


Introduction to Physical Therapy and Patient Skills?

CHAPTER 1: The Profession



CHAPTER OBJECTIVES
At the completion of this chapter, the reader will be able to:

1. Provide a definition of physical therapy

2. Give a historical perspective of how the role of a physical therapist has changed over the years

3. Name some of the pioneers who played a significant role in the development of today's physical therapy

4. Describe how the name of the American Physical Therapy Association (APTA) was derived

5. Describe how social change affected the growth of physical therapy in the United States

6. Discuss the purposes of having a code of ethics for a profession

7. Describe the differences between morals and ethics

8. Have a good understanding of the Code of Ethics of the APTA

9. Describe the various practice settings that employ physical therapists

10. Describe the various members of the healthcare team

OVERVIEW
The American Physical Therapy Association (APTA) is the organization that represents physical therapists and physical therapist assistants. It currently has a national office in Alexandria Virginia, as well as a chapter office in almost every state. APTA membership is voluntary and not mandatory for licensure. A number of APTA publications, including The Guide to Physical Therapist Practice ("the Guide")1 and a monthly journal aptly named Physical Therapy, provide guidance for the physical therapy profession.
The Guide has defined physical therapy as follows:

Physical therapy includes diagnosis and management of movement dysfunction and enhancement of physical and functional abilities; restoration, maintenance, and promotion of optimal physical function, optimal fitness and wellness, and optimal quality of life as it relates to movement and health; and prevention of the onset, symptoms, and progression of impairment, functional limitations, and disabilities that may result from diseases, disorders, conditions, or injuries.
An APTA publication, Today's Physical Therapist: A Comprehensive Review of a 21st Century Health Care Profession,2 describes the practice of physical therapists in the following way:
Physical therapists are health care professionals who maintain, restore, and improve movement, activity, and health enabling an individual to have optimal functioning and quality of life, while ensuring patient safety and applying evidence to provide efficient and effective care. Physical therapists evaluate, diagnose, and manage individuals of all ages who have impairments, activity limitations, and participation restrictions. In addition, physical therapists are involved in promoting health, wellness, and fitness through risk factor identification and the implementation of services to reduce risk, slow the progression of or prevent functional decline and disability, and enhance participation in chosen life situations.



In addition to providing habilitation and rehabilitation services, as well as prevention and risk reduction services, physical therapists also collaborate with other healthcare professionals to address patient needs, increase communica tion, and provide efficient and effective care. Physical therapists also provide consulting, education, research, and administration services across the continuum of healthcare settings.
The APTA further defines physical therapists and physical therapy services as follows:

  Physical therapists are experts in how the musculoskeletal and neuromuscular systems function.

 Physical therapist services are cost effective. Early physical therapy intervention prevents more costly treatment later, can result in a fast recovery, and reduces costs associated with lost time from work.
  Patients pay less when they have direct access to physical therapy services.

As we move forward in the 21st century, the practice of physical therapy continues to evolve. Many of the challenges facing today's physical therapist are due to an increased prevalence to certain contemporary lifestyle conditions. These include hypertension, obesity, diabetes, ischemic heart disease, cerebrovascular accidents, and smoking related diseases. In addition to having a primary focus of rehabilitating those individuals with impairments and dysfunction, today's physical therapists are becoming more involved in multi pronged strategies to help reduce or prevent poor lifestyle choices. The evolution of physical therapy can best be appreciated through a historical perspective.
HISTORICAL PERSPECTIVE
Current physical therapy treatment methods, such as hydrotherapy, breathing exercises, positioning techniques, therapeutic massage, and therapeutic exercises, have been used since around 3000 bc for the relief of pain and the treatment of a variety of health problems.3 From these rudimentary beginnings, therapeutic interventions began to emerge as various civilizations added advancements and adaptations (see Box 1 1).




Box 1 1

Approximately 1000 bc: Taoist priests in China describe a type of exercise that involves body positioning and breathing routines to relieve pain and other symptoms.
Approximately 500 bc: A Greek physician called Herodicus gives written descriptions about an elaborate system of exercises called Ars Gymnastica, which consisted of various gymnastic exercises.
Approximately 400 bc: Hippocrates, who is considered the father of medicine, recommends the use of muscle strengthening exercises, an early form of transverse friction massage, and therapeutic massage. Hippocrates was also the first to use electrical stimulation.
Approximately 180 bc: The ancient Romans introduce a series of therapeutic exercises that they called gymnastics.

Approximately 200 ad: Galen, a renowned physician of ancient Rome, emphasizes the importance of moderate exercise to strengthen the body, increase body temperature, allow the pores of the skin to open, and to improve a person's spiritual well being.
Approximately 1400 ad: Therapeutic exercises are intro duced into schools as physical education courses.

Approximately 1500 ad: The first printed book on exercise is published in Spain.

Approximately 1700 ad: Massage, hydrotherapy, and exercises performed en masse are first introduced in the United States.

1723 ad: Nicolas Andry, considered to be the grandfather of orthopedics, emphasizes the importance of exercise to cure many infirmities of the body.
Mid 1700s ad: Exercise equipment appears on the market.

1800s ad: Introduction of Swedish exercise/gymnastics by Per Henrik Ling. These exercises are adapted by Dr. Johann Georg Mezger, who introduced the terms effleurage, petrissage, and tapotement, which became known as Swedish massage. In 1864, Gustav Zander introduced 71 different types of apparatus to assist in the performance of Swedish exercise/gymnastics and opened numerous Zander institutes throughout Europe and the United States. At the end of the 1800s, H. S. Frenkel introduced a series of neurological exercises and rehabilitation techniques to enhance coordination and gait in those patients with ataxia resulting from nerve cell destruction. Frenkel's exercises continue to be used today.


Descriptions of the early years of the physical therapy profession in the United States begin between 1914 and 1916 and center mainly in the New England states. These descriptions portray the role of the physical therapist to include the assessment, prevention, and treatment of movement dysfunction and physical disability, with the overall goal of enhancing human movement and function. In essence, these descriptions contain many of the vital elements still used in the practice of physical therapy today.





Much of the impetus behind the profession during these early years resulted from the high incidence of acute anterior poliomyelitis, referred to then as infantile paralysis, which occurred in 1916 (Figure 1 1). At that time, the primary modes of treatment for infantile paralysis included long term splinting and casting to immobilize the limbs or the spine, combined with prolonged bed rest, while keeping the patient in quarantine and isolation. Predictably, these immobilizations and prolonged bed rests resulted in muscle atrophy and a loss of flexibility in the extremities of the patients. At this point in history, the majority of Americans regarded disability as irreversible, but that was about to change, as was the type of treatment offered.

FIGURE 1-1


Early treatment approach to poliomyelitis




The focus on different interventions for infantile paralysis resulted in a huge demand for muscle testing and muscle reeducation to restore function. Much of this emphasis on muscle testing and muscle reeducation was based on the work by Robert W. Lovett, a professor of orthopedic surgery at Harvard, who had discovered that muscle training exercises were the most important early therapeutic measures for polio treatment. Lovett organized teams of workers including physicians, nurses, and other nonphysician personnel. Included among the nonphysician personnel were three individuals
 Wilhelmine Wright, Janet Merrill, and Alice Lou Plastridge who received special training in massage, muscle training, and corrective exercises from Dr. Lovett.
The United States entered World War I by declaring war on Germany in 1917, and the Army recognized the need to rehabilitate soldiers injured in the war.3 The U.S. Congress authorized the military draft and passed legislation to rehabilitate all servicemen permanently disabled from war related injuries. Attention became focused on the use of multiple and combined methods to restore physical function in members of both the military forces and the civilian workforce under the umbrella term physical reconstruction. A report from the Division of Orthopedic Surgery called for the establishment of hospitals for the reconstruction of soldiers with disabilities, and a national training corps for personnel (therapists). Physical reconstruction was defined as the "maximum mental and physical restoration of the individuals achieved by the use of medicine and surgery, supplemented by physical therapy, occupational therapy or curative workshop activities, education, recreation, and vocational training." Many of the exercises used were based on Ling's Swedish exercise/gymnastics and the use of Zander's exercise machines (Figure 1 2) (see Box 1 1). These exercise based approaches and their subsequent outcomes began to change the belief that disability was irreversible.

FIGURE 1-2


Exercises using machines





The report from the Division of Orthopedic Surgery also suggested that standards be developed by the schools. In 1917, a special unit of the Army Medical Department, the Division of Special Hospitals and Physical Reconstruction, developed 15 "reconstruction aide" training programs to respond to the need for medical workers with expertise in rehabilitation to treat the more than 200,000 U.S. troops wounded in battle (Figure 1 3). Preference for applicants with high scholastic standing in the fundamentals of physical education demonstrated the importance that was placed on the knowledge of human movement. Individuals who completed the courses, and who worked in the Division of Special Hospitals and Physical Reconstruction in the Office of the Surgeon General, U.S. Army, were given the title Reconstruction Aide (those practitioners rendering similar service in civilian facilities were referred to as physical therapy technicians, physiotherapy aides, and physiotherapy technicians). Two different groups of reconstruction aides were established.

FIGURE 1-3


Gait training

1. Reconstruction aides/physical therapists who assisted physicians by providing exercise programs, hydrotherapy (Figure 1 4), and other modalities, and massage (Fig 1 5) for these patients.
2. Reconstruction aides/occupational therapists who had been working in alms houses and insane asylums and who were to provide training to patients in those vocational skills necessary for them to return to gainful employment.

FIGURE 1-4


Early use of hydrotherapy




FIGURE 1-5


Massage therapy

Marguerite Sanderson and Mary McMillan were the first two individuals involved in the training of those reconstruction aides responsible for caring for individuals wounded during the war. Marguerite Sanderson was hired under this new division as director of the Reconstruction Aide Program in 1917 at Walter Reed General Hospital and was joined by Mary McMillan.
By 1918, outlines for a three month course to be used in training programs had been developed to prepare practitioners who would serve, in a civilian capacity, as reconstruction aides in the recently established Division of Special Hospitals and Physical Reconstruction. The required subjects for this



course included:
  Biological and physical sciences, including anatomy, physiology, chemistry, physics, and kinesiology  Social sciences, including psychology and ethics
 Clinical sciences (physical therapy), including electrotherapy, exercise, hydrotherapy, light therapy, massage, thermotherapy, physical agents, tests and measures
  Clinical sciences (medical), including medicine, neurology, orthopedics, surgery, and pathology


As World War I drew to a close, physical reconstruction practices, which had previously been directed toward preserving, restoring, and maintaining a fighting force, were directed toward preserving and maintaining a working force. Between 1919 in 1920, there was a major postwar decrease in large hospitals, whose numbers shrank from 748 to 49. The remaining hospitals had physiotherapy facilities and employed more than 700 reconstruction aides. Nearly 50,000 veterans, or almost half of those 125,000 Americans who were disabled during World War I, were treated at these facilities.4

CLINICAL PEARL 

The American Women's Physical Therapeutics Association (AWPTA) was founded in 1921.5 Mary McMillan was elected the first president of the AWPTA by a mail in vote. The first issue of the association's official publication, The P.T. Review, appeared on March 1, 1921. Today, the P.T. Review is called Physical Therapy and is the official publication of the APTA. The first edition of the P.T. Review reported the full text of the constitution and bylaws of the association, which promised:
Professional and scientific standards for its members

To increase competency among members by encour aging advanced studies To promulgate medical literature and articles of professional interest
To make available efficiently trained members To sustain professional socialization
During the early years of the association, membership was open to nurses who had additional training in specific types of clinical experiences. From 1929 until 1933, an American Physical Therapy Association existed as an organization that was formed through the merger of two organizations of physicians, the Western Association of Physical Therapy and the American Electrotherapeutic Association. In 1922, at its first conference, the name of the American Women's Physical Therapeutics Association was changed to the American Physiotherapy Association (APA)5 in recognition of the fact that men also practiced physiotherapy, and subsequently, in 1947, to its current name, the American Physical Therapy Association (APTA).6


In the early 1920s, the passage of the Rehabilitation Bill in New Jersey resulted in a growing enthusiasm about the future of rehabilitation and of "reconstruction aids or teachers of vocational and educational forms of work that are therapeu tic in process." This resulted in a partnership of physical therapists with the medical and surgical communities and increased public recognition and validation of the profession of physical therapy.3 In 1921, Mary McMillan published Massage and Therapeutic Exercise, the first textbook written by a physiotherapist.7 McMillan referred to four distinct branches in physical therapeutics: massage, therapeutic exercise (Figure 1 6), electrotherapy, and hydrotherapy. Textbooks from the early years of



the profession document the application of physical therapy for problems related to the musculoskeletal, neuromuscular, cardiovascular, pulmonary, integumentary, reproductive, renal, and psychogenic systems.

FIGURE 1-6


Therapeutic exercise



In 1924, Leo Buerger, a urologist, and Arthur W. Allen, a surgeon, created a series of exercises for patients with vascular disease, specifically arterial insufficiency in the legs, which used the application of the effects of gravity and posture on the vascular musculature and blood circulation.
Poliomyelitis continued to rage throughout the United States in the 1920s and 1930s, with the country witnessing an increase in both the incidence and magnitude of poliomyelitis outbreaks. During this period, the APA attempted to stay side by side with the medical profession. In 1925, a group of physical therapy physicians founded the American College of Physical Therapy (ACPT), and then established the American Registry of Physical Therapy Technicians for the purpose of conferring a registered title on physiotherapists who passed the test.7 Under this arrangement, registered physiotherapists remained technicians under the supervision of physicians.7 Later that year the ACPT joined the AMA and changed its name to the American Congress of Physical Therapy. By 1937, physical therapy physicians had achieved recognition as a medical specialty. At that time, in an effort to further distinguish themselves from physiotherapists, and in order to gain respect within the medical profession, the physical therapy physicians began to call themselves "physiatrists."7 The AMA became concerned that the public might consider physiotherapists to be physicians. This concern led to a name change from physiotherapists to physical therapists in the early 1940s.




The advent of World War II resulted in an ever increasing demand for physical therapy specialists. During this time, drastic improvements in medical management and surgical techniques led to increasing numbers of survivors, albeit with disabling war wounds.8 Wounded veterans who returned home with amputations, burns, cold injuries, wounds, fractures, and nerve and spinal cord injuries required the attention of physical therapists in the first half of the 1940s, with World War II at its peak.9 However, the principles of muscle training that had been used by reconstruction aides in World War I and for the treatment of polio were found to be ineffective for treating many of the problems associated with war related injuries. The subsequent demand for more effective techniques propelled the practice of physical therapy through a major growth period as the attention switched to a focus on the application of neurophysiologic principles, which in turn prompted the advent of a number of techniques still used today, including progressive resistive exercise (PRE).
In 1945, Thomas DeLorme, a physician, first introduced the concept of PRE after using increasing resistance on himself following knee surgery.


The rehabilitation concepts introduced to treat those wounded in World War II fostered the growth of this new specialty of physical medicine, also referred to as rehabilitation medicine, or simply as rehabilitation.
The passage of the Hospital Survey and Construction Act of 1946, the "Hill Burton Act," initiated a nationwide hospital building program and increased public access to hospitals and healthcare facilities, which in turn led to an increase in hospital based practice for physical therapists. To this day, the hospital has continued to be the primary setting for the services of therapeutic intervention provided by a physical therapist, with up to 50% of active physical therapists currently practicing in a hospital setting.
Because of the increased need for physical therapists and the discontinuation of the army based schools, the Schools Section of the APTA, which recognized the need to educate more physical therapists, made recommendations about admissions, curricula, education, and administration of physical therapy programs, and the APTA embarked on an effort to encourage more universities and medical schools to create programs and expand existing programs, including creating opportunities for graduate level education.10


The role of the physical therapist progressed further in the 1950s from that of a technician to a professional practitioner.7

The outbreak of the Korean War in 1950 involved the United States in yet another war effort.7 In addition, poliomyelitis continued to afflict thousands of Americans. As the practice of physical therapy evolved, aides, attendants, and volunteers began to provide valuable assistance in direct care of the large numbers of persons injured in the war and those who had poliomyelitis during the epidemics. These individuals assisted patients before and after treatment, performed general housekeeping duties, and were involved in the routine maintenance of equipment and supplies. It is during this time that Margaret Rood, a physical therapist and occupational therapist, broke new ground in the treatment of individuals with central nervous system (CNS) disorders.13 In an effort to discover a vaccine that would prevent polio, massive national field trials were organized. These trials, from the research that had been initiated in earnest in the 1940s, bore fruit when, in 1955, Jonas Salk developed such a vaccine, and massive vaccination



programs were initiated. In 1957, Albert Sabin developed an oral vaccine using attenuated poliovirus, which was licensed in 1962.
The 1950s decade was a pivotal time for the physical therapy profession in terms of gaining independence, autonomy, and professionalism.


Two events in the 1950s contributed to the progression of the physical therapist from technician to professional practitioner10:  The Self Employed Section formed as a component of the APTA in 1955 as private practice expanded.
  The Physical Therapy Fund, created in 1957, fostered science through research and education within the profession.

Pursuing a replacement to the system of registration that had been fashioned through the American Medical Association (AMA), which required a questionable assessment of professional competence in physical therapy, the APTA pressed its state chapters to seek licensure through the states, and by 1950, Connecticut, Maryland, and Washington had adopted physical therapy practice acts, joining New York and Pennsylvania, whose initial licensing efforts dated back to 1926 and 1913, respectively.2, 10


The 1960s brought profound changes in the U.S. healthcare system as increasing numbers of states began to enact a number of practice acts.5 In addition, the polio vaccines had virtually eradicated poliomyelitis in the United States by 1961. While some physical therapists continued to treat those patients with poliomyelitis, many others began focusing their efforts on the management of many other types of disabling conditions.
The earlier efforts to gain state licensure clearly influenced the Medicare program in 1967 and 1968 as the majority of states had licensure laws by this time, which regulated the practice of physical therapy and the services provided by physical therapists. Amendments to the Social Security Act (SSA) in 1967 added a definition of "outpatient physical therapy services." This meant that the Social Security organization recognized physical therapy services as a healthcare provider for reimbursement. This amendment also resulted in dramatic changes to the practice of physical therapy for patients with neuromuscular disorders. Influenced by the earlier work of Margaret Rood, Margaret Knott, Dorothy Voss, and Signe Brunnstr m, Berta and Karl Bobath developed techniques for adults with a cerebrovascular accident (stroke), cerebral palsy, and other disorders of the central nervous system.9 Since that time, the physical therapy profession has continued to expand its treatment areas, which has led to the need for specializations.




In the late 1960s and early 1970s, open heart surgery became possible, and the physical therapy profession expanded the cardiovascular/pulmonary area of its practice with increasing chest physical therapy programs for pre  and postoperative patients. In the orthopedic practice arena, there was an expansion of joint replacements, resulting in the emergence of new avenues for orthopedic physical therapist practice through the introduction of new options for patients with severe joint restrictions to live more independent and pain free lives. During this time, technological advances provided new testing methodologies and options to improve patient function, which allowed physical therapists new opportunities to develop more objective outcome measures, new intervention strategies, and an increase in the types of diseases and conditions that physical therapy could positively influence.










The 1970s and 1980s saw an increase in opportunities for practice with the implementation of Occupational Safety and Health Administration (OSHA) rules and regulations, the passage of the Education for All Handicapped Children Act (PL 94 142), and the epidemic spread of acquired immunodeficiency syndrome (AIDS). OSHA was formed for the prevention, management, and compensation of on the job injuries. The AIDS epidemic resulted in physical therapists once again providing services to patients with multisystem involvement. In addition, physical therapists began providing services in the areas of women's health, oncology, and hand rehabilitation.
In the early 1980s, the APTA adopted a policy indicating that "physical therapy practice independent of practitioner referral was ethical as long as it was legal in the state."9
The first examinations for specialist certification were taken in 1985 by three physical therapists who became members of the American Board for Physical Therapy Specialties certified cardiopulmonary specialists.7 These specialist certifications were followed by clinical electrophysiology, pediatric, neurology, sports, and orthopedic certifications.7 Also significant during this time was the formation of the Federation of State Boards of Physical Therapy (FSBPT) in 1986, providing an organization through which member licensing authorities could coordinate to promote and protect the health, welfare, and safety of American communities.2
Substantial changes in the healthcare delivery system in the United States required a major association focus in the 1990s, influencing the practice of physical therapy in ways that continue today.2 The Americans with Disabilities Act (ADA) and the National Center for Medical Rehabilitation Research (NCMRR) led to new opportunities for practice. Physical therapists were faced with the challenges of increasing governmental cost savings, decreasing reimbursement, increasing governmental regulations, the influences of the insurance industry and corporate America, and the sudden personnel supply exceeding demand for services.7
In August 1997, President Clinton signed the Balanced Budget Act (BBA) to eliminate the Medicare deficit. The BBA, which took effect in January 1999, applied an annual cap of $1500 (for both physical therapy and speech therapy services) per beneficiary for all outpatient rehabilitation services. These changes had a dramatic effect, reducing rehabilitation services to Medicare patients. In November 1999, because of increasing pressure from the public, President Clinton signed the Refinement Act, which suspended the $1500 cap for two years in all rehabilitation settings starting on January 3, 2000.




CLINICAL PEARL 

The 1990s introduced some major changes in the healthcare delivery system, including Managed Care, point of service plans, and other alternative organizational structures (see Chapter 2). In addition, skilled nursing facilities were affected by the following regulations7:
PPS: Medicare Prospective Payment System. A PPS is a method of Medicare reimbursement that is intended to motivate providers to deliver patient care efficiently, effectively, and without an overutilization of services in hospitals, skilled nursing facilities (SNFs), and home health agencies. The payment is based on a unique assessment classification of each patient, and the payment amount for a particular service is derived based on a classification system (e.g., per diem or per stay).
MDS: Minimum Data Set. MDS is part of a federally mandated process for all residents in Medicare  or Medicaid certified nursing facilities regardless of the source of payment for the individual resident. The MDS is a comprehensive resident assessment instrument (RAI) that measures functional status, mental health status, and behavioral status to identify chronic care patient needs and formalize a care plan in response to 18 Resident Assessment Protocols (RAPs). Under federal regulation, assessments are conducted at the time of admission into a nursing facility, on return from a 72 hour hospital admission, whenever there is a significant change in status, quarterly, and annually. In the majority of cases, participants in the assessment process are licensed health care professionals employed by the facility. Data collected from the MDS assessments are used for the Medicare reimbursement system, many state Medicaid reimbursement systems, and to monitor the quality of care provided to nursing facility residents.
RUGs (Resources Utilization Groups): A RUG is a mutually exclusive category that reflects various levels of resource need in a long term care (LTC) setting. These categories, which are assigned to individuals based on data elements derived from the LTC Minimum Data Set (MDS), are primarily used to facilitate Medicare and Medicaid payment. Each RUG, which is organized in a hierarchical fashion, is associated with relative weighting factors. A number of RUGs have evolved over the years:
RUG 34: An initial set of RUGs that was developed primarily to support resource risk adjustment for Medicaid payment.

RUG 44: An expanded version of RUG 34 that included 14 Rehab RUGs and a new hierarchical order primarily to support Medicare PPS starting in 1998.
RUG 53: An expanded version of RUG 44 that included nine mixed Rehab and Extensive Service RUGs, which were used to support Medicare PPS since January 2006.
OBRA: Omnibus Budget Reconciliation Act of 1987. OBRA requires a comprehensive assessment of all nursing facility residents within 14 days of admission, a quarterly assessment (within 92 days) thereafter, and an annual full assessment (within 366 days of prior full assessment).


Prompted by a need to formally define the role of the physical therapist and to describe the practice of physical therapy, the Guide to Physical Therapist Practice (the Guide) was created.15 This model for physical therapist practice was adopted in 1997 and the Guide to Physical Therapist Practice, published in 1999 introduced the terminology of examination, evaluation, diagnosis, prognosis, intervention, reexamination, and the assessment of outcomes.7


Thus, throughout the 20th century, biomedicine was the dominant model of medical care with its focus on an impairment model. During this time, healthcare priorities shifted from the prevention, cure, and management of acute infectious conditions to the present day focus on the prevention,



cure, and management of lifestyle conditions such as hypertension, obesity, and metabolic syndrome (a group of risk factors that occur together and increase the risk for coronary artery disease, cerebrovascular accident, and type 2 diabetes).16
With the arrival of the 21st century, a vastly revised version of the Guide to Physical Therapist Practice was published in 2001.1 Continued development of the Guide led to the development of an interactive CD ROM version that included the specifics of all the tests and measures used in the physical therapist examination process.7
The Guide is divided into two parts:

  Part I delineates the physical therapist's scope of practice and describes patient management by physical therapists (PTs).  Part II describes each of the diagnostic preferred practice patterns of patients typically treated by PTs.
That same year, the "Hooked on Evidence" project was developed to facilitate increasing practice based on evidence, when available. Legislation was introduced in 2001 in the House of Representatives to allow Medicare patients direct access to physical therapist services.7
The impetus behind these publications and legislations was driven by a combination of increased life expectancy, end of life morbidity, and thus prolonged disability. Unfortunately, it had also become apparent that many of the lifestyle conditions that had only affected adults, such as heart disease, type 2 diabetes, and obesity, were now affecting the pediatric population. In an effort to combat these lifestyle conditions, it was necessary to shift the focus from symptom reduction with drugs and surgery to one that addressed their causes through prevention at both the individual and societal levels. It became clear that many of the most common lifestyle conditions were preventable, and in some cases reversible, with removal of their associated risk factors (Table 1 1).
TABLE 1-1
Six Major Risk Factors Related to Lifestyle Conditions

The environment in which physical therapists practice continues to be subjected to the push and pull of multiple forces. These forces include17:  Ethical considerations, including patient confidentiality and informed consent
 Societal and cultural beliefs and values Population demographics
The economy

Governmental legislation, rules, and regulations Public and private organizations and agencies Scientific and technological advances
Given that most people have one or more risk factors or adverse manifestations of lifestyle conditions, strategies to address these conditions in the 21st century have included multiple health behavior change strategies and evidence informed interventions. These strategies are targeted at the individual based on an assessment of health and risk factors.18 To be equipped to address present day health issues, the contemporary physical



therapist needs sufficient clinical competencies, knowledge, and expertise to serve as the primary caregiver with respect to smoking cessation, basic nutritional recommendations, weight control, regular physical activity guidelines, exercise prescription, stress and sleep management, and recommendations for moderate rather than excessive alcohol consumption.16 These non invasive interventions will play an increasingly important role as the profession progresses through the 21st century.
The growing responsibility for physical therapists in patient care has led the APTA to develop a vision statement known as Vision 2020, which states, "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other healthcare professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health." The year 2020 is fast approaching, necessitating continual changes in the preparation of students to become physical therapists and physical therapist assistants. For Vision 2012 to be realized, there are six key elements:
1. Autonomous practice. The physical therapist is solely responsible for the patient's physical therapy diagnosis, evaluation, intervention, and outcomes from the treatment. It is important to note that with this autonomy comes accountability and increased liability exposure.
2. Direct access. This is a situation in which a state's licensure laws allow a physical therapist to evaluate and treat a patient without the requirement of the physician's referral or prescription. At the time of writing, 43 states now have some type of direct access. For this to be effective, physical therapists must recognize the parameters associated within the scope of practice.
3. Doctor of physical therapy. By the year 2020, practicing physical therapists will have obtained a doctorate degree in physical therapy. This doctoral degree can take two forms:
  An academic doctoral degree (PhD) in physical therapy

  A transitional doctoral degree (DPT or tDPT) in physical therapy

4. Evidence based practice. The goal is to provide the most cost effective and beneficial treatment based on research. The APTA's Hooked on Evidence program now provides a platform called "Open Door: APTA's Portal to Evidence based Practice" to help members obtain this goal.
5. Practitioner of choice. The goal for this is that physical therapists and physical therapist assistants will be the consumer's first choice for treatment of movement dysfunction, dysfunction related to pain, and restoration of function lost to diseases and disabilities. As with autonomy of practice, this describes a situation in which there is no one overseeing the evaluation of services the physical therapist provides, which increases therapist liability.
6. Professionalism. The APTA has identified seven core values of professionalism in physical therapy:  Accountability
 Altruism

 Compassion/caring  Excellence
 Integrity

 Professional duty

 Social responsibility

THE EDUCATION OF THE PHYSICAL THERAPIST
Over more than a century, physical therapy education has evolved from early training programs for reconstruction aides to its current status as the doctor of physical therapy (DPT) degree.19 As mentioned in the History section, the early beginnings of the profession emerged from the U.S. Army's



Division of Special Hospitals and Physical Reconstruction, Office of the Surgeon General, which established an education program with focuses on anatomy and exercise. Graduates of this program were given the official title of "reconstruction aide."20 By 1918, a number of educational institutions worked in partnership with the Army to expand the program to a 6 month, intensive, certificate granting physical therapy program that focused more on the study of technical skills. Then, in 1928, the APA established the first Minimum Standards for an Acceptable School for Physical Therapy Technicians, which included a 9 month program of instruction. The prerequisite for admission to this program was graduation from a recognized school of physical education or nursing.6


These requirements continued for almost a decade until, in 1936, the AMA established the Essentials for an Acceptable School for Physical Therapy Technicians, and the first 13 institutions were accredited.5 During the next 25 years, the various physical therapist programs offered certificates, a certificate or baccalaureate degree, or a baccalaureate degree. By the 1960s there were more patients with complex and multisystem dysfunctions that called for advanced problem solving and analytical skills on the part of the physical therapist.2 These requirements resulted in changes in the school curricula, with the addition of neuroanatomy, neurophysiology, psychology of individuals with disabilities, research, education, administration, and management classes, and resulted in the baccalaureate degree becoming the minimum required qualification.5
Postprofessional advanced degrees for physical therapists began to emerge in the 1960s, with schools offering a master's degree program, and by the mid 1960s a number of schools were offering postprofessional PhD programs.
Over the past few decades a number of legislative and healthcare industry changes have provided physical therapists with greater autonomy within their scope of practice, further expansion of settings in areas of practice, and greater autonomy for the physical therapist to practice without a physician referral to varying degrees.8 To address the new demand for knowledge, skills, and professional behaviors, in 1979, the APTA adopted a resolution to require a postbaccalaureate degree to enter physical therapy beginning in 1990, although in reality, it took 23 years to complete the full transition.8 To help augment this transition, two APTA documents were introduced2:
 The Guide to Physical Therapist Practice (Volume I: A Description of Patient Management published in August 1995 and Volumes I and II: Preferred Practice Patterns published in November 1997).1 This document described the breadth, depth, and scope of physical therapist practice across the various systems and life span, and outlined the physical therapist's role in patient/client management.
 A Normative Model of Physical Therapist Professional Education.3 This document defined the preferred curricular content in the foundation, behavioral, and clinical sciences; entry level practice expectations and associated curricular content; clinical education; and noncurricular components (i.e., educational settings, admissions criteria, and qualifications and role of faculty and program administrators).
The rather quick transition to the Doctor of Physical Therapy (DPT) degree began to occur in 1995 1996. This transition is thought to have occurred for a number of reasons2:
The expanding needs of society for physical therapy services in a broad range of settings Greater evidence available about physical therapy interventions
Increased competition among programs for high quality applicants Augmentation in required basic and applied science curricular coursework Lengthening of clinical internships
To prepare for contemporary and future healthcare needs



The voluntary transition to the DPT degree has moved very rapidly, with 96.7% of accredited programs offering the DPT as of August 2010.21

Accreditation
Between 1933 and 1956, at the APA's invitation, the AMA Council on Medical Education reviewed and approved PT education programs. Between 1957 and 1976 the AMA and the APTA had first informal and then formal collaborative arrangements for accreditation based on the AMA's 1955 revision of the Essentials of an Acceptable School of Physical Therapy.2 In 1977, the APTA severed their relationship with the AMA by creating a new accrediting body: the Commission on Accreditation in Physical Therapy Education (CAPTE). Since that time, CAPTE has been recognized by the U.S. Department of Education (USDE) to accredit physical therapy (physical therapist and physical therapist assistant) programs.2 In the private sector, CAPTE has been recognized continuously since 1977, first by the Council for Post Secondary Accreditation (COPA), then by the short lived Council for Recognition of Post Secondary Accreditation (CORPA), and currently by the Council for Higher Education Accreditation (CHEA).2


As of January 1, 2002, CAPTE took the step of no longer accrediting baccalaureate physical therapy programs. The rationale for this was that the amount of information that physical therapy students were required to learn was beyond the scope of a baccalaureate program.
The Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists used by CAPTE to assess the quality of physical therapist education programs are organized around two major components2:
1. Integrity and capacity of the institution and program. The evaluative criteria address a number of program characteristics, including institutional integrity and capacity, program integrity and capacity, curriculum, and outcomes.
2. Curriculum content and outcomes. CAPTE's Evaluated Criteria include a list of 98 skills that graduates of accredited physical therapist programs are expected to possess, which it subdivides into three groupings:
 Professional practice expectations

 Patient/client management expectations  Practice management expectations
These competencies form the basis of CAPTE's evaluative criteria regarding curriculum content. In such competency based curricula, the emphasis is less on the courses offered, or how the content is delivered, and more on the outcomes of the educational efforts.2




THE PRACTICE OF PHYSICAL THERAPY
The following descriptions of physical therapist practice are based on the Guide to Physical Therapist Practice.22

Role in Patient/Client Management

A physical therapist provides care to patients/clients of all ages who have impairments, activity limitations, and parti cipation restrictions due to musculoskeletal, neuromuscular, cardiovascular/pulmonary, and/or integumentary disorders. Following the patient/client management model (described in Chapter 5), a physical therapist designs an individualized plan of care (POC) based on clinical judgment and the patient/client goals.
To facilitate communication among healthcare disciplines, the APTA has adopted the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to provide a standardized language and framework for the description of health and functioning (see Chapter 5).
Role in Prevention and Risk Reduction
A physical therapist provides prevention services and promotes health and fitness by helping prevent a targeted health condition in a susceptible or potentially susceptible population or individual through risk identification and mitigation strategies.
In such specific populations, a physical therapist can decrease the duration, severity, and the sequelae of health conditions through prompt intervention.
Finally, a physical therapist plays an important role in limiting a person's degree of disability, through the restoration and maintenance of function in patients/clients with chronic health conditions to allow optimal performance and participation.
Additional Clinical and Nonclinical Roles

A physical therapist may assume additional clinical and nonclinical roles, which can include consultation, education, research, and administration to health facilities, educational programs (e.g., public schools), colleagues, businesses, industries, third party payers, families and caregivers, and community organizations and agencies.
A physical therapist may also provide education and other professional services to patients/clients, students, facility staff, communities, and organizations and agencies and may also engage in research activities, including those related to measuring and improving the outcomes of service provision.
A physical therapist administrates in practice, research, and education settings and is involved in shaping community services and policies.

Standards of Practice

It is the role of the primary representative body for the physical therapy profession, the APTA, to outline and promote the expected level of quality of care for that profes sion. The APTA's commitment to society is to promote optimal health and functioning in individuals by pursuing excellence in care.2 To that end, the APTA has established the Standards of Practice for Physical Therapy (see Appendix A) and the corresponding Criteria for Standards of Practice in Physical Therapy (see Appendix B). These are the profession's statements of conditions and performances that are essential for high quality professional service to individuals in society and the necessary foundation for the assessment of physical therapy.
Code of Ethics



It is generally recognized that a code of ethics is important to professions, professionals, and the public, such that every clinician patient interaction should be performed with a high degree of professionalism.


Professionalism enhances trust. Throughout the history of physical therapy, physical therapists have always been concerned about the ethics of their profession. A formal set of ethical principles was first adopted by members of the APA in 1935. The four principles listed covered professional practice, advertising, behavior, and discipline. In effect, the 1935 Code of Ethics sacrificed professional autonomy for stability in their relations with the medical profession.24 Since then, the code of ethics has undergone a number of revisions and expansions. The Guide for Professional Conduct was issued by the Ethics and Judicial Committee of the American Physical Therapy Association in 1981 (last amended in January 2004) and published in the Guide to Professional Conduct, APTA.22 In June 2009, the House of Delegates (HOD) of the APTA passed a major revision of the APTA Code of Ethics for physical therapists (see Appendix C) and the Standards of Ethical Con duct for the Physical Therapist Assistant (see Appendix D). The revised documents were effective July 1, 2010. It may be that the 2009 revision of the core ethics documents represents the culmination of an increasing awareness within the profession and the professional organization of the ethical implications of the maturation of the profession.24
A number of authors have elaborated on the purposes of a professional code of ethics, putting forth such descriptions as "providing a vocabulary for intraprofessional argument, self criticism, and reform,"25 and "a profession's code of ethics is perhaps its most visible and explicit enunciation of its professional norms."26 A code not only embodies the collective conscience of a profession and is testimony to the group's recognition of its moral dimension,24 but also serves as a set of broad moral guidelines and as a public document stating the moral commitments of a group at a period in time.


Two words that are commonly used when describing an individual's attitude and behavior are morals and ethics.

 Morals. Morals are the attitudes and behaviors that society agrees on as desirable and necessary for maximizing the realization of things cherished most in that society.28 Within healthcare, the basic moral is to do no harm. Other examples include honesty, the rights of a patient to his or her life and autonomy, and character traits such as compassion, empathy, and conscientiousness.
 Ethics. Ethics is the study of morals and moral judgments. At its basic level, it is the study of right and wrong. An ethical dilemma is a situation in which there is no right answer.

Practice Settings
Physical therapists practice in a broad range of inpatient, outpatient, and community based settings. At a fundamental level, healthcare is divided into three levels: primary, secondary, and tertiary.



 Primary care. This level of care, which accounts for 80% to 90% of visits to a physician or other caregiver, involves basic or entry level healthcare, which includes diagnostic, therapeutic (e.g., diabetes, arthritis, or hypertension) or preventive services (e.g., vaccinations or mammograms) for common health problems. The care is provided on an outpatient basis by primary care physicians (PCPs), including family practice physicians, internists, and pediatricians. These physicians often serve as gatekeepers to other subspecialists, such as physical therapy. The physical therapist serves a supportive role for the primary care teams by providing an examination, evaluation, physical therapy diagnosis, prognosis, and intervention for musculoskeletal and neuromuscular dysfunctions.
 Secondary care. Secondary care services are provided by medical specialists (e.g., orthopedists, cardiologists, urologists, or dermatologists) for problems that require more specialized clinical expertise. This second level of care may require inpatient hospitalization or ambulatory same day surgery. Physical therapy involvement varies according to how much the patient's condition affects his or her function.
 Tertiary care. This level of care involves the management of rare and complex disorders (e.g., pituitary tumors, organ transplants, major surgical procedures, or congenital malformations) that require sophisticated technologies. At this level of care, physical therapy may be prescribed on an as needed basis.

Hospital

A hospital is an institution whose primary function is to provide inpatient diagnostic and therapeutic services for a wide variety of medical, surgical, and nonsurgical conditions. In addition, most hospitals provide some outpatient services, particularly emergency care. Hospitals may be classified in a number of ways, including by:
 Length of stay (short term or long term):

 Acute care (short term hospital). An acute care hospital can be defined as a facility that provides hospital care to patients who generally require a stay of up to 7 days, but less than 30 days, and whose focus is on a physical or mental condition requiring an immediate intervention and constant medical attention, equipment, and personnel. The goal of a hospital is for rapid discharge to the next level of care (to home or to another healthcare facility), and the physical therapist's recommendation is often very important in the discharge planning.
  Subacute (long term). Medical care is provided to medically unstable patients who cannot return home. Required services (medical, nursing, rehabilitative) are provided within a hospital or skilled nursing facility.
  Teaching or nonteaching hospital.

  Teaching: A hospital that serves as a teaching site for medicine, dentistry, allied health, nursing programs, or medical residency programs

  Nonteaching: A hospital that has no teaching responsibilities, or one that serves as an elective site for health related programs

  Major types of services: psychiatric, tuberculosis, burn, general, and other specialties, such as maternity, pediatric, or ear, nose, and throat (ENT).

  Type of ownership or control: federal, state, or local government; for profit or nonprofit.

Home Healthcare

Home healthcare involves the provision of medical or health related care by a home health agency (HHA), which may be governmental, voluntary, or private; nonprofit or for profit. Home care services were introduced to reduce the need for hospitalization and its associated costs. A HHA provides part time and intermittent skilled and nonskilled services and other therapeutic services on a visiting basis to persons of all ages in their homes.
Patient eligibility includes:

 Any patient who is homebound or who has great difficulty leaving the home. A person may leave home for medical treatment or short infrequent nonmedical absences such as a religious service, dialysis, or a hairdresser/barber.
 Medicaid waiver clients. The Medicaid Waiver for the Elderly and Disabled (E&D Waiver) program is designed to provide services to seniors and the disabled whose needs would otherwise require them to live in a nursing home. The goal is for clients to retain their independence by providing
	services that allow them to live safely in their own homes and communities for as long as it is appropriate.	



 A patient who requires skilled care from one of the following disciplines: nursing, physical therapy, occupational therapy, or speech therapy. The home health services provided by intermittent skilled nursing (<7 days/wk; <8 hours a day) include:
 Observation and assessment  Teaching and training
 Complex care plan management and evaluation  Administration of certain medications
 Tube feedings

 Wound care, catheters and ostomy care

 Nasopharyngeal and tracheostomy aspiration/care  Rehabilitation nursing
 Physician certification. In the case of an elderly patient, recertification by Medicare is required every 60 days. Medicare only pays for skilled home health services that are provided by a Medicare certified agency. Medicare defines intermittent as skilled nursing care needed or given for less than 7 days each week or less than eight hours per day over a period of 21 days (or less), with some exceptions in special circumstances. A patient must have a face to face encounter in 90 days prior or 30 days after the start of home health care with a physician, advanced practice nurse, or a physician assistant related to the condition(s) that necessitate home health care
 Patients who continue to demonstrate the potential for progress. The physical therapy focus includes:
  Environmental safety, including proper lighting, securing scatter rugs, handrails, wheelchair ramps, and raised toilet seats  Early intervention (refer to the following section, School System)
 Addressing equipment needs:

 Equipment ordered in the hospital is reimbursable.

  Adaptive equipment ordered in the home is not reimbursable except for items such as wheelchairs, commodes, and hospital beds.

  Observing for any evidence of substance abuse, or physical abuse:

  Substance abuse should be reported immediately to the physician.

  Physical abuse should be immediately communicated to the proper authorities (varies from state to state).

School System

The major goal of physical therapy intervention in the school is to enhance the child's level of function in the school setting the physical therapist serves as a consultant to teachers working with children with disabilities in the classroom. Recommendations are made for adaptive equipment to facilitate improved posture, head control, and function.
  Early Intervention Program (EIP). National program designed for infants and toddlers with disabilities and their families.

 The EIP was created by Congress in 1986 under the Individuals with Disabilities Education Act (IDEA). To be eligible for services, children must be less than 3 years of age and have a confirmed disability, or established developmental delay, as defined by the state, in one or more of the
	following areas of development: physical, cognitive, communication, social emotional, and/or adaptive.	



Therapeutic and support services include:

 Family education and counseling, home visits, and parent support groups  Special instruction
 Speech pathology and audiology  Occupational therapy
 Physical therapy

 Psychological services  Service coordination  Nursing services
 Nutrition services

 Social work services  Vision services
 Assistive technology devices and services

Private Practice

Private practice settings are privately owned and freestanding independent physical therapy practices.  Practice settings vary from physical therapy and orthopedic clinics, to rehabilitation agencies.
   Documentation is required every visit, and reevaluations are required by Medicare every 30 days for reimbursement purposes. Other healthcare facilities in which a physical therapist can practice are described in Table 1 2.
TABLE 1-2
Physical Therapist Practice Settings



Setting

Characteristics
Physical Therapist Role 


Transitional care
Non medically based facility, which may be in a group home or part of a continuum of a
Physical therapy


unit
rehabilitation center.
emphasis is on improving



Typical stay is 4 8 months with discharge to home, assisted living facility, or skilled nursing facility
functional skills for



(SNF).
maximum independence



Greater focus placed on compensation versus restoration.
to prepare a patient for




community reentry or for




transfer to an assisted-




living/skilled nursing




facility.


Skilled
Freestanding facility or part of a hospital that is licensed and approved by the state (Medicare
A SNF must be able to


nursing/Extended
certified).
provide 24-hour nursing





care facility (ECF)
Eligible individuals receive skilled nursing care and appropriate rehabilitative and restorative services.
Accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in the acute/subacute care setting of a hospital.
Provides skilled services, including rehabilitation, and various other health services (nursing) on a daily basis (Medicare defines daily as seven days a week of skilled nursing care and five days a week of skilled therapy).
Physician orders must be rewritten every 60 days.
coverage and the availability of physical, occupational and speech therapy.


Inpatient rehabilitation facility
Usually based in a medical setting.
Provides early rehabilitation, social, and vocational services once a patient is medically stable. Primary emphasis is to provide intensive physical and cognitive restorative services in the early months to disabled persons to facilitate their return to maximum functional capacity.
Typical stay is 3 4 months.
Physical therapist involved in the coordinated services of medical, social, educational, vocational, and the other rehabilitative services (OT, Speech).


Chronic/Long- term care facility
Long-term care facility that is facility- or community- based. Sometimes referred to as extended rehabilitation.
Designed for patients with permanent or residual disabilities caused by a nonreversible pathological health condition. Also used for patients who demonstrate slower than expected progress.
Used as a placement facility 60 days or longer, but not for permanent stays.
The facility has a full range of rehabilitation services (physical, occupational, and speech therapy) available.


Comprehensive outpatient rehabilitation facility (CORF)
A nonresidential facility established and operated exclusively for the purpose of providing outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician. Services include physician services; physical, occupational, and respiratory therapy; speech- language pathology services; prosthetic and orthotic devices, including testing, fitting, or training in the use of these devices; social and psychological services; nursing care provided by or under the supervision of a registered professional nurse; drugs and biologicals that cannot be self- administered; and supplies and durable medical equipment.
CORFs are surveyed every six years at a minimum.
Physical therapy (and occupational therapy and speech-language pathology services) may be provided in an off-site location.


Custodial care facility
Provides medical or nonmedical services, which do not seek to cure, but which are necessary for the patient who is unable to care for him/herself.
Provided during periods when the medical condition of the patient is not changing. Patient does not require the continued administration of medical care by qualified medical personnel.
This type of care is not usually covered under managed-care plans.
Physical therapy involvement is minimal.


Hospice care
A facility or program that is licensed, certified, or otherwise authorized by law, which provides supportive care for the terminally ill.
Focuses on the physical, spiritual, emotional, psychological, financial, and legal needs of the dying patient and the family.
Services provided by an interdisciplinary team of professionals and perhaps volunteers in a variety
Physical therapy may be consulted on an as- needed basis.






of settings, including hospitals, freestanding facilities, and at home.
Medicare and Medicaid require that at least 80% of hospice care be provided at home. Eligibility for reimbursement includes:
Medicare eligibility.
Certification of terminal illness (less than or equal to six months of life) by physician.



Personal care
Optional Medicaid benefit that allows a state to provide services to assist functionally impaired individuals in performing the activities of daily living (e.g., bathing, dressing, feeding, grooming).
Physical therapy may be consulted on an as- needed basis.


Ambulatory care (outpatient care)
Includes outpatient preventative, diagnostic, and treatment services that are provided at medical offices, and surgery centers or outpatient clinics (including private practice physical therapy clinics, outpatient satellites of institutions or hospitals).
Designed for patients who do not require overnight hospitalization.
More cost-effective than inpatient care, and therefore favored by managed-care plans.
Physical therapy may be consulted on an as- needed basis.


THE HEALTHCARE TEAM
As a physical therapist begins a career in healthcare, he or she becomes part of the healthcare team, the extent of which depends on the type of facility. It is important that the student physical therapist has an understanding of the various members of the healthcare team in terms of their roles and capabilities.
Primary Care Physician (PCP)

A practitioner, usually an internist, general practitioner, or family medicine physician, providing primary care services and managing routine healthcare needs. Most PCPs serve as gatekeepers for the managed care health organizations they provide authorization for referrals to other specialty physicians or services, including physical therapy. State medical boards require that physicians applying for license should document a passing grade on national licensing examinations, certification of graduation from medical school, and, in most cases, completion of at least one year of residency training after medical school.
Physician Assistant (PA)

As the name suggests, a physician assistant (PA) works closely with physicians, especially in primary care fields and underserved communities. A PA can perform physical examinations, make a diagnosis, prescribe medications, and administer therapies under the supervision of a physician (see also Registered Nurse). Studies of PAs in primary care settings have found that the scope overlaps with approximately 80% of the scope of work of primary care physicians. A PA is usually licensed by the same state boards that license physicians. To be eligible for licensure in most states, a PA must have graduated from an accredited training program and pass the Physician Assistant National Certifying Examination.
Physiatrist

A physiatrist is a physician specializing in physical medicine and rehabilitation, who has been certified by the American Board of Physical Medicine and Rehabilitation. The primary role of the physiatrist is to diagnose and treat patients with disabilities involving musculoskeletal, neurological, cardiovascular, or other body systems.
Nurse Practitioner

A nurse practitioner (NP) is an advanced practice registered nurse who has completed graduate level education at either a Master of Nursing or Doctor of Nursing Practice level in addition to the basic nurse training. NPs can diagnose a wide range of acute and chronic diseases, provided that they are



within their scope of practice, and can provide appropriate treatment for patients, including the prescribing of medications. Licensing and related regulations for NPs are less uniform across states than those for physicians, PAs, and RNs. In lieu of a single national licensing examination for all NPs, certification examinations are administered by different organizations and are specialty specific, similar to medical specialty board certification. State boards of nursing vary in the scope of practice they allow NPs, with most states requiring that NPs work in collaboration with the physician.
Physical Therapy Director
The director of physical therapy is responsible for the day to day running of the physical therapy department. The director is either promoted or hired because he or she has demonstrated the necessary education and experience in the field of physical therapy and is willing to accept the inherent responsibilities of the role.22 The director of a physical therapy service must:
 Establish guidelines and procedures that will delineate the functions and responsibilities of all levels of physical therapy personnel in the service and the supervisory relationships inherent in the functions of the service and the organization.22
  Ensure that the objectives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization, and in accordance with safe physical therapist practice. This often includes the design of policies and procedures.
 Interpret administrative policies.

 Act as a liaison between line staff and administration.  Foster the professional growth of the staff.
  Be responsible for the departmental budget.

Staff Physical Therapist

A physical therapist engages in the examination, evaluation, diagnosis, prognosis, and intervention in an effort to maximize patient outcomes. CAPTE serves the public by establishing and applying standards that ensure quality and continuous improvement in the entry level preparation of physical therapists and physical therapist assistants. All physical therapists in the United States are licensed in all 50 states and the District of Columbia, Puerto Rico, and the Virgin Islands. State licensure is required in each state in which a physical therapist practices and must be renewed on a regular basis (typically every two years), with a majority of states requiring continuing education units (CEUs) or other continuing competency requirement for renewal. A physical therapist must practice within the scope of physical therapy practice defined by his or her state licensure law (physical therapy practice act), including supervision of physical therapist assistants (PTAs).

Physical Therapist Assistant

A physical therapist assistant (PTA) works under the direction and supervision of the physical therapist, who directs appropriate physical therapy interventions to the PTA. Care provided by a PTA may implement selected components of patient/client interventions; obtain outcomes data related to the interventions provided; modify interventions either to progress the patient/client as directed by the physical therapist or to ensure patient/client safety and comfort; educate and interact with other healthcare providers, students, aides/technicians, volunteers, and patients/clients and their families and caregivers; and respond to patient/client and environmental emergency situations.



PTAs currently are licensed or certified in 49 states (Hawaii is the only state that does not regulate PTAs.). Typically, a PTA has an associate's degree from an accredited PTA program and operates within the scope of work and supervision requirements defined by the physical therapy practice act in each state.
Physical Therapy Aide

A physical therapy aide is an individual who may be involved in support services under the direction and supervision of a physical therapist or physical therapist assistant. A physical therapy aide receives on the job training and is permitted to function only with continuous on site supervision. The duties of a physical therapist aide are limited to those methods and techniques that do not require clinical decision making or clinical problem solving by a physical therapist or a physical therapist assistant.
Physical Therapist and Physical Therapist Assistant Student
The PT or PTA student can perform duties commensurate with their level of education.

Physical Therapy Volunteer

A volunteer is usually a member of the community who has an interest in assisting with departmental activities. Responsibilities of a voluntary include:  Taking phone messages
 Basic nonclinical/secretarial duties

Home Health Aide

A home health aide provides health related services to the elderly, disabled, and unwell in their homes. Their duties include performing housekeeping tasks, assisting with ambulation or transfers, and promoting personal hygiene. The registered nurse, physical therapist, or social worker caring for the patient may assign specific duties to, and supervise, the home health aide.
Occupational Therapist
An occupational therapist (OT) assesses a patient's function in activities of daily living (ADLs), including dressing, bathing, grooming, meal preparation, writing, and driving, which are essential for independent living. In making treatment recommendations, the OT addresses a number of factors including, but not limited to, (1) fatigue management, (2) upper body strength, movement, and coordination, (3) adaptations to the home and work environment, including both structural changes and specialized equipment for particular activities, and (4) compensatory strategies for impairments



in thinking, sensation, or vision. All states require an OT to obtain a license to practice.

Certified Occupational Therapy Assistant

A certified occupational therapy assistant (COTA) works under the direction of an OT. COTAs perform a variety of rehabilitative activities and exercises as outlined in an established treatment plan. The minimum educational requirements for the COTA are described in the current Essentials and Guidelines of an Accredited Educational Program for the Occupational Therapy Assistant (AOTA, 1991b).
Speech Language Pathologist (Speech Therapist)

A speech language pathologist evaluates speech, language, cognitive communication, and swallowing skills of children and adults. Speech language pathologists are required to possess a master's degree or equivalent. The vast majority of states require a speech language pathologist to obtain a license to practice.
Chiropractor

A Doctor of Chiropractic (DC), or chiropractor, is an indiv idual trained in the science, art, and philosophy of chiropractic. A chiropractic evaluation and treatment is directed at providing a structural analysis of the musculoskeletal and neurological systems of the body because, according to chiropractic doctrine, abnormal function of these two systems may affect the function of other systems in the body. In order to practice, chiropractors are usually licensed by a state board. A patient may see a chiropractor and physical therapist concurrently.
Certified Orthotist

A certified orthotist (CO) designs, fabricates, and fits orthoses (braces, splints, collars, corsets), prescribed by physicians, to patients with disabling conditions of the limbs and spine. A CO must have successfully completed the examination by the American Orthotist and Prosthetic Association (AOPA).
Certified Prosthetist

A certified prosthetist (CP) designs, fabricates, and fits prostheses for patients with partial or total absence of a limb. A CP must have successfully completed the examination by the AOPA.

Respiratory Therapist
A respiratory therapist evaluates, treats, and cares for patients with breathing disorders. The vast majority of respiratory therapists are employed in hospitals. Patient care activities include performing bronchial drainage techniques, measuring lung capacities, administering oxygen and aerosols, and analyzing oxygen and carbon dioxide concentrations. Education programs for a respiratory therapist are offered by hospitals, colleges, and universities, vocational technical institutes, and the military. The vast majority of states require a respiratory therapist to obtain a license to practice.
Respiratory Therapy Technician Certified (CRRT)

A CRRT is a skilled technician who:

 Holds an associate's degree from a two year training program accredited by the Committee in Allied Health Education and Accreditation  Has passed a national examination to become registered
  Administers respiratory therapy as prescribed and supervised by a physician, including:



 Pulmonary function tests

 Treatments consisting of oxygen delivery, aerosols, nebulizers  Maintenance of all respiratory equipment
Registered Nurse

A registered nurse is an individual who has graduated from a nursing program at a college or university and has passed a national licensing exam. Historically, many nurses received their education in vocational programs administered by hospitals and were awarded diplomas of nursing.
Nowadays, most nurses are educated either in 2  to 3 year associate degree programs administered by community colleges or in baccalaureate programs administered by 4 year colleges. A registered nurse is licensed by the state to provide nursing services and is legally authorized or registered to practice as a registered nurse (RN) and use the RN designation. A registered nurse may:
 Make referrals to other services under a physician's direction  Supervise other levels of nursing care
  Administer medication, but cannot change drug dosages

  Communicate to the supervising physician any change in the patient's medical or social condition

Rehabilitation (Vocational) Counselor

A rehabilitation counselor helps people deal with the personal, physical, mental, social, and vocational effects of disabilities resulting from birth defects, illness or disease, accidents, or the stress of daily life. The role of the rehabilitation counselor includes:
 An evaluation of the strengths and limitations of individuals  Providing personal and vocational counseling
  Arranging for medical care, vocational training, and job placement

Audiologist

An audiologist evaluates and treats individuals of all ages with the symptoms of hearing loss and other auditory, balance, and related sensory and neural problems.
Athletic Trainer Certified (ATC)
The certified athletic trainer is a professional specializing in athletic healthcare. In cooperation with the physician and other allied health personnel, the athletic trainer functions as an integral member of the athletic healthcare team in secondary schools, colleges and universities, sports medicine clinics, professional sports programs, and other athletic healthcare settings.
Certified athletic trainers have, at minimum, a bachelor's degree, usually in athletic training, health, physical education, or exercise science.

Social Worker

A social worker helps patients and their families to cope with chronic, acute, or terminal illnesses and attempts to resolve problems that stand in the way of recovery or rehabilitation. A bachelor's degree is often the minimum requirement to qualify for employment as a social worker; however, in the health field, the master's degree is often required. All states have licensing, certification, or registration requirements for social workers.
Massage Therapist
 Massage therapy is a regulated health profession with a growing number of states and provinces now requiring a license. Registered massage	



therapists must uphold specific standards of practice and codes of ethics in order to hold a valid license. In order to become a licensed or registered massage therapist, most states and provinces require the applicant to pass specific government board examinations, which consist of a written and a practical portion. A registered massage therapist is covered under most health insurance plans.
Acupuncturist

An acupuncturist treats symptoms by inserting very fine needles, sometimes in conjunction with an electrical stimulus, into the body's surface to, theoretically, influence the body's physiological functioning. Typical sessions last between 30 minutes and an hour. At the end of the session, the acupuncturist may prescribe herbal therapies for the patient to use at home. At the time of writing, 32 states and the District of Columbia use National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) certification as the main examination criterion for licensure; this takes three to four years to achieve. Each state may also choose to set additional eligibility criteria (usually additional academic or clinical hours). A small number of states have additional jurisprudence or practical examination requirements such as passing the CNT (Clean Needle Technique) exam.
The Patient

Although often overlooked, the patient is critical to the healthcare team. The population of patients evaluated and treated in physical therapy can vary in age from newborn to elderly.
WORKING IN HEALTHCARE
Despite the fact that working in healthcare is altruistic, caring for other individuals can prove stressful over time. These stresses can result in a condition known as caregiver burnout. The classic symptoms for this condition include the following:
 A depletion of physical energy  Emotional exhaustion
 Physical withdrawal

 An increasingly pessimistic outlook  Increased absenteeism from work
 Excessive use of alcohol, medications, or sleeping pills  Difficulty concentrating
It is important for every clinician to put time into taking care of him  or herself emotionally and physically. Whenever possible, any caregiving responsibility should be varied or delegated. If necessary, the clinician should strongly consider finding a support group or speaking to someone about getting help. A number of activities have been shown to be beneficial to reduce stress. These include aerobic exercise, meditation, massage, and relaxation techniques.
REFERENCES

1. American Physical Therapy Association: Guide to Physical Therapist Practice (ed 2). Phys Ther 81:9 746, 2001. [PubMed: 11175682] 

2. American Physical Therapy Association: Today's Physical Therapist: A Comprehensive Review of a 21st Century Health Care Profession. Alexandria, Va, American Physical Therapy Association, 2011.

3. American Physical Therapy Association: A Normative Model of Physical Therapist Professional Education: Version 2000. Alexandria, Va, American Physical Therapy Association, 2000.




4. U.S. Army Medical Services: Medical Department of the United States Army in the World War. Washington, DC, The Surgeon General's Office Government Printing Office, 1923.

5. Murphy W: Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association. Lyme, Conn, Greenwich, 1995.

6. Pinkston D: Evolution of the practice of physical therapy in the United States, in Scully RM, Barnes MR (eds): Physical Therapy (ed 1). Philadelphia, JB Lippincott, 1989, pp 2 30.

7. Moffat M: The history of physical therapy practice in the United States. JOPTE 17:15 25, 2003.

8. Moffat M: Three quarters of a century of healing the generations. Phys Ther 76:1242 1252, 1996. [PubMed: 8911436] 

9. American Physical Therapy Association: Professionalism in Physical Therapy: Core Values. Alexandria, Va, American Physical Therapy Association, 2003.

10. Cary JR, Ness KK: Erosion of professional behaviors in physical therapist students. JOPTE 15:20 24, 2001.

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12. Bobath K, Bobath B: The facilitation of normal postural reactions and movements in the treatment of cerebral palsy. Physiotherapy 50:246 262, 1964. [PubMed: 14179895] 

13. Rood MS: Neurophysiological reactions as a basis for physical therapy. Phys Ther Rev 34:444 449, 1954. [PubMed: 13194374] 

14. Knott M, Voss DE: Proprioceptive Neuromuscular Facilitation (ed 2). New York, Harper & Row, 1968.

15. American Physical Therapy Association: Guide to Physical Therapist Practice: Revisions. Phys Ther 79:623 629, 1999. [PubMed: 10372871]


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