Physical Therapy

Physical therapy is an evolving health-related practice that involves restoring and maintaining the highest achievable psychomotor functionality of the individual. The field grew out of the first and second World Wars, and, over the past few decades, has increased its educational requirements. Pediatric physical therapists are PTs that have chosen to receive specialty training in order to lend their talents to children and their families. PTs who work in schools collaborate with educators and family members in order to design a regiment that balances a child's rehabilitation with his or her non-physical needs such as social integration, self-esteem and cognition.

Keywords Adapted Physical Education (APE); Commission on Accreditation in Physical Therapy Education (CAPTE); Direct Service; Individualized Education Program (IEP); Individuals with Disabilities Education Act (IDEA); Least Restricted Environment (LRE); Motor Delay; Physical Disability; Physical Therapy; Related Services; Special Education

Overview

Physical therapy, or physiotherapy, is the provision of services designed to diagnose and treat health-related issues that limit or will limit an individual's ability to move or go about their daily activities. Such issues can be caused by a wide variety of congenital and acquired conditions including but not limited to cerebral palsy, juvenile rheumatoid arthritis, spina bifida, traumatic brain injury and other physical injuries.

Physical therapy is administered by nationally licensed health-care providers called physical therapists. These professionals are trained to properly assess and diagnose the severity and nature of a patient's condition(s), formulate a rehabilitation program tailored to the individual and finally execute the treatment. The population that requires physical therapy is incredibly diverse, spanning all age groups, social classes and ethnicities. Therefore, physical therapists must be thoroughly trained to ensure they are able to meet the needs of the public.

It is difficult to say exactly when the practice of physical therapy was born. However, it is generally accepted that physical therapy in the modern sense took shape during World War I in order to care for injured civilians and military personnel. The physical therapists trained by the Army were exclusively women, most of whom had a background in physical education. It was not until the 1940s and 1950s, though, that a combination of injuries from World War II and the nation's poliomyelitis epidemic showed how great the need for rehabilitation was becoming on and off the battlefield.

During the peace of the decades that followed, physical therapists began moving beyond hospital-based practice. While many went back to military service (by now the Army was allowing men into the program) some formed autonomous organizations that pushed to professionalize the occupation. One of the key factors that led to the eventual success of this movement was the shift from certificate programs to academic programs with higher standards based in colleges and universities. These new degrees (bachelor's, master's and eventually clinical doctorate) and the better education associated with them gave physical therapists a chance to better specialize for specific communities. It is now common to find physical therapists working not only in hospitals and rehabilitation facilities but also schools, occupational environments and fitness centers. Some therapists have specialized in sports medicine which focuses on athletes' bodies and the physical stresses they are under.

History

Wartime Development

This section discusses the changes to the physical therapy degree over the past century. Modern physical therapy began development during World War I when women were recruited by orthopedic surgeons to assist in the rehabilitation of wounded civilians and servicemen. These early physical therapists (then known as reconstruction aides) were members of the Division of Special Hospitals and Physical Reconstruction which was established by the Surgeon General's Office in 1917. The following year, Mary McMillan became the first physical therapist appointed by the United States Army. In 1921 she would become president of the American Women's Physical Therapeutic Association, an organization which would eventually admit men (late 1930s) and change its name (late 1940s) to the American Physical Therapy Association (APTA) as it is still known today (Wakiji, 1997). Physical therapy training in these decades was little more than an apprenticeship which involved some classroom instruction as well as supervised practice in a hospital that was run by the military. However, after World War II, it became apparent that physical therapy had applications in civilian hospitals as well and that these facilities could also train physical therapists through a certificate program. Most of these curricula required a bachelor's degree prior to admission. These certificate programs, however, would be relatively short-lived.

Increasing Educational Requirements

In 1960, the American Physical Therapy Association House of Delegates passed a resolution stating that the minimum educational requirement to become a physical therapist was a bachelor's degree. This change spelled the end for the certificate programs as the universities offering them began concentrating on undergraduate programs for physical therapy. This coincided with the developing concept of schools and colleges of allied health professions whose growth was spurred by the federal government's emphasis on job creation and subsequent education for these emerging fields. This culminated in the passage of the Allied Health Professions Personnel Training Act of 1967 which allowed the development of assistant-level programs such as the physical therapist assistant (PTA).

The next big leap in physical therapy education started in the late 1960's to early 1970's when the United States was in a state of political unrest. Physical therapists began asking why their post-baccalaureate work, often an additional two years of study, yielded a second baccalaureate degree rather than something higher. By 1979, the American Physical Therapy Association House of Delegates passed another resolution requiring a post-baccalaureate degree for physical therapy education after 1990. In 1987 the number of schools that made the transition was relatively small. However, the movement led to the formation of the Commission on Accreditation in Physical Therapy Education (CAPTE) which gave the American Physical Therapy Association the autonomy to oversee its own degree programs (previously managed by the American Medical Association). This new leadership allowed the transition from a baccalaureate to master's as the first professional degree (Echternach, 2003).

The final change to physical therapy education began approximately a decade ago and is still in progress. In the early 1990's there was a push to go from a master's to a clinical doctorate as the first professional degree. By 1996, the first doctor of physical therapy (DPT) program graduated its first class. Currently, 75% of physical therapy programs have converted to a clinical doctorate while the others intend to make the switch in the future (Wojciechowski, 2006).

Applications

Physical Therapists as Educators

According to the American Physical Therapy Association website, 4.4% of practicing physical therapists work in a school system (preschool/primary/secondary). Pediatric physical therapists are PTs that have chosen to receive specialty training in order to lend their talents to children and their families. It is their goal to rehabilitate children with temporary injuries and promote independence in handicapped children by attaining maximum function relative to the individual's disability.

In children with temporary injuries, the duration of physical therapy is generally relatively short, rarely lasting more than six months except in extreme circumstances (severe car accident, etc). However, pediatric physical therapists often work with disabled patients from birth (or onset of the disability) until late adolescence after which they continue their treatment with a general physical therapist. Physical therapy for children, particularly those with an ongoing disability, must be a collaborative effort between the therapist, educators and family in order to design a regiment that balances rehabilitation with the child's non-physical needs such as social integration, self-esteem and cognition (APTA Section on Pediatrics, 2003). However, the cause and severity of the disability may vary widely from child to child which dictates a need for an Individualized Education Program (IEP). This written document is developed for each child by a team of people responsible for the child's well being (parents, teachers, etc). When this team determines that physical therapy is necessary to allow the child to meet his or her specific annual goals (the focus of an IEP is short term goal setting), intervention is planned. The team then decides which model of service delivery (direct services such as individual or group therapy or indirect services such as consultation or monitoring) the child needs in order to be involved and make progress in the general education curriculum (Kaminker, Chiarello, O'Neil & Dichter, 2004).

Pediatric Physical Therapy & the Law

The Individualized Education Program is one of four components to a complete Adapted Physical Education (APE) program which is defined as physical education that can be modified to address the physical needs of children with some form of physical disability. The other three parts are:

• Assessment and instruction to ensure qualified personnel are prepared to analyze progress and make adjustments as necessary.

• Accurate assessment data to be sure the program is optimized for the child.

• Instruction in a Least Restricted Environment (LRE) to ensure that all students can fully and safely participate in the activities.

Under the Individuals with Disabilities Education Improvement Act (IDEIA or IDEA 2004), local education agencies and school districts are required to provide special education and its related services to its students. The objective of special education is to employ direct services such as APE to attain measurable annual goals. Physical therapy, as a related service, does not need to adhere to these standards. However, it is often used in conjunction with direct services and other related services (occupational or speech therapy, etc.) towards similar ends. IDEA also states that special education and related services must be provided to the parent(s) or family at no cost. Funding for these programs come from a number of sources such as Medicaid or private organizations and each state has different procedures for procuring reimbursement (APTA Section on Pediatrics, 2003).

Common Pediatric Disabilities

As stated above, the adaptations vary widely from child to child. Some examples of disabilities a physical therapist may encounter (and subsequent general strategies to employ) include:

• Autism - the variations inherent in autism have changed the way we describe this disorder. Individuals diagnosed are described within a range called the Autistic Spectrum with symptoms ranging from mild to severe. Their disability generally involves difficulty with change and issues with sensitive sensory functions, though some may experience motor retardation. The therapist must be cautious to ensure physical contact is gentle while employing demonstration techniques.

• Cerebral Palsy - characterized by motor delay that may negatively impact the child's entire body. Children with cerebral palsy will often require some form of adaptive equipment such as a wheelchair or crutches. Generally the therapist should avoid extreme movements (fast or slow) and modifications to the activity may be required (larger ball, light objects such as balloons or scarves, etc).

• Down syndrome - characterized by mental retardation and overall developmental delays. Motor delay is also common due to low muscle tone which also places them at risk for atlanto-axial joint instability, a malformation between two vertebrae that may lead to severing of the spinal cord if activity is too rigorous. Care should be taking to avoid extreme neck flexion. General strength and endurance activities are relatively low-risk.

Issues

The Future of the Field

In the 1990s, physical therapy was considered one of the hot markets in the United States. The profession saw a dramatic increase in applicants and new programs for both physical therapists and physical therapist assistants were opening across the nation to meet the demand for education. However, by 2005 many of these programs closed due to a sharp decline in enrollment. Many factors contributed to this loss of applicants including, but not limited to, competition from other health occupations, the lack of a defined identity for physical therapy and the poor promotion of the field to prospective students by its own professionals. APTA's response was the development of a comprehensive plan, titled RC 28-05, to identify methods of attracting additional capable students to physical therapy programs.

Promoting the Field

There is a growing consensus that the profession does not get enough exposure to younger children. RC 28-05 calls for more physical therapists visiting their community's elementary school classrooms to discuss the career and perform hands-on demonstrations. However, this issue is not only found in grade schools.

High school and college guidance counselors also began steering prospective students away from physical therapy in the late 1990s after learning of the downturn in physical therapy employment. This exacerbated the problem even further and it forced the leaders of the physical therapy community to act. Program directors from St. Petersburg College in Florida, Washington University and others began meeting with these counselors. They found that nearly all of the advisors said a lack of information regarding the programs made preparing students for a physical therapy or physical therapy assistant degree (i.e., advising which classes to take) very difficult. Two parts of RC 28-05 address this concern: 1) implementing promotional strategies and materials such as a recruitment kit that would be an informative, easy-to-use guide for educators, counselors and prospective students as well as 2) continued communication with these individuals to gain valuable feedback, criticism and address further concerns.

Training

Once an individual decides to pursue a career in physical therapy, he or she will generally observe a therapist by shadowing for several hours. This was originally designed to give the student an idea of what their day would be like and perhaps make some contacts in the field. However, program directors found that many of the clinicians were actually steering prospective students away and some speculated the therapists were acting in their own interest in order to limit potential future competition. Leaders in the physical therapy community agree that this behavior is unacceptable. In response, they have adopted the stance that, for the betterment of the field, practitioners must be honest and positive with prospective students as well as understand the job market's cyclical nature (Ries, 2005).

Professional Directives

According to APTA, recruitment of new physical therapists and physical therapist assistants should converge on three key points:

• Dynamism - Recruiters must be able to explain the ever-changing nature of health professions as a whole with an emphasis on where physical therapy fits into the general scheme. Also, physical therapists and their assistants can be found all over the world performing many different functions from school therapists to sports medicine.

• Opportunity - Recruiters need to emphasize how the clinical doctorate has opened doors for physical therapists who wish to pursue new areas of research and practice. On a related note, it is also important that potential students understand that PTs and PTAs enjoy comfortable salaries.

• Service - Recruiters need to emphasize the importance of physical therapy in the lives of a wide range of people. However, in order to be more accessible to a younger generation, it is encouraged that recruiters highlight such famous recipients of physical therapy as Tiger Woods. It is important to show how physical therapy not only heals but helps its recipients regain the life they once had (Ries, 2005).

The Doctorate of Physical Therapy

In 1999, the American Physical Therapy Association's Education Division issued a strategic plan for the future called the Vision Statement for Physical Therapy 2020 (Vision 2020). Since the adoption of Vision 2020, the leaders of the physical therapy community in the United States have been pushing to establish the clinical doctorate as the standard requirement for practicing physical therapy. However, not everyone agrees with this.

Concerns have been raised by practicing professionals that requiring a Doctorate of Physical Therapy as the entry-level degree may create a closed market for physical therapy professionals as it limits the potential for foreign-trained physical therapists to move to and practice in the United States. However, it must be noted that, due in large part to the different requirements and regulations individual nations have adopted, the labor markets for physical therapists have always been restricted to some degree.

A more basic complaint has been raised regarding the clinical doctorate. Some argue that the DPT is a case of 'degree inflation' where individuals in the field are earning a more advanced degree despite doing the same level of work as those who were only awarded a master's degree not long ago. This raises the question, does the care patients receive improve from this change or does it benefit only the professionals who attain the degree? It is too soon to formulate a definitive answer at this time. However, the global nature of the debate ensures that the issue will be examined closely in the coming years (Baxter, 2003).

Terms & Concepts

Adapted Physical Education: A diversified program of developmental activities designed to meet the individual needs of disabled students who are unable to participate in a general physical education program. This program is mandated by federal and state law as a part of special education programs across the country.

Commission on Accreditation in Physical Therapy Education (CAPTE): Designed to regulate and apply standards to the education of physical therapists and physical therapist assistants. CAPTE is mostly involved in the continuous improvement of entry-level preparation of the practice.

Direct Services: Those services provided to a student with a disability as established through an Individualized Education Program or other similar written plan. Direct services are specifically mentioned in the definition of Special Education found in the Individuals with Disabilities Education Improvement Act. Related services cannot be substituted in place of direct services.

Individualized Education Program: A written statement developed by a team of representatives including the teacher, parents and the local educational agency used to define an appropriate educational program for a student with a disability. The plan focuses on proper evaluation of the student's performance as well as goal-oriented learning.

Least Restrictive Environment: The Least Restrictive Environment is one in which disabled and non-disabled students are educated together to the maximum extent appropriate. If a disabled student is unable to meet goal set forth in his Individualized Education Program in the LRE, an Adapted Physical Education program may be required.

Motor Delay: Defined by lag in a child's motor development where the individual does not meet established norms for their age group. Early motor delays, within the first six to 18 months after birth, often point to some neurological dysfunction such as cerebral palsy or spina bifida. With proper treatment it is possible to diminish or even eliminate the delay depending upon the severity of the child's condition.

Related Services: Those services required for a student to benefit from Special Education but not specifically defined as such in the Individuals with Disabilities Education Improvement Act. Physical therapy is an example of a related service.

Bibliography

American Physical Therapy Association Section on Pediatrics. (2003). Providing Physical Therapy in Schools Under IDEA [Brochure]. Retrieved March 4, 2007 from http://www.pediatricapta.org/graphics/IDEA%20Part%20B.pdf

American Physical Therapy Association Section on Pediatrics. (2003). Using APTA's Guide to Physical Therapist Practice in Pediatric Settings [Fact Sheet]. Retrieved March 4, 2007, from http://www.pediatricapta.org/graphics/GuideFactSheet.pdf

Echternach, J. L. (2003, Winter). The political and social issues that have shaped physical therapy education over the decades. Journal of Physical Therapy Education. Retrieved February 6, 2007, from http://www.findarticles.com/p/articles/mi_qa3969/is_200301/ai_n9302453/pg_14

Hedrick, B. N., Stumbo, N. J., Martin, J. K., Martin, L. G., Nordstrom, D. L., & Morrill, J. H. (2012). Personal assistant support for students with severe physical disabilities in postsecondary education. Journal of Postsecondary Education & Disability, 25, 161-177. Retrieved December 10, 2013, from EBSCO Online Database Academic Search Premier.http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=82747990&site=ehost-live

Kaminker, M. K., Chiarello, L. A., O'Neil, M. E., & Dichter, C. G. (2004). Decision making for physical therapy service delivery in schools: A nationwide survey of pediatric physical therapists. Physical Therapy, 84 , 919-933. Retrieved February 7, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=14689830&site=ehost-live

Lieberman, L. J., & Conroy, P. (2013). Training of paraeducators for physical education for children with visual impairments. Journal of Visual Impairment & Blindness, 68, 107, 17-28. Retrieved December 10, 2013 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=84993698&site=ehost-live

Michaud, L. J., Sandler, A. D., Cartwright, J. D., Duby, J. C., Johnson, C. P., Kaplan, L. C., et al. (2004). Prescribing therapy services for children with motor disabilities. Pediatrics, 113 , 1836-1838. Retrieved February 8, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=13164779&site=ehost-live

Ries, E. (2005). Recruiting the Next Generation of PTs and PTAs. PT: Magazine of Physical Therapy, 13 , 36-47. Retrieved February 20, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=18739271&site=ehost-live

Wakiji, E. M. (1997). Mapping the Literature of Physical Therapy. Bulletin of the Medical Library Association, 85 , 284-288. Retrieved February 7, 2007, from PubMed http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=226272

Webb, D., Webb, T. T., & Fults-McMurtery, R. (2011). Physical educators and school counselors collaborating to foster successful inclusion of students with disabilities. Physical Educator, 68, 124-129. Retrieved December 10, 2013 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=67018184&site=ehost-live

Wojciechowski, M. (2006). The future of physical therapy education: APTA's education strategic plan. PT: Magazine of Physical Therapy, 14 , 54-58. Retrieved February 6, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=21580472&site=ehost-live

Suggested Reading

Baxter, D. (2003). The changing face of professional education. Physical Therapy Reviews, 8 , 55. Retrieved February 7, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=11029160&site=ehost-live

Dole, R. L. (2004). Collaborating successfully with your school's physical therapist. Teaching Exceptional Children, 36 , 28-35. Retrieved February 9, 2007 from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=13046920&site=ehost-live

Education programs leading to qualifications as a physical therapist assistant. (2006). Physical Therapy, 86 , 313-317. Retrieved February 8, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=20430566&site=ehost-live