Physical Therapy

Progress notes, repeated measurements, reexaminations, and discharge records can document gains, setbacks, or limited progress in mobility, strength, endurance, balance, gait, transfers, and other functional goals. These records can also show changes to interventions or goals in response to the patient’s progress, but they do not by themselves establish the medical cause of every reported symptom or limitation.

A physical therapist may evaluate gait, balance, transfers, assistive-device use, lower-extremity strength, fall history, functional mobility, and response to treatment using observation and appropriate tests and measures. These findings can help assess movement and functional limitations within the physical therapy episode of care, while questions focused primarily on mechanical forces, loading, or impact may require additional biomechanics expertise.

Physical therapy addresses movement, function, examination, evaluation, diagnosis and prognosis within PT practice, plans of care, and therapeutic intervention. A PM&R physician may be appropriate when physician-level medical diagnosis, prognosis, or rehabilitation-medicine opinions are needed, while occupational therapy may be particularly relevant to participation in daily occupations, adaptive strategies, and the influence of the person, activity, and environment on performance. The disputed issue and each expert’s qualifications should determine which discipline is appropriate.