PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2022;102:1–17

https://doi.org/10.1093/ptj/pzab281
Advance access publication date January 5, 2022
Perspective

Updated Integrated Framework for Making Clinical

Decisions Across the Lifespan and Health Conditions
Judith E. Deutsch, PT, PhD, FAPTA1 ,* , Kathleen M. Gill-Body, PT, DPT, NCS, FAPTA2 ,
Margaret Schenkman, PT, PhD, FAPTA3
1 Rivers Lab, Department of Rehabilitation and Movement Science, School of Health Professions, Rutgers University, Newark, New Jersey,
USA

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2 Rehabilitation Services, Newton-Wellesley Hospital, Newton, Massachusetts, USA
3 Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora,
Colorado, USA
*Address all correspondence to Dr Deutsch at: deutsch@rutgers.edu and @JudithDeutsch

Abstract
The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since
the publication of the first version in 2008. The original framework was proposed for persons with neurological health
conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition,
the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode
of care around the patient’s goals for participation; (3) explicitly describes the role of movement science; (4) reconciles
movement science and International Classification of Function language, illustrating the importance of each perspective to
patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient
management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low
back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female
librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is
proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan.
Keywords: Decision-Making: Clinical, Movement Analysis of Tasks, Movement System, Shared Decision-Making

Received: February 23, 2021. Revised: September 16, 2021. Accepted: October 26, 2021
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For
permissions, please e-mail: journals.permissions@oup.com
2 Clinical Decision-Making Across Health Conditions
Introduction
The Integrated Framework for Clinical Decision Making,
published in 2006,1 innovated clinical reasoning in neurolog-
ical physical therapy by being explicitly patient centered and
combining both enablement2 and disablement3 perspectives
of health, with an emphasis on a person’s role in society.4 It
incorporated the Hypothesis Oriented Algorithm for clinical
decision-making5,6 and was organized using the Patient
Client Management from the Guide to Physical Therapist
Practice.7 The framework was based on knowledge at that
time regarding neural plasticity. Motor learning, included
as a critical component of rehabilitation and task analysis,
was identified as central to the examination process. This
framework has been used over the last 15 years to organize
curricula of selected academic physical therapy programs.8 In
addition, it has been used specifically to teach neurological
content in physical therapy programs and for regional
courses taught by the Academy of Neurologic Physical
Therapy.
Since 2006, substantive changes have occurred in knowl-
edge, evidence, policy, and practice that make it timely to
update the Integrated Framework for Clinical Decision Mak-
ing. First, in 2013, the American Physical Therapy Association
(APTA) adopted a new vision for the profession of physical
therapy and identified the human movement system as the
“core of physical therapist practice, education and research.”9
Second, the third edition of the Guide to Physical Therapist
practice incorporated the International Classification of Func-
tion (ICF).10 Next, APTA, through task forces, academies,
working groups, and summits, has advanced the definition
and application of clinical reasoning,11–14 the human move-
ment system,15–17 and diagnosis.18,19 These initiatives have
focused the profession to define specific approaches to exam-
ining and managing movement system problems as they relate
to activity limitations and participation restrictions for all
individuals across the lifespan. The importance of framing the
plan of care to improve the patient’s ability to participate in
life roles also has come into sharper focus.
Literature on shared decision-making also has advanced
beyond patient-centered practice. In partnership with their
clinician, individuals are encouraged to consider the benefits
and harms of available treatment or management options,
communicate their preferences, and collaborate with clin-
icians to choose the course of action that best fits their
preferences.20,21 Taken into consideration are individual
preferences, abilities, self-efficacy, a person’s readiness to
change, and clinicians’ knowledge.22 Implementation of
shared decision-making into health care practice23 has
been adapted for physical therapy24 using evidence-based
strategies around communication, motivational interviewing,
and decision aids to increase the person’s knowledge and
options.25,26
Finally, the manner in which physical therapists use
evidence to guide practice has exploded with the publication
of physical therapy–specific clinical practice guidelines,27–29
clinical prediction rules,30,31 the integration of evidence-
based practice with clinical reasoning,32–35 and the growth
of knowledge translation and implementation efforts across
the profession.36,37 The availability of synthesis documents
and resources for practice (eg, EDGE task force materials for
examination,38,39 synthesis and implementation resources40 )
has also aided in clinical reasoning.41
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Figure 1. The Revised Integrated Framework illustrates the centrality of
the shared decision-making and the influence of both movement science
and the movement system in the reasoning process. The patient-client
management organizes the steps of the reasoning process. Hypothesis
generation occurs at each step. An episode of care may follow the steps
of the patient client management sequentially.
This manuscript describes the revised Integrated Frame-
work for Clinical Decision Making (Fig. 1), identifies the
emerging concepts and evidence that led to the revisions, and
extends the framework to persons with all health conditions.
Each step in the process is illustrated using 2 case examples:
a bus driver with low back pain and a librarian with postural
instability and falls. For those aspects of the framework
that have not changed, the reader is referred to the original
manuscript for details.1 Specifically, the revised Integrated
Framework of Clinical Decision Making:
a) applies to persons with any health condition across the
lifespan,
b) updates patient-centered concepts with shared clinical
decision-making,
c) frames the episode of care around the patient’s goals for
participation,
d) explicitly describes the role of movement science,
e) reconciles movement science and ICF language, illustrat-
ing the importance of each perspective to patient care,
f) provides a process for movement analysis of tasks, and
g) integrates the movement system into patient manage-
ment.
History and Interview
A key change in this revised framework is a focus on shared
decision-making. This client–therapist partnership begins dur-
ing the history and interview. The questions that the clinician
asks and the way they are phrased lays the groundwork for
collaboration. This approach is informed by the ICF, Gordon-
Quinn’s adaptation of the ICF,42 strategies from motivational
interviewing,43–45 and an appreciation of a person’s “readi-
ness to change.”46,47 A major focus is to understand the
patient’s perception of their condition, goals related to the
episode of care, and meaningful benchmarks of progress. It is
important to gain an appreciation of existing life constraints
or resources such as health insurance, home support, job
Deutsch et al 3

Table 1. Representative Probing Interview Questions to Promote Shared Decision-Making

Category Question
Physical therapist’s questions about why a Why are you seeking care?
patient is seeking care
What would you like to do? When was the last time you were able to do the activities
you desire? What are you able to do? What are you unable to do?
How limiting is the problem for which you are seeking care?
How long have you had this problem?
What do you think is contributing to this problem?
Are there other factors or health conditions that you think I should know about?
Patient’s goals What do you hope to achieve with therapy?
What would you consider as benchmarks (examples) of progress towards your goals?
Patient’s role in society What roles do you play (eg, at home, at work)?

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Patient’s resources and constraints
Patient’s preferences for solutions
How do the identified problem(s) interfere with your important home, work, and
social activities?
What are your prior physical therapy experience, knowledge of your health condition,
and recent physical activity?
What kind of assistance do you get on a daily basis from family and friends?
What additional assistance do you (or your family members, significant others) think
you need from family or others?
How feasible is access to health care—both financially and in terms of accessibility (eg,
distance, transportation, schedule, insurance coverage)?
How do you prefer to learn and remember (eg, verbal, written)?
What barriers might make it difficult for you to do what you need to do to participate
in therapy or reach your goals? What do you consider as facilitators to reach your
goals? How ready are you to assume an active role in managing your care? How
comfortable are you in changing a particular behavior that needs to change in order to
optimize your outcome from this episode of care?

flexibility, and access to health care. Examples of probing
questions, not recommended in a specific order, guide the
interview (Tab. 1).
To fully share decision-making, the clinician needs to
appreciate the patient’s preferences regarding their roles
and activities while considering what might be realistic for
the patient. This exchange of information, which occurs
throughout the episode of care, provides contextual insight to
the clinician regarding the individual’s specific situation and
provides insight to the person regarding likely expectations
and time frames.
In parallel with gathering information during the interview,
the physical therapist observes the person’s spontaneous
movement, which can inform tasks and tests/measures to be
included in the systems review and examination. Likewise,
observations and queries related to cognition, learning
style, and preferences are important for the scope of the
intervention.
Systems Review
The second major change in this revised framework is the
organization of the systems review using the 6 body sys-
tems that comprise the movement system (cardiovascular,
pulmonary, integumentary, musculoskeletal, endocrine, and
nervous).17 The systems review systematically rules out body
systems with which the physical therapist need not be con-
cerned, identifies those that are resources for the patient,
guides choices regarding which aspects of the remaining body
systems impact movement, and identifies if referral to another
health care provider is indicated.10 An existing component of
the systems review, obtained for all patients, is the minimum
data set (vital signs [heart rate, blood pressure], height, weight,
orientation, attention, communication ability, and learning
style).10
The systems review must be tailored to each person and
includes information obtained from a variety of sources
(eg, medical record, health history questionnaire, subjective
report, direct assessment). Targeted questions during the
interview process can identify unknown or unreported
health conditions as well as signs and symptoms that could
suggest alterations in function in specific body systems. Some
examples of such targeted interview questions are provided
(Tab. 2, middle column). Other information is obtained by
direct assessment; examples of useful tests/measures are
presented (Tab. 2, right column).
The clinician determines the combination of targeted ques-
tions and screening tests and measures that are useful for each
patient. Because sources of information vary across individu-
als, the order of obtaining information is person specific. On
completion of the systems review, the clinician can generate
an initial hypothesis related to the patient’s movement limita-
tions and makes preliminary decisions regarding the specific
activities that need to be examined and the tests and measures
that will be included in examination. The history and clinical
reasoning during systems review are demonstrated for 2 cases:
a bus driver with low back pain and a librarian who incurred
a recent fall and injury (Tab. 3).
Examination
Regarding examination, major changes include the blending
of both ICF and movement science terminology and concepts,
the process of dissecting a participation goal into compo-
nent activities, and the movement analysis of activities and
tasks. The purposes of the examination are to (1) collect
baseline data on participation and activity that will be used
to determine clinical outcomes of the episode of care and
(2) obtain data from movement observations-analyses and
4 Clinical Decision-Making Across Health Conditions

Table 2. Sources of Information for a Systems Review That Integrates the Movement Systema

Medical Record Review, Medical Screening Questionnaire,

Body System Screening Tests and Measures
and History and Interview
Cardiovascular Known health condition? Heart rate
Shortness of breath? Blood pressure
Chest pain or pressure? Temperature at hands and feet
Sense of irregular heartbeat? Lower extremity edema
Leg cramps with ambulation? Pedal pulse
Slow healing wounds? 2- or 6-min walk test
Pulmonary Known health condition? Breathing pattern
Shortness of breath? Respiratory rate
Difficulty breathing? Color of nail beds and lips
Cough? Oxygen saturation

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Wheezing? 2- or 6-min walk test
Integumentary Known health condition? Skin color, integrity, and pliability
Open or healing wounds? Wound/scar inspection
Musculoskeletal Known health condition? Gross AROM and strength
Joint pain, swelling, or stiffness? Posture and symmetry
Weakness? Joint temperature
FTSTS
Joint alignment
Endocrine Known health condition? FACIT Fatigue Scale
Fatigue? 2- or 6-min walk test
Recent weight loss or gain?
Usual level of blood sugar when checked (diabetes)?
Nervous Known health condition? Gross sensory screen
Numbness or pins and needles? Reflex tests
Weakness? Romberg Test/SLS
Dizziness? Myotome/dermatome tests
Problem with balance/falls? Gait observation or TUG
Headaches? FTSTS
Loss of consciousness? Tandem walk
Visual changes? ABC Scale
Cognition, affect, behavior?
aA standardized approach to systems review involves assessing all 6 body systems that comprise the movement system (left column). The systems review
can be performed by using a combination of medical record/questionnaire review and targeted interview questions that address each body system (middle
column) as well as tests/measures (physical examination elements or self-report measures) administered by the physical therapist (right column). Examples of
commonly used interview questions and examination tests/measures related to the 6 body systems are presented. ABC = Activities-Specific Balance Confidence;
AROM = active range of motion; FACIT = Functional Assessment of Chronic Illness Therapy; FTSTS = Five-Times Sit-to-Stand Test; TUG = Timed “Up &
Go” test.

tests/measures of activity and Body Function Structure (BFS)
that will inform the evaluation, diagnosis, and prognosis. In
this revised integrated framework, we explicitly reconcile the
differences in language that exist between the ICF and move-
ment science and clarify how each perspective contributes to
clinical decisions.
The World Health Organization proposed the ICF as the
current model of health in 2001.2 ICF concepts and language
were incorporated into the third edition of the Guide to Phys-
ical Therapist practice, replacing the previous World Health
Organization disablement models and terminology found in
the first edition of the “Guide.”71
Movement science was proposed as a basis for physical
therapist practice by Carr and Shepherd72 in 1987 and is
informed by biomechanics, kinesiology, psychology, and neu-
roscience.73 Motor control and motor learning are distinct
areas of study within the field of movement science. Many
motor control theories have been described to guide the
examination of movement. A current theory, the “systems
theory,” frames motor control by examining the relation-
ship between internal attributes of the person (eg, cognition,
perception, and action) and how these interact with the envi-
ronment and the attributes of the specific movement or task.74
Movement science terminology provides useful language and
tools for physical therapy that are not provided by the ICF. We
acknowledge the value of both sources. In this version of the
framework, we consider the words “tasks” (motor learning)
and “activities” (ICF) as synonyms.
To combine the ICF and movement science concepts into
the examination of goal-directed motor behavior, we propose
that clinicians follow this 3-step process (Fig. 2).
The clinician’s first step is to dissect the person’s partici-
pation goal into relevant component activities (ICF) or tasks
(movement science) in the context of their personal factors,
identifying what the client is both able and unable to do.
Activities that the clinician identifies as resources (able to do)
need no further examination; those that are not performed
successfully or efficiently require movement observation and
are interpreted through a “movement analysis of tasks”
(Step 2).
Consider the person with chronic low back pain who wants
to participate in their role as a bus driver (case example 1,
Tab. 3). Achievement of this goal requires that the person
performs the following activities: driving, stopping at the
required points to collect and deposit passengers, opening
and closing the bus door, inspecting passengers as they pay,
Table 3. Case Examples Illustrating the Revised Integrated Framework of Clinical Decision-Makinga

Category Case Example 1 Case Example 2

Patient overview
Deutsch et al

Description of patient The patient is a 45-y-old man employed as a New York City bus The patient is a 66-y-old woman employed part time as a librarian.
driver. He has 2 teenage daughters and lives in a second-floor walk-up She has had 3 falls in the last 6 mo. Her last fall was 4 wks ago and
apartment with his wife, who is a guidance counselor at a high school. resulted in a wrist fracture for which she is currently casted. She is
This patient has had intermittent, localized LBP for the past 5 y, but referred for evaluation of her gait and balance. She lives with her
this time, the pain in his back has persisted for 2 mo. He is currently spouse in a 1-level home. The spouse is retired and has assumed
not working and is unable to sleep through the night. household tasks since the fracture. She has been out of work for the
past month and is eager to return.
Walks into appointment at a slow pace. Sits down slowly and shifts Walks into appointment independently, with no device, at a slow pace,
away from right lower extremity. with B foot slap, and carrying purse. Able to walk and talk.
Statements from patient “I know that it is important to lose the weight, but I am really not sure “I need to return to work as soon as I can because we depend on my
that I can do it. I have tried so many times and failed.” “I miss being income.” “I really miss my walking club friends; I haven’t seen them in
more active and playing ball with the guys.” “I want to do it but just a while.”
have to find the time to get it back into my routine.” “I am the sole
breadwinner and really need to get back to work.”
Medications Lipitor, lisinopril, Aleve Insulin, Synthroid, Tylenol PRN, calcium with vitamin D
Patient’s goals
For episode of care Resume full-time bus driver duties (participation) Resume librarian duties (participation)
Play basketball with the neighborhood guys (participation) Avoid future falls (activity)
Benchmark Get a full night of sleep (activity) Resume independent outdoor walking with confidence (activity)
Resume part-time bus driver duties (participation) Resume limited meal preparation (participation)
History and interviewb Sitting for too long (>1 h), especially on the bus, bothers his back. He Falls have mostly occurred outside the home, when she was walking or
has difficulty with prolonged standing and has stopped playing turning on an uneven surface. The most recent fall was the only fall
basketball. He is physically uncomfortable with the size of his gut and with an injury; it occurred when she was reshelving books at work.
weight gain. He went to his primary care physician, who did blood She reports intact hearing and vision. Since her fall, she has
work and ruled out any systemic problems; a spine radiograph showed discontinued daily outdoor walking with friends.
degenerative arthritis.
Systems review
Minimum data set Alert and oriented × 4 (person, place, time, situation); Alert and oriented × 4 (person, place, time, situation);
height = ∼1.7 m [67 in]; weight = ∼90 kg [200 lb]; follows directions height = ∼1.6 m [63 in]; weight = 68 kg [150 lb]; follows directions
well and communicates clearly well and communicates clearly
Medical history High cholesterol, HTN, chronic left ankle sprains Type 2 diabetes, knee OA, and hypothyroidism
Review of body systems
Pulmonary Denies issues Denies issues
Integumentary Denies issues Denies issues
Cardiac HTN Denies issues
Musculoskeletal Ankles feel wobbly sometimes; back is stiff after prolonged sitting Denies pain but reports early-morning knee stiffness that typically is
reduced by midmorning and returns after 30 min of sitting
Endocrine Denies fatigue Blood sugar levels are in range, and patient checks levels every other
day
Neurologic Denies any referred pain or feelings of tingling or numbness Reports numbness, tingling, and heaviness in both feet; denies dizziness
Tests and measures
Rationale for selection of screening Screen for possible: Screen for possible:
tests and measures lower extremity strength deficit Cardiac, pulmonary, or integumentary system deficits
Fear of returning to work Possibility of LE pain or weakness affecting performance of tasks
LE sensory deficit Level of fall risk
Rule out structural deformity

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Table 3. Continued

Category Case Example 1 Case Example 2

Tests and Measures Cardiovascular: HR = 76 bpm, BP = 125/75, RR = 12 bpm
Neuromuscular: sensory integrity—B LE WNL for sharp/dull and deep
tendon reflexes
Musculoskeletal: standing posture—posterior pelvic tilt, rounded
shoulders
Combined system measures: FTSTS = 12 s
Other: FABQW = 10
Initial hypotheses
Hypothesis 1 Patient may have a combination of trunk weakness, incoordination,
and low endurance coupled with poor posture, resulting in decreased
tolerance for prolonged sitting while driving, resulting in back pain.
Hypothesis 2 Patient’s sleeping position may influence LBP and decreased tolerance
for standing for playing basketball.
Hypothesis 3 Patient may have residual balance and force generation deficits in the
ankle that compromise basketball playing.
Further movement observation and analysis are needed for bus driving
tasks: sitting simulation, sit-to-stand transitions, ascending and
descending stairs, observation of sitting and sleeping positions, and
specific tests of motor control and strength of trunk and LE as well as
neuromuscular endurance of the trunk.
Examination Strategy: MCF
Observation of movement during Sitting in driving simulator: narrow base of support, lumbar spine
tasks/activities slides into a posterior tilt of pelvis, resulting in LS flexion, after 2 min
in the position
Sit-to-stand transitions related to bus driving: unable to perform
without using UEs, amplitude of trunk extension is decreased during
execution; trunk does not achieve full extension on termination
Cardiovascular: HR = 76 bpm, BP = 126/80, RR = 16 bpm; intact
pedal pulses
Integumentary: normal skin color and integrity
Musculoskeletal: standing posture—mild B genu varum, ∼10-cm
(4-in) BOS
Combined system measures: FTSTS = 16 s, ∼20.25-cm (8-in) BOS, no
symptoms; TUG (no device) = 15.3 s, slows on turns
Other: ABC Scale = 60%
Patient moves slowly and appears hesitant during functional tasks; this
behavior may reflect reduced balance confidence.
Patient may have reduced distal LE strength and sensation that affects
her balance and gait.
Further movement observation and analysis are needed for selected
core tasks and work-related tasks (reaching to surfaces at various
heights, walking while pushing a cart, stair-climbing, and standing
activities with UE tasks), and specific tests of postural control, LE
flexibility and strength, and sensory integrity (especially in LEs).
Strategy: MCF and ANPT Framework
Sit-to-stand transitions: the patient is hesitant to perform without UE
support, but with encouragement and close supervision, she can
initiate, execute, and complete the task in a stable manner; execution
(rising to stand) is slow, and the patient reports that it is difficult to
rise without using UEs to assist.
Reaching in standing to place an object (book) from a cart to a shelf at
knee, waist, and overhead levels:
- Able to reach ∼15.25 cm (6 in) and place an object on a shelf at
waist level in a typical manner without support/difficulty
- Able to reach ∼15.25 cm (6 in) in forward and diagonal directions at
low/high levels before needing UE support; grasping and manipulation
of an object are typical; during execution of reaching in any direction,
reduced weight shift and increased trunk lean are noted
- When reaching more than ∼15.25 cm (6 in) in any direction, the
patient widens the BOS at initiation and requires UE support to
complete the task.

(Continued)
Clinical Decision-Making Across Health Conditions

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Table 3. Continued
Deutsch et al

Category Case Example 1 Case Example 2

Ascending and descending stairs: alignment and direction of the trunk
show excessive flexion from initial conditions through termination,
more prominently with descending stairs; asymmetry of movement
with decreased movement speed and amplitude of the entire right LE
while unweighted with ascending stairs
Sleeping positions in bed: preferred initial position is supine with knees
bent; rolling to lying on a side occurs without trunk dissociation
across the spine and pelvis and with the use of UEs; moving from lying
on a side to sitting relies on the use of UEs
Basketball: to be examined later
Tests and measures
Participation Oswestry Disability Index = 13/50 = 26% (moderate disability)
Activity 6-min walk test (500 m)
Body structure and function Neuromuscular
Balance: SLS = 35 s on right, 15 s on left
Posterior lumbar trunk muscle endurance using the Biering-Sorenson
Test: 125 s
Musculoskeletal
Soft tissue: increased resistance to stroking and skin rolling at B
paraspinals, L4–S1
Mobility-ROM
SLR No symptoms 0–65 degrees (−): B
- Positive Thomas Test: with −10 degrees of hip extension
- B pectoralis minor length = ∼3.2 cm (1.25 in)
- AROM: hip = WNL throughout
- Lumbar flexion (fingertip to floor) = 12 cm; lumbar extension = 20◦
- Side bending (fingertip to thigh) = 17 cm
Muscle performance (MMT):
- B UE generally = 5/5, except parascapular muscles = 4/5
- LEs = 5/5, except hip extension = 4/5, hip abduction = 4/5, and right
ankle = 4/5
- Lower abdominals = 3/5
Walking
- Walks forward on a level surface at a slow pace with an ∼15.25 cm
(6-in) BOS, B feet flat at initial contact, and B short steps; speed
decreases further during turning (10 steps to turn), on unlevel surfaces,
or when carrying an object; pauses before stepping over an ∼10-cm
(4-in) box; unsteady (increased trunk lateral movement) when walking
on a narrow (∼10-cm [4 in]) path and uses UE to regain balance
(wall). [Walking while pushing a cart: to be examined later]
Stair climbing
- Performs with 1 rail and using foot-over-foot pattern at a slow speed
- Ascent—steps up with B increased hip flexion and reduced DF
- Descent—uses UEs for significant weight bearing; performs 1 step at
a time
- Reports fear of falling with the task
Activities-Specific Balance Confidence Scale = 60%
Functional Gait Assessment = 18/30
Gait Speed = 0.8 m/s
TUG manual = 16.3 s, slow on turns
TUG cognitive = 16.7 s
Musculoskeletal
AROM: hips = WNL; B knees = 5◦ –100◦ ; ankle DF = 5◦ with knee
extended, 10◦ with knee flexed; PF, inversion, and eversion = WNL
Muscle performance (MMT): B hips = 5/5; B knee flexion and
extension = 4/5; B ankle DF and PF = 3+/5
Neuromuscular
Sensory integrity:
- Impaired response to light touch in B LEs distal to knees (3/5 correct
responses)
- Reduced proprioception in B great toes (2/5 correct responses)
Steady-state postural control:
- Independent in sitting/standing with self-selected BOS
- Standing with feet together and EO/EC = 30 s, minimal sway
- B tandem stand with EO = 4 s; uses UEs to avoid falling
- B SLS with EO = 2–3 s
Anticipatory postural control:
- With alternating toe tapping, catches B toes on step in 4/10 trials
Reactive postural control: During tasks/activities (above), ineffective
stepping responses in forward and backward directions; effective hip
strategies; ankle strategies effective 50% of the time

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Table 3. Continued

Category Case Example 1 Case Example 2

Evaluation The patient is a 45-y-old man who is a New York City bus driver with The patient is a 66-y-old active woman with a history of falls and
LBP. His goals are to return to work, sleep better, and resume recent fracture. Her goal is to return to work as a librarian. She has a
recreation. He is in the contemplation phase for changing his diet and high degree of motivation but reduced confidence in her ability to
the preparation phase for increasing physical activity. He performs return to her job. She performs tasks that require reaching to high/low
job-related tasks with a flexed posture and a lack of extension in levels, turning, and stair-climbing slowly and hesitantly. For some but
movement termination, impaired sequencing between movements, and not all tasks, she requires UE support to be stable.
some asymmetry in standing tasks.
Standardized tests reveal moderate disability with no fear avoidance Standardized tests reveal that current level of fall risk is high when
behavior. walking without a device on level surfaces, which is her current level
of ambulatory function.
Deficits in trunk strength endurance and coordination result in poor She has deficits in both anticipatory and reactive postural control;
biomechanics when holding positions and moving into positions. Soft factors contributing to her falls likely include impaired sensory
tissue and joint mobility limitations as well as force generation deficits integrity, reduced strength, and limited flexibility in B distal LEs.
interfere with both posture and active movement of the trunk.
Diagnosis Deficits in trunk and LE movement stability and sequencing and Deficits in anticipatory and reactive postural control
asymmetry related to impaired force generation, neuromuscular
endurance, and pain
Prognosis
Related to health condition Recurrent LBP = guarded; chronic LBP recurs and is exacerbated by Falls = guarded; diabetes is a progressive health condition and a major
lifestyle choices; score on Biering-Sorenson Test and weight are risk factor for falls50
predictive of recurrence48,49
Related to goals for episode of care Return to work and recreational basketball = good; there is no fear Return to work = good; balance and gait training, in addition to
avoidance for work,51,52 and there is a high degree of motivation; resistance exercise, can help reduce falls54 and improve balance
motor control, force generation, and endurance deficits are amenable confidence55
to rehabilitation53
Plan of care
Direct intervention Mobility and stretching (joint and muscle length and soft tissue) of Functional task retraining,57 including reaching, gait on various
trunk and LEs56 surfaces, turns, and possible trial of ankle-foot orthoses/assistive
devices
Trunk activation and motor control exercises for the trunk56,58 Reactive59,60 and anticipatory61 balance training during functional
tasks
Work hardening for driving tasks62,63 Resistive exercises for B LEs,64 including repeated sit-to-stand tests
with various BOS values and levels of load/resistance
Force generation practice during LE and trunk activities63,65 Calf-stretching exercises
Prevention, health promotion, and Physical activity for conditioning56,55 and establishing smart goals66 Integumentary management
wellness
Assessment for return to basketball Walking program
Motivational interviewing to progress beyond contemplation phase for
diet and referral to nutritionist67
Education Body mechanics for sitting and driving Fall risk reduction strategies, including environmental factors
Positioning for sleeping Role of exercise in managing diabetes
Self-management and pain science68 Strategies to address low balance confidence69,70
a
ANPT = Academy of Neurologic Physical Therapy; AROM = active range of motion; B = bilateral; BOS = base of support; BP = blood pressure; bpm = beats/min; DF = dorsiflexion; EC = eyes closed; EO = eyes
open; FABQW = Fear Avoidance Beliefs Questionnaire—Work; FTSTS = Five-Times Sit-to-Stand Test; HR = heart rate; HTN = hypertension; LBP = low back pain; LE = lower extremity; OA = osteoarthritis;
MCF = Motor Control Framework; MMT = Manual Muscle Test; PF = plantar flexion; PRN = as occasion requires; RR = respiratory rate; SLR = straight-leg raise; SLS = single-leg stand; TUG = Timed “Up &
b
Go” Test; UE = upper extremity; WNL = within normal limits. History and interview were abbreviated and were related to this episode of care.
Clinical Decision-Making Across Health Conditions

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Deutsch et al 9

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Figure 2. Examination consists of complementary processes of dissection of the participation goal into relevant activities, movement observation and
analysis of tasks (using 3 frameworks: biomechanics, Motor Control Framework and Academy of Neurologic Physical Therapy [ANPT] Framework),
hypothesis generation related to body function structure (left side), and administration of tests and measures (right side). The influences of International
Classification of Function (icf) with personal factors (orange) and the environment (grey) are represented with dotted circles.

observing behavior on the bus, following a route, ascending
and descending the stairs on the bus, walking to and away
from the bus at the start of the shift, and sitting for prolonged
periods of time. All these tasks take place under different
environmental conditions (eg, weather, driving terrain, and
traffic patterns). The bus driver needs to move and func-
tion in both a moving environment as a stationary person
while performing some upper extremity manipulation tasks
and in a stationary environment as a moving person with
upper extremity manipulation tasks. The contribution of the
environment is integral to the identification and subsequent
movement analysis of tasks. For a person to return to driving a
bus, they must be competent in all these component activities.
Similarly, for a person to return to work as a librarian (case
example 2, Tab. 3), activities such as walking while pushing
a cart, bending and lifting while holding books, reaching in
various directions to place books on/off shelves at different
heights, etc must be performed competently. Table 3 illustrates
how the participation goals for the person with low back
pain and the librarian are reflected in the activities that are
examined.
A third example is an adolescent soccer player (mid-fielder)
3 weeks after a grade 2 talofibular sprain whose participation
goal is to return to play. For this person, the relevant activities
would include sprinting, dribbling, running in multiple direc-
tions, passing, receiving a pass, shooting on goal, and heading
the ball. These activities need to be examined on surfaces
that resemble the soccer pitch and under weather conditions
consistent with a game (eg, sun at different angles, rain and
cold, very hot weather).
In the second step, the physical therapist performs a move-
ment observation and analysis of the relevant tasks that
have been identified as important by the person and the
clinician (Fig. 2, left side). The term “tasks” is used here
from movement science to be consistent with “task analysis”
and “task specific training.” Movement Analysis of Tasks
begins with movement observation, followed by interpreta-
tion/analysis of how the task was performed and leads to
the generation of hypotheses of underlying body structure–
function impairments. This information about the patient’s
movement is then analyzed and compared with what is known
about typical performance of the relevant tasks under vari-
ous environmental and contextual conditions to identify the
specific aspects of movement that are problematic for the
patient.
In the first iteration of the framework, a simplified version
of Gentile’s taxonomy was offered as a tool to examine
the patients’ movement (stationary or moving) relative to
the environment (stationary or moving); this approach
provided a systematic progression of complexity.1,75 We
now extend the environment construct to incorporate the
additional considerations (physical, social, and attitudinal)
included in the ICF. When feasible, movement analysis of
activities-tasks should be examined in the environmental
context in which the person executes them. For example, in
the case of the bus driver (Tab. 3), examination of driving
could be performed in a simulated driving environment
to reproduce all the contextual cues. In the case of the
librarian (Tab. 3), locomotion and reaching tasks can be
assessed in the clinic using a mobile cart, shelves, and light
objects.
The clinician then generates hypotheses about what
may interfere with typical movement performance. Several
approaches to the movement analysis of the tasks are
10
available, such as biomechanical analyses across the lifespan
and health conditions,76–81 the Motor Control Framework
(MCF),82 and, more recently, the Academy of Neurologic
Physical Therapy (ANPT) Framework.83
In the first iteration of the integrated framework, we used
the MCF described by Hedman and colleagues82 in combi-
nation with Gentile’s taxonomy75 to guide movement obser-
vation and analysis. In this iteration of the integrated frame-
work, we expand the movement analysis of the tasks to
also include the approach recently recommended by ANPT
Movement System Diagnosis-Movement Analysis Task Forces
Framework (ANPT Framework).83 The ANPT Framework
expands the original taxonomy described by Hedman and
colleagues and furthermore defines specific “observable con-
structs of movement” that can be analyzed across tasks. These
constructs of movement, when considered together, reflect
what we refer to as “movement control.” Of importance,
this concept of movement control goes beyond the BSF and
activity categories of the ICF and is integral to the role of the
physical therapist as the movement specialist.
To date, the ANPT Framework has been applied to assess
the performance of 6 core tasks (sitting, sit-to-stand, stand-
ing, step up/step down, walk and turn, and reach/grasp/-
manipulate), but it may also be applied to other tasks (eg,
those relevant to examining high-level athletic performance,
age-appropriate motor development, etc). In the case exam-
ples presented in Table 3, the MCF is primarily used for
the movement analysis of tasks for the bus driver, while a
combination of the ANPT/MCF frameworks is used for the
librarian.
The third step in the examination process is to identify
body function/structure limitations that may interfere with
optimal movement and activity-task performance. To this
end, the clinician generates hypotheses from the movement
analysis of tasks (Step 2). These hypotheses may be tested
by combining movement observations with modification to
the environment as well as conducting relevant tests/mea-
sures (right side of Fig. 2). For example, the clinician may
change the height of the chair during sit-stand to differentiate
between a force generation deficit or a range of motion
limitation. Known relationships between body function struc-
ture limitations and activity-task performance guide this pro-
cess.84,85
Tests and Measures
The use of tests and measures (right side of Fig. 2) com-
plements the participation goal dissection and movement
analysis of tasks (left side of Fig. 2). APTA and its academies
have compiled and recommended standardized tests/measures
across multiple practice areas and clinical settings86–88
and health condition–specific clinical practice guidelines.
For example, the case example of a person with low back
pain (Tab. 3) demonstrates application of recommendations
regarding activity, participation,89 and physical90,91 and
mental body function structure measures92 from the first
physical therapy–specific clinical practice guidelines on low
back pain.93
The proposed sequence of the examination process as
described above is not obligatory. For example, a person
in the ICU with multiple trauma from a car accident and
loss of consciousness may not be able to communicate or
move without maximum assistance. For this person, the
relevant participation goals may need to be negotiated with
Clinical Decision-Making Across Health Conditions
the caretaker. The limitations of purposeful active movement
may lead the clinician to directly assess cognition and range
of motion, bypassing a movement analysis of tasks during the
initial encounter. As the individual recovers, the clinician can
then assess those activities that the person can attempt and
that are consistent with their participation goals. A second
example is a person with an acute total hip arthroplasty; the
clinician may examine range of motion, strength, and edema
prior to examining bed mobility, sit-to-stand, and gait.
Throughout the examination process, clinicians continue
to refine hypotheses about the relationship between the par-
ticipation goal, activity requirements, movement analysis of
tasks, and contributing body function/structure limitations,
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all within the context of environmental and personal factors.
The results of the examination combined with the history
and systems review guide the evaluation and diagnosis. The
hypotheses generated throughout the examination process for
2 cases are described in Table 3.
Evaluation
In this iteration of the revised framework, we focus on inte-
grating each person’s movement ability into the evaluation
process, an element of decision-making that, to our knowl-
edge, has not been described to date. To achieve this, the
clinician should first identify which of the 6 identified body
systems, as components of the movement system, contribute
to the patient’s activity/participation limitations, which body
systems are not involved, and which body systems may be
enhancing activity/participation.
Next, as outlined by the ICF2 and elaborated on by oth-
ers,94 it is imperative for the clinician to identify any rel-
evant personal or environmental factors that impact, in a
positive or negative manner, the person’s ability to achieve
their stated goal or participate fully in rehabilitation. The
assessment of task-activity performance, as described above
in examination, adds the movement observation of tasks
to identify underlying movement control limitations. The
movement control factors underlying the person’s difficulty
with performed desired tasks and roles must be specifically
identified. Factors proposed by the MCF and the ANPT Task
Force include movement accuracy, symmetry, sequence and
timing, speed, smoothness, and amplitude as well as stability,
verticality, body alignment, and symptom provocation.81–83
Additional factors that affect task performance may relate
to body function structure limitations such as the muscu-
loskeletal system (muscle performance,95 joint hyper/hypo-
mobility) or the cardiovascular or pulmonary systems (activity
tolerance). It is also important to determine if the person’s
task performance is consistent or changes across various
environmental conditions. For example, a person post-total
knee replacement may demonstrate similar difficulty rising
to stand from a low seat at home or at the barber shop
if the factors underlying task performance are deficits in
muscle performance and knee flexibility. In contrast, a person
with Parkinson disease may be able to walk safely within
a quiet, familiar environment but not in the community if
the key movement-related factors underlying walking are
decreased movement speed and impaired dual-task ability and
endurance.
This evaluation summary linking participation and activity
restrictions to movement control factors and impairments in
body structure/function is discussed with the person, rein-
forcing the ongoing shared decision-making. Analysis of the
Deutsch et al
contribution of the primary movement control and body func-
tion/structure deficits contributing to the person’s limitations
is illustrated by the 2 case examples (Tab. 3).
Diagnosis
Perspectives related to diagnosis made by physical therapists
have changed substantially since publication of the first frame-
work. These changes were driven by the profession arriving
at a definition of the human movement system, recognition
that movement analysis of tasks is a critical component of
the examination, and ongoing efforts to develop agreed on
movement system diagnoses, referred to as diagnostic labels.
To date, only a limited number of diagnostic labels have been
proposed30,31,96–104 ; further work will be required to arrive
at useful diagnostic labels that can be used in a consistent
manner by health professionals, for all health conditions, and
across the lifespan.105
Identifying the movement system diagnosis for each patient
extends the clinical reasoning process because it requires
the clinician to consider all available information about the
person and clearly identify each person’s primary movement
control problem(s), independent of health condition or age.
This step in the clinical reasoning process differs from what
is currently reflected in the Guide to Physical Therapist Prac-
tice, which states that “a diagnosis is typically made at the
impairment, activity and participation levels.”10 In fact, we
are proposing that the movement system diagnosis may reflect
both movement control attributes and underlying body struc-
ture/function impairments. We acknowledge the importance
of linking together findings related to the person’s impair-
ments, activity, and participation as well as to the patient’s
goals as described in the evaluation section above. In contrast,
however, our use of the term movement system diagnosis
(label) identifies the primary underlying cause(s) of movement
dysfunction, which may affect multiple activities. This change
is important because the step of identifying and labeling
the primary causes of the movement problem focuses the
intervention clearly on those movement deficits (and their
underlying contributing factors) that are likely to have the
greatest impact on participation.
We envision that movement system diagnoses, as they con-
tinue to be developed, will be best labeled at the level of
movement control and/or at the level of impairments in body
structure/function, and that each diagnosis will be associated
with a clear description of the movement control charac-
teristics and body structure/function impairments associated
with the diagnosis. The diagnosis we propose for the bus
driver with low back pain identifies deficits in both movement
control characteristics (ie, sequencing, asymmetry) and BSF
impairments (ie, force generation, neuromuscular endurance,
and pain). In contrast, the diagnosis proposed for the person
with frequent falls is solely at the level of movement control
(ie, deficit in anticipatory and reactive postural control).
Individuals with the same health conditions may present
with different movement system diagnoses. For example, the
person with frequent falls (case example 2, Tab. 3) with a
diagnosis of “deficits in muscle performance” would lead the
clinician to choose intervention strategies primarily aimed at
improving strength. In this example, intervention plans would
be focused differently than what is outlined in Table 3, even
though the health condition and presenting history may be
the same.
11
Goals
Goals for rehabilitation should relate to the person’s partici-
pation in relevant life roles or activities and must be carefully
identified to target their reported concerns and participation
limitations. In this revision of the integrated framework, we
emphasize how to use a shared decision-making approach to
arrive at agreed on goals, emphasizing meaningful benchmark
goals that indicate progress at participation and activity levels.
In the context of shared decision-making, the clinician and
patient should revisit the person’s initially stated goals to
determine if they are realistic and appropriate. Information
obtained during the systems review and examination, includ-
ing movement analysis, guides this process along with acuity
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and severity of the health condition and other comorbid con-
ditions. In addition, the clinician and patient together carefully
consider the main concerns and aspirations as well as environ-
ments in which the person functions and life circumstances
(eg, relevant personal and environmental factors) that might
impact their ability to participate in or respond to rehabilita-
tion. Early in the episode of care, the patient should identify
realistic “benchmark goals” or improvements in activity/par-
ticipation that they consider meaningful progress (Tab. 3).
If a patient does not articulate the goals at the level of
participation (eg, goal is to walk, without any context), the
clinician assists them to relate their stated goals to important
life activities. If a patient’s stated goals are inappropriate or
unrealistic, the clinician assists them to identify additional
goals that are central to improving the person’s desired activ-
ity and participation or are preventative. Taking all these
factors into consideration, the clinician and patient may need
to renegotiate goals at this point in the episode of care to
arrive at mutually agreed on, meaningful to the person, and
realistic goals to achieve within the available time frame.
Examples from the cases presented in this article include goals
for individuals related to both return to work and return to
recreational activities (Tab. 3).
To facilitate shared decision-making, the clinician can share
data regarding best practice and typical outcomes related to
the patient’s condition. In addition, a growing body of health-
or condition-specific decision aids can assist individuals seek-
ing care to participate in an informed manner. For example,
the Ottawa Personal Decision Guide25 may help the person
with low back pain (Tab. 3) prioritize the return to work
and sleep goals before the recreation goal. It should be noted
that many decision aids are still being vetted for quality and
efficacy.106–108
Prognosis
Prognosis is based on the patient’s goals, with an emphasis on
those related to activity and participation. Prognosis should
be specific for each goal (eg, goal of walking in the house may
have a different prognosis than goal of walking in the commu-
nity). To determine prognosis for activity and participation,
the clinician synthesizes knowledge from the examination,
health condition, foundational knowledge, theory, evidence,
and experience.
Consider, for example, a person who sustained a lower limb
amputation due to dysvascularity (eg, diabetes). The person’s
goal is to return to work within 4 months to a job that requires
walking. Regarding the health condition, consideration is
given to the expected level and rate of recovery based on evi-
dence. Issues to consider include the nature of the pathology
12
Figure 3. Plan of care organized at a high-level using the Guide to
Physical Therapist Practice. It incorporates the language of the
International Classification of Function (ICF). Interventions are based on
movement science and physiology principles. The process uses shared
decision making.
(in this case, dysvascularity) as well as stage, acuity, and tissue
irritability. The clinician draws on substantial information
about morbidity and mortality associated with lower limb
amputation.109–112
To determine prognosis with regard to benchmark goals
related to activity (walking) and participation (return to
work), the clinician draws on available data such as those
related to likelihood and timing of achieving independent
ambulation within 1-year post amputation,113 likely average
daily steps, and114 likely overall level of disability.114–116
The clinician keeps these types of data in mind when
assessing likelihood that this person will have sufficient
walking capacity at 4 months to return to work but tempers
expectations with respect to important modifiers that may
be facilitators or barriers to recovery. These modifiers
may include presurgical activity and endurance, previous
engagement and success with physical therapy, access to
rehabilitation services, and support. The clinician also
considers resources and constraints based on personal factors
(eg, their social, emotional, and motivational status) and
environmental factors. Prognosis statements are provided for
both case examples in Table 3.
Plan of Care
The plan of care (POC) focuses on the patient’s participa-
tion goals and related activities and body function/structure
requirements and is based on results of the examination,
evaluation, and movement system diagnosis. Elements that
are new to this revised framework include (1) application of
evidence-based shared decision-making to identify and select
options for intervention; (2) use of the movement system diag-
nosis to guide intervention; (3) recommendation to include
wellness and prevention in every plan of care; (4) application
of task-specific training for all health conditions and across
the lifespan; and (5) intervention at the body function struc-
ture level guided by the physiology of tissue healing and the
Frequency, Intensity, Time and Type (FITT) principle117,118
(see Fig. 3).
Clinical Decision-Making Across Health Conditions
Evidence-based Shared Decision-Making
The shared decision-making conversation in the POC focuses
on the clinician identifying evidence-based options for treat-
ment that are then selected and agreed on with the patient.
Examples of options that can be offered to the patient include
choices among different appropriate interventions, how often
to attend clinic-based visits, and how to best structure a
realistic home exercise program.24
Movement System Diagnosis to Guide Intervention
The shared decision-making conversation also includes the
explanation of the movement system diagnosis and how to
address it. Individuals with the same health condition may
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have different movement system diagnoses. We include in
Table 3 possible diagnostic labels for the bus driver and
librarian case examples and then outline an appropriate POC
for each example based on the diagnosis. In the low back
pain case example, the person has a movement system diag-
nosis of “motor control deficits.” Another individual with the
same health conditions could present with a fear-avoidance
movement system diagnosis, and the POC might then include
activities to increase self-efficacy rather than strength and
endurance.
Prevention and Health Promotion-Wellness
Included in Every POC
Education complements the direct interventions and is the key
strategy for prevention and wellness.119 In the revised frame-
work, prevention and health promotion–wellness are recom-
mended in every episode of care. Prevention addresses both
patient-identified problems and non–patient-identified prob-
lems (Hypothesis Oriented Algorithm for clinical decision-
making) and relies on the clinician’s knowledge of the health
condition, potential complications, and movement system.
Health promotion–wellness is an addition to this revised
framework and reflects the expanded role of the physical
therapist.66,120 Prevention and health promotion–wellness
are administered through patient education, direct care, or
referral and collaboration with colleagues. The transtheo-
retical model of behavior change uses stages of readiness
to guide the wellness intervention.60,61 These elements of
the POC are especially relevant for persons with chronic
health conditions.121,122,123 Health promotion and wellness
and prevention may be delivered as a single intervention; for
example, promotion of physical activity is an intervention that
can address both wellness and prevention.124
Task-Specific Training
Knowledge of movement science is used to organize activity-
task–specific training; this includes selection of the task and
the environment, practice schedule, type and frequency of
feedback provided to the patient, and dose. Principles of
exercise complement movement science. The specificity of the
intervention (ie, how task-specific training is implemented
for each patient) is derived from the movement analysis of
tasks and hypotheses about the factors contributing to the
patient’s limitations. Evidence of the relevance of task speci-
ficity is extending beyond treating persons with neurological
conditions. For example, persons with chronic knee pain
due to osteoarthritis who had task-specific training improved
both their trained tasks (sit-stand, floor-to-stand, and stair
negotiation) and had pain reduction.125
Deutsch et al
In this revised framework, there is a fundamental assump-
tion that plasticity occurs across the cardiovascular, neuro-
muscular, integumentary, and musculoskeletal systems and
plasticity can be augmented with training and stimulation.
Evidence supports plasticity across systems126 and requires
that interventions or training be task specific and of a high
enough duration and intensity to achieve both behavioral
and structural changes.127–129 For this reason, we restate the
importance of dose in task-specific training. As an example,
the delivery of rehabilitation using task-specific training at
the correct dose to achieve improved walking for a person
post stroke is achieved with the use of high-intensity interval
training on a treadmill.127 The high-intensity interval training
improves the cardiovascular and neuromusculoskeletal sys-
tems by improving aerobic capacity,130 balance126 and neuro-
muscular endurance,126 all of which contribute to achieving
improved ambulation (activity/task goal) that will enable the
person to return to their job as a security guard.
Body Function/Structure–Level Intervention
Interventions to address relevant alterations in body func-
tion/structure are guided by knowledge of physiologic recov-
ery, tissue healing, and the FITT principle. Inflammation and
tissue healing are important to understand in the selection of
interventions that may promote optimal restoration. These
approaches are well defined based on the understanding of
tissue repair phases based on physiology: inflammation, pro-
liferation, and maturation; and tissue-healing phases based
on time acute, sub-acute, and chronic.131,132 Foundational
knowledge of the physical therapist guides selection of modal-
ities and interventions.132
The FITT principle provides a systematic way to dose body
function/structure interventions across health conditions. For
example, strengthening guided by FITT principles has been
applied to persons post stroke,133 post lung transplant,134 and
with inflammatory myopathy.135 The movement system diag-
nosis guides the intervention of the body function/structure as
illustrated by the driver with low back pain (Tab. 3). In this
example, several interventions will directly address the limita-
tions with joint and soft tissue mobility to complement the
trunk and lower extremity strengthening activities. Further,
interventions aimed at reducing deficits in body structure/-
function can be performed in the context of the relevant tasks.
In the example of the librarian, lower extremity strengthen-
ing can be performed using repeated sit-to-stand tasks from
various height surfaces with different foot positions; this task
could also incorporate holding objects and reaching to place
them onto surfaces.
Summary of the Framework and Application
There is a critical need for a unifying clinical decision-making
framework in physical therapy to highlight our expertise
as movement specialists and enhance communication within
and outside of the profession. This paper offers a unifying
framework that responds to changes in evidence and practice
that occurred over the last 15 years. It is organized around the
patient-client management of the Guide to Physical Therapist
practice and is framed by shared decision-making between the
patient and the clinician. Goals that focus on participation
are emphasized as an organizing principle, and guidelines are
provided for dissecting participation goals into activities-tasks
13
that can be examined or simulated in the clinic. Approaches
to task dissection and movement observation of tasks are
presented as a critical component of examination to enable
specific deficits in movement control to be identified, recog-
nizing that these deficits are not included in the ICF concepts
of BSF or tasks/activities. Movement and exercise science
serve as the theoretical foundation. ICF and movement science
terminology are integrated to link these distinct bodies of
knowledge. The human movement system is integrated into
the systems review, evaluation, and diagnosis. Throughout this
article, case examples are used to illustrate the application of
the framework across all health conditions. The framework
is proposed as a tool for physical therapist education and
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guide for clinical practice for all health conditions across the
lifespan.
Author Contributions
Concept/idea/research design: J.E. Deutsch, K.M. Gill-Body,
M. Schenkman
Writing: J.E. Deutsch, K.M. Gill-Body, M. Schenkman
Project management: J.E. Deutsch
Acknowledgments
The authors thank Cory Christiansen, PT, PhD; Gerard Fluet, PT,
DPT, PhD; Dana Judd, PT, DPT, PhD; Laura Plummer, PT, DPT, EdD,
board-certified clinical specialist in neurologic physical therapy; Susan
Paparella-Pitzel, PT, DPT; and Genevieve Pinto Zipp, PT, EdD for
their careful read and thoughtful feedback on an early version of the
manuscript. The authors also thank Ellen Anderson, PT, PhD, board-
certified clinical specialist in geriatric physical therapy, and Tara Jo
Manal, PT, DPT, FAPTA, board-certified clinical specialist in orthopedic
physical therapy, for source material on the cases.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential
Conflicts of Interest and reported no conflicts of interest.
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