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Physical Therapy of the Shoulder
FIFTH EDITION
• Image Collection

• Reference lists linked to Medline

• Video clips
Physical Therapy of the Shoulder
FIFTH EDITION

Edited by

Robert A. Donatelli, PhD, PT, OCS

National Director of Sports Rehabilitation
Physiotherapy Associates
Las Vegas, Nevada
3251 Riverport Lane
St. Louis, Missouri 63043

PHYSICAL THERAPY OF THE SHOULDER, FIFTH EDITION ISBN: 978-1-4377-0740-3

Copyright # 2012, 2004, 1997, 1991, 1987 by Churchill Livingstone, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
permission in writing from the publisher.

Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Physical therapy of the shoulder / edited by Robert A. Donatelli. – 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0740-3 (hard copy)
1. Shoulder–Wounds and injuries. 2. Shoulder–Wounds and injuries–Treatment. 3. Shoulder–Wounds
and injuries–Physical therapy. I. Donatelli, Robert. II. Title.
[DNLM: 1. Shoulder–injuries. 2. Shoulder Joint–injuries. 3. Physical Therapy Modalities. WE 810]
RD557.5.P48 2011
617.5’72044–dc22
2011001297

Executive Editor: Kathy Falk

Developmental Editor: Megan Fennell
US/Chennai Publishing Services Managers: Julie Eddy and Rajendrababu Hemamalini
US/Chennai Project Managers: Celeste Clingan and Srikumar Narayanan
Designer: Jessica Williams

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Dedication

I would like to dedicate this book to my family—my wife Georgi Donatelli, my son,
Robby, and my daughters, Briana and Rachel. They have added a new meaning of love,
joy and happiness to my life.
 Contributors

RANDA A. BASCHARON, DO, AT XAVIER A. DURALDE, MD

Owner, President, Orthopedic and Sports Medicine Peachtree Orthopedics Clinic, Assistant Clinical Professor
Institute Of Las Vegas, Sports Performance Institute of of Orthopedic Surgery, Clinical Instructor, Emory University
Las Vegas, Las Vegas, Nevada School of Medicine, Atlanta, Georgia

MOLLIE BEYERS, DPT RICHARD A. EKSTROM, PT, DSC, MS

Physical Therapist, Biomax Rehabilitation, Effingham, Professor, Department of Physical Therapy, University of
Illinois South Dakota, Vermillion, South Dakota

PETER BONUTTI, MD, FACS, FAAOS, FAANA TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS
Founder and Director, Bonutti Clinic, Founder and Clinic Director, Physiotherapy Associates Scottsdale Sports
Director, Bonutti Technology, Effingham, Illinois, Assistant Clinic, National Director of Clinical Research, Physiotherapy
Clinical Professor, Department of Orthopedic Surgery, Associates, Director of Sports Medicine, ATP World Tour,
University of Arkansas, Fayetteville, Arkansas Scottsdale, Arizona

KENJI C. CARP, MPT, OCS, ATC ROBERT L. ELVEY, BAPPSC, GRAD. DIP. MANIP. THER.
Certified Vestibular Therapist, Director, Owner, Senior Lecturer, Curkin University, Physiotherapy
Cooperative Performance and Rehabilitation, Eugene, Consultant, Southcare Physiotherapy, Perth, Australia
Oregon
KATHLEEN GEIST, PT, DPT, OCS, COMT
JEFF COOPER, MS, ATC Assistant Professor, Division of Physical Therapy,
Athletic Training Solutions, Wilmington, Delaware, Department of Rehabilitation Medicine, Emory University
Consultant, Player Development, Philadelphia Phillies, School of Medicine, Atlanta, Georgia
Philadelphia, Pennsylvania
JOHN C. GRAY, DPT, OCS, FAAOMPT
DONN DIMOND, PT, OCS Lead Clinical Specialist, Department of Physical
Director of Clinical Operations, Owner, The KOR Physical Therapy, Sharp Rees-Stealy, Clinical Instructor, Ola
Therapy, Portland, Oregon Grimsby Institute, Credentialed Clinical Instructor,
American Physical Therapy Association, Associate Editor,
JAN DOMMERHOLT Journal of Manual and Manipulative Therapy, San Diego,
President and Physical Therapist, Bethesda Physiocare, California
Inc/Myopain Seminars, LLC, Bethesda, Maryland
BRUCE H. GREENFIELD, PT, PHD, OCS
PHILLIP B. DONLEY, PT ATC MS Assistant Professor, Department of Rehabilitation, Center
Optimum Physical Therapy, West Chester, Pennsylvania for Ethics, Emory University, Atlanta, Georgia
viii Contributors

OLA GRIMSBY, PT DOUGLAS M. MURRAY, MD

Chairman of the Board, Ola Grimsby Institute, San Diego, Surgeon, Peachtree Orthopedic Clinic, Consulting
California Physician, Shepherd Center, Atlanta, Georgia

TOBY M. HALL, PHD, MSC, POST GRAD DIP MANIP THER,

ROY W. OSBORN, PT, MS, OCS
ASSOC IN PHYSIOTHERAPY
Associate Professor, Physical Therapist, Physical Therapy
Director Manual Concepts, Perth, Australia, Adjunct
Department, Avera McKennan Hospital and University
Senior Teaching Fellow, School of Physiotherapy, Curtin
Health System, Sioux Falls, South Dakota
Innovation Health Research Institute, Curtin University of
Technology, Bentley, Australia, Senior Teaching Fellow, The
University of Western Australia, Perth, Australia, Director JAIME C. PAZ, PT, DPT, MS
Manual Concepts, Perth, Australia Clinical Associate Professor, Division of Physical Therapy,
Walsh University, North Canton, Ohio
SCOT IRWIN, DPT, CCS{
Formerly, Associate Professor, Department of Physical
SCOTT D. PENNINGTON, MD
Therapy, North Georgia College and State University,
Surgeon, Peachtree Orthopedic Clinic, Atlanta, Georgia
Dahlonega, Georgia

ROBERT C. MANSKE, PT, DPT, SCS, MED, ATC, CSCSC VIJAY B. VAD, MD
Associate Professor, Department of Physical Therapy, Assistant Professor of Rehabilitation Medicine, Hospital
Wichita State University, Wichita, Kansas for Special Surgery, New York, New York

JOHNSON MCEVOY, PT, BSC, MSC, DPT, MISCP, MCSP

JOSEPH S. WILKES, MD
Chartered Physiotherapist in Private Practice, United
Clinical Associate Professor, Orthopedics, Emory
Physiotherapy Clinic, Limerick, Ireland, Head
University, Active Staff Member, Piedmont Hospital,
Physiotherapist, Irish Boxing High Performance Team,
Specialty Consulting, Crawford Long Hospital, Atlanta,
Dublin, Ireland, External Lecturer, Sports Science, University
Georgia, Active Staff Member, Fayette Community Hospital,
of Limerick, Limerick, Ireland
Fayetteville, Georgia
CRAIG D. MORGAN, MD
Clinical Professor, University of Pennsylvania, Department MICHAEL S. ZAZZALI, DSC, PT, OCS
of Orthopaedics, Philadelphia, Pennsylvania, Morgan Kalman Co-Director and Partner, Physical Therapy Associates of
Clinic, Wilmington, Delaware New York, New York, New York

{
Deceased.
 Preface

The first edition of Physical Therapy of the Shoulder was pub- Part 2, Neurologic Considerations, has been updated with
lished in 1987, and now we are publishing the fifth edition new information and references. John C. Gray and Ola Grimsby’s
nearly 25 years later. I would like to thank my readers for chapter, Interrelationship of the Spine, Rib Cage, and Shoulder,
their support throughout the years that has made this book along with Neural Tension Testing by Tobby Hall and Bob
successful. The fifth edition has kept up with the tradition Elvy have been revised, and Bruce H. Greenfield and Kathleen
of Physical Therapy evidence-based practice. It is amazing Geist did a great job updating the chapter on Evaluation and
how the literature now has developed our profession from Treatment of Brachial Plexus Lesions. A new chapter, Sensory
and art to a science. Each chapter is a excellent example of Integration and Neuromuscular Control of the Shoulder by
how the science of Physical Therapy continues to grow. Kenji Carp has been added to the neurological section. I think
The shoulder joint is a complicated structure consisting of you will find that Kenji did an excellent job on defining
three synovial joints, the scapula thoracic articulation, and 17 neuromuscular control in the upper limb. The chapter is an
muscles. The shoulder complex hangs off the rib cage and is excellent representation of state of the art information that is
connected to the cervical and thoracic spine. The complexity of critical to the rehabilitation of shoulder patients.
the shoulder makes many rehabilitation students and clinicians Part 3, Special Considerations, was highlighted by the
uncertain in assessing shoulder pathomechanics and in establish- separation of Chapter 10 into two chapters, Impingement
ing treatment approaches for different shoulder pathologies. Syndrome and Shoulder Instabilities. Bruce Greenfield did
In keeping up to date with new and innovative treatment an excellent job on describing the mechanisms of impinge-
techniques, surgical procedures, and evaluation methods for ment and the new chapter, on shoulder instabilities, by
the shoulder, this fifth edition of Physical Therapy of the Shoulder Michael Zazzali, focused on the conservative approach to the
has been updated appropriately. There are 7 new chapters and evaluation and treatment of shoulder instabilities. The Frozen
8 new authors. The fifth edition is once again divided into five Shoulder chapter was update by Mollie Beyers and Peter
parts; Mechanics of Movement and Evaluation, Neurologic Bonutti. This chapter provides an excellent summary of the
Considerations, Special Considerations, Treatment Approaches, evidence-based research on treatment of frozen shoulder
and Surgical Considerations. pathology. John C. Gray’s chapter on Visceral Referred Pain
In honor of the memory of the late Scot Irwin, Jaime Paz to the Shoulder, was rewritten, along with important updates
helped to revise the Guide to Physical Therapist Practice. from Todd S. Ellenbecker on rotator cuff pathology.
The chapter is an overview of the Guide. Chapter 2 was In the Treatment Approaches Section, Richard A. Ekstrom
updated with new anatomic and biomechanical information and Roy W. Osborn did an excellent job on adding addition
on how the shoulder moves. Chapter 3 was rewritten by Jeff research on Muscle Length Testing and Electromyographic
Cooper with all the new information on the throwing injuries Evidence for Manual Strength Testing and Exercises for the
to the shoulder. Jeff has included new research data that he Shoulder. The Manual Therapy Techniques was updated with
has collected over the past several years on professional baseball additional illustrations of new manual procedures for the
pitchers. His approach to evaluation and treatment is state shoulder, with a section on evidence-based manual therapy
of the art. Chapter 4 is a new chapter by Donn Dimond treatment approaches. The treatment section was highlighted
that finishes the first section with updates on all the new- by one of two new chapters by Donn Dimond on strength
evidenced-based special tests for the shoulder. The special tests training in the shoulder. As previously noted the shoulder
on the shoulder greatly assist the clinician in the development has 17 muscle that allow it to move in multiple planes.
of a differential soft tissue diagnosis. In addition, manual Therefore this chapter is long awaited as the strength of
muscle testing to isolate the shoulder muscles is illustrated. the shoulder muscles is critical to the overall function. Finally,
x Preface

I am honored to have Johnson McEvoy and Jan Dommerholt I am pleased to include a companion Evolve site with the
in the fifth edition with a new chapter on Myofascial Trigger fifth edition of Physical Therapy of the Shoulder. The Evolve site
Points of the Shoulder. The chapter is very comprehensive compliments the text and enhances the clinical application with
covering evaluation and treatment of trigger points. The excerpts of an evaluation of a patient using manual therapy
treatment approaches described include, Myofascial release treatment techniques of the shoulder. A link to an electronic
techniques using manual therapy, massage techniques, dry image collection that features most of the illustrations contained
needling, spray and stretch, and the use of modalities. in the book are included on Evolve.
The Surgical Considerations Section includes the addition Any rehabilitation professional entrusted with the care and
of a chapter by Dr. Ronda Bascharon and Robert Manske on treatment of mechanical and pathologic shoulder dysfunction
the Surgical Approach to Shoulder Instabilities. The chapter will benefit from this book. I trust that the fifth edition will
includes state-of-the-art concepts in evaluation and treatment meet the reader’s expectation of comprehensive, clinically
of the Bankart lesion, S.L.A.P lesions, and rotator cuff interval relevant presentations and case studies that are well documen-
concepts. Dr. Joseph Wilkes and Dr. Xavier Duralde made ted, contemporary, and personally challenging to the student
important updates in their chapters on Rotator Cuff Repairs and the experienced specialist alike.
and Total Shoulder Replacements, respectively.
Robert A. Donatelli, PhD, PT, OCS
 C H A P T E R

1 Scot Irwin and Jaime C. Paz

The Guide to Practice

In this fifth edition of Donatelli’s Physical Therapy of the none alone. For most of the decade of the 1980s and early
Shoulder, the clinical cases continue to be written in the 1990s, the APTA debated the merits and even the existence
format of Guide to Physical Therapist Practice1 (the Guide) of of physical therapy diagnoses. The term diagnosis is so fraught
the American Physical Therapy Association (APTA). This with interpretations that, within the APTA, confusion and
format was developed and has been promoted by the APTA, debate have consumed an inordinate amount of the associa-
which is the largest professional representative for physical tion’s governance time. Finally, the APTA House of Delegates
therapists, physical therapy assistants, and physical therapy came to an agreement that physical therapists did diagnose
students in the United States. and that those diagnoses were directed at movement and
This chapter is designed to orient the reader to the origins, movement dysfunction.
purposes, content, and nature of the Guide. In this way, the The basic premise here is that human movement, like
intent of this chapter is to encourage clinicians and students digestion, is a system. The movement system has normal
who use this current book to incorporate the Guide’s language behaviors that can become dysfunctional, and a physical ther-
and philosophy into the examination, evaluation, diagnosis, apist can provide remedies for those dysfunctions. Eventually,
prognosis, intervention, and outcome provided for their because of a need to describe the scope of a physical therapist’s
patients with shoulder dysfunction. practice more clearly for many health care agencies and for the
physical therapy profession, the APTA undertook the develop-
ment of the Guide. From 1992 through the completion of the
ORIGINS current edition, a handful of physical therapists and staff
members of the APTA constructed this document. Those
To speak at any length about the origins of this document who have tried to produce anything by committee can imag-
would take most of this text. For the abbreviated yet complete ine the amount of time and effort required to write the Guide.
review, the reader is encouraged to read the Guide.1 Since The authors of the Guide are too numerous to list, but they are
Mary McMillan first constructed and presided over the acknowledged within the Guide itself, and they deserve the
Women’s Physiotherapy Association in the early 1920s—and respect and thanks of every physical therapist. All the authors
until the first edition of the Guide in 1997—the reconstruc- were chosen for their expertise and knowledge in a particular
tion aides, general practitioners, and certified clinical specia- practice pattern arena (musculoskeletal, neuromuscular, car-
lists all intuitively have known the value and importance of diovascular/pulmonary, and integumentary). Each of those
rehabilitation services. Throughout that short but illustrious authors is quick to point out that this document is not writ-
history, the association members have professed the unique- ten on a stone tablet. Its origins derive from the cataclysmic
ness and talent within the physical therapy profession to any changes that have occurred in health care delivery and reim-
who cared to listen. The scientific evidence of this effective- bursement in the United States. Those driving forces, along
ness, in contrast, remains to be presented. No defined body with the dynamic growth and development of the profession
of knowledge for physical therapists exists. The Guide pro- of physical therapy, created an environment that required this
vides a foundation for developing the evidence for the effec- document’s publication and demanded that the Guide be in
tiveness of physical therapist interventions. The body of constant evolution. Evidence of this evolution is electronic
knowledge will be defined from the evidence that proves the access to the revised second edition of the Guide in compact
value of these interventions. disk format, which includes a catalog of tests and measures
Physical therapy originated from many facets of health care employed by physical therapists. Furthermore, the APTA
and health sciences, nursing, physical education, medicine, has provided Internet access to the latest edition of the
pathology, and rehabilitation—yet physical therapists claim Guide.2
2 Physical Therapy of the Shoulder

The challenge for future physical therapists is to continue research. The current edition of the Guide was not written
to amend and edit the Guide by documenting errors and omis- to provide that level of information.
sions and by providing new practice patterns for impairments In this book, the case examples have been “Guideized,”
and functional limitations yet to be identified or discovered. including formatting and terminology. It is the intention that
A future edition of the Guide is likely to include the Interna- the reader should become familiar with this system of patient
tional Classification of Functioning, Disability, and Health evaluation and treatment and incorporate it into his or her
(ICF) developed by the World Health Organization (WHO) daily practice. It is also hoped that academic and clinical fac-
to promote human functioning with a standardized frame- ulty will use the Guide approach when instructing future gen-
work and language. The APTA House of Delegates endorsed erations of physical therapists and will thus fulfill the purpose
this model in 2008.3 of the Guide.

PURPOSES CONTENT

The list of purposes for the Guide can be found in the first The Guide was developed with three key concepts in mind:
section, “About the Guide,” of the revised second edition.1 (1) the Nagi model of disablement4 (Table 1-1); (2) the variety
Throughout the document, these purposes are reiterated. of work settings for physical therapists; and (3) the provision
Each of the diagnostic patterns described in the Guide uses of services by physical therapists through the continuum of
terminology found in the list of purposes. Although many health care.
readers find this constant redundancy a distracting feature To understand the Guide, a good understanding of the dis-
of the Guide, it is used to demonstrate the basic constructs ablement model is required. Articles by Guccione5 and Jette6
of a physical therapist’s approach to patient management. have provided the background for understanding disablement.
The authors of the Guide also used the combined term The reader can find these articles in the journal Physical Therapy
patient/client throughout the Guide. For this chapter, the from 1991 and 1994, respectively. The Nagi model4 was
term client is used. selected by the authors of the Guide because it provides the best
A summary of the purposes is as follows: The Guide was fit for the development of physical therapy practice patterns
developed to assist internal (physical therapists) and external and diagnoses. As Guccione’s diagram (Fig. 1-1) so aptly
(all others involved in health care delivery and reimburse- demonstrates, the Nagi model encompasses the entire spec-
ment) individuals in understanding the scope of a physical trum of health care. Pathology and pathophysiology lead to
therapist’s practice. As stated in the Guide, this list impairment, which can either cause more pathology or lead
includes—but is not limited to—practice settings, roles, ter- to functional limitations. These functional limitations may
minology, tests and measures, and interventions used by phys- revert back to impairments or progress to disability. The
ical therapists in the delivery of physical therapy. Perhaps domain of a physical therapist’s practice is outlined by the dot-
most important, the Guide establishes preferred practice pat- ted lines in Figure 1-1. The Guide was developed to address the
terns based on the Nagi model of disablement.4 Common delivery of health care services by physical therapists from
themes within the purposes listed in the Guide are the promo- pathology to impairment to functional limitation and to dis-
tion of health, wellness, and fitness along with prevention of ability with the greatest emphasis on identification and rectifi-
movement dysfunction and the appropriate use of physical cation of impairments and functional limitations. In effect, the
therapy services as provided by physical therapists. Guide is saying that physical therapists are the diagnosticians of
The authors of the Guide clearly describe what the Guide is movement impairments and provide interventions to prevent,
not. To quote the authors: “The Guide does not provide spe- improve, or eliminate functional limitations and disability.
cific protocols for treatments, nor are the practice patterns The Guide goes on to enhance and adapt the Nagi model
contained in the Guide intended to serve as clinical guide- by expanding it to include the larger arena of quality of life
lines.”1 The authors go on to state that the Guide is only an (Fig. 1-2). This enhancement requires that the Guide include
initial step in the development of clinical guidelines. Clinical psychological and social functions, as well as the constructs
guideline development requires evidence from peer-reviewed of the promotion of wellness, prevention, and fitness.

Table 1-1 Nagi Model of Disablement

Active Pathology Impairment Functional Limitation Disability

Interruption or interference with Anatomic, physiologic, Limitation in performance Limitation in performance of socially
normal processes, and efforts of the mental, or emotional at the level of the whole defined roles and tasks within a
organism to regain normal state abnormalities or loss organism or person sociocultural and physical environment
 Chapter 1 The Guide to Practice 3

Health care

Medical aspects Domain of physical therapist practice Social aspects

Pathology/ Functional
Impairment Disability
pathophysiology limitation

Figure 1-1 Scope of physical therapist practice within the continuum of health care services and the context of the disablement model. (Modified from
the American Therapist Association from Guccione AA: Physical therapy diagnosis and the relationship between impairments and function, Phys Ther
71:499–504, 1991.)

Pathology/ Functional
Impairment Disability
pathophysiology limitations

Physical function Physiologic function Social function

Non-health factors

• Economic status Health-related

quality of life
• Individual
expectations
and achievements Quality of life

• Personal
satisfaction with
choices and life

• Sense of
personal safety

Figure 1-2 Relationship of the disablement model, health-related quality of life, and quality of life.

The actual content of the Guide currently includes five become a physical therapist; the types of settings in which
major parts. The first part is a description of the Guide itself physical therapists practice; the roles of physical therapists
that provides insight into its development, purpose, scope, in primary, secondary, tertiary, and preventive care; the
and content overview. The second part of the Guide defines components of a physical therapist’s episode of care; and
who physical therapists are and describes their approaches to the criteria for termination of physical therapy services. In
the management of clients. The second part of the Guide also addition, this section describes in greater detail the six ele-
provides a description of the tests and measures used by phys- ments of patient management: (1) examination, (2) evalua-
ical therapists as a part of their examination process. In addi- tion, (3) diagnosis, (4) prognosis, (5) intervention, and
tion, the second part provides definitions and lists of physical (6) outcomes (Fig. 1-3). Finally, this section gives a broader
therapists’ interventions. The third and by far the longest por- description of the roles of physical therapists in manage-
tion of the Guide is made up of preferred practice patterns. ment, administration, communication, critical inquiry, and
The fourth part provides expanded access to the catalog of education.
tests and measures. The fifth part provides a document tem- The second part of the Guide provides the list of the tests
plate to facilitate the use of Guide terminology and the patient and measures used by physical therapists in their examination
management system in clinical practice. A glossary is of clients. If a test or measure is not listed in the Guide, this
included at the end of the Guide. does not preclude physical therapists from using that test or
The section that describes physical therapists provides measure. It is the intent of the Guide, however, that any test
information on the following: the prerequisites required to or measure used is valid and reliable and that each follows
4 Physical Therapy of the Shoulder

DIAGNOSIS
Both the process and the end
result of evaluating examination
data, which the physical therapist
organizes into defined clusters,
syndromes or categories to help
determine the prognosis (including
the plan of care), and the most
appropriate intervention strategies.

PROGNOSIS
(Including plan of care)
Determination of the level of
EVALUATION optimal improvement that may be
A dynamic process in which the attained through intervention and
physical therapist makes clinical the amount of time required to
judgments based on data gathered reach that level. The plan of care
during the examination. This specifies the interventions to be
process may also identify possible used and their timing and
problems that require consultation frequency.
with or referral to another provider.

INTERVENTION
Purposeful and skilled interaction
of the physical therapist with the
patient/client and, if appropriate,
with other individuals involved in
EXAMINATION care of the patient/client, using
The process of obtaining a history, various physical therapy methods
performing a systems review, and and techniques to produce
selecting and administering tests changes in the condition that are
and measures to gather data about consistent with the diagnosis and
the patient/client. The initial prognosis. The physical therapist
examination is a comprehensive conducts a re-examination to
screening and specific testing determine changes in patient/client
process that leads to a diagnostic status and to modify or redirect
classification. The examination intervention. The decision to
process also may identify possible re-examine may be based on new
problems that require consultation clinical findings or on lack of
with or referral to another provider. patient/client progress. The
process of re-examination also
may identify the need for
consultation with or referral to
another provider.

OUTCOMES
Results of patient/client
management, which include the
impact of physical therapy
interventions in the following
domains: pathology/
pathophysiology (disease,
disorder, or condition);
impairments, functional limitations,
and disabilities; risk reduction/
prevention; health, wellness, and
fitness; societal resources; and
patient/client satisfaction.

Figure 1-3 The elements of patient management leading to optimal outcomes. (From American Physical Therapy Association: Guide to Physical
Therapist Practice, ed 2. Baltimore, APTA, 2003.)

the Standards for Tests and Measurements in Physical Therapy required to perform when intervening on behalf of a client.
Practice as presented in the journal Physical Therapy in 1991.7 This list includes coordination, communication, administra-
The interventions section is provided primarily for external tion, client education, and the entire spectrum of the physical
groups. This section contains definitions and descriptions of therapists’ interventions from therapeutic exercise to physical
all the activities in which physical therapists are trained and agents and modalities.
 Chapter 1 The Guide to Practice 5

The bulk of the Guide is dedicated to the practice patterns. projection of the frequency and duration of treatment required
The patterns are broken up into four broad classifications: and plans for discharge from therapy.
(1) musculoskeletal, (2) neuromuscular, (3) cardiovascular/ Perhaps the most important contribution of the Guide to
pulmonary, and (4) integumentary. All the client cases the clinician is in the intervention segments of each practice
described in this edition of Physical Therapy of the Shoulder pattern. These suggested interventions are not cookbooks for
can be found in the musculoskeletal and neuromuscular prac- care, but rather are listed specifically as possible physical thera-
tice patterns. Although the physical therapists’ evaluations pist approaches to achievement of the desired outcomes for
direct them initially to a specific pattern, this does not the client. In all cases, education of the client or of supportive
preclude therapists from changing to an alternative pattern personnel is included as part of the interventions listed
if the examination information leads them to another conclu- regardless of the selected practice pattern. Alternative inter-
sion. It is also possible for a client to fit into more than one ventions listed under a particular pattern should not be inter-
pattern. In this case, the professional opinion of the therapist preted by the therapist as an indication to try one or two
directs the allocation of resources and time to the pattern of interventions and then move on to the next practice pattern
highest priority. if the interventions do not work. Each intervention should
The practice patterns were developed using the Nagi be applied as appropriate to the client’s responses, goals,
model4 and the patient management system previously needs, and projected outcomes. Nowhere in the Guide is it
described.1 This system includes six components. Each com- suggested that the interventions listed are the only ones
ponent in the patient management system is found in every appropriate to a particular practice pattern. As the reader will
practice pattern. The purpose of this format is to create a con- learn later in this book, however, application of the correct
sistent, uniform methodology for patient examination and intervention to the client with shoulder dysfunction has been
treatment. As depicted in Figure 1-3, each component of this found to improve the client’s functional level and to reduce
system has specific supportive parts. Examination includes his or her overall impairment.
obtaining a history, review of systems (cardiopulmonary, mus- In few, if any, cases are the interventions of the physical
culoskeletal, neuromuscular, and integumentary), choice and therapist directed solely toward the pathologic or pathophysi-
administration of tests, measurements of appropriate values, ologic features of the client’s medical condition. The Guide is
and identification of any need for referral to another a textbook for providing direction for physical therapists to
practitioner. intervene at the level of impairment and functional limitation
Figure 1-4 provides an in-depth summary of the data that without the use of medication for the most part or surgical
can be gathered during client history taking. The evaluation interventions. Intervention also includes the need for the ther-
is the process of using the information obtained during the apist to interact with the rest of the medical community
examination to determine a diagnosis or need for referral. This involved in the client’s care. This interaction requires coordi-
process continues throughout the client’s contact with the nation and communication with, and documentation of, all
therapist and requires clinical judgment on a regular and rou- the physical therapist’s clients.
tine basis. The diagnosis is a determination of which practice Inherent in the system of patient management is that at
pattern is a “best fit” for the previously gathered examination any point during the client’s treatment, the therapist is man-
and evaluation information. This physical therapist diagnosis dated to provide re-examination. The re-examination should
relates directly to an impairment classification in the Nagi be performed periodically during an episode of care, to ensure
model4 and should lead the therapist to determine the relative that the client is progressing according to his or her prognosis
level of functional loss the client is experiencing. This infor- and that short- and long-term goals are being achieved. Dur-
mation, in turn, directs the therapist to the appropriate inter- ing re-examination, the patient management system steps are
vention to obtain the optimal outcome for the client. repeated as in the original examination process.
The next component is the prognosis. This component also
includes the plan of care. The prognosis is a natural extension SUMMARY
of the diagnosis. Once the diagnosis has been made, the ther- Why is the Guide entitled Guide to Physical Therapist Practice
apist should begin to formulate a realistic prognosis and esti- and not Guide to Physical Therapy Practice? That is the nature
mate how much improvement in function can be achieved of the document. It is intended to describe the scope, role,
given the amount of impairment suffered as a result of the and spectrum of the physical therapist’s activity. Why not
disease. The logical progression of these interwoven formula- physical therapy? Because many other practitioners who are
tions between the Nagi model and the patient management not physical therapists are legally allowed to provide and be
system has been included in the Guide to create a continuum reimbursed for physical therapy. The APTA believes that
of care that leads to improved function or appropriate referral. physical therapy per se is well described within the Guide,
The plan of care is the culmination of all the steps previ- but physical therapy is really performed only by physical
ously listed and includes the client’s goals, the short- and therapists. Therefore, the Guide correctly describes the physi-
long-term goals of the therapist, specific interventions, and cal therapists’ diagnoses (practice patterns), tests and mea-
the projected outcomes of those interventions. Included sures, interventions, and responsibilities within the context
within the interventions and outcomes should be some of the Nagi model.4
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