100 Years of Optimizing Movement
A Story of Wars, Pandemics, and Policy
2021 marks a century for the American Physical Therapy Association.
And January 15, is the 100th anniversary of it’s founding day.
A centennial birthday is a good time to look back at where we came from, and how drastically things have changed for our profession.
Typical PT practice is so different now, than it was even 25 years ago.
What did PTs do 100, 75, 50, and 25 yrs ago?
What wisdom can be gleaned from 100 years of practice?
100 years ago we were just starting out, proving that early mobility was essential to improving the outcome and functional ability of our soldiers who were wounded during battle. 50 years ago complex fractures were still being managed with traction and physical therapy referral post bone or ligament injury was not commonplace. Now, there is a widespread awareness of physical therapy, most people thinking of it as something you have or do after an injury or to do intermittently when you have chronic pain. That is such a success compared to 50 years ago! Moving forward, several therapists including myself want to continue pushing forward and expanding public awareness of the benefit and use of physical therapy for prevention, wellness, and eliminating mild nagging issues before they become a bigger problem.
Our Roots
100 years ago Mary McMillan, the "mother of physical therapy", was a physical therapy reconstruction aide of the US Medical Corp during World War I, educated with a Bachelor's degree in physical education. She and her other aides provided orthopedic aftercare to soldiers, utilizing massage, exercise, and therapeutic modalities (like electrical stimulation, whirlpool, etc). Prior to these reconstruction aides, physicians prescribed rest and immobilization following fractures, amputation, and nerve damage due to traumatic injury. The World War Reconstruction Aides Association was formed post-war, and then later dissolved in 1952.
Concurrently, reconstruction aides also had a role to play during the 1918 flu pandemic, which hit army camps and hospitals especially hard, since this flu strain was most deadly for those 20 - 40 years old. McMillan was employed to make dressings and swabs for patients with the flu. The physical reconstruction aides often acted as aides to the overworked and understaffed nurses (apparently, a tale as old as time for nurses). Due to nursing staff shortages, the physical reconstruction aides stepped in to help where help was needed, as many physical therapists have also done this past year (2020). Just one surprising parallel to be made between the 1918 and 2020 pandemics.
Reconstruction Aides in WWI
The First 25 Years (1921 - 1946)
The American Women’s Physical Therapeutic Association (AWPTA) started on January 15, 1921 at a meeting at a steak house in New York City. In these early years, the profession was female dominant. They referred to themselves as Re-Aides for short and described themselves in their first professional publication edition, The PT Review, as "pioneer women" with "an undaunted spirit". They felt they proved the value of their services by the disability they prevented for wounded soldiers during World War I. Indicating the need for physical therapy in the healthcare landscape they said "Good primary surgery and good nursing, of themselves, do not yield results which can be considered satisfactory". PT perspective today is a similar sentiment regarding the typical treatment and unsatisfactory outcomes of low back pain and other chronic pains by many primary care, orthopedic, and pain management physicians (i.e. the opioid epidemic). Even in 1921, Re-Aides had recognized that "early restoration of function in the damaged part are essential". Due to the immediate success of these Re-Aides in saving injured men "to useful lives', the PT Review states "the principle of physiotherapy and occupational therapy was so definitely established that civil hospitals must provide a staff of such workers."
[These strong words and views are shocking to read, because they echo messages we are still disseminating 100 years later. What are we to learn from this? It sheds light on understanding the struggle of validating yourself as a profession. It underlies the importance of spreading any message outside your bubble of peers who agree with you, among all medical providers and healthcare workers, and beyond to the general public. We must leverage all avenues of reaching the wider population, especially as the digital space and technology continues to grow and morph.]
The AWPTA was in part founded to sustain social and professional ties between Aides who had created strong relationships and bonds during their time of service during the war effort. In their first meeting, they covered the topic of changing the name to remove "women" allowing men who are adequately trained to join. Thus, it did not remain an all girls club for long, and in 1922 changed to become the American Physiotherapy Association (APA). The PT Review also changed names to The Physiotherapy Review.
In its first 20 years, the APA began to have some male involvement, saw the initiation of a university bachelor's degree, and a significant shift from hospital-based training to all university bachelor training. They had the support of a sitting president (Franklin Delano Roosevelt) for their involvement in helping treat patients with polio. At 20-25 years old, physiotherapists returned to their roots when another world war exploded on the global scene. They even acted proactively, noting the global tensions, and initiated a War Emergency Training Course for their own, 6 months prior to the bombing of Pearl Harbor. Education advancements also extended into the first continuing education courses provided during war time. By the end of the first 25 years they founded their first headquarters and a house of delegates (governing body of the association).
The Second 25 Years (1947 - 1971)
The second quarter century, began with an association name change to the current name: The American Physical Therapy Association (APTA), and the journal changed name again to the Physical Therapy Review (in concert with the association). The Korea War began in 1950 and activated the physical therapists (PTs) serving in the Women's Medical Specialist Corps to help rehabilitate wounded soldiers. Again back to our roots.
What else happened during the '50s? PTs began to interact on a global scale, helping to plan the World Congress for Physical Therapy. Locally, regulatory controls began to be enacted on a state level: including adoption of state practice acts and a standard competency exam for state licensing boards to use to evaluate licensing applicants. Polio vaccine inoculation began mid-decade. Because we had data on normal muscle strength across the population, and therefore had developed a standardized muscle testing procedure, physical therapists were of specific help during the late-stage randomized double blind vaccine trials for testing muscle strength outcomes.
The first graduate program for physical therapy was launched in 1960 at Western Reserve University in Cleveland, Ohio. One goal was to continue to expand and improve scientific research in the field of physical therapy, by including this in the curriculum and requiring a final thesis of the graduates. A secondary goal, was to inspire some students to become teachers themselves in the future to continue to expand graduate physical therapy education reach. This program was lost in 1971 due to reduction of federal funding which was redirected to Vietnam War efforts. Again PTs were activated to assist in the war effort and traveled to Vietnam. They treated both injured friend, foe, and civilians and they trained many of their Vietnamese counterparts.
In the middle of the decade, the first legislation for Medicare and Medicaid was enacted, vastly expanding healthcare access to millions. There was already a feeling of limited numbers of physical therapists unable to meet all of the current physical therapy needs. The need to attract more people to the field and educate them was a necessity. In 1967, physical therapy was added as a covered benefit for Medicare and Medicaid beneficiaries. By the end of the decade, the first class of PTAs (physical therapy assistants) graduated and joined healthcare teams. The final move of this quarter century was to move our headquarters from NYC to Washington DC in hopes of creating a stronger advocacy presence. And thus we turned 50.
From 50 - 75 Years (1972 - 1996)
Our 50th anniversary was marked by the Social Security Amendments of 1972, 17 of which pertained to physical therapy, allowing PT to be provided in all settings - inpatient, outpatient, private offices, and in the home. Overall, a big win - however in retrospect, the not-so-happy outcome of a precedent for having an annual outpatient PT cap started this year at $100 per year. [Adjusted for inflation only, this would be $619 in 2020. For reference, in 2020, the first threshold requiring additional documentation is $2100]. The APTA recognized additional needs for shaping policy and created the PT Political Action Committee (PT PAC) the next year.
Despite 50 years as a profession, many leaders observed a lack of scientific evidence and support for our methods, and called for more research. This requires appropriately trained clinicians as researchers, a sentiment that has also been echoed in recent years. [It is interesting that despite so much progress made, the needs remain the same.] In 1973 NYU began the first PhD program for physical therapy, a step toward preparing future researchers.
Additional advancements in education, included recognition of the need for programs to certify clinicians as specialists. This culminated in the first specialist exams occurring in 1985, for cardiopulmonary specialists. 1986 saw specialists in electrophysiology and pediatrics, with Neuro and Sports following in 1987. The first orthopedic specialty was earned in 1989, and geriatrics in 1992.
IDEA (Individuals with Disabilities Education Act) was passed in 1975 which moved many PTs into public schools providing habilitative services to children with disabilities. 15 years later in 1990, ADA (Americans with Disabilities Act) was enacted by congress. The PT role here was evaluating functional abilities to match people to job tasks and skills they could perform and educating employers on reasonable modifications.
The idea of autonomous practice, meaning no physician oversight needed, grew strongly during the '70s. This led to verbiage changes in our code of ethics and then to plans to progress our minimum education requirements to post-baccalaureate level by 1990. As of 1991 that would mean all physical therapists are graduating with a Master's level degree or greater. Two-year masters programs were developed, and by the HOD goal of 1990, they marked >50% of existing programs. Thus the goal was not fully achieved, however, undeterred, we pushed forward into doctoral level degrees. In 1993 the first Doctor of Physical Therapy (DPT) program launched at Creighton University and the first DPTs graduated in 1996, a mark of substantial progress by our 75th year.
The Past 25 Years (1997 - 2021)
Legislation kicked off the past quarter century with a bang! The Balanced Budget Act of 1997 required all federal expenditures to be balanced each year but also disproportionately eliminated funding of Medicare, applying restrictions on covered services across all of healthcare. It placed an annual cap on outpatient rehabilitative services under Medicare. Because of a missing Oxford comma, the cap amount combined speech language rehab and physical therapy services together; occupational therapy had a separate bucket of money allowed. Quick advocacy and congressional realizations led to including an annual exceptions process to prevent an actual hard cap (but not adding that Oxford comma - perhaps we had to pick our battles). The exceptions process had to be congressionally renewed every year to prevent a hard stop on covered rehabilitative services. 20 years later, this annual review was finally repealed by the Bipartisan Budget Act of 2018. The idea of any cap was completely eliminated, but continued with a similar threshold to the prior exceptions process allowing for continued services when medically necessary. Documenting this medical necessity to prove to insurance companies that a patient needs physical therapy is one of the many reasons we spend so much of our patient sessions on the computer. It was a breath of fresh air in 2018 to no longer feel beholden to the cap and exceptions process
In 2000, Vision 2020 was created emphasizing the need for direct access and autonomous practice, as well as moving the education standard forward to a Doctor of Physical Therapy degree. Practice should become more evidence-based and embody professionalism to fulfill the goal of becoming the practitioner of choice for improving quality of life for society. By 2016 physical therapy educational programs could not be accredited if they did not train and confer the Doctor of Physical Therapy degree. Transitional DPT programs were made available to clinicians who had graduated with master's level degrees and wanted to support Vision 2020.
Texas was the first state to have a small fragment of direct access in 1991. PTs could perform any evaluation without referral and could treat patients for recurrent issues that had been prescribed PT by a physician in the past year. In 2009 enough research had been completed to report that direct access to physical therapy is "safe and results in improved health outcomes, more timely care, higher patient satisfaction, and lower costs for all health systems, whether public or private." (1) Six years later, after many hard-fought battles, in 2015 all states had granted some form of direct access for physical therapists, though some still have limitations even today. These limitations include: physician prescription within or after 30 days or certain # of visits in order to continue treatment, referral needed to perform certain treatments like spinal manipulation or needle EMG, and only certain populations can receive treatment without a referral. In all states and for all populations, you can be evaluated by a physical therapist for any reason or condition without physician referral. However, our ability to treat you may be limited by state laws. This is where patient-led advocacy for your best care becomes important in addition to profession-level advocacy and supporting the federal or state PT PAC. If you are reading this in North Carolina, you are one of the 20 lucky states with unrestricted access to your preferred physical therapist!
In 2013, a new vision statement was released, since such expedient progress had been made toward the original goals set 13 years earlier. I remember this moment in PT school, it was certainly a quiz question at some point, and we were all tasked with memorizing it.
"Transforming society by optimizing movement to improve the human experience."
I wonder how many people outside of physical therapy heard this vision? PTs were called to empower society to move more and thereby "reduce preventable healthcare costs" through helping clients overcome participation barriers (like pain, stiffness, weakness, lack of knowledge, awareness of the detriments of a sedentary lifestyle, etc). I fully support this vision and hope to empower my clients and beyond to become more active and combat the conditions associated with being sedentary and be their healthiest self.
Did you know? In 2016 the Choose PT campaign was launched to combat the opioid epidemic and encourage the public to choose PT instead of medications for management of their musculoskeletal pains. By this point, the APTA had a website, multiples social media channels, member email campaigns, and started the hashtag #choosePT. To commemorate 100 years, a brand new headquarters was designed and built in Alexandria, VA.
2020 - COVID 19
COVID 19 exploded and there was a new pandemic for us to find our role in. For many in acute care, they became over-worked on the frontlines providing early mobility and contracture prevention for those struggling for life in the ICU. They also were one of few people patients could receive touch and in-person experiences from in their final days. These frontline PTs experienced the same mental overwhelm and fatigue as nurses, doctors, respiratory therapists, and all other healthcare workers on the frontlines.
We also became a necessary force to provide treatment for COVID 19 survivors who had Post Intensive Care Syndrome (PICS) commonly affecting people who experienced respiratory distress and mechanical ventilation during hospital admission. Cardiopulmonary specialists now were needed to share their expertise with a wider network of PTs to train them in best methods for recovery for outpatient PT clinics to support pulmonary rehab centers. As chronic neurological deficits continue to be explored and understood, we will continue to have a role of helping improve function related to these deficits like imbalance, poor coordination, and difficulty walking.
The struggle of many outpatient clinics was a mass reduction in volume despite rapid adoption of telehealth by many. Many physical therapists lost their jobs or were furloughed for months and the new graduates were hard-pressed to find jobs in a field which is typically regarded as having a safe and reliable job outlook. By the end of the year, volume had increased and returned to near normal levels, or had increased to max capacity (altered to adhere to CDC guidelines and local mandates). Many PTs also began offering mobile services - having outpatient services brought to your home - to reduce your exposure in a busy clinic setting.
100 Years of Growth
Physical therapy started as a novel and necessary treatment for injured soldiers in WWI and has now exploded into all facets of civilian life. In 2021, we are a profession of nearly 250,000 DPT-educated neuromusculoskeletal movement experts with direct access for patients [USA statistic]. We treat the entire age and ability spectrum, from 0 to 100+ years old and from hospital admission day 1 to utilizing adaptive technologies or to training performance achievements that push the limits of the human body. We are specialists, residents, and fellows as well as business-owners, researchers, leaders, educators, and above all human motivators. And we aim to transform society by optimizing movement to improve the human experience.
Moving Forward
Promotion of wellness, prevention, proactive health, and both lifestyle and planet sustainability are necessary components of a strategic plan to achieve this vision moving forward. Optimizing movement doesn't happen in a vacuum, and we must ensure that there is an earth environment in which to enjoy our human movement experience. As we continue to increase our life expectancy, for our personal happiness and the sustainability of our planet, we need to focus on preserving and maximizing our function into our later years. This requires some forethought and a proactive health and wellness mindset. We can't just use healthcare reactively - when something goes wrong. We need to take ownership for our health, get educated on what will help us thrive and stay moving as we age, and invest time and money into our health now. The healthier we are, the more we're able to reduce our carbon footprint - by using human-powered transportation, maintaining a capability of growing our own food or gardening, and demanding less hospital, pharmaceutical, and surgical resources.
There is a current trend of imbalance between the rising cost of DPT education and declining insurance reimbursement rates which has a direct effect on salary reduction. Physical therapists are caught in the thick of the student debt crisis. In an effort to prevent severe salary reductions, companies are requiring therapists to see an enormous volume of patients in order to account for declining reimbursements. This leads to quick burnout in the profession, and many turn to other careers, or double employment. An environment like this does not support the growth and maturation of newly licensed therapists into experienced and expert clinicians - which is ultimately who patients prefer to see and who we therapists thought we would become.
High volume also does not support provision of best care to our patients nor ensure best outcomes. This high volume (dictated by low insurance reimbursement) and lack of best care continues to drive more physical therapists into cash-based or non-insurance-based practice. Cash-based practices continue to grow in numbers exponentially as therapists try to provide the best care to their clients and get results - the reason they went to school to become a PT in the first place. These businesses allow patients the choice of experience and results they wish to have with physical therapy. Unfortunately, Medicare beneficiaries are not currently afforded this choice if needing physical therapy. They do have the right to choose a doctor/physician who is cash-based, but physical therapists and their patients are not allowed the same privilege. I see this as an important point for advocating change by CMS (Centers for Medicare Services) - the Medicare rule-makers.
Here’s to the next 100 years!
References
