Physical therapy is knowledge. Physical therapy is clinical science. Physical therapy is the reasoned application of sence to warm and needing human beings, Or tis nothing Helen |. Hislop, PT, FAPTA l The Profession of Physical Therapy: Definition and Development Michael A. Pagliarulo CHAPTER OUTLINE DEFINITION PHYSICAL THERAPY AS A PROFESSION HISTORICAL DEVELOPMENT Origins of Physical Therapy Impact of World War I and Polio Post-World War I Period Impact of World War Il and Polio Post-World War II Period 1960s through 1980s 1990s, Twenty-First Century SUMMARY KEY TERMS American Physiotherapy Association (APA) ‘American Women’s Physical Therapeutic “Association autonomous practice client core values evidence-based practice Guide to Physical Therapist Practice National Foundation for Infantile Paralysis ("the Foundation”) patient physiatrist physical therapist physical therapy physiotherapist physiotherapy Profession reconstruction aide Vision 2020 OBJECTIVES ‘After reading this chapter, the reader will be able to = Define physical therapy = Describe the characteristics of a profession = Describe a brief history of the profession of physical therapy in the United States and the major factors that influenced its growth and development4 rant m Profession DEFINITION "The profession of physical therapy has evolved significa in the past tree decades, Although Ht has recived substantial publicity, confusion remains fegarding is unique characteristics. For ample, how does Phystal therapy fife rom occupational or chiropractic therapy? Ths chapter's ist purpose, then, must be to present and define this profession To define physical therapy thoroughly, re must present a bri history of its development, A review ofthe past wll demonstrate how the profesion has fesponce fo sol needs and gained respect as an essential component of the vehaiifation team, Itwil also link some caren rends and practices with pastevents Part of the confusion regarding the definition of physical therapy results from the variety of legal definitions scen from state to state. Each state has the right to define the profession of physical therapy and regulate its practice. Such defini- tions are commonly included in legislation known as practice acts, which pertain to specific professions (practice acts are further described in Chapter 5). ‘To limit the variety of definitions, the Board of Directors of the American Physical Therapy Association (APTA) created the Physical Therapist Scope of Practice (Box 1-1), which was originally titled Model Definition of Physical Ther- ‘apy for State Practice Acts2 This definition identifies several activities inherent in the practice of physical therapy. It uses language and terminology based on the Guide to Physical Therapist Practice (“the Guide”),’ a pivotal document describing the approach of the physical therapist (PT) to patient care, One of the fundamental concepts of the Guide is the five clements of the patient/client management model, and these are incorporated into the definition. (These are briefly described here. For more details on the elements of the model see Chapter 2) First and foremost, physical therapy begins with an examination to determine the nature and status of the condition. An evaluation is then con- ducted to interpret the findings and establish a diagnosis and prognosis that includes a plan of care, Interventions are then administered and modified in accordance with the patient's responses. Interventions focus on musculoskel- etal, neuromuscular, cardiovascular and pulmonary, and integumentary dis- orders. Other important activities in the role of the PT include consultation, education, and research, These may be separate from, but ultimately contribute to, effective practice. ‘The definition of physical therapy also reflects the areas of prevention; health, promotion, wellness, and fitness; and consultation, all of which occur across the life span. Traditionally, PTs have provided care to patients—individuals ‘who have disorders that require interventions to improve their function. Client is the term used to refer to an individual who secks the services of a PT to ‘maintain health or a business that hires a PT for consultation.® These areas of involvement have become more significant in the recent development of the profession. In addition to identifying the activities of PT, the definition states that phys- ical therapy is “provided by or under the direction and supervision of a physi cal therapist.” This qualification is further stipulated in a section of anothercuarrer 1_m The Profession of Physical Therapy: Definition and Development 5 BOX 1-1 Guidelines: Physical Therapist Scope of Practice Physical therapy, which is limited to the care and services provided by oF under the direction and supervision of a physical therapist, includes: 1. Examining (history, systems review, and test and measures) individuals with impairments, functional limitations, and disability or other health- related conditions in order to determine a diagnosis, prognosis, and intervention. Tests and measures may include the following ‘Aerobic capacity and endurance ‘Anthropometric characteristics Arousal, attention, and cognition Assistive and adaptive devices Circulation (arterial, venous, lymphatic) Cranial and peripheral nerve integrity Environmental, home, and work (job/school/play) barriers Ergonomics and body mechanics Gait, locomotion, and balance Integumentary integrity Joint integrity and mobility Motor function (motor control and motor learning) Muscle performance (including strength, power, and endurance) Neuromotor development and sensory integration Orthotic, protective, and supportive devices Pain Posture Prosthetic requirements Range of motion (including muscle length) Reflex integrity Self-care and home management (including activities of daily living and instrumental activities of daily living) Sensory integrity 1 Ventilation, and respiration or gas exchange = Work (job/school/play), community, leisure integration or reintegration (including instrumental activities of daily living) 2. Alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions that include but are not limited to: = Coordination, communication, and documentation 1 Patient/client-related instruction = Therapeutic exercise 1 Functional training in self-care and home management (including activities of daily living and instrumental activities of daily living) '= Functional training in work (job /school /play) and community and leisure integration or reintegration activites (including instrumental activities of daily living, work hardening, and work conditioning) ‘Conn6 Pant m Profession BOX 1-1 BOX 1-2 PHYSICAL THERAPY AS A PROFESSION Guidelines: Physical Therapist Scope of Practice—cont'd = Manual therapy techniques (including mobilization manipulation) Prescription, application, and, as appropriate, fabrication of devices and equipment (assistive, adaptive, orthotic, protective, supportive, and prosthetic) ‘Aieway clearance techniques Integumentary repair and protection techniques Blectrotherapeutic modalities Physical agents and mechanical modalities 3. Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of health, wellness, fitness, and quality of life in all age populations. 4. Engaging in consultation, education, and research. From American Physieal Therapy Association (APTA): Guidelines physical therapist sap practise, BOD G08-01-09-29, Board of Directors Standards, Positions, Guidelines, Polis, And Procedures, Alexandria, Va, 200, APTA, Provision of Physical Therapy Interventions and Related Tasks Physical therapists are the only professionals who provide physical therapy interventions, Physical therapist assistants are the only individuals who provide selected physical therapy interventions under the direction and at least general supervision of the physical therapist. From American Physial Therapy Astociation (APTA): Provision of pysia therapy intrae ‘ions and related tsis, HOD PO6-00-17-28, House of Delegates Standards, Plicies, Positions, and Guidelines, Alexandria, Va, 2008, APTA. policy (adopted by the House of Delegates, the highest policymaking body of the APTA) specifying that PTs and physical therapist assistants (PTAs) work- ing under the direction of a PT are the only individuals who provide physical therapy (Box 1-2) ‘The definition of physical therapy provides a broad description of the scope ‘of practice of physical therapy. A companion document addresses physical therapy as a profession (Box 1-3) This position was adopted by the House of Delegates of the APTA in 1983 and was subsequently revised to incorporate Guide language. Although the position states, “Physical therapy is a health pro- fession...,” it does not offer a spectrum of characteristic evidence to support this statement, Perhaps one reason is the difficulty in conclusively defining a profession,CHAPTER 1 m_The Profession of Physical Therapy: Definition and Development 7 BOX 1-3 Position on Physical Therapy as a Health Profession Physical therapy is a health profession whose primary purpose is the promotion of optimal health and function, This purpose is accomplished through the application of scientific principles to the processes of examination, evaluation, diagnosis, prognosis, and intervention, to prevent or remediate impairments, functional limitations, and disabilities as related to movement and health. Physical therapy encompasses areas of specialized competence and includes the development of new principles and applications to ‘meet existing and emerging health needs. Other professional activities that serve the purpose of physical therapy are research, education, consultation, and administration, ‘From American Physical Therapy Assocation (APTA): Physica therapy as «helt profsion, HOD P06-99-19-23, House of Delegate Standards, Policies, Position, and Guidelines, Alexandria, Va, 2008, APTA, Swisher and Page presented a comprehensive review of the variety of descriptions of a profession. They addressed definitions based on a description of characteristics, stages of evolution, or power, but they focused on three quali- ties commonly held in high regard: autonomy, ethical standards, and account- ability. Distinct applications of these qualities were made to physical therapy. Moore” also included autonomy in a description of a profession and posi- tioned it at the peak of a hierarchy of characteristics (Figure 1-1). This descrip- tion is particularly applicable to physical therapy. The first characteristic, a lifetime commitment requiring an individual’s dedication to the profession, is formidable yet admirable, PTs and PTAs do not commonly leave this profes- sion. The second characteristic, a representative organization, provides stan- dards, regulations, structure, and a vehicle for communication. In physical therapy this characteristic is fulfilled by the APTA. The third characteristic, specialized education, ensures competency to practice. For example, evalua- tive criteria for accreditation stipulate that the degree for professional-level PT ‘education programs must be at the postbaccalaureate level and that the degree for PTA education programs is the associate degree.** The fourth characteris- tic, service to clients, is obvious in physical therapy and provides a direct ben- fit to society. In this context the term “patients” would also apply. The final feature, autonomy of judgment, applies regardless of whether the therapist practices in a jurisdiction where a physician's referral is required by law. Inde- pendent and accurate judgment is inherent in every evaluation, plan of care, and discharge plan conducted by the PT. This last criterion is frequently used to distinguish a professional from a technician (an individual who requires supervision) ‘Asa profession, physical therapy is guided by the criteria listed in Figure 1-1 Such was not always the case, and evolution of the profession has entailedBrant m Profession HISTORICAL DEVELOPMENT é ‘Autonomy of judgment t a ‘Service to clients t Specialized ‘education t Figure I-1 m Hierarchy of the criteria to define a profession. significant change and varying degrees of recognition from other professions, ‘The next section provides a brief overview of the history of physical therapy. Examining the origin and development of the profession and practice of physi- cal therapy in the United States will serve to explain some of the current char- acteristics and conditions. It will also demonstrate how certain positions have changed over time, The reader is referred to the resources at the end of this chapter for more detailed historical accounts. Onicins oF PrysicaL THERAPY Granger" described how physical measures were used in ancient civiliza- tions to relieve pain and improve function. Massage was used by the Chinese in 3000 ac, described by Hippocrates in 460 nc, modified by the Romans, and accepted as a scientific procedure in the early 1800s, Techniques of muscle reeducation developed from this evolution. Hydrotherapy was practiced by the Greeks and Romans through the use of baths and river worship. The develop- ment of electrotherapy began in the 1600s with the introduction of electricity and electrical devices. More modern techniques of physical therapy were practiced extensively in Europe, particularly England and France, before being used in the United States. It took the outbreak of polio epidemics and World War I to bring these techniques to the United StatesCHAPTER 1 a The Profession of Physical Therapy: Definition and Development 9 vl Figure 1-2 m Reconstruction aides treating soldiers wounded in World War I at Fort Sam Houston, Texas, in 1919. (From American Physical Therapy Association: Historical Photograph Packet) Impact of WorLD War I aN Poti Itis unfortunate that the impetus to develop physical therapy in this country was the response to widespread suffering; at the same time, such an origin demon- strates the direct humanitarian motivation that serves as the foundation of physi- cal therapy. First came the epidemics of polio (poliomyelitis or infantile paralysis) in 1894, 1914, and 1916, which left tens of thousands of children paralyzed and in need of “physical therapy.” Then at the outbreak of World War I, the Surgeon General of the United States sent a group of physicians to England and France to lear about physical therapy techniques for the better management of those ‘wounded in war. Asa result, the Division of Special Hospitals and Physical Recon- struction was created in 1917."' This division was responsible for training and ‘managing reconstruction aides (exclusively women) who would provide physi- cal reconsteuction to those injured in war. These women were the forerunners of the profession and practice of physical therapy in the United States Figure 1-2). ‘During this period, polio epidemics were occurring in Vermont. A statewide program known as the “Vermont Plan” was developed to study the cause and effects of the disease. Under this plan, health care teams conducted field visits to provide care for children with polio. These teams consisted of orthopedic surgeons, public health nurses, physiotherapists (commonly known as “phy- sicians’ assistants”), brace makers, and stenographers. The physiotherapists became involved in taking accurate measurements to determine muscle strength and providing therapy through exercise and massage (Figures 1-3 and 1-4) Post-Wortp War I Periop Even after the war, the need for physical therapy continued. Attention shifted from preserving a fighting force to maintaining a working force, Humanitarian interests and the labor requirements of an industrial society resulted in a focusPARTI m Profession Figure 1-3 m Physical therapists and physicians working together to evaluate and treat children ata polio clinic in New England in 1916. (From American Physical Therapy Association: Historical Photograph Packet) Figure I-4 m Aquatic therapy was very effective for individuals who had polio. (From American Physical Therapy Association: Historical Photo- graph Packet) ‘on “crippled children.”"? As the reconstruction aides moved into civilian facili- ties to address these needs, their titles and practices were plagued by confu- sion and ambiguity. The time had come to establish a clear identity through a national organization, ‘The origin of the first national organization representing “physical therapeu- tics” is traced to a mecting suggested by a military physician. This meeting, on January 15, 1921, at Keen's Chop House in New York City, was attendedcHaPrer 1_m The Profession of Physical Therapy: Definition and Development 11 BOX 1-4 Founding Objectives of the American Women's Physical Therapeutic Association 1. To establish and maintain a professional and scientific standard for those engaged in the profession of physical therapeutics 2. To increase efficiency among its members by encouraging them in advanced study 3. To disseminate information by the distribution of medical literature and articles of professional interest 4, To make available efficiently trained women to the medical profession 5. To sustain social fellowship and intercourse on grounds of mutual interest ‘Data from Beard G: Foundations for growth:a review’ of the firs forty years in terme of ‘education, practice, and research, Phys Ther Reo 41843, 1961, by 30 reconstruction aides and five physicians. Accomplishments of the first ‘meeting included creation of a national organization, the American Women's Physical Therapeutic Association, and lection of the first president, Mary MeMillan.™* According to the first constitution, the organization was estab- lished to maintain high standards and provide a mechanism for sharing infor- ‘mation (Box 1-4), Mary McMillan was the overwhelming choice for president (Figure 1.5) ‘Trained in England, she is credited with becoming the first “physical therapist” in the United States. As a reconstruction aide she was stationed at Walter Reed General Hospital in Washington, DC, where she was appointed head recon- struction aide in 1918. Later, while at Reed College in Portland, Oregon, she participated in the largest (over 200 students) of seven emergency training pro- ‘grams for reconstruction aides. Under the leadership of Miss McMillan, the new organization took imme- diate action. Two membership categories were established: charter members (reconstruction aides), and active members who “shall be graduates of recog- nized schools of physiotherapy or physical education, who have had training and experience in massage and therapeutic exercise, with some knowledge of either electrotherapy or hydrotherapy." An official journal, PT. Review, was established and first published in 1921. Annual meetings were initiated in con- junction with annual meetings of the American Medical Association (AMA) to capitalize on their programs and gain recognition. The name of the organiza- tion was changed in 1922 to the American Physiotherapy Association (APA). ‘Two men were admitted in 1923. In 1926 the journal was retitled Physiotherapy Review. To honor the pioncering work of Mary McMillan, the organization even- tually created in her name a lectureship (presented as a major opening event at the Annual Conference) and student scholarship programs that continue today. ‘Two issues involving physicians took decades to resolve. The first pertained to identity. Physicians perceived these practitioners to be technicians or aides12___ parti m Profession Figure 1-5 m Mary McMillan was elected in 1921 as the founding presi- dent of the American Women’s Physieal Therapeutic Association (pre- cursor to the American Physical Therapy Association). (From American Physical Therapy Association: Historical Photograph Packet) and suggested that this distinction be reflected in their title, Members of the APA believed that they had a more professional status and objected to that ref- ‘erence. This issue was not settled until the 1940s, when physicians established physical medicine as a medical specialty. These physicians were known as physiatrists, and the term physical therapist (without adding technician or aide) became acceptable thereafter. !* ‘The second issue was more substantive and involved education require- ments, No standard educational program existed for a physiotherapist; there- fore the APA developed a suggested curriculum and published it in 1928. ‘This was a 9-month program (1200 total clock hours). Entrance requirements included graduation from a school of physical education or nursing." In con- trast, most of the stucients in the 14 training programs for reconstruction aides ‘were physical education teachers or graduates of physical education schools. A.committee of the APA visited all institutions offering educational programs for physiotherapists and published a list of 11 approved programs in 1930. ‘The action by the APA did not fully resolve the issue of education require- ments. Greater recognition of education programs and standards was required, so the APA sought assistance from the AMA in 1933. Consequently, the Coun- cil on Medical Education and Hospitals of the AMA inspected 35 schools ofcuarrer 1_m The Profession of Physical Therapy: Definition and Development 13 physiotherapy. Based on this inspection, as well as input from the APA and other related organizations, the AMA adopted the Essentials of an Acceptable ‘School for Physical Therapy Technicians in 1936, Entrance requirements and length of program remained essentially unchanged; however, the curriculum ‘was stated in detail, and other characteristics were stipulated (institutional affil- iation, faculty, resources, clinical facilities). Thirteen schools were approved by the AMA in 1936." Impact of Wortp War II AND Poi ‘Once again, national and global tragedies combined to expand the need for physical therapy, and, as before, the profession responded. To meet the dlemands of the war, eight emergency 6-month courses were authorized to be offered among the 15 approved full-length programs in physical therapy. These shortened courses were discontinued in 1946 when war-related demands for services dropped. Unfortunately, polio continued to create a need for therapy. In response to repeated epidemics, the National Foundation for Infantile Paralysis (often referred to as “the Foundation”) was established in 1938 for research, educa- tion, and patient services."! PTs continued to provide vital services for children. affected by polio. ‘The Foundation was a source of substantial support for the profession and. practice of physical therapy. Catherine Worthingham, a past president of the APA, accepted the position of Director of Professional Education on the staff of the Foundation in 1944. In the same year, the first national office of the APA ‘was established in New York City and the first executive director was hired. Both these actions were made possible by a grant from the Foundation. Also in 1944, a permanent headquarters and staff for the APA enabled the organiza- tion to create the House of Delegates to serve as a policymaking body. Other grants from the Foundation provided scholarships to recruit and retain physical therapy students and faculty, funds to hire a consultant to recruit and assign PTs for emergency work relating to polio, and financial support for training in techniques fostered by Sister Elizabeth Kenny for individuals with polio (carly application of moist heat to permit mobilization and prevent contractures) Post-Worio War Il Periop ‘The US. Army recognized the need to retain PTs in an organized unit to provide service to military personnel. As a result, the Women’s Medical Specialist Corps ‘was established in 1947, It consisted of PTs, occupational therapists, and dieti- tians. APT, Emma Vogel, became the first chief of the Corps and was accorded the rank of colonel.!! In 1955 the Corps became the Army Medical Specialist Corps to allow men and women to serve with commissions in the military." ‘A major breakthrough in the treatment of polio occurred during this period with the introduction of gamma globulin and the Salk vaccine. Finally the dis- case could be controlled. PTs played prominent roles during field trials of these ‘medications, which began in 1951 ‘Name clarification continued as the term physiatrist became recognized as the title given to physicians who practiced physical medicine. Physical therapists14 PARTI m Profession (PTS) could now practice physical therapy. This role clarification was reflected in the new name for the national organization, the American Physical Therapy Association, in 1947 and a new title for the journal, Physical Therapy, in 1962. It was also demonstrated in the title of the new Essentials, which extensively revised the original document of 1936. The new title, Essentials of an Acceptable ‘School of Physical Therapy, no longer referred to technicians. This document ‘was adopted by the AMA in 1955 and was used to approve new and existing educational programs for over 20 years. The new Essentials established mini- ‘mum curricular standards, including a program length of 12 months, 1960s THroucs 1980s ‘The three-decade period of the 1960s through the 1980s was characterized by ‘growth and recognition in education, practice, and research, Socictal issues of this period included an aging population, health promotion, and disease pre- vention. Federal legislation funded health care for a variety of populations, ‘which increased the demand for physical therapy. The profession responded with several actions First, the APTA adopted policy statements in the 1960s to clarify the prepa- zation and use of PTAs and aides. These positions were necessary to meet the ‘growing demand for services. Tae headquarters of the APTA was relocated to Washington, DC, in 1971 to increase political involvement. Executive operations were further strengthened ‘when an office building was purchased in Alexandria, Virginia, in 1983 ‘New education programs were developed in an attempt to keep pace with the demand; curricular evolution was inherent as health care in general expanded. ‘Tris period opened with an APTA policy in 1960 declaring the baccalaureate degree to be the minimum educational requirement for a PT. By the late 1970s it became clear that a postbaccalaureate degree would be necessary to master the knowledge and skills required for competent practice. Consequently, a criti cal policy adopted by the APTA in 1979 (amended in 1980) stated that new and ‘existing programs in physical therapy must award a postbaccalaureate degree by December 31, 1990. This requirement had a major impact on curricular development. Tris period also saw an evolution in the historical ink between the AMA and the APTA (formerly APA) regarding approval (accreditation) of educational programs. The APTA became more actively involved in the accreditation pro- cess, In 1974 it adopted the Essentials of an Accredited Educational Program for the Physical Therapist, which represented a dramatic departure from the pre- scriptions in the 1955 Essentials." In 1977 the Commission on Accreditation in Education (a body separate from, but administratively supported by, the APTA) became recognized by the U.S. Office of Education and Council on Postsecond- ary Education as an accrediting agency. Standards for Accreditation of Paysical ‘Therapy Educational Programs was adopted by the APTA in 1979, In 1983, after contesting the value of the AMA in the accreditation process, the Commission ‘on Accreditation in Education became the sole agency for accrediting educa- tion programs for PTs and PTAs. This recognition marked the maturity of the profession,cuarrer 1_m The Profession of Physical Therapy: Definition and Development 15 Increased demand for services and educational requirements resulted in advances in practice opportunities. The profession lobbied aggressively at the state level for direct access: the right to conduct patient examinations and inter- ventions without a physician's referral. The patient was the ultimate benefi- ciary: health care costs were reduced (no required physician visit), and physical therapy could begin sooner. In 1957, Nebraska became the first state to have direct access. The second state to enact legislation for direct access was Califor- nia in 1968, Legislation proliferated through the 1980s, and by the end of the decade, direct access was legal in 24 states. ‘Advances in practice fostered new opportunities to demonstrate excellence. ‘The American Board of Physical Therapy Specialties was created by the APTA in 1978, This provided a mechanism for PTs to become certified and recognized as clinical specialists in certain practice areas (see Chapter 4 for more details. ‘The need for research to substantiate physical therapy interventions became essential. This was particularly true as insurance providers began to challenge the cost of health care, The Foundation for Physical Therapy was initiated in 1979 to promote and support research in physical therapy (see Chapter 4 for ‘more details on this organization) 1990s During the 1990s, skyrocketing costs of health care resulted in significant cost control measures in the private and government sectors. New methods of financing and reimbursing health care, created by the proliferation of managed care and the Balanced Budget Act of 1997, had a direct impact on the deliv- ery of health care services, including physical therapy. Costs were controlled by limitation of the type, number, and reimbursement amounts for services ‘The circumstances of PTs and PTAs deteriorated as job availability and salaries plateaued and then declined in some facilities. This unfavorable situation was compounded by the continued proliferation of education programs. One study predicted a surplus of PTs by the end of the decade." Unemployment suddenly became a real issue. Practice issues had a domino effect on education. With a tight job market, applications to PT and PTA education programs dropped. In fact, many of the programs for assistants closed voluntarily because of limited enrollment, Even- tually the APTA established a position recommending against the development ‘of new education programs. ‘The shift to postbaccalaureate education gave rise to several national con- ferences, which resulted in documents that described the values and prefer- ences in PT and PTA education programs. A Normative Model of Physical ‘Therapist Professional Level Education: Version 2004 was originally devel- ‘oped in 1994-95 to provide guidance to these programs."7 Similar activi- ties for PTA education programs resulted in a parallel document for these programs."® Although the need for clinical research had been known for decades, the con- trols imposed by third-party payers were a direct call for research that would justify physical therapy services. First published in 1995, the Guide fo Physical Therapist Practice provided a comprehensive and detailed description of physical16 PARTI m Profession therapy services, but research was needed to substantiate these services. A Clin- ical Research Agenda for Physical Therapy was established to identify areas where research was needed and feasible. Programs offered by the Foundation for Physical Therapy to fund research were expanded. The developing concept, of evidence-based practice (practice based on proof) was promoted through the new Hooked on Evidence program. This provided a user-friendly database of current literature pertinent to the practice of physical therapy. New accredi- tation criteria for PT education programs increased the expectation regarding faculty scholarship. These new opportunities and expectations created by exter- nal and internal forces combined to promote further research activities in the profession, ‘Through the course of this period, the APTA took a strong leadership role in addressing the issues. Extensive lobbying and rallying of public sentiment resulted in legislation that protected patients’ rights in managed care organi- zations and lifted a major funding cap in the Medicare program for physical therapy services, Several task forces were established to consider the role and governance rights of PTAs. Final reports were instrumental in new policies and [positions that clarified their clinical role, education level, continuing education ‘opportunities, recognition of advance proficiencies, and governance rights. In 1998 a separate deliberative body for PTAs, the Representative Body of the ‘National Assembly, was approved. The decade closed with a bright outlook for improvements in the future. ‘Twenty-First Century ‘The twenty-first century opened with an evolutionary action by the APIA House of Delegates when, in the year 2000, it adopted the APTA Vision State- ‘ment for Physical Therapy 2020 (Box 1-5; sce Box 7-1 for the shortened version, the Vision Sentence).!? Commonly cited as Vision 2020, it has become a beacon, for the profession and has provided a distinct direction for current and future action. Its six key components address the areas of practice, education, and research: (1) autonomous practice, (2) direct access, (3) practitioner of choice, (4) Doctor of Physical Therapy (DPT), (5) evidence-based practice, and (6) pro- {essionalism. It has been the source for follow-up action by the Board of Direc- tors and House of Delegates to further define these elements and establish goals and actions to achieve them. Some examples of these actions follow. In 2008 the APTA Board of Directors issued a position listing and describ- ing the clements of autonomous practice (Box 1-6) This position indicates that PTs have the capability to exercise professional judgment to practice under direct access within their scope of practice and refer patients and clients to other health care professionals when necessary. These attributes reiterate the impor- tance of autonomy of judgment as one of the highest, if nat the highest, charac- teristic of a profession. In the same year the Board of Directors approved another document related to the Vision Statement, “Professionalism in Physical Therapy: Core Values,” developed by a consensus conference method (Table 1-1). The purpose of identifying and describing these Core Values was to assist the transition to a doctoring profession by articulating what a PT practitioner would do in hercuarrer 1_m The Profession of Physical Therapy: Definition and Development 17 BOX 1-5 American Physical Therapy Association (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 physical therapist 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. From American Physical Therapy Associaton (APTA): APTA Vision Sentence for Physical’ Therapy 2020 and APTA Vision Statemen! fr Physical Therapy 2020, HOD PO6-00-24-35, House of Delegates Standards, Policies, Positions, and Guidelines, Alexandria, Va, 2008, APTA, or his daily practice to demonstrate professional behavior. This document has focused greater attention on professional behaviors and how to teach and emu- late them. Continued lobbying efforts were successful in advancing direct access legis- lation. Evidence became available to demonstrate the fiscal and human benefits of this practice delivery model. One study concluded the total paid claims for physician-referred physical therapy were 2.2 times higher than paid claims to PTs practicing in direct access states.2® By 2007 direct access was legal in 45 states, and the District of Columbia Perhaps the most dramatic impact generated by Vision 2020 was in PT edu- cation programs. No one predicted the rapid pace of transition to the DPT degree created by the opening sentence. The first class of PTs with the designa- tion “DPT” graduated in 1996 from Creighton University in Omaha, Nebraska, but by 2010 nearly all professional-level PT education programs were at the doctoral level. Moreover, this degree will be required for accreditation by December 31, 2015.8 One of the reasons for this rapid transition was that most18, PARTI m Profession BOX 1-6 Autonomous Physical Therapist Practice: Definitions and Privileges ‘Autonomous physical therapist practice is characterized by independent, self-determined professional judgment and action. Physical therapists have the capability, ability, and responsibility to exercise professional judgment within their scope of practice and to professionally act on that judgment. Privileges of Autonomous Practice in 2020 Each of these elements includes two overarching concepts: recognition of and respect for physical therapists as the practitioners of choice, and recognition of and respect of the education, experience, and expertise of physical therapists in their professional scope of practice 1, Direct and unrestricted access: ‘The physical therapist has the professional capability and ability to provide to all individuals the physical therapy services they choose without legal, regulatory, or payer restrictions. 2, Professional ability to refer to other health care providers: ‘The physical therapist has the professional capability and ability to refer to others in the health care system for identified or possible medical needs beyond the scope of physical therapist practice, Professional ability to refer to other professionals: ‘The physical therapist has the professional capability and ability to refer to other professionals for identified patient/client needs beyond. the scope of physical therapist practice. 4, Professional ability to refer for diagnostic tests: ‘The physical therapist has the professional capability and ability to refer for diagnostic tests that would clarify the patient/client situation and enhance the provision of physical therapy services, From American Physical Therapy Assocation (APTA): Autonomous physiol therapist practirdefiritions and privileges, BOD PO3-15-12-28, Board of Directors Stands, Positions, ‘Guidelines, Policies, and Procedures, Alexandria, Va, 2008, APTA. of the existing PT education programs already far exceeded the minimal cur- ricular requirements for the master’s degree, which was the common degree awarded. Another was that this was a professional doctorate (e.g, MD, JD), ‘which requires advanced education and practice in the profession, unlike the acadlemic doctorate (e.g, PRD, EdD), which requires extensive research to gen- erate new knowledge. This period also experienced further analysis and evolution of organiza- tional structure of the APTA as it affected the PTA. In 2005, after an extensive review of the limited effectiveness of the Representative Body of the National Assembly, the APTA House of Delegates replaced it with the PTA Caucus, ‘which had its fist meeting in 2006, Other mechanisms for direct input from thecuarrer 1_m The Profession of Physical Therapy: Definition and Development 19 Te Core Values of Professionalism in Physical Therapy. Core Value Definition ‘Accountability “Accountability is active acceptance of the respon- sibility for diverse roles, obligations, and actions of the physical therapist, including self-regulation and other behaviors that positively influence patient/client outcomes, the profession, and health needs of society. Altruism Altruism is the primary regard for or devotion to the interest of patients clients, thus assuming the fiduciary responsibility of placing the needs of the patient/client ahead of the physical therapist's, self-interest Compassion/earing Compassion isthe desire to identify with or sense something of another's experience; a precursor of caring Caring is the concern, empathy, and consideration for the needs and values of others. Excellence Excellence is physical therapy practice that consis- tently uses current knowledge and theory while understanding personal limits, integrates judg- ‘ment and the patient/client perspective, embraces, advancement, challenges mediocrity, and works toward development of new knowledge. Integrity Integrity is steadfast adherence to high ethical principles or professional standards, Professional duty Professional duty is the commitment to meeting ‘one's obligations to provide effective physical therapy services to individual patients clients, to serve the profession, and to positively influence the health of society Social responsibility Social responsibility is the promotion of a mutual ‘trust between the profession and the large public that necessitates responding to societal needs for health and wellness From American Physical Therapy Association (APTA): Profesional in physical derapy: coe rls, BOD 05-04.02-08, [louse of Delegates Standards, Policies, Pesitions, and Guidelines, Alexandria, Va, 2009, APTA,20 PARTI m Profession ‘SUMMARY REFERENCES PTA community to the Board of Directors were also approved. These and other, related changes are further described in Chapter 3. ‘Although the first decade of the new century opened with a limited job mar- ket for PTs and PTAs, the outlook changed dramatically for the better. Employ- ment projections for these two groups over the period from 2008 to 2018 were excellent: 30% for PTs and 33% for PTAs2® The profession is well on its way to achieving Vision 2020. Physical therapy is a profession that enjoys a proud heritage, From the recon- struction aides of World War I to the autonomous practitioners of today, PTs continue to provide services to reduce pain, improve function, and maintain health, As a preamble to the remainder of the text, this chapter provided a defi- nition of physical therapy and the qualities that characterize it as a profession, particularly autonomy of judgment, The history of the profession was traced from its origins in World War I The influence of poliomyelitis and world wars, relationships with the AMA, development of the APTA, and recognition as 1a profession were described. In the decades after World War II, growth and development were paramount features of the profession until managed care and other forces for cost control in health care took hold in the 1990s. The mil- Iennium ended with a tight job market that had an unfavorable impact on edu- cation programs. The twenty-first century opened with Vision 2020, which set new goals and instigated follow-up action. The job market improved, and this helped lead to the rapid establishment of DPT programs. Research was further promoted by the Hooked on Evidence program and higher expectations of faculty. The profession was on the move to achieve the goals established by Vision 2020. 1. Hislop H]: The notsc-impossible dream, Phys Ther 55 1058-1089, 1975. 2. Americ Physical Therapy Association (APTA) Guidelines: Physical Therapist Sope of Practice, BOD G3-01-09.28, Board of Directors Standards, Positions, Guidelines, Policies, and Procedures, Alexandria, VA, 2008, APTA. 23, Guide to Physical Therapist Practice revised ed 2, Alexaniria, VA, 2008, American Physical Therapy Assocation, 4. Amencan Physical Therapy Assocation (APTA): Provision of Physical Therapy Interventions snd Related Tasks, HOD PO 0-17-28. 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Evaluative Criteria for Accreditation of Eduestion Programs forthe Preparation of Physical ‘Therapist Assistants, Alexandra, VA, 2009, American Physical Therapy Aeociaton, Avatlable at wwwapta org/ AM/Templat cmn?Section=PTA_Program2&Template=/TaggedPage/ ‘Tagged? ageDisplay.ctm{TPLID-247%ContentID-49492. Accessed September 23, 2010CHAPTER 1 m_The Profession of Physical Therapy: Definition and Development 21 ADDITIONAL RESOURCES 10, Granger FB: The develepment of physiotherapy, Phys Ther 56:13-14, 1976, 11, Davies Bj: The beginning of “modern physiotherapy”, Phys Ther 56-15-21, 1976 12, Davies Ef: Infantile paralysis, Phys Ther 56:42-48, 1975, 13, Pinkston D: Evolution of the practice of physical therapy in the United States. In Scully RM, Barnes ML, editors: Physical Therapy, Philadelphia, 98, Lippincott 14, Beard G: Foundations for growth: A review ofthe fst forty years in terms of education, [pactice, and research, Phys Ther Rev 41:843-861, 1961 15, Hazenhyer IM: Ahistory of the American Physiotherapy Association, Physiother Rev 21) 314, 1946, 16. Vector Research Ine: Executive Suramary, Workforce Study, Alexandria, VA, 1997, American Physial Therapy Assocation, 17, & Normative Mode of Physical Therapist Professional Education: Version 2004, Alexandria, VA, 2004, American Physical Therapy Association. 18, A Normative Mode! of Physical Therapist Assistant education: Version 1998, Alexandria, VA, 1999, American Physical Therapy Aseocation, 18, American Physial Therapy Assocation (APTA): APTA Vision Sentence for Physical Therapy 2020 and APTA Vision Statement for Physical Therapy 2020, HOD 06-00-2435. House of Delegates Standards, Policies, Positions, and Guidelines, Alexandria, VA, 2009, APTA, 20, Autonemous Physical Therapist Practice: Definitions and Privileges, BOD PUS-03-1228. Board ‘of Diretors Standards, Positions, Guidelines, Policies, andl Procedures, Alexandria, VA, 2008, ‘American Physical Therapy Association. 21. Professionalism in Physical Therapy: Core Values, BOD 05-04-02-03. House of Delegates Standards, Policies, Positions, and Guidelines, Alexandria, VA, 2009, American Physical “Therapy Association. 22. Mitchell JM, de Lissovoy G: A comparison of resource use and cost in diect access versus physician episodes of physical therapy, Phys Ther 7710-18, 197, 23, Occupational Outlook Handbook (OOH), 2010 Edition. United States Department of Laber, Bureau of Labor Statistics, Washington, DC. Available at: www bls gov /oeo/. Accessed September 24, 2010, Ameren Physi Therapy Association Healing the Generations: A History of Physical Therapy and the American Phys! Therapy Asocation Lyme, CT, 195, Grenich Pushing Som ‘Compichesive and dete description of the history and evolution ofthe profession and race of physical therapy nthe United States Hazeiyer MEA istry ofthe Amrcan Physical Therapy Association: 2. Formative year, 1926 88, Pryotee Re 252 95-7, 1986 Deserios the pertinent sues costtontng the proesion during this period, nclading the fist published Curiccam ard a revie of sdazaenal programa; conkovesy over tcaicans ‘erus professionals laiation o regulate proce ar roa ef the euro Hazenhyer IMA history of he Amencan Physical Therapy Assodaton 3. Coming of 96, TS31I995,Prysoher Rev 256) 122-129, 1946, CContinses desertion of neues in previous rice as thy evolved doing this poe Word War ened HagenhyerIM:A history of he American Physical Therapy Association: & Matar, 1999-946, Physiother Rev 254) 174-184, 45 Inthe final ete in the cin the athor doses asus involving membership righty, chapter organization, further cura change, impact the Nation Foundation fr infantile Pearly ateties sn mitary service, and he ora worwaptaary \Webntef the American Physical Therapy Astocation Excellent source fr curet information fu documents pertinent tothe prtesion