respondents who were older or who
When asked to list what they thought was the most had more experience were more likely to consult the Guide
beneficial aspect of the Guide, 181 responses were ob- in a new or unusual situation. Respondents who were en-
tained. Of those, respondents reported the most beneficial rolled in an educational program, older, or with more ex-
aspect of the Guide was its organization and standardiza- perience were more likely to categorize the child in a prac-
tion of practice (49%), use as a teaching tool and reference tice pattern.
(21%), and explaining the components of physical therapy
to those outside of the profession, for example, administra- Do Pediatric Physical Therapists Want the Guide
tors and third-party payers (8%). Changed?
Two separate questions addressed the need for change
Which Factors Influence Pediatric Physical in the Guide. Most respondents (51.3%, Table 13) reported
Therapists Use of the Guide? that they want the content of the practice patterns changed
A relationship was found between some demographic and many (47.3%, Table 13) believed (“strongly believed”
variables and 3 questions that imply use of the Guide. Table or “somewhat strongly believed”) that the disablement
11 indicates that the number of years a therapist was in framework needed to be changed. Some respondents indi-
practice was significant for the 3 questions that imply use cated that they believed the elements of the Guide needed
of the Guide. All demographic variables except highest de- to be changed: examination (27.4%), evaluation (28%), diag-
gree earned were significant for categorization of the child nosis (35.1%), prognosis (40.8%), intervention (39.4%), out-
in a practice pattern. When respondents were asked how comes (42.4%), and content of the practice patterns (51.3%,

Pediatric Physical Therapy Use of the Guide to PT Practice by Pediatric PTs 181
 Fig. 1. Methods respondents used to determine if outcomes have been met.
TABLE 10
Usefulness of the Guide in Patient/Client Management
Not Useful* (%) Useful† (%)
Examining 58.8
Evaluating 57.6
Determining physical therapy diagnosis 53.7
Determining prognosis 58.1
Selecting and providing interventions 59.9
*Combined results from 1 (not useful) and 2 (somewhat useful).
†Combined results from 3, (useful), 4 (very useful), and 5 (ex-
tremely useful).
Table 13). Most respondents reported that change was nec-
essary for examination (83.2%), diagnosis (68.2%), prog-
nosis (69.1%), and outcomes (66.3%, Table 14). While
most respondents indicate a need for change, they indi-
cate that the elements of the patient/client management
model as defined by the Guide are consistent with their
practice: examination (86.5%), diagnosis (86.9%), prog-
nosis (85.9%), and outcomes (88.4%, Table 14).
When asked how they would change the practice pat-
terns, 84 responses were obtained. Twenty-six percent of
those responses indicated that they would like the practice
patterns to be more specific or more specific to pediatrics.
Twelve percent would like them to be impairment based,
8% functionally based, 8% related to the medical diagnosis,
and 20% gave a variety of other responses. Several respon-
dents indicated that they find the practice patterns mean-
ingless and the language not family friendly.
DISCUSSION
Although no studies have been published to date on
the use of the Guide, many sources advocate the use of the
Guide and its patient/client management model,2–9,15–19 This
survey demonstrated that pediatric physical therapists use
the patient/client management model, even though they do
not find the Guide useful or relevant. As one respondent
said “the Guide provides the standard that we may aspire
to” in patient/client management. This survey also demon-
strated that pediatric therapists have a variety of percep-
182 Johnson and Long
tions of the Guide; some have difficulty with its applica-
tion due to a perceived lack of knowledge and report
difficulty applying the practice patterns to a pediatric
population.
41.1
42.3
46.4 Patient/Client Management Model
42.0 Respondents do not find diagnosis, as defined in the
40.1
Guide, relevant. Most use diagnosis of functional limitation
and impairment to guide selection of interventions, define
objectives, assist parents with referral to other specialists,
and to explain causes of dysfunction to families. Individu-
als who selected diagnostic classifications of practice pat-
terns are those who were older, more experienced, enrolled
in educational programs, or had a higher entry level degree.
These respondents may have been influenced by their ex-
perience or educational programs to use the Guide in their
practice. Many respondents identified a lack of under-
standing of diagnosis, how it applies to them, and why it is
important. In addition, some did not like the language of
the practice patterns and regard them as “not family
friendly.” A majority of the respondents indicated that the
language of the practice patterns is not meaningful and
does not lead to interventions.
The apparent confusion and lack of definition of diag-
nosis was not unique to these respondents. At a consensus
meeting in 2006, Diagnosis Dialog II participants accepted
the following definition19:
Diagnosis is both a process and a descriptor. The diagnostic
process includes integrating and evaluating the data ob-
tained during the examination for the purpose of guiding the
prognosis, the plan of care, and intervention strategies. Phys-
ical therapists assign diagnostic descriptors that identify a
condition or syndrome at the level of the system, especially
the movement system, and at the level of the whole person.6
The group agreed that research is needed to define diag-
noses using a variety of research methodologies. They also
agreed that we “should not use qualifiers with the term
‘diagnosis,’ except as required by context.” Physical thera-
pists are specialists of the human movement system and
should identify human movement syndromes that may or
Pediatric Physical Therapy
 TABLE 11
Relationship Among Demographic Characteristics and Use of the Guide: Results of Kruskal-Wallis Test

Highest Degree First Entry Level Enrollment in Years Physical Years Pediatric
Earned Degree Postprofessional Program Age Therapist Physical Therapist
Do you consult the Guide 0.03* 0.108 0.156 0.136 0.037* 0.075
on a regular basis?
Do you consult the Guide 0.080 0.001* 0.584 0.039* 0.003* 0.007*
when confronted with a
new or unusual
situation?
Do you categorize the child 0.379 0.003* 0.01* 0.004* 0.006* 0.003*
into a physical therapy
practice pattern based on
evaluation findings?
*Denotes significant result (p ⬍ 0.05) for Kruskal Wallis Test.

TABLE 12
Relationship Among Demographic Characteristics and Use of the Guide: Results of Spearman Rank Order Correlation Coefficient

Highest Degree First Entry Level Enrollment in Years Physical Years Pediatric
Earned Degree Postprofessional Program Age Therapist Physical Therapist
Do you consult the Guide 0.138* ⫺0.094 0.081 0.098* 0.101* 0.108*
on a regular basis?
Do you consult the Guide 0.012 ⫺0.146† 0.063 0.107* 0.120* 0.106*
when confronted with a
new or unusual
situation?
Do you categorize the child 0.019 0.132† ⫺0.124† ⫺0.139† ⫺0.144† ⫺0.148†
into a physical therapy
practice pattern based on
evaluation findings?
*Spearman rank order correlation significant at 0.05 (2 tailed).
†Spearman rank order correlation significant at 0.01 (2 tailed).

may not be linked to physician diagnoses, such as shoulder
instability associated with rotator cuff tendinitis. Defini-
tion of diagnostic labels should be linked to standardized
and existing anatomical, physiological, or functional
terminology.
A recently published case study on individuals with
stroke, advocated for the use of diagnoses at the impair-
ment level such as force production deficit, fractionated
movement deficit, and perceptual deficit.20 The Guide de-
fines impairment as alterations of structure and function,
such as “abnormal muscle strength, range of motion, or
gait . . .”1 The authors described the use of the patient/client
management model and interventions that are generated from
the physical therapy diagnosis. When asked to describe and
define how they use diagnosis in our current study, respon-
dents reported use of impairment level diagnoses (70.1%);
thus, our findings are consistent with this case study.20
Contemporary practice demands that the physical
therapists use evidence to guide practice and make prog-
nosis. Most therapists responded that they use prognoses
in their practice. Respondents indicated a need for research
to assist them with integrating prognostic concepts into
their practice; a growing body of literature supports the use
of prognostic concepts. Three valuable research studies
offer predictive value for children with cerebral palsy,21
Down syndrome,22 and brain injury.23 The latter assists
therapists with predicting ambulation at discharge from a
hospital based on predictors of recovery; the former two
predict gross motor abilities based on current gross motor
ability. Beattie et al24 recently published a framework to
assist therapists with making prognostic judgments by de-
scribing the components of prognostic research studies
and how to use and implement the findings. These studies
assist therapists making prognostic decisions.
Respondents reported the need for information on a
variety of prognostic variables and factors affecting out-
comes; contemporary pediatric physical therapy practice
also requires that therapists take into consideration family
desires and hopes for their children, legal requirements for
access to education, and collaboration across service sys-
tems and providers. One respondent indicated the need for
therapists to “make prognostic determinations based on
current evidence for specific conditions and comorbidities
rather than general statements and extremely wide ranges
in session numbers.” Other respondents indicated that
many children have lifelong impairments; prognosis needs
to incorporate the many variables that can affect a child,
using language that is positive and instills hope in children
and their families. Although respondents want information
on prognostic variables, they want to be able to use this
information to motivate and comfort the children and fam-
ilies with whom they work. This can be difficult due to the

Pediatric Physical Therapy Use of the Guide to PT Practice by Pediatric PTs 183
 TABLE 13 strength/power/endurance training (86.7%). While some
Respondents Belief Regarding the Need for Change for the Guide interventions are more popular than others, all interven-
Guide Should not Guide Should be tions listed by the Guide were used by respondents. When
be Changed* (%) Changed† (%) asked to list interventions used that were not listed in the
Guide, many respondents listed interventions that would
The disablement framework 41.5 47.3
The examination element of 23.7 27.4 fall under categories already listed in the Guide. For exam-
the patient/client ple, “partial body weight supported treadmill training”
management model could be categorized under gait training. Respondents view
The evaluation element of the 23.6 28 terminology used in the Guide as not applicable to pediat-
patient/client management
rics, when in fact it may be. This may contribute to respon-
model
The diagnosis element of the 15.4 35.1 dents’ view of the Guide as not useful or relevant to their
patient/client management practice.
model
The prognosis element of the 14.9 40.8
Knowledge Deficit
patient/client management
model Respondents reported lack of knowledge as a barrier
The intervention patient/client 16.2 39.4 to the use of the Guide. Some reported that they “haven’t
management model
taken the time to understand it” or know how to integrate
The outcome component 13.5 42.4
The content of the practice 8.5 51.3 it into their practice. Others indicated a lack of support for
patterns the use of the Guide from peers and administrators. These
*Combined results from 1 (I strongly believe the Guide should not
comments underscore the need for training and education
be changed) and 2 (the Guide should not be changed). on the use of the Guide.
†Combined results from 4 (the Guide should be changed) and 5 (I Several publications describe how to apply the Guide,
2,3
strongly believe the Guide should be changed). including fact sheets, books,4,5,9,16 and published case
25–27
studies. Adult learning, as described by Knowles, is
TABLE 14 based on a need to know, self concept, experience, readi-
Changes to the Physical Therapy Practice Pattern ness, orientation, and motivation to learn.28 Although the
current form and methods for disseminating information
Examination Diagnosis Prognosis Outcomes
(%) (%) (%) (%) may have been helpful in educating some therapists about
the Guide, most respondents reported that these efforts
No change is necessary 16.8 31.8 30.9 33.7
The information should 25.7 16.6 15.2 13.7
have not been sufficient to meet their needs for education
be more specific and training. Pediatric physical therapists do not see the
The information should 1.9 0.6 2.3 1.3 relevance and benefit of using the Guide, and therefore are
be more generic not motivated to access readily available materials and ed-
. . ., as defined by the 13.5 13.1 14.1 11.6 ucate themselves on the Guide. Future educational efforts
Guide is not
consistent with my
should be aimed at making the Guide relevant to clinicians
practice (both in language and utility), helping clinicians to under-
stand why it is important to use the Guide, and the value its
use adds to their practice. Respondents suggested the use
of other means of education such as web-based and class-
nature of the many chronic disabilities that pediatric phys-
based seminars. Without educated clinicians, it is difficult
ical therapists encounter.
to implement any change in practice. These factors may be
Pediatric Content of the Guide contributing to the perceived lack of relevance, under-
standing, and use of the Guide.
Comments regarding lack of pediatric content were
Clinicians aspire to models published in the literature.
evident in several parts of the survey, but most apparent in
Several recently published case studies in physical therapy
the comments regarding interventions. Some respondents
journals were scanned for terminology consistent with the
reported use of site-specific interventions such as “thera-
patient/client model.25–27 Most case studies reported prac-
peutic play in natural environment,” “NICU,” and “aquatic
tice consistent with some elements of the patient/client
therapy.” Respondents confused terminology by defining
management model, as did respondents in the survey.
interventions by setting, instead of delineating the inter-
However, the case studies did not adequately address each
vention and the setting the intervention took place in.
element of the patient/client management model. It might
Pediatric physical therapists view their terminology
be useful to clinicians if published research used language
and practice as unique. Respondents report that they did
consistent with the Guide.
not use the Guide to select interventions, but subsequently
reported use of interventions listed in the Guide such
as prescription/application/fabrication orthotic devices Perception of the Guide
(85.7%), neurodevelopmental training (92.6%), passive The current study found that clinicians would like a
range of motion (85.5%), flexibility exercises (90.9%), and variety of documents to support their practice; documents

184 Johnson and Long Pediatric Physical Therapy

that are setting specific, intervention specific, and diagno-
sis specific. These types of documents are available to ther-
apists. Competencies for early intervention,29 school-based
practice,30 and neonatal intensive care31 are setting-specific
documents that have been developed to provide practitio-
ners with standards of competency and the scope of prac-
tice for specific settings. Systematic reviews summarizing
research on the effectiveness of specific interventions in-
cluding yoga,32 neurodevelopmental treatment,33 develop-
mental programs for premature infants,34 and aquatic in-
terventions35 are available. A practice guideline for
management for children with spastic diplegic cerebral
palsy was published describing clinical management con-
sistent with the patient/client management model.36 AP-
TA’s Hooked on Evidence provides case scenarios that in-
clude a typical presentation of a case with supporting
evidence.37
The Guide provides a construct and framework for
practice; the purpose of the Guide is to define and describe
physical therapy practice.1 Perhaps, the perception of the
Guide as an all-inclusive document does not serve the phys-
ical therapist well. The Guide should be viewed as a refer-
ence and resource, with the use of other supporting docu-
ments to guide practice.
LIMITATIONS
This survey was the first attempt to analyze the use
of the Guide. The results may have been affected by 5
limitations. Although the response rate met our power
estimations it was lower than expected; this may have
been affected by its administration during the month of
December. Demographic information was based on the
APTA demographic profile, which does not include a
category for providers of early intervention services. Re-
sponses could not be analyzed specifically for these ther-
apists. Additionally, the sample was limited to APTA
membership including those practicing in pediatrics
who are non Section on Pediatrics members. Even with
definitions included in the survey, some respondents
who lacked familiarity with the Guide, and did not have
access to a Guide, may not have answered questions con-
sistently with the Guide. Face validity was ensured by
the process used to develop the survey, but the survey
may lack internal consistency.
CONCLUSION
Pediatric physical therapists practice consistent with
the Guide’s patient/client management model and value the
Guide as a reference, resource, and teaching tool. Respon-
dents would like the Guide to be evidence based, accessible,
and consistent with the ICF framework. Some pediatric
physical therapists report a deficit in their knowledge of
the Guide because they do not see the Guide as relevant to
them and have not taken the time to incorporate it into
their practice. Future research should include pilot studies
and/or focus groups of the new edition of the Guide, pub-
lication of updated documents that support practice (such
as intervention, setting specific guidelines, and case studies
Pediatric Physical Therapy
consistent with the elements of the patient/client manage-
ment model), effects of various factors on outcomes, out-
come measures, evidence related to elements that comprise
the patient/client management model, and how physical
therapists in other specialty areas view and use the Guide.
ACKNOWLEDGMENTS
The authors thank survey reviewers: Rachel Brady,
PT, DPT, Lisa Chiarello, PT, PhD, Marc Goldstein, EdD,
Kenneth Harwood, PT, PhD, and MaryJane Rapport, PT,
PhD; guidance on statistical analysis: Michael Harris-Love,
PT, PhD and Bennett Barth; peer reviewers: Peggy Belmont,
PT, MEd and Joan Bohmert, PT, MS; and for assistance
with coding: Deborah Rose, PT, DPT.
REFERENCES
1. Rothstein J, ed. Guide to physical therapist practice [Special issue].
Phys Ther. 2001;81(1).
2. Section on Pediatrics, American Physical Therapy Association. Appli-
cation of the Guide to Physical Therapist Practice to a Pediatric Case.
Available at: www.pediatricapta.org/graphics/Guidefactsheet.pdf.
Accessed September 5, 2006.
3. Using APTA’s Guide to Physical Therapist Practice in Pediatric Settings.
Available at: www.pediatricapta.org/graphics/GuideFactSheet.pdf.
Accessed September 5, 2006.
4. Massery M. Multisystem consequences of impaired breathing me-
chanics and/or postural control. In: Cardiovascular and Pulmonary
Physical Therapy: Evidence and Practice. 4th ed. St. Louis, MO:
Elsevier; 2006:695–718.
5. Moffat M. Musculoskeletal Essentials. New Jersey: Slack Inc.; 2006.
6. Coffin-Zadai CA. Disabling our diagnostic dilemmas. Phys Ther.
2007;87:641– 653.
7. Culver, L. Reliable resource: the screening process. Available at: http://
www.apta.org/AM/Template.cfm?Section-Archives3&CONTENTID⫽
29205&TEMPLATE⫽/CM/HTMLDisplay.cfm. Published 2006. Ac-
cessed December 1, 2006.
8. VanSant A. Physical therapy diagnoses. Pediatr Phys Ther. 2006;18:
181.
9. Bohmert J, Woods M. Applying the guide to physical therapist prac-
tice. In: Montgomery P, Connolly B, ed. Therapeutic Exercise in De-
velopmental Disabilities. 3rd ed. Thoroughfare, NJ: Slack; 2005:121–
156.
10. Dillman DA. Mail and Internet Surveys: The Tailored Design Method.
2nd ed. NY: John Wiley & Sons; 2000.
11. SPSS for Windows. Version 16. Chicago, IL:2007.
12. SPSS for Windows. Version 10. Chicago, IL:2007.
13. Patton MQ. Qualitative Research and Evaluation Methods. California:
Sage Publications; 2002.
14. Dumboldt E. Rehabilitation Research: Principles and Applications. St.
Louis, MO: Elsevier; 2005.
15. Effgen S. Meeting the Physical Therapy Needs of Children. Philadel-
phia, PA: FA Davis; 2005.
16. Campbell S, Vander Linden D, Palisano R, eds. Physical Therapy for
Children. 3rd ed. St. Louis, MO: Saunders, Elsevier; 2006.
17. Jette A. Toward a common language for function, disability, and
health. Phys Ther. 2006;86:726 –734.
18. VanSant A. The international classification of functioning, disability
and health. Pediatr Phys Ther. 2006;18:237.
19. Norton BJ. Harnessing our collective professional power: diagnosis
dialog. Phys Ther. 2007;86:635– 638.
20. Scheets PL, Sahrmann SA, Norton BJ. Use of movement system diag-
noses in the management of patients with neuromuscular conditions:
a multiple-patient case report. Phys Ther. 2007;87:654 – 669.
21. Rosenbaum P, Walter S, Hanna S, et al. Gross motor function in
cerebral palsy: creation of motor development curves. JAMA. 2002;
288:1357–1363.
Use of the Guide to PT Practice by Pediatric PTs 185
22. Palisano R, Walter S, Russell D, et al. Gross motor function of chil-
dren with Down syndrome: development of motor growth curves.
Arch Phys Med. 2001;82:494 –500.
23. Dumas HM, Haley SM. Ludlow LH, et al. Recovery of ambulation
during inpatient rehabilitation: physical therapist prognosis for chil-
dren and adolescents with traumatic brain injury. Phys Ther. 2004;
84:232–242.
24. Beattie P, Nelson RM. Evaluating research studies that address prog-
nosis for patients receiving physical therapy care: a clinical update.
Phys Ther. 2007;87:1527–1535.
25. George DA, Elchert L. The influence of foot orthoses on the function
of a child with developmental delay. Pediatr Phys Ther. 2007;19:332–
336.
26. Holtgrefe KM. Twice weekly complete decongestive physical therapy
in the management of secondary lymphedema of the lower extremi-
ties. Phys Ther. 2006;86:1128 –1136.
27. Kelly MJ, Kane TE, Leggin BG. Spinal accessory nerve palsy: associ-
ated signs and symptoms. J Orthop Sports Phys Ther. 2008;38:78 – 86.
28. Yannacci J, Roberts K, Ganju V. Principles from adult learning theory,
evidence-based teaching, and visual marketing: what are implications
for toolkit development. Center for Mental Health Quality and Ac-
countability (2006). Available at: http://ebp.networkofcare.org/
uploads/Adult_Learning_Theory_2497281.pdf. Accessed on Sep-
tember 8, 2008.
29. Chiarello L, Effgen SK. Updated competencies for physical thera-
186 Johnson and Long
pists working in early intervention. Pediatr Phys Ther. 2006;18:
148 –158.
30. Effgen SK, Chiarello L, Milbourne SA. Updated competencies for phys-
ical therapists working in schools. Pediatr Phys Ther. 2007;19:266 –274.
31. Sweeney J, Heriza C, Reilly M, et al. Guidelines for clinical practice in
the neonatal intensive care unit (NICU) environment. Pediatr Phys
Ther. 1999;11:118 –126.
32. Galantino ML, Galbavy R, Quinn L. Therapeutic effects of yoga for
children: a systematic review of the literature. Pediatr Phys Ther.
2008;20:66 – 80.
33. Butler CB, Darrah J. Effects of Neurodevelopmental Treatment
(NDT) for Cerebral Palsy. Dev Med Child Neurol. 2001;43:778 –790.
34. Spittle AJ, Orton J, Doyle LW, et al. Early developmental intervention
programs post hospital discharge to prevent motor and cognitive
impairments in preterm infants. Cochrane Review, Published 2007.
Available at: www.cochrane.org/reviews/en/ab005495.html. Ac-
cessed on February 23, 2008.
35. Getz M, Hutzler Y, Vermeer A. Effects of aquatic interventions in
children with neuromotor impairments: a systematic review of liter-
ature. Clin Rehabil. 2006;20:927–936.
36. O’Neil M, Fragala-Pinkham M, Westcott S, et al. Physical therapy
clinical management recommendations for children with cerebral
palsy—spastic diplegia: achieving functional mobility outcomes. Pe-
diatr Phys Ther. 2006;18:49 –72.
37. American Physical Therapy Association. Hooked on evidence. Avail-
able at: www.hookedonevidence.com. Accessed March 20, 2008.
Pediatric Physical Therapy