Functional Activities and Mobility in Physical Therapy Practice
Definition and Philosophical Scope of Functional Activities
- Definition of Functional Activities: These are tasks, activities, or anything that a patient identifies as essential to their role in transitioning toward or maintaining independent adulthood. For a child, these are activities involved in progressing towards independent adulthood.
- Named Examples of Functional Activities:
- Yard work.
- Bathing.
- Grooming.
- Dressing.
- Walking up and down stairs.
- Preparing meals.
- Occupational Therapy Contrast: An occupational therapist once defined these as "things that occupy your daily life." While occupational therapists (OTs) are often more practiced at defining functional activities, physical therapists (PTs) must also integrate the concept deeply into practice.
- Biopsychosocial Aspect: Therapy should not merely be a series of rote exercises. Activities must be meaningful to the patient.
- Anecdote: The speaker mentions working in facilities where older patients performed "balloon taps." While entertaining, if such an activity is not meaningful or progressing toward a specific functional goal, its clinical value is limited.
Rehabilitation Goals and Functional Potential
- Prior Level of Function (PLOF): Rehabilitation goals are primarily set to help a patient return to their PLOF, or as close to it as possible.
- Maximize Current Potential: In cases of catastrophic injury (e.g., spinal cord injuries), the outlook for a return to PLOF may change. In these scenarios, the goal shifts to maximizing and helping the patient maintain their current potential level of function.
- Role of Functional Activities: Beyond physical tasks, these activities help patients identify who they are and their role in society and their own lives.
- Building Blocks: Therapeutic exercises are viewed as the "building blocks" used to reach functional activity goals.
Coding and Billing in Physical Therapy
- CPT (Current Procedural Terminology) Codes: Clinicians use these for documentation and billing in SOAP (Subjective, Objective, Assessment, Plan) notes.
- Specific Codes:
- Transfer Training: Code .
- Therapeutic Exercise (TheraX): Code . This involves isolated movements, such as performing a long arc quad (LAQ).
- Therapeutic Activity (TherAct): This involves larger, more functional activities, such as working on stairs or sit-to-stand movements.
- Billing Nuances:
- Some hospital systems historically restricted PTs from billing for TherAct, reserving it for OTs, though this is considered "crazy" by the speaker.
- Therapeutic Activity (TherAct) is generally reimbursed at a higher rate than Therapeutic Exercise (TheraX).
Clinical Rationale for Measuring Function
- Discharge Criteria and Placement: Functional measurements help determine if a patient can go home after surgery or if they require skilled rehab services or home health care.
- Acute Care Dynamics: In acute settings, patients stay for short durations. The Physical Therapist Assistant (PTA) may see the patient for several visits following the initial evaluation by the PT. Therefore, the PTA often makes or heavily influences discharge decisions.
- Interdisciplinary Collaboration: Doctors and social workers frequently ask the PTA for their opinion on the discharge plan. PTAs must understand different setting types and the amount of therapy provided in each to make informed recommendations.
- Safety During Performance: Understanding a patient’s functional level allows for proper safety precautions. For example, a patient with Parkinson’s disease, a vestibular disorder, or a history of three falls in the past year requires a therapist to be physically close (hands-on) rather than monitoring from across the room.
Categories of Functional Mobility
- Bed Mobility: Includes basic skills for surface-level transfers in bed or on a mat.
- Tasks: Rolling side-to-side, bridging, and propping up on elbows.
- Clinical Importance of Bridging: Bridging is vital for dressing and toileting. For a patient who has been bedbound, the ability to bridge can be the difference between needing a catheter and being able to use a bedpan.
- Clinical Importance of Elbows: Going up on elbows facilitates more complex transfers later.
- Transfers: Includes moving between surfaces.
- Specific Directions: Supine to sit, sit to supine (often overlooked), sit to stand, and stand to sit.
- Transfer Types: Squat pivot, stand pivot, and sliding board (described as functional but often a least favorite for therapists to perform).
- Activities of Daily Living (ADLs):
- Basic ADLs (BADLs): Usually fall under the OT umbrella, including feeding and dressing. PTs may integrate these into balance tasks but typically do not bill for them specifically as the primary intervention.
- Instrumental ADLs (IADLs): Advanced skills for independent living such as managing finances, food preparation, laundry, and housekeeping.
- Crossover Example: A PT might have a patient fold laundry while standing to address dynamic balance and neuro-tasking, even if they bill it as a balance activity rather than "laundry."
Documentation: Levels of Assistance
Note: Levels of assistance are determined by how much effort the patient puts in, not how much effort the therapist exerts. This ensures consistency across different therapists of different physical sizes.
- Independent: Patient performs transfers and gait without cueing, without an assistive device, and without special equipment.
- Modified Independent: Patient does not require physical or hands-on assistance but uses an assistive device (cane, walker, wheelchair). Even a completely capable person is categorized here if they use a device.
- Supervision: Patient requires assistance from another person to complete things in a timely manner or correctly, but the therapist does not need to be right next to them. This can include Providing verbal cueing/instructions from a distance (e.g., reminding a patient to lock wheelchair brakes).
- Standby Assist (SBA): The therapist is close enough to grab the patient/gait belt but is not touching them. The patient may require verbal or tactile cues for posture or muscle facilitation.
- Contact Guard Assist (CGA): The therapist has hands on the patient or the gait belt. This is used if the patient is a fall risk due to poor balance or weakness.
- Minimal Assistance (Min Assist): The patient performs or more of the activity. Only minimal physical assistance is required.
- Moderate Assistance (Mod Assist): The patient performs to of the activity.
- Maximum Assistance (Max Assist): The patient performs to of the activity.
- Example Calculations: If a -pound patient is Max Assist doing only of the work, the therapist is lifting pounds.
- Dependent (Total Physical Assist): The patient performs less than of the effort, or requires total physical assistance from one or more people/special equipment.
- Special Equipment: A sky lift (track system on the ceiling) is categorized as a dependent transfer.
- Clinical Note: Dependance is based on physical ability, not body composition. A -pound patient may be dependent due to the physics of the task and their lack of ability, just as a quadriplegic patient would be.
Standardized Tests and Performance Measures
- Patient Self-Reported Standardized Test: Patients identify three activities they find difficult due to their injury and rate them on a Likert scale.
- Objective Performance-Based Tests:
- Six-Minute Walk Time: A measure of endurance.
- Timed Up and Go (TUG): The only test where a patient can use an assistive device without being penalized for it.
- Functional Reach: A measure of balance and stability.
Community Ambulation Standards
- Hospital Discharge Cutoff: Often a patient is cleared for home discharge if they can walk feet in a straight line on a level surface.
- Medicare (CMS) Guidelines: Historically set at feet for community ambulation.
- Current Research/Literature: To be considered a true "community ambulator" capable of navigating real-world environments safely, a distance of feet is the realistic threshold.