Who Are Physical Therapists?
Physical Therapists (PTs) are highly-educated health care professionals who can help patients reduce pain and improve mobility and function, in many cases without expensive imaging, medical interventions, and surgery, often reducing the need for long-term prescription medications and their side effects. They engage in evidence-based practice in a variety of settings, including, but not limited to hospitals, nursing homes, private clinics, the Armed Forces, public schools, professional sports teams, patients’ homes, universities, and research institutions.
National accreditation standards now require physical therapist candidates to earn a clinical doctoral degree in physical therapy (DPT), requiring 7-8 total years of college coursework, before sitting for the state board exam.
A physical therapist patient examination is similar to that performed by other health care practitioners in the area of physical medicine, but perhaps more detailed and focused on movement dysfunction and pain. An examination always includes a patient history, screening for serious medical disorders, a detailed physical examination with numerous objective tests and measures, a physical therapy diagnosis, and a treatment plan in which specific goals and expected outcomes of care are discussed with the patient.
Vision 2020: Are Physical Therapists There Yet?
In the year 2000, the American Physical Therapy Association’s (APTA) House of Delegates passed Vision 2020, a lofty vision for the future of the physical therapy profession:
“APTA Vision Sentence for Physical Therapy 2020: By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health. “
“APTA Vision Statement for Physical Therapy 2020: Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice. Physical therapists may be assisted by physical therapist assistants who are educated and licensed to provide physical therapist directed and supervised components of interventions. Guided by integrity, life-long learning, and a commitment to comprehensive and accessible health programs for all people, physical therapists and physical therapist assistants will render evidence-based services throughout the continuum of care and improve quality of life for society. They will provide culturally sensitive care distinguished by trust, respect, and an appreciation for individual differences. While fully availing themselves of new technologies, as well as basic and clinical research, physical therapists will continue to provide direct patient/client care. They will maintain active responsibility for the growth of the physical therapy profession and the health of the people it serves.”
The above Vision has been much easier to talk about than to execute because while Vision 2020 was crafted by APTA on the national level, the practice of physical therapy is regulated on the state level. Therefore, in order to realize Vision 2020, the evolution of physical therapy education and policies must happen in all 50 states. But first, let’s take a step back in time to look at how the practice of physical therapy started.
APTA VISION SENTENCE FOR PHYSICAL THERAPY 2020 AND APTA VISION STATEMENT FOR PHYSICAL THERAPY 2020 HOD P06-00-24-35 [Position]
The Early Days: We’ve Come a Long Way, Baby!
Physical therapy, known as “physiotherapy” in countries other than the United States, can be traced back over 200 years to when The Royal Institute of Gymnastics in Sweden was founded in 1813. The practice of treating patients’ pain and injuries with manipulation, mobilization, and exercise was termed “medical gymnastics.” Review of old medical charts shows practitioners correcting positional faults and postural dysfunction in the spine and pelvis, in a strikingly similar fashion to manual therapists today. In the latter part of the century, the practice of medical gymnastics was squashed by the medical profession because of their competing interests and thought that it was quackery. Looking back retrospectively, this idea seems ironic coming from a profession that believed in blood letting to cure disease and not washing hands between surgeries because patients’ blood was more sterile than water.
Fortunately, the practice of mobilization, manual therapy, and exercise was reinvigorated in England in 1894 by a group of nurses who founded the Chartered Society of Physiotherapy in England. The first physical therapy schools were founded a few decades later in New Zealand and subsequently, in 1914, at Walter Reed Army Hospital in Washington, DC. Walter Reed was nationally recognized for the rehabilitation of injured soldiers and the practicing clinicians were called “reconstruction aides.” The “mother” of Physical Therapy, Mary McMillan, served as one of the first reconstruction aides and authored a text on exercise and massage, including illustrations of anatomy. She routinely encouraged injured patients out of bed for mobilization and exercise to the dismay of many on the physician staff. Over time, the medical community learned that injured patients healed much faster with physical therapy and the hospital no longer had a consistent shortage of beds. Today, early mobilization is considered the standard of practice and the failure to do so could be considered malpractice.
McMillan also helped found the first US PT association, the American Womens’ Physical Therapeutic Association, in 1921, which later included men and became the American Physiotherapy Association. In the 1940’s, the association became the American Physical Therapy Association, which is now the largest PT association in the world with about 100,000 members.
Early Physical Therapist Stands Up to Polio and Develop Muscle Testing
Following the success of early physical therapy in World War I and World War 2, physical therapy began to be applied to soldiers without severe injuries and then to the civilian public. It became extremely important in the evaluation and treatment of polio patients during World War II. Two people deserve special mention in this regard: Dr. Henry Kendall, a physical medicine doctor and his wife, Florence Kendall, who is still the most famous physical therapist in the United States.
“The couple wrote several pamphlets on the treatment of polio patients and in 1936 produced a five-reel film demonstrating methods of care. From 1943 until 1961, they taught body mechanics at the Johns Hopkins School of Nursing. In the 1940s, she was supervisor of physical therapy for the Maryland State Department of Health, specializing in polio patients.”
“It was a very difficult time because nobody knew what caused polio,” she said in a 2000 interview with PT Magazine. “After treating children with polio at the hospital all day, we didn’t know if we were exposing our own children to the disease.”
During the polio epidemic, physical therapy was not a licensed specialty, but the Kendalls changed that by drafting and passing the Maryland licensure bill in 1947, and PT’s are now licensed in all 50 states. A few years later, in 1949, Henry and Florence began sharing their expertise by publishing the first edition of their book, “Muscle Testing and Function.” This text has became the gold standard for manual muscle testing and postural assessment, has been updated numerous times across decades, and is still used by many university-based physical therapy schools today.
In 1952, the Kendalls opened one of the first private physical therapy practices in the country, and within a year their Baltimore clinic had more than 1,300 patients.
Physical Therapists Become Experts in Gait
Dr. Jacqueline Perry, MD, PT was a physical therapist and orthopaedic surgeon who also received extensive training in gait, or walking, mechanics during her medical residency at the UCSF Biomechanics Lab. She later moved to Southern California where she supervised the gait lab at Rancho Los Amigos Medical Center in Downey, California. In the 1970s and 80s, with the clinical use of advancing computer technology, electromyography (EMG or muscle testing), and goniometry (joint range of motion), Perry quickly became the nation’s top expert in gait analysis and post polio syndrome. Many rehabilitation techniques, bracing procedures, and corrective surgical techniques were invented and perfected on her watch. Her text, “Gait: Normal and Pathological Function,” is still considered the’ gold standard’ text for gait analysis. Rancho Los Amigos became one of the foremost training centers for physical therapists on the West Coast. She mentored thousands of physicians and physical therapists at Rancho and later on the campus of the University of Southern California, where the physical therapy school was eventually moved.
The 70s: Emergence of Private Practice and a Rainbow of Prominent Clinicians
Physical therapist private practice started to flourish in the 1970s, in part, because legislation was passed in 1972 allowing outpatient PT practices to bill for Medicare services. However, Charles Magistro, PT, is largely credited for being the ‘Father of Private Practice.’ His service as President of the APTA and founder and first chair of the Foundation for Physical Therapy Research laid the groundwork for the professionalization of physical therapy. He was not only one of the early proponents of evidence-based practice, but led the effort to improve physical therapists’ autonomy by taking control of physical therapy education standards away from the American Medical Association. He was later credited for thwarting physicians attempting to make a profit by referring patients to physical therapy clinics they owned.
The 70s were also a time when the science of hands-on physical therapy expanded. Stanley Perris brought manual and manipulative therapy back into the mainstream of physical therapist practice and education. Proprioceptive Neuromuscular Re-education (PNF) was taught to improve functional strength and coordination. And experts like Bobath and Root helped make thousands of physical therapists experts in treating neurologic and pediatric disorders with their ‘Neuro- Developmental’ techniques and training.
The 80s: The Sports Medicine Era
Advances in ligament reconstruction and arthroscopic surgery made postoperative physical therapy a necessity in the 80s, especially when it came to college and professional athletes. Post-operative rehab protocols were initially developed by orthopaedic surgeons and were extremely conservative. For example, a patient with an ACL reconstruction would wear a long-leg cast for several weeks after surgery. Fortunately, physical therapists engaged in clinical research eventually determined more appropriate guidelines that hastened recovery from surgery. The utilization of computer technology became popular to measure gains in strength and to predict readiness for sport and other high-level physical activities.
During this period, many orthopaedic surgeons began opening their own PT clinics and referring their patients to them. Meanwhile, physical therapists began networking with organizations, like Physical Therapy Provider Network (PTPN), founded by Michael Weinper, DPT, to help them contract with insurance companies at fair payment rates.
Meanwhile, manual therapy and mechanical assessment continued to flourish, especially with regard to the treatment of spinal disorders and extremity joints. There was continuing heavy influence by Australian physiotherapists, such as Geoffrey Maitland and Robin McKenzie, who offered systematic approaches to the examination and treatment of neck and back patients. Unfortunately the 80s were also infiltrated with the heavy use of physical modalities, like ultrasound and electrical stimulation, which were heavily marketed by medical equipment companies, but have still proven largely ineffective to this day.
The 90s: Evolving Physical Therapy Education
Few professions have had the explosion of scientific research and knowledge in a short period of time that physical therapy had in the latter half of the 20th century. It became increasingly obvious that while physicians typically had only a few hours in medical school dedicated to rehabilitation, a few years of physical therapist training was becoming totally inadequate to prepare students for the vast range of clinical problems they would encounter.
In the early days of physical therapy, a certificate was awarded after a few years of study, including clinical internships. By the 70s and 80s, most universities offered a Bachelor’s degree in physical therapy.
In 1985, the American Board of Physical Therapy Specialties began administering post-graduate board testing and certification to those with several years of experience within a specific physical therapy specialty. These PT board certified specialists now include:
- Orthopaedic Certified Specialist
- Neurologic Certified Specialist
- Sports Certified Specialist
- Pediatric Certified Specialist
- Women’s Health Certified Specialist
- Cardiovascular and Pulmonary Certified Specialist
- Clinical Electrophysiology Certified Specialist
- Geriatric Certified Specialist
There are now about 15,000 physical therapist board certified specialists in the US.
By the early 90s, PT education had largely moved to a Masters’ degree requirement. Among the first schools offering a Master’s in Physical Therapy were Stanford, USC, and Children’s Hospital, Los Angeles.
Helen Hislop, who served as Director of Physical Therapy at the University of Southern California between 1975 and 1998, was the torch-bearer for the advancement of physical therapist education and professionalism. She introduced clinical specialization, expanded clinical internship opportunities, and developed post-graduate residency programs. Perhaps she will be most remembered for transforming physical therapy into a doctoring profession through her advocacy and breaking ground on the nation’s first fully developed clinical Doctorate of Physical Therapy (DPT) program at USC in 1995. Hislop was convinced that physical therapists were ‘doctoring professionals with specialized knowledge, who are expected to engage in evidence-based practice.’
Given that the 1990s were a time that HMOs flourished, physician knowledge of many musculoskeletal conditions was insufficient, and patients’ time with their doctor was decreasing, the additional training for PTs was warranted. Their coursework in diagnosis, clinical disease processes, imaging, statistics, and research was increased to meet the evolving expectations of patients and the health care community.
By 2010, about 97% of physical therapy programs offered the DPT degree as the minimum requirement to become a physical therapist. There were 206 schools offering the DPT in the United States. In 2011, California legislation was passed allowing the last 4 schools in the nation offering a Masters degree, which were CSU schools, to convert to a DPT program. As of 2014, all US physical therapy schools offer only entry-level Doctor of Physical Therapy programs and require that candidates have at least a Bachelor’s degree with additional pre-med prerequisite coursework prior to admission.
The Millennium Focus on Research Evidence-Based Practice and Outcomes
The profession of physical therapy had been grounded in the basic sciences and clinical sciences during the latter half of the 20th century, but health care cost containment, the thirst for superior alternative/conservative medical care, and physical therapist specialization brought increasing scientific and clinical research to top universities, industry and practice. Physical therapist researchers were regularly published in top refereed medical journals, such as Spine, The New England Journal of Medicine, The Journal of the American Medical Association, Archives of Physical Medicine and Rehabilitation, Medicine and Science in Sport and Exercise, Physical Therapy Journal, and the Journal of Orthopaedic and Sports Physical Therapy, Stroke, and Neurorehabilitation and Neural Repair. Drs. Julie Fritz, Tony Delitto, and John Childs, all physical therapists, were among those who led the way in clinical science, while Carolee Winstein, , PhD, PT and Christopher Powers, PhD, PT led the way with neuroscience and biomechanics research, respectively.
Scientific and clinical research has helped physical therapists determine not only what works, but what may not work, and what is not helpful. The research focused not only on the basic science of physical therapy, but clinical prediction rules (that is, who was likely to benefit from a specific treatment), treatment-based classification, and risk factors which might lead to worse outcomes, all which greatly improved clinical decision making. The research has also helped fine tune practice in physical exam techniques, manual (hands on) therapy, muscle control, exercise prescription and many other areas of practice. It has also been used to help determine the best methods of treatment and best outcomes during an era of rising health care costs and the need for cost containment. During this period, several PT companies, such as Focus on Therapeutic Outcomes (FOTO), rushed to ‘beat the clock’ and perfect outcome databases in an attempt to demonstrate the value of physical therapists’ services, as well to demonstrate which therapists were providing the most efficient care.
2010 to 2017: Affordable Care Act, PT Advocacy, and the Opioid Crisis
While the last seven years have been marked by an “access to health care” crisis, ironically, it has also been a period troubled by legislative battles between various health care professional associations. Most notably, the California Medical Association was pitted against other professions such as nursing, physical therapist, optometrist, and pharmacist professional associations who were pursuing legislation to increase their scope of practice in order to give patients better access to health care. In 2013, California legislation was passed making California the 44th state with some form of direct access to physical therapists, allowing patients to see a physical therapist for up to 45 days or 12 visits without first seeing a physician (M.D. or D.O.). After being defeated by Jim Dagostino, DPT and California Physical Therapy Association (CPTA) ) four years in a row in a quest to legalize physician-owned physical therapy clinics (POPTS), the California Medical Association and Orthopaedic Association compromised with the California Physical Therapy association and traded limited direct access for legalization of POPTS.
Where are your Health Care Dollars Going? You might be Surprised!
The last several years have continued to present many challenges for physical therapists and other providers in clinical practice, especially declining insurance payment to small, independent practices. While the cost of physical therapy education has risen to an average of $250,000 and the cost of housing has escalated out of control in many regions of the country, the payment for physical therapists’ services has plummeted by over 20% over the last decade. During this time, health care spending increased to almost 18% of the Gross Domestic Product (GDP). A reasonable person, or a person with a knowledge of 3rd grade math might ask, “How do insurance companies justify massive increases in premiums, deductibles, and co-pays while decreasing payment and access to rehab providers who prevent the need for more expensive medical testing and procedures?” The answer is… they have largely done it through a loophole in the Affordable Care Act called the Medical Loss ratio, which compels insurers to spend at least 80% of the premiums on direct care services.
The loophole allows insurance companies and third party administrators to hire a ‘middleman’ discount network to perform some of the insurance companies’ administrative tasks while pressuring health care providers to take steep discounts from their normal fees, presumably in exchange for increased access to that network’s patients. The payers then list the discount network services as if they represented direct patient care. Some of these ‘middlemen’, such as One Call, Align Networks, and American Specialty Health, are known to demand a rate of significantly less than half of the Medicare Official Medical Fee Schedule, which means that many doctors are compelled to spend less time with their patients, since they are often effectively being paid half of what they made thirty years ago!
Providers Fight Back!
The Independent Physical Therapists of California (iPTCA), the California Chiropractic Association, and several medical societies interested in patient recovery from illnesses and injuries have led the charge to protect patients from unfair insurance practices, payer fraud, and substandard clinical conditions forced on health care providers. In fact,in 2017 iPTCA filed suit against a $2-3 billion dollar Workers Comp ‘middleman,’ One Call Medical, and their discount network, Align Networks. Instead of immediately responding to the allegations in the media or in the courtroom, One Call ditched the Align Networks brand name and, according to media reports, is attempting to settle the case out of court. A review of the literature and association records revealed that iPT vs. One Call and Align may be the first suit ever filed by a physical therapy association against payers. Thousands of supporting physical therapists and their patients are cheering for an impending victory in the near future!
Perhaps the biggest headlines touching the medical industry during the last few years, other than Affordable Care Act (“Obamacare”) legislation were about the opioid crisis. Opioids are widely used pain medications with a high rate of addiction, and include such brands as Tylenol with CodeineÒ, OxycontinÒ, VicodinÒ, and others. This costly human disaster has drawn much attention to the medical and big pharmaceutical industries’ history of ‘pill pushing’ and inappropriate management of chronic pain, which started in the 1990s and now affects over 20% of Americans.
The public is coming to realize, based on the high cost of opioid abuse and addiction, together with better evidence of what best-practices should be, that pain pills, expensive x-rays and MRI’s, , medical interventions, and surgery are not the ‘silver bullet’ for chronic pain. Reasonable solutions are more likely to be found by a conservative approach, which includes collaboration between health care professionals, as well as a cognitive behavioral-informed approach, in which patients are taught skills to deal with chronic pain on their own. When it comes to the treatment of chronic pain, the days of ‘top down’ medicine are coming to an end. And the majority of physical therapists (and Help What Hurts) agree…..IT’S ABOUT TIME!!!