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Brian Barney
McNair Scholars Summer Research Experience Final Paper
Utilization of Aerobic Exercise in Physical Therapy Practice: A Survey Study of U.S. Therapists
Faculty Mentor: Pierce Boyne
INTRODUCTION
Stroke, sometimes referred to as a cerebrovascular accident, is one of the leading causes
of disability and is the third leading cause of death in the United States, with over 700,000
people suffering from a stroke each year
1
. Unfortunately, a fairly large amount of this population
also live with some type of cardiovascular disease which, when left untreated, can lead to
recurrent stroke or even death.
1
However, aerobic exercise (AE) has proven to be an effective
tool in improving the cardiac health of the post-stroke population.
3
Comparatively, standard
rehabilitation exercises do not provide enough cardiovascular stress to produce a substantial
training effect.
3
Although many studies have shown the benefits of AE, there continue to be
significant issues with its implementation in clinical rehabilitation programs. According to a
recent survey of physical therapists in Canada, one of the major concerns with AE was patient
safety due to poor cardiac health .
4
Furthermore, this study as well as other studies have shown
an alarming observation about the lack of pre-exercise screening and heart monitoring in the
clinical setting. In another study by Mackay-Lyons and Makrides, they observed that
experienced therapistsdid not monitor heart rate and blood pressure of patients poststroke
even in patients with well documented cardiac disease.
5
This observation is especially
dangerous for the post-stroke population because the lack of a consistent protocol goes against
the American College of Sports Medicine recommendations for persons classified as moderate or
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high risk, and persons with stroke usually fall into this category.
6
Additionally, a study by
Koopman et al. described cardiac monitoring as essential for providing the right load to the
right patient.
7
In total, prescribing AE of the appropriate intensity can be of great benefit to
post-stroke patients and the barriers to its utilization should be identified to a greater extent.
Although it is commonly known that AE can have positive effects on the cardiovascular
health of the post-stroke population, not enough research has been done on this subject in the
United States. Recently, a cross-sectional survey was completed that assessed AE utilization for
patients with neurological impairments in Canadian PT clinics, but there is no such information
for the U.S. population and the study was not specific to persons with stroke.
4
Therefore, the
purpose of this study is to refine a survey instrument that will be used to assess the utilization of
AE in physical therapy practice in the U.S., most specifically for the post-stroke population.
METHODS
Study Design
Focus groups of local physical therapists and post-stroke AE experts were conducted over
a period of 2 weeks in July 2014 so that the survey instrument could be properly refined. During
these focus groups, therapists who provided informed consent to participate completed the draft
survey and provided feedback regarding item selection, comprehensiveness, readability,
organization, presentation, and time to complete the survey. The survey was then further edited
based on the feedback received from these focus groups.
Participants
A local physical therapist was chosen to participate in the focus group if (s)he (1) was a
licensed PT and (2) worked at the Daniel Drake Center for Post-Acute Care in Cincinnati, OH,
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HealthSouth Rehabilitation Hospital at Drake in Cincinnati, OH, or the University of Cincinnati
Medical Center in Cincinnati, OH. Seven participants who had a diverse range of practice
settings (acute care, outpatient clinic, inpatient rehabilitation, and skilled nursing facilities; 1-24
years of licensure) and years of PT licensure completed the survey and provided feedback on the
surveys structure and content.
Three experts in the field of post-stroke aerobic exercise (Marilyn Mackay-Lyons, Sandra
Billinger, and Ada Tang) also served as external consultants for this study. In fact, one of these
experts (Marilyn Mackay-Lyons) was the author of the Canadian survey that this study is
modeled after
4
. The consultants reviewed the initial survey and provided additional input on
potential changes that should be made.
Survey Deployment
After signing informed consent, therapists were given paper copies of the email
recruitment message, the survey and specific questions to focus their written feedback. These
questions encouraged the participants to provide feedback wherever they felt it necessary.
Therapists were instructed not to put any identifying information in the feedback and to place all
information together in a folder afterward to provide some anonymity. The surveys and feedback
were then retrieved one week later. Lastly, the electronic version of the survey was emailed to
the three external consultants and they returned their feedback at their own convenience. This
entire process took approximately two weeks.
Data Collection and Analysis
Qualitative data from this study was collected from the comments, suggestions, and
questions written by the therapists. All comments (but especially recurring ones) were taken into
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consideration during the survey revision process. Revisions were made in response to specific
comments (define quickly or how many outcomes) and in response to general thoughts about
the survey (slightly longer than I would like for it to have been).
RESULTS
After evaluating the focus group feedback, there were two main themes related to the
overall length, comprehension, and clarity of the survey that emerged. First, the survey was
simply too long. Six out of the 7 focus group participants indicated that the survey was lengthy,
with one person going as far as to say (s)he would probably start the survey but not finish it
because it was so long. Some of the respondents also offered suggestions as to methods that
could be used to make the assessment seem shorter. One participant suggested that we use a
percentage complete status bar as a way to encourage therapists to complete the entire survey,
while another participant offered that we should state upfront how many questions there are so I
know how much time to allow.
The second major issue that the participants indicated about the survey was that the
wording and the format of certain questions and answers should be clarified or changed so that
more accurate answers could be provided. This request for a change in the format of the answer
was especially apparent with fill-in-the-blank questions that asked for a numerical answer (e.g. I
prescribe aerobic exercise for approximately _______ % of my patients with stroke). For these
types of questions, three of the therapists suggested that the question(s) be changed to multiple
choice format so that they could pick a numerical range (it might be easier if there were
choicesi.e. ranges) instead of having to estimate a single number.
Two of the focus group members also proposed that a few of the multiple answer (check
all that apply) questions had too many options to choose from and thus became overwhelming
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to the reader (too many options-could this be a tiered question?). The multiple answer
questions that received comments were usually the ones that inquired about the methods used
when prescribing aerobic exercise, which had more than 10 answer choices available. With this
large amount of choices, one question would take up almost half of the page which made it
harder to comprehend and could make the survey take longer.
There were also specific qualms about the wording of the answer choices for certain questions,
and the feedback offered was often related to the therapists primary practice setting. For
example, both of the acute care physical therapists stated that they would have trouble answering
the question on the primary practice pattern of their patients because they treated an equal
number of all of the four different types of patterns (musculoskeletal, neuromuscular,
cardiopulmonary, and integumentary). An acute care physical therapist also suggested that the
option of too much monitoring equipment (i.e. lines, drains, tubes) be added as answer choice
for a question about patient-related concerns that would cause a therapist to avoid prescribing
AE. Additionally, one of the outpatient therapists suggested that insurance limitations be listed
as an answer choice for institutional barriers to prescribing AE.
Although some therapists had no issues completing the survey, a few of them asked for
clarification on certain phrases in a couple of the questions. These responses, however, did not
seem to follow a consistent trend. One participant wanted clarification on the question Are any
of the following aerobic exercise resources routinely availableat your primary facility?
because (s)he thought that a therapist may have access to a certain resource but it could be
terribly inconvenient to utilize. Another therapist thought that the question Do any of the
followingcause you to routinely avoid? could be implying that you routinely avoid
prescribing aerobic exercise. Yet another therapist stated that the wording in the question What
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is the highest non-physical therapy degree you have obtained after entering clinical practice?
seemed confusing. Conversely, none of the other participants had any trouble answering these
individual questions.
Lastly, 3 of the 7 participants answered that the survey questions did not come across
poorly (i.e. they were not biased or condescending), that they flowed logically, and that the
definition of aerobic exercise that was given was concise and descriptive enough to complete the
survey. The other 4 participants did not answer these particular questions, but they did not
specifically write anything to the contrary of those who did give answers.
DISCUSSION
The focus groups input was both valuable and feasible, so as a result most of the
therapists recommendations are actually reflected in the final version of the survey. One of the
most significant changes made to the survey was to shorten it in length and to inform the
participant on how long the assessment would take. The information sheet used in the invitation
email now lists the time estimated to take the exam. Additionally, the length of the entire
assessment shrunk from over 34 questions to 30 questions in an effort to make the survey more
palatable to potential participants. This reduction came from deleting questions regarding group
exercise, personnel involvement in exercise and exercise adherence/self-efficacy, and by
combining similar questions into sub-questions (i.e. 29a, 29b, 29c, etc.).
Moreover, when the final survey was programmed into the Electronic Data Capture
system, there were additional branched logic features available that could potentially make the
survey easier to maneuver. For example, if the user answered no to the question Do you
perform direct patient care in a clinical setting in any of your current physical therapy
position(s)? then the assessment would end at only 8 questions. If the user indicated that they
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had not worked with a patient with stroke in the last 3 months, certain questions that were
specific to the use of aerobic exercise for the post-stroke population would not appear. There was
also a status bar at the top each page of the survey that told the participant how many pages they
had left to finish as well as an option to save ones answers and return to the assessment later.
These features could help with the completion rate of the assessment when it is deployed to a
national sample because it would allow therapists to finish the survey in a timeframe that is most
convenient to them.
Most of the focus group participants expressed that the survey flowed well overall, so
only small changes were needed to ensure that all of the questions and answer choices would be
well understood. Certain questions with a large amount of answer choices were not able to be
broken down into small sub-questions due to the information being requested (Prior to
prescribing aerobic exercise, do you routinely use any of the following items to screen patients
with stroke for safety?), while other inquiries (Do you use any of the following methods to
determine the initial (baseline) intensity of aerobic exercise for patients with stroke?) were able
to be broken down into specific categories (general, target heart rate, and target workload).
In other instances, new questions were included and additional headings were added so
that we could get a better picture of each therapists best practices. Questions like On average,
about what volume of OVERALL THERAPY do you provide for patients with stroke? were
added so that we could compare the amount of time a therapist spends on aerobic exercise to the
total time that they spend with their patients with stroke. New headers were also created so that
therapists would have a better idea of how we were asking them to answer the question. These
headers contained instructions such as Please answer the rest of the survey based on your
patients with stroke in your primary clinical practice setting. This was especially important to
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include because not all physical therapists work in only one practice setting. As one focus group
participant put it, I found myself switching between work settings when answering. Our goal
with the headers is to lead the survey users towards giving us information about the utilization of
AE that is specific to their primary practice pattern and setting.
Although the final survey is distinct from the original, many of the questions remained
untouched because we ultimately decided that they would provide the most accurate and
thorough information on aerobic exercise utilization in physical therapy practice. The survey is
still fairly lengthy at 30 questions, but only takes approximately 15 minutes to complete. Also,
each of these inquiries can potentially provide insight that would change the current best
practices in the profession. As we move into the next stage of this study (survey deployment), we
hope that the revisions to this survey instrument will make it an effective tool at assessing the
current rate of use of AE in clinical setting and the different barriers that prevent physical
therapists for prescribing AE for their patients with stroke.








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REFERENCES
1. Neil F. Gordon, Meg Gulanick, Fernando Costa, et al. An American Heart Association
Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise,
Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on
Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation
2004;109;2031-2041.

2. Rimmer JH, Wang E. Aerobic exercise training in stroke survivors. Top Stroke Rehabil.
2005;12: 17-30.

3. Kuys S, Brauer S, Ada L. Routine physiotherapy does not induce a cardiorespiratory training
effect poststroke, regardless of walking ability. Physiother. Res. Int. 2006;11(4): 219227.

4. Doyle L, Mackay-Lyons M. Utilization of Aerobic Exercise in Adult Neurological
Rehabilitation by Physical Therapists in Canada. Journal of Neurological Physical Therapy
2013;37: 2026.

5. MacKay-Lyons MJ, Makrides L. Cardiovascular stress during a contemporary stroke
rehabilitation program: is the intensity adequate to induce a training effect? Arch Phys Med
Rehabil 2002;83:1378-83.

6. American College of Sports Medicine. ACSMs Guidelines for Exercise Testing and
Prescription. 8th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2010.

7. Koopman ADM, Maaike ME, Bezeij T, Valent LJM, Houdijk H. Does clinical rehabilitation
impose sufficient cardiorespiratory strain to improve aerobic fitness? Journal of Rehabilitation
Medicine 2013; 45: 9298
APPENDIX (Final Version of Survey)
For this survey, aerobic exercise refers to planned, structured and repetitive physical
activity performed for extended periods of time and at sufficient intensity to improve or
maintain physical fitness.

For this survey, prescribing aerobic exercise means including it in your plan of care.
This can be exercise that is done during a therapy session or exercise that the patient
does outside of therapy under your instruction.

1. Your sex
Female
Male

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2. How many years have you been in clinical practice as a licensed physical therapist?
___________

3. What is the highest clinical physical therapy degree you have obtained?
Certificate
Bachelors
Masters (e.g. MSPT)
Doctorate (e.g. DPT or tDPT)

4. Do you have any additional degrees or certifications? Check all that apply.
No
PhD
Graduate degree in exercise physiology
Certified athletic trainer (ATC)
Cardiovascular and Pulmonary Clinical Specialist (CCS)
Electrophysiologic Clinical Specialist (ECS)
Geriatric Clinical Specialist (GCS)
Neurologic Clinical Specialist (NCS)
Orthopaedic Clinical Specialist (OCS)
Pediatric Clinical Specialist (OCS)
Sports Clinical Specialist (SCS)
Women's Health Clinical Specialist (WCS)
APTA Certified Exercise Expert for the Aging Adult (CEEAA)
ACSM Certified Exercise Specialist (CES)

Other:_________________________________________________________________
_____

5. What is your primary practice setting?
Acute care hospital
Long-term acute care hospital
Inpatient rehabilitation center
Outpatient clinic
Home health
Skilled nursing facility
Independent/assisted living facility
School
Academic/research center

Other:_________________________________________________________________
_____


5b. Do you practice in any other settings or have you previously practiced in any other
settings? Check all that apply.
No
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Acute care hospital
Long-term acute care hospital
Inpatient rehabilitation center
Outpatient clinic
Home health
Skilled nursing facility
Independent/assisted living facility
School
Academic/research center

Other:_________________________________________________________________
_____

6. Do you perform direct patient care in a clinical setting in any of your current physical
therapy position(s)?
Yes
No

If the answer to this question is no, the survey will end.

PLEASE ANSWER THE REST OF THE SURVEY BASED ON YOUR PRIMARY
CLINICAL PRACTICE SETTING

7. What is the primary practice pattern of the majority of your patients? (If you practice
equally in multiple practice patterns, please check the one that best represents your
current patients.)
Musculoskeletal
Neuromuscular
Cardiopulmonary
Integumentary

Within the past 3 months, APPROXIMATELY how many patients did you evaluate or
treat

8a. for cardiac rehabilitation? ______________

8b. for stroke rehabilitation? _____________

If the answer to this question is 0, the rest of the questions will ask about patients from
the therapists' primary practice pattern (e.g. patients with orthopedic problems) rather
than patients with stroke.

9. Please rate how much you agree or disagree with the following statement: Aerobic
exercise should be incorporated into treatment programs of patients with stroke (alt: in
your primary practice pattern).
Strongly Agree
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Agree
Neither agree nor disagree
Disagree
Strongly disagree

10. I prescribe aerobic exercise for approximately _________ % of my patients with
stroke.

(If the answer is 0%, many of the following questions will not appear. However, we
would still ask about barriers and related items.) (Green = answer this question even if
answer to q10 is 0%)


11. Are you able to prescribe aerobic exercise for every patient with stroke for whom
you feel it is indicated?
Yes
No
If no, why not?
________________________________________________________________

12. Do any of the following factors routinely cause you to avoid prescribing aerobic
exercise for patients with stroke? Check all that apply.
Institutional barriers
Not part of routine practice in my work setting
I dont know how to prescribe aerobic exercise
Lack of an available screening test or protocol to help ensure patient safety
Lack of an available assessment tool to determine the need for aerobic
exercise
Lack of exercise equipment
Lack of patient monitoring equipment
Lack of staff to supervise exercise
Lack of time
Short length of stay
Lack of carry over to next phase of rehabilitation
Lack of administrative support for aerobic exercise
Lack of available support in case of medical emergency
Patient characteristics
Advanced age of patient
Patients' limited ability to exercise at a training level
Patients' limited motivation to exercise at a training level
Patients' cognitive/perceptual impairments
Patients' depression
Patients' cultural issues
Patients' limited pre-stroke physical activity history
Patients' low current fitness level
Patients' fall risk
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Patients limited access to exercise equipment after discharge
Financial constraints (e.g. health insurance limitations)
Improved aerobic fitness is not a goal of most patients
Aerobic exercise is low on my treatment priority list
Insufficient scientific evidence to support aerobic exercise for patients with
stroke

Patient-related concerns
Concern about musculoskeletal injury
Concern about cardiac status
Concern about recurrent stroke
Concern about medical stability
Concern about excessive fatigue
Concern about other co-morbidities (please specify below)
Excessive monitoring equipment, lines, drains or tubes
Abnormal results from exercise testing
Abnormal results from exercise testing
Aerobic exercise is low on my treatment priority list

Other:_________________________________________________________________
_
None



13. When prescribing aerobic exercise for patients with stroke, are you uncertain about
your clinical decisions in any of the following areas? Check all that apply.
Safety screening or monitoring
Frequency of exercise (e.g. days/week)
Intensity of exercise (e.g. target workload, heart rate or perceived exertion)
Duration of exercise (e.g. minutes/session)
Mode of exercise (e.g. treadmill, recumbent stepper)
Prescribing individual or group aerobic exercise
Personnel involvement in aerobic exercise (e.g. PTA, support staff, nursing, etc)
Strategies to increase motivation for aerobic exercise
Strategies to increase self-efficacy for aerobic exercise

Other:_________________________________________________________________
_____
No, I am confident in all aspects of aerobic exercise prescription for patients with
stroke

14. Before prescribing aerobic exercise for patients with stroke, do you routinely use
any of the following items to screen for safety? Check all that apply.
Past medical history
General patient presentation/symptoms
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American College of Sports Medicine's contraindications to exercise
A risk stratification category (Please specify)
Six-Minute Walk Test
Symptom-limited exercise test
Submaximal exercise test
Pulse rate or heart rate response to exercise
Resting blood pressure
Blood pressure response to exercise
Resting electrocardiogram (ECG)
Exercise ECG
Consultation with a physician

Other:_________________________________________________________________
_____
None

15. Do you believe that most patients with stroke need to have an exercise stress test
with electrocardiographic (ECG) monitoring prior to participation in aerobic exercise?
Yes
No

16. Is exercise stress testing with ECG monitoring available for your patients with
stroke, either at your primary facility or by referral?
Yes - available at my primary facility
Yes - available by referral
No
I dont know

17. I have results from an exercise stress test with ECG monitoring prior to aerobic
exercise prescription for approximately __________ % of my patients with stroke.



18. When starting a new aerobic exercise program, do you believe that most patients
with stroke need ECG monitoring during initial exercise sessions?
Yes
No

19. I monitor an ECG during initial aerobic exercise sessions for approximately
________% of my patients with stroke.

20. Do you know how to perform and/or interpret ECG monitoring? Check all that apply.
No
I can setup ECG monitoring (i.e. lead placement)
I can recognize dangerous arrhythmias (e.g. ventricular tachycardia/fibrillation)
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I can read an ECG and identify important abnormalities (e.g. ST depression/elevation,
increased PR or QRS interval, atrial fibrillation waves, etc)
I can interpret ECG findings

21. Are you familiar with the recommendations from any of the following exercise
guidelines? Check all that apply.
ACSMs Guidelines for Exercise Testing and Prescription
AHAs Physical Activity and Exercise Recommendations for Stroke Survivors
AHAs Exercise Standards for Testing and Training

Other:_________________________________________________________________
_____
None

22. Do you routinely prescribe any of the following modes of aerobic exercise for
patients with stroke? Check all that apply.
Over ground walking
Active exercises in standing
Active exercises in sitting or lying
Stair climbing
Treadmill walking or jogging
Lower extremity ergometer (i.e. exercise bike)
Upper extremity ergometer (i.e. arm bike)
Combined lower and upper extremity ergometer (i.e. total body recumbent stepper)
Elliptical
Aquatic therapy
Circuit training
Virtual reality (e.g., Wii)

Other:_________________________________________________________________
_____











23. Are any of the following aerobic exercise resources readily available for your
patients with stroke at your primary facility? Check all that apply.
Treadmill
Body weight support system
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Other harness system for fall prevention
Lower extremity ergometer (i.e. exercise bike)
Upper extremity ergometer (i.e. arm bike)
Combined lower and upper extremity ergometer (i.e. total body recumbent stepper)
Accessible pool
Exercise ECG equipment
Continuous heart rate monitoring equipment
Pulse oximetry equipment
Metabolic system for respiratory gas exchange analysis during exercise
Activity monitors (e.g. pedometers)

Other:_________________________________________________________________
_____
None

24. Do you use any of the following methods to determine the initial (baseline) intensity
of aerobic exercise for patients with stroke? Check all that apply.
General observed response to the exercise
Patient feedback about degree of difficulty
Rating of perceived exertion (RPE)
Talk test
24a. Target heart rate (HR)
Percentage of predicted maximal HR
Percentage of peak HR achieved during exercise testing
Percentage of HR reserve (i.e. Karvonen formula) based on predicted maximal HR
Percentage of HR reserve based on peak HR during exercise testing
Below HR threshold of an abnormal exercise response found during exercise
testing
HR associated with the first ventilatory threshold
An absolute HR (e.g. 120 bpm)
24b. Target workload
Workload associated with a specific percentage of predicted maximal oxygen
uptake (VO
2
) or
VO
2
reserve
Workload associated with a specific percentage of peak VO
2
achieved during
exercise testing
(or peak VO
2
reserve)
Below workload threshold of an abnormal exercise response found during exercise
testing
Workload associated with the first ventilatory threshold
An absolute workload (e.g. 3 metabolic equivalents [METs], 100 W, 1.0 mph)

Other:_________________________________________________________________
_____
None

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25. Do you routinely monitor any of the following during aerobic exercise for patients
with stroke? Check all that apply.
General observed response to the exercise
Blood pressure
HR, measured manually
HR, measured using a heart rate monitor or oximeter
Rating of perceived exertion (RPE)
ECG
Oxygen saturation

Other:_________________________________________________________________
_____
None

26. How many patients with stroke have you observed having one of the following life-
threatening events during or immediately after aerobic exercise?

26a. Serious cardiac event (myocardial infarction or cardiac arrest)? __________

26b. Recurrent stroke? _________

28. On average, about what intensity of aerobic exercise do you prescribe for patients
with stroke? Choose the category that best fits your practice.

27. On average, about what intensity and volume of aerobic exercise do you prescribe
for patients with stroke? (Remember, PRESCRIBING aerobic exercise refers to
exercise that is done during a therapy session AND exercise that the patient does
outside of therapy under your instruction.)

27a. Intensity
Very light; RPE (6-20) < 10; <20% HR or VO
2
reserve; <50%
maximal HR
Light; RPE(6-20) 10-12; 20%-39% HR or VO
2
reserve; 50-63%
maximal HR
Moderate; RPE(6-20) 12-14; 40%-59% HR or VO
2
reserve; 64-76%
maximal HR
Hard (vigorous); RPE(6-20) 14-16; 60%-84% HR or VO
2
reserve; 77-93%
maximal HR
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Very hard; RPE(6-20) 17-19; 85% HR or VO
2
reserve; 94%
maximal HR
Maximal; RPE(6-20) 20; 100% HR or VO
2
reserve; 100%
maximal HR
Unknown

27b. Session length. How many minutes per day? _________ minutes.

27c.. Frequency. How many days per week? ________ sessions per week.

27d.. Total duration. How many weeks? ________ weeks.

27e. Do you routinely recommend that your patients with stroke continue with aerobic
exercise after formal therapy has ended?

Yes
No


28. Do you routinely recommend that your patients with stroke continue with aerobic
exercise after formal therapy has ended?
Yes
No

29. On average, about what volume of OVERALL THERAPY do you provide for patients
with stroke? (Please include only time spent with a therapist and NOT exercise that the
patient does outside of therapy.)

29a. Session length. How many minutes per day? _________ minutes.

29b.. Frequency. How many days per week? ________ sessions per week.

29c. Total duration. How many weeks? ________ weeks.



30. What is the primary reason that an episode of care ends for most of your patients
with stroke?
Patients meet all goals and are satisfied with their level of recovery
Patients stop improving (plateau) and continued improvement is not expected with
more therapy
Financial constraints (e.g. insurance payment systems) limit the number of therapy
visits, duration of therapy or length of stay
Patients discharge to the next level of care (e.g. inpatient to outpatient)
Patients stop coming to therapy, refuse therapy or limited adherence is expected with
more therapy
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Other (please specify below):
____________________________________________________

30b. Are there any other reasons that an episode of care typically ends your patients
with stroke? (Check all that apply.)
No
Patients meet all goals and are satisfied with their level of recovery
Patients stop improving ("plateau") and continued improvement is not expected with
more therapy
Financial constraints (e.g. insurance payment systems) limit the number of therapy
visits, duration of therapy or length of stay
Patients discharge to the next level of care (e.g. inpatient to outpatient)
Patients stop coming to therapy, refuse therapy or limited adherence is expected
with more therapy
Other (please specify below):
____________________________________________________