Spinal Cord Injury Community Follow-up

Role of the Physical Therapist

KATHLEEN A. CURTIS
and KARYL M. HALL

This study was conducted over a 14-month period to assess the physical therapy
intervention needs of 201 patients who attended monthly spinal cord injury (SCI)
outpatient clinics conducted in three outlying local communities of northern
California. Methods to identify and provide appropriate physical therapy services
for the patients were explored. An experienced physical therapist from a regional
SCI center and other clinic staff members screened the patients and identified
66 patients (33%) who needed physical therapy services, including evaluation
(82%), patient education (62%), and referrals to appropriate local health care
professionals or equipment vendors (52%). Losses of joint range of motion,
changes in sitting posture as a result of increased muscle tone or contracture,
and malaligned or misfitting lower extremity orthoses were identified as problem
areas not commonly recognized in routine follow-up examinations. Recommen-
dations based on our study findings included the use of a screening form for
physical therapy needs at each clinic, improved patient education about the role
of the physical therapist as a resource person during follow-up care, coverage
for each of the three clinics on a biannual basis, and continued study of the
mechanisms used by other SCI centers to fulfill the outpatient needs of their
patients. Physical therapy involvement in SCI follow-up services can maximize
efficient use of our health care resources and provide early identification and
management of specific postdischarge needs.
Key Words: Physical therapy, Spinal cord injury.

The goal of the spinal cord injury (SCI) rehabilitation function in skills of daily living and vocational pursuits.1
process is to prepare the individual for life after discharge with Approaches to follow-up care commonly involve physical
a maximal level of functional independence and the necessary therapy intervention only when problems are noted in one of
resources and modifications to assist in returning to the these areas. Fragmentation in the follow-up care of the SCI
family, home, school, or work environment.1 Follow-up stud- patient frequently leads to management that is inappropriate
ies of SCI patients indicate that medical problems frequently to the chronic nature of the disability and to frustration for
encountered postdischarge include noncompliance with self- the patient and his family.7
care routines or medication schedules, joint contractures, skin
breakdown, edema, bowel problems, spasticity, pain, bladder
SPINAL CORD INJURY OUTREACH
management problems, diaphoresis, and insufficient home
CLINIC SYSTEM
health services.2 Social and environmental problems also are
reported, including architectural barriers, insufficient or mal- Our regional SCI center serves a geographical area that
functioning equipment, financial difficulties, and inappro- includes north-central California, southern Oregon, and west-
priate dependence on others.2 The postdischarge functional ern Nevada, with an estimated population of 9 million indi-
skills of SCI patients frequently improve.3-5 Few patients with viduals and an estimated SCI population of 1,800 individuals.
complete SCIs at T5 or below, however, continue lower This region includes heavily populated urban and suburban
extremity orthotic use for functional purposes after discharge.6 areas, as well as extensive, sparsely populated rural and agri-
The literature reveals little information on the postdischarge cultural areas.
use of physical therapy services by the SCI patient. Patient The regional SCI system sponsored and staffed monthly
education programs frequently address physical therapy con- SCI outreach clinics in one of three outlying community
cerns such as prevention of joint contractures, prevention of hospitals for the six years before the study was initiated. These
respiratory complications, and achievement of maximum clinics were instituted to provide comprehensive outpatient
SCI follow-up care for those individuals who were unable to
commute to the regional SCI center. Because the area served
is so large, many patients were limited by distance, lack of
Ms. Curtis is Director and Educational Services Consultant, Health Direc- transportation, or expense.
tions, PO Box 491116, Los Angeles, CA 90049 (USA). She was Education
Coordinator and Supervisor, Spinal Cord Injury Service, Physical Therapy Staffing for each clinic routinely included a physician(s), an
Department, Santa Clara Valley Medical Center, at the time this article was occupational therapist, a local public health nurse(s), and an
written.
Dr. Hall is with the Department of Rehabilitation Medicine, Veteran's
SCI Project Outreach Coordinator. The SCI outreach clinic
Administration Medical Center, Palo Alto, CA. She was Co-Director, Northern team used automobile or air transportation to travel to the
California Regional Spinal Injury System, Santa Clara Valley Medical Center, clinics, which were located within a 120- to 300-mile radius
San Jose, CA, at the time this article was written.
This article was submitted April 2, 1985; was with the authors for revision 16 of the regional SCI center. For two of the clinics, travel also
weeks; and was accepted January 9, 1986. involved overnight accommodations for the SCI outreach

1370 PHYSICAL THERAPY

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clinic team. The SCI outreach clinic team saw an average of Screening Procedure
200 patients a year before the study.
The SCI outreach clinic team initially lacked physical ther- The physical therapist briefly screened each patient attend-
apy representation. When the SCI outreach clinic program ing the clinic to determine whether he required physical
was implemented, the physical therapy department at the therapy services. The therapist asked the patient to describe
center was understaffed, and experienced staff members were any loss of joint range of motion, increased pain or discom
needed for patient treatment and supervision of physical fort, change in motor or sensory function, malfunctioning
therapy services at the SCI center. The physical therapy needs equipment or orthoses, and changes in functional abilities or
of many of the SCI patients seen in follow-up remained unmet endurance.
and unknown because local physical therapists participated
in the clinics only sporadically. The substantial expense of Referrals to the Physical Therapist
providing physical therapy coverage did not justify an SCI The physical therapist encouraged all clinic staff members
center physical therapist attending the clinics. A local physical and patients to request physical therapy intervention directly
therapist, therefore, could provide clinic services and ongoing for any of the above problem areas. The physical therapist
treatment locally, or the SCI center's physician could refer briefly assessed each referred patient and discussed with the
the patients for physical therapy services locally. clinic team any active or potential problems of those patients
This study was conducted 1) to document the types of receiving physical therapy services. Appropriate team mem-
physical therapy services needed in the follow-up care of the bers agreed on and carried out the plan. Individual physical
SCI patient and to determine the role of the physical therapist therapy records were filed with the patients' other medical
in providing these services; 2) to document the actual number records.
of hours of physical therapy services needed at each monthly
SCI outreach clinic and to determine the optimal utilization Data Analysis
of the therapists' time; and 3) to assess the desired involve-
ment, capabilities, and availability of the SCI center's physical The data were analyzed by tabulating demographic infor-
therapists versus local physical therapists in each of the out- mation, referral patterns, and postdischarge problems and by
reach clinic areas. calculating the total time spent in and frequency of perfor-
mance of physical therapy functions. In addition, we deter-
METHOD mined the mean number and percentage of patients seen and
the mean time for each type of physical therapy service
We initially contacted the outreach clinic staff members performed.
and participating local physical therapists to explain the ob-
jectives of the project and the potential functions at the clinic RESULTS
of the physical therapists. An experienced physical therapist
from the SCI center collected data for 14 months at one of Of the 201 patients attending the follow-up clinics, 66 (33%)
the SCI outreach clinics. received the services of the physical therapist. All subsequent
data are described for this group of 66 patients. The group
Physical Therapy Services included 54 men and 12 women with a mean age of 29 years.
Eight patients (12%) were seen more than once during sub-
The SCI center's physical therapist performed essential sequent clinic visits. Forty (61%) of the patients had cervical
services arid recorded information on a data collection form lesions, and the remaining 26 patients (39%) had thoracic or
(Appendix 1) regarding the frequency and time spent provid- lumbar lesions. One patient had a brain stem lesion in addi-
ing evaluative and therapeutic services, making local referrals, tion to a cervical SCI; two patients were recovering from
ordering equipment, and providing patient education and Guillain-Barre syndrome and were functionally incomplete
professional consultation. Additionally, the physical therapist paraplegics.
documented the types of physical therapy intervention
needed; the patterns of referral for these services (by patient, Types of Physical Therapy Functions
family, other clinic staff member, or initial contact by physical
therapist); the age, sex, and degree of neurological involve- Evaluation, arranging for referrals, ordering equipment,
ment of the patients needing physical therapy services; and and patient education were the functions performed most
postdischarge problems. frequently by the physical therapist (Table). Fifty-four patients
(82%) were evaluated for at least one problem. Thirty-four
Local Physical Therapy Survey (52%) of the patients required follow-up services. Patient
education was provided for at least one problem for 41 (62%)
We contacted local physical therapy department directors of the patients. Consultation was requested by another health
to explain the purposes of the study. The directors completed care professional regarding the appropriate plan of care for 19
a follow-up questionnaire regarding the availability of specific (29%) of the patients. Actual treatment was initiated at the
patient services, potential staff coverage for the SCI clinic, clinic for only 12 (18%) of the patients.
and capabilities of the local physical therapists to provide SCI The most frequently performed individual functions were
patient care. Written resource materials about SCI treatment evaluation of ROM, gait analysis, patient education for ROM
emphasizing appropriate functional goals and the role of the or stretching exercises, and referral for physical therapy in the
physical therapist were distributed to all local physical therapy local community.
departments. Local physical therapists were encouraged to Evaluation. Assessment of ROM, gait analysis, and manual
attend the quarterly clinic in their area. muscle testing were the most frequently performed evaluation

Volume 66 / Number 9, September 1986 1371

TABLE efficacy of a single treatment required the therapist to refer
Physical Therapist Spinal Cord Injury Outreach Clinic Functions patients to a local physical therapist if ongoing treatment was
indicated.
Average Total
Patientsa Patients
Therapist Functions Time Time
(min) (%) (n) (%) Referral Sources

Evaluation 84 46 54 82
The physical therapist made initial contact with 43 (65%)
Equipment-referral follow- of the 66 patients. Only 18 (27%) of the patients receiving
up (paperwork-phone) 39 21 34 52 physical therapy services were referred initially by the SCI
Patient education 32 18 41 62 center's physicians.
Professional consultation 17 9 19 29
Treatment 12 6 12 18 Postdischarge Problems
TOTAL 184 100 160 —
The most common physical therapy problem noted during
a
N = 66 (32.8% of the 201 patients screened for physical therapy the postdischarge follow-up examinations was the patients'
needs in the SCI outreach clinic). failure to comply with the physical therapy home program (8
patients, 12%). The second most common problem was the
functions, involving 32 (49%), 23 (33%), and 12 (18%) of the delay in receiving outpatient physical therapy services on the
local level (6 patients, 9%).
patients, respectively. Other procedures included evaluation
for standing equipment (10%), orthotic evaluation (10%),
scoliosis or posture evaluation (8%), endurance evaluation Time Requirements for Physical Therapy Services
(8%), and respiratory evaluation (8%). In addition, evalua- An average of 184 minutes was spent in direct patient-care
tions of dysphagia, inhibition of muscle tone, back pain, and services at each one-day clinic, although the time spent ranged
edema each were conducted for one patient. from as little as 75 minutes at one clinic to as much as 320
Referral and equipment follow-up. The referral and follow- minutes at another clinic. Patient attendance varied markedly
up activities primarily involved documentation or telephone with the extremes of weather and ranged from a low of 8
contact to arrange for desired services or equipment locally. patients to a high of 32 patients. The physical therapist
Most of the referrals were for local physical therapy services devoted an average of 38 minutes to each patient.
and involved 13 (20%) of the patients. The most frequently
reported equipment needs were for the replacement or repair Local Physical Therapy Survey
of lower extremity or spinal orthoses and transcutaneous
electrical nerve stimulation devices. A total of 11 patients Only one of three directors of local physical therapy de-
(17%) received services for equipment repair or purchase. partments reported that their staff members were trained
Patient education. Therapist involvement in patient edu- sufficiently to meet the physical therapy needs of the SCI
cation was most frequent in reviewing ROM and stretching patient. No director could send a physical therapist full time
procedures (21%) and in encouraging compliance with the routinely on the day of the clinic because of staffing shortages.
standing program (14%). Patients routinely received individ- The average number of SCI patients referred for outpatient
ualized instruction with written materials and a detailed pa- physical therapy at each facility was 7 a year. Many local
tient education manual before discharge from the clinic. physical therapists expressed a need for training in both acute
Many patients denied having been instructed previously in care skills and community follow-up services. Although most
these procedures. of them indicated a willingness to learn the needed skills, they
Professional consultation. Local physical therapists were also emphasized the extreme limitations in their available
encouraged to participate in the SCI outreach clinics. Even time.
though one area consistently scheduled local staff coverage of
its clinic, other priorities, such as inpatient hospital care, DISCUSSION
frequently resulted in cancellation of the services of the phys-
ical therapists assigned to the clinic. Effective decision making In determining whether physical therapy services are
and planning, however, was possible because of the sharing needed in the follow-up care of the SCI patient, we assume
of specialized SCI expertise by the SCI center's physical ther- that the patient's quality of life is improved by the delivery of
apist and the coordination of local resources and appropriate these services. Within the scope of this article, however, we
follow-up services by the local physical therapists. The SCI cannot probe the validity of this assumption.
center's physical therapist explained the role of the physical
therapist, provided evaluation skills, and recommended Need for Physical Therapy Services
equipment resources to other health care professionals for 19
(29%) of the patients seen. The results of our study indicate that physical therapy
intervention is needed in the areas of evaluation, referral, and
Treatment Procedures patient education. Actual evaluation and treatment services
can be provided by a physical therapist with some training in
Of the limited actual treatment that was initiated at the SCI treatment techniques. The decision-making functions of
clinic, the most frequently performed procedures (12%) in- problem identification, goal setting, and treatment planning
volved techniques to increase ROM and to improve posture can be accomplished more effectively by the SCI center's
or positioning. Time constraints, the rapid turnover of pa- experienced physical therapist. Inappropriate referrals for gait
tients examined during the clinic hours, and the limited training, orthoses fabrication, and maintenance functions can

1372 PHYSICAL THERAPY

 RESEARCH

be monitored effectively by a physical therapist in attendance Time Requirements to Provide Physical

at the SCI outreach clinics. This prevention of inappropriate Therapy Services
treatment may save considerable time and money. The SCI
center's physical therapist can improve the continuity of care The actual hours of direct reimbursable patient-care serv-
in the rehabilitation process by identifying problems in reach- ices provided by the physical therapists were insufficient to
ing functional goals after discharge (eg, orthosis malalignment support financially a full-time physical therapist's attendance
and inconsistencies in present status and projected goals). at the SCI outreach clinics. According to the SCI center's
The SCI outreach clinic physical therapist performs a val- physical therapy department standards, the center's loss of a
uable function in assessing the need for physical therapy therapist for the day was equivalent to the loss of six treatment
services as the patient's initial contact, rather than secondarily hours. The average time spent in the delivery of direct services
to physician referral. Physical therapists are able to recognize was three hours, resulting in a productivity rate of 50%.
areas in which they have potential influence. Postdischarge Important, nevertheless, are the intangible benefits of the
problems, such as orthosis fit or repair and progressive muscle nonreimbursable services performed by the physical therapists
tone and postural changes often go unrecognized until they in the clinic, such as screening patients for potential problems,
cause major skin breakdown or loss of functional mobility. educating and interacting with local health care professionals
This screening function also may be helpful in the early and the outreach clinic staff, and acting as a liaison for the
identification of loss of ROM, chronic pain, or change of transfer of information between the clinics and the SCI center.
neurological function. These complications often are not no-
ticed until function has been compromised severely. Physical Therapy Staffing of Spinal Cord Injury
A close working relationship among the physical therapist, Outreach Clinic
the physician, and the other team members is necessary to
coordinate and plan the delivery of services. Incorporating Spinal cord iniury center physical therapist. Direct involve-
the screening function of the physical therapist into the clinic ment of the SCI center's physical therapy staff may lead to a
routine can improve the efficiency and productivity of the more realistic appraisal of patient compliance with assigned
entire outreach clinic team. therapeutic home-exercise programs and local physical ther-
Occasionally, local public health nurses refer new patients apy follow-up care. The revision of plans to reflect this aware-
to the clinics. These patients have received their initial reha- ness ultimately will improve the effectiveness of the SCI
bilitation services at a center other than the regional SCI center's patient-education efforts and may prevent ordering
center and require follow-up services. Previous medical infor- unnecessary and under-used therapeutic equipment (eg,
mation on these patients frequently is unavailable. A medical standing frames, tilt tables, or orthoses).
history and a summary of patients' current health status are Nonmedical community resources (community-college
required for the SCI center to provide adequate services. programs, social agencies) are of critical importance to the
Patient needs often are too extensive to be met in the outreach SCI patient's postdischarge reintegration. Knowledge of these
clinic situation. Additionally, financial and bureaucratic con- resources and a working relationship with liaison staff mem-
straints often prevent us from meeting their needs in an bers are helpful in facilitating referrals.
adequate fashion, such as admitting them to the SCI center. Local physical therapists. Inadequate staffing, rather than
The local public health nurse is instrumental in the delivery a lack of interest, is the primary factor preventing more
of ongoing medical services to this patient group. Consulta- frequent and consistent local physical therapist involvement.
tions between the local public health nurse and other members When no physical therapist is available at the clinic and when
of the outreach clinic team, therefore, are critical to successful physician-initiated referral is the only means of physical ther-
follow-up treatment in the weeks after the quarterly outreach apy involvement, the patient may not receive needed services
clinics. and may receive (and pay for) unneeded or inappropriate
services. Additionally, the SCI center's physicians often are
Role of the Physical Therapist inaccessible to local physical therapists. The distance between
the SCI center and the outlying areas often limits communi-
To provide these services, the SCI outreach clinic's physical cation and prohibits an atmosphere conducive to team partic-
therapist must be a resource person, a consultant, and an ipation.
educator. The model we have depicted may be useful in An optimal model arrangement is for a local physical
defining the role of the physical therapist in the follow-up therapist and the SCI center's physical therapist to participate
care of many chronically disabled patient populations. Phys- in the clinic together, thereby providing consultation and
ical therapists know best what they have to offer the patient education while facilitating local follow-up physical therapy
and the health care community. Competence in physical care. At a minimum, the SCI center's physical therapist should
therapy evaluation and treatment techniques is not enough provide written materials and maintain periodic contact with
to function effectively in this capacity. The physical therapist the local physical therapy staff.
also must be well-informed about SCI research, aware of
technological advances in equipment, assertive in presenting Recommendations
new ideas to other health care team members, and receptive
to the questions and suggestions of both professionals and To maximize the use of physical therapy services at the SCI
patients. The patient education function may be implemented outreach clinics, we recommend the following:
est with careful attention to the health-related behavioral 1. Establish a check list-format screening tool for use at the
sciences because patient compliance with education efforts clinics to identify problems such as orthotic, postural, or
(eg, home programs and prophylactic care) at the SCI center functional changes and loss of ROM or neurological func-
often was nonexistent. tion (Appendix 2).

Volume 66 / Number 9, September 1986 1373

2. Schedule new patients for full evaluations at the regional economic constraints and from the perspective of patients
SCI center before a referral to a follow-up clinic. and other health care professionals. Alternative models of
3. Communicate with patients before the outreach clinics to providing outpatient follow-up physical therapy services
determine their potential needs for physical therapy. This should be developed for patient populations with chronic
contact could maximize appointment scheduling, coordi- disabilities. Physical therapy administrators must not con-
nation, and the availability of necessary equipment at the sider potential reimbursement for services as the only meas-
clinics for subsequent evaluations. ure of the worth of a physical therapist as a team member
in the clinic situation. Further research also might focus on
4. Provide more education to inpatients about the appropriate
the physical therapy needs of the aging SCI patient group.
use of outpatient physical therapy services, especially warn-
ing signs (changes in seating posture, gait instability or
CONCLUSIONS
change in speed, loss of ROM or neurological function), to
facilitate timely self-referral. Physical therapy involvement in SCI follow-up care serves
5. Continue to study methods to meet outpatient needs in the a previously unmet need in the SCI outpatient health care
context of our third-party payment system and growing system. Physical therapists skilled in SCI care should continue

APPENDIX 1
Data Collection Form Content

NCRSIS Outreach Clinic

Summary of Time Spent Providing Physical Therapy Services

1. Evaluation at clinic f. Other

a. Range-of-motion evaluation g. Other
b. Manual muscle testing h. Other
c. Standing evaluation 6. Professional consultation-education
d. Orthotic evaluation a. Explaining role of physical therapy
e. Gait analysis b. Attendant training
f. Endurance evaluation c. Evaluation skills
g. Scoliosis-posture evaluation 1. Describe
h. Respiratory evaluation 2. Describe
i. Other d. Treatment skills
j. Other 1. Describe
2. Treatment initiated at clinic 2. Describe
a. Range-of-motion-stretching exercises e. Equipment resources
b. Respiratory exercises 1. Describe
c. Endurance training 2. Describe
d. Strengthening exercises 7. Neurological level of each patient receiving physical therapy
e. Standing program services
f. Gait training 8. Contacts or referrals to outreach clinic physical therapist for
g. Posture-positioning patient care services initiated by:
h. Other a. SCVMC physical therapist (self)
i. Other b. Local physical therapist
3. Patient education (instruction of patient-family or attendant) c. SCVMC occupational therapist
a. Range-of-motion-stretching exercises d. Local occupational therapist
b. Respiratory exercises
e. SCVMC physician or nurse
c. Endurance training
f. Local physician or nurse
d. Strength training
e. Weight control g. NCRSIS staff
f. Standing program h. Patient
g. Transfer techniques i. Other
h. Posture-positioning 9. Observation of postdischarge follow-up problems
i. Other a. Delays in receiving outpatient physical therapy services (phys-
j. Other ical therapist- or patient-caused)
4. Local referrals made b. Poor follow-through with home program
a. Physical therapy c. Attendant not trained
b. Occupational therapy d. Inappropriate use of professional physical therapy services
c. Orthoses-prostheses e. Not aware of community resources
d. Community college program f. Other
e. Public health nurse follow-up g. Other
f. Other h. Other
g. Other 10. a. Total patients receiving your services at clinic:
h. Other Evaluation
5. Equipment ordered Treatment
a. Standing frame Patient education
b. Tilt table Referrals
c. Lower extremity orthosis b. Total patients seen at clinic
d. Spinal orthosis or corset c. Patient seen for physical therapy research purposes only
e. Transcutaneous electrical nerve stimulation 11. Other comments on utilization of physical therapy services

1374 PHYSICAL THERAPY

 RESEARCH

their interdisciplinary-team involvement to make the most REFERENCES

efficient use of our health care and patient-family resources. 1. Pierce DS, Nickel VH (eds): The Total Care of Spinal Cord Injuries. Boston,
Physical therapists are valuable resources to patients and to MA, Little, Brown & Co Inc, 1977
2. Better SR, Fine PR, Celes GW, et al: Complications among spinal cord
other health care professionals in the outpatient SCI follow- injury patients following discharge. Rehabilitation Nursing 4:8-10,1979
up system. A physical therapist trained in the care of the SCI
patient is able to minimize inappropriate referrals for equip- 3. Bracken MB, Hildreth N, Freeman DH, et al: Relationship between neuro-
logical and functional status after spinal cord injury: An epidemiological
ment and outpatient physical therapy services. Local physical study. J Chronic Dis 33:115-125,1980
therapy departments often are staffed inadequately or lack 4. Forer SK, Miller LS: Rehabilitation outcome: Comparative analysis of
the resources to fulfill this function. Our recommendations different patient types. Arch Phys Med Rehabil 61:359-365,1980
5. Rogers JC, Figone JJ: Traumatic quadriplegia: Follow-up study of self-care
include a biannual staffing of clinics with preclinic screening skills. Arch Phys Med Rehabil 61:316-321,1980
by telephone, improved patient education for self-referral, 6. Mikelberg R, Reid S: Spinal cord lesions and lower extremity bracing: An
overview and follow-up study. Paraplegia 19:370-385,1981
and continued study of methods to meet the outpatient needs 7. Jacobs BW, LaMantia JG: Lifetime follow-up care. Model Systems Spinal
of this patient population. Cord Injury Digest 4:51-55,1982

APPENDIX 2
Spinal Cord Injury Outreach Clinic Physical-Occupational
Therapy Screening Form

Spinal Cord Injury Clinic

Physical-Occupational Therapy Needs

Name Date

In the past year: Yes No Comments

1. Have you noticed increased difficulty in moving arms, legs,

neck?
2. Have you noticed a change in your sitting position or wheelchair
fit?
3. If you are on a standing program, have you noticed a change
or trouble in getting into the standing position?
4a. If you wear braces or splints, are there any red areas on your
skin?
4b. Are your braces or splints broken?
4c. Are you using your braces or splints at least once a day?
5. Can you not do something you could do when you were
discharged from rehabilitation? (Have you lost any functions
such as dressing-feeding yourself, self-care, transfers, hand
skills, standing, or walking?)
6a. Are there things you might be able to do independently with
more training?
6b. Have you noticed return of muscle strength or movement?
7. Is any of your equipment (wheelchair, braces, splints) in need
of repair or replacement?
8. Are you noticing shortness of breath or fatigue after light
activity?
9. Is there any problem that you would like to discuss with a
physical therapist or occupational therapist?
10. Is there any other area of concern we have left off this list?
11. For our future programs with spinal cord injured patients, are
there any areas that you feel should have been stressed
more or were left out of your physical or occupational therapy
program during your initial rehabilitation?

Physical-Occupational Therapy Action Taken:

OTR or RPT signature Date

Volume 66 / Number 9, September 1986 1375