History of Physical Therapy in the US

Since Physiobob has got members from almost every continent, won't it be great if Physios from every country send in the origin of Physiotherapy in their respective countries. Well history is fun too!:p

To get the ball rolling, I've concised a report of the history of Physical Therapy in the US.The same can also be downloaded in (.doc) format

History of Physical Therapy Practice in the United States

The Journal of Physical Therapy Education, Winter 2003 by Moffat, Marilyn

Physical therapy practice in the United States evolved around two major historical events: the poliomyelitis epidemics of the 1800s through the 1950s and the effects of the ravages of several wars. Marguerite Sanderson and Mary McMillan were the first two individuals involved in the training of "reconstruction aides" responsible for caring for those individuals wounded in World War I.

Poliomyelitis raged throughout the country in the 1920s and 1930s. The primary modes of treatment were isolation, immobilization, splinting, bed rest, and later surgery. During World War II, drastic improvements in medical management and surgical techniques led to increasing numbers of survivors with disabling ivar wounds. In 1940, Sister Elizabeth Kenny brought her treatment techniques for the management of patients with poliomyelitis to the United States.

The passage of the Hospital Survey and Construction Act of 1946, the "Hill Burton Act," led to an increase in hospital-based practice for physical therapists. The Korean War again challenged physical therapists with the treatment of those with disabilities related to war wounds. The Salk vaccine virtually eradicated poliomyelitis in the United States by 1961. The role of the physical therapist progressed increasingly in the 1950s from that of a technician to a professional practitioner. Amendments to the Social Security Act (SSA) in 1967 added a definition of "outpatient physical therapy sciences." Increasing numbers of states enacted such practice acts during the 1950s and 1960s. The practice of physical therapy for patients with neuromuscular disorders dramatically changed. In the 1960s and 1970s, cardiopulmonary physical therapist practice expanded with increasing chest physical therapy programs for pre- and postoperative patients. With the expansion of joint replacements, new avenues for orthopedic physical therapist practice emerged. The 1970s and 1980s saw the increased opportunities for practice with the implementation of Occupational Safety and Health Administration (OSHA) rules and regulations, the passage of the Education for All Handicapped Children Act (PL 94-142), and the AIDS epidemic. Physical therapists began providing services in the areas of women's health, oncology, and hand rehabilitation. Specialty certification was developed.

In the 1990s, the Americans with Disabilities Act and the National Center for Medical Rehabilitation Research led to new opportunities for practice. Physical therapists were faced with the challenges of increasing governmental cost savings, decreasing reimbursement, increasing governmental regulations, the influences of the insurance industry and corporate America, and the sudden personnel supply exceeding demand for services.

In the new millennium, the American Physical Therapy Association developed the Guide to Physical Therapist Practice, the CD-ROM version of the Guide, and the "Hooked-on-Evidence" project. Most states had some form of direct access, and bills were introduced on Capitol Hill to allow Medicare patients direct access to physical therapist services.

THE BEGINNINGS

Physical therapist practice evolved around two major historical events: the poliomyelitis epidemics in the United States and the effects of the ravages of war upon US citizens. The first US epidemics were recorded in Boston, Mass, in 1893 and in Rutland, Vt, in 1894, with approximately 132 cases reported.1 The poliomyelitis virus was identified by two Austrian physicians, Dr Karl Landsteiner and Dr E Popper, in 1908. In 1909, Massachusetts became the first state to begin counting the number of poliomyelitis cases.2 The first major outbreak of poliomyelitis occurred in 1916 with over 9,000 cases in New York State alone. Medicine utilized the prevailing treatment methods of the time, quarantine and isolation. The accepted treatment of patients typically involved long-term splinting and casting to immobilize the limbs or the spine, combined with prolonged bed rest. Unfortunately, these practices led to increasing muscle atrophy and decreasing flexibility in weakened extremities, which ultimately required increasing physical therapy intervention.

Prior to World War I, support for those with disabilities had been growing gradually at both the private and governmental levels. Under the Surgeon General, Merritte W Ireland, MD, the Medical Department of the US Army had two divisions that influenced the development of physical therapy: the Division of Orthopedic Surgery and a newly created Division of Physical Reconstruction.3 A report from the Division of Orthopedic Surgery, which was headed by Elliott Brackett, MD, called for the establishment of hospitals for the reconstruction of soldiers with disabilities.4

The physiotherapy section of the report indicated the need for massage and mechanical hydrotherapy, and more importantly, for a national training corps for personnel (therapists). The report suggested that the personnel be drawn from schools of physical training and allied therapies. As a follow-up, several schools were chosen: the Boston School for Physical Education; the New Haven Normal School in Connecticut; the Normal School for Physical Education in Battle Creek, Mich; Posse Normal in Boston, Mass; the Teacher's Physical Education Program at Oberlin College, Ohio; and the Physical Education Department of Leland Stanford Junior University in California. The report also suggested that standards be developed by the schools and that the trainees be designated "physical reconstruction aides." The work of these aides would subsequently be transferred to a new Division of Physical Reconstruction. Frank B Granger, MD, an early advocate of adding physical therapy techniques to general practice, was influential in planning the training program for these reconstruction aides.5
The Division of Physical Reconstruction had three special sections: one for education; one for physiotherapy, including equipment, gymnasiums, and other edifices; and a section for clinical work such as general surgery, orthopedic surgery, head surgery, and neuropsychiatry. The clinicians prescribed the types of physical therapy and occupational therapy services to be carried out by the reconstruction aides.4

World War I, also known as "the Great War," began in 1914 in Europe. After the United States declared war on Germany on April 16, 1917, Frank Granger, MD, and Joel Goldthwait, MD, chief of orthopedics at Massachusetts General Hospital and chairman of the War Reconstruction Committee of the American Orthopedic Association, respectively, studied the British system of treating the disabled, a system largely conceived by Robert Tait McKenzie, MD.* Granger and Goldthwait were sent to Europe by the Surgeon General to investigate how people wounded in the war were being medically treated in England and France. Upon their return to the United States, they developed a plan to meet the needs of the over 200,000 US troops wounded at the battle-front. The plan put together by Granger and Goldthwait established two different groups of reconstruction aides. One group was to assist the physicians, and they were reconstruction aides/physical therapists. They were to provide exercise programs, hydrotherapy and other modalities, and massage for these patients. The other group had been working in almshouses and insane asylums since about the 1840s, and they were reconstruction aides/occupational therapists.6 They were to provide the training in the vocational skills of the day needed for return to gainful employment.

The Division of Special Hospitals and Physical Reconstruction, a special unit of the Army Medical Department, was authorized by the government to begin to meet the therapy needs of the war wounded. Marguerite Sanderson, who had been working with Goidthwait, was hired under this new division as director of the Reconstruction Aide Program in 1917. Her task was to prepare and mobilize these new reconstruction aide workers for overseas duty. To do this, she established a training program for reconstruction aides at Walter Reed General Hospital. Mary McMillan joined Marguerite Sanderson to head the Walter Reed program. McMillan, who was born in the United States but raised in England after the death of her mother, had completed a bachelor's degree in physical culture and corrective exercises. Finding this study incomplete, she went to London for special courses in neuroanatomy, neurology, and psychology and later accepted a position in a children's hospital. At the outbreak of World War I, she returned to the United States. In 1918, McMillan took a leave of absence from the Army to train two emergency classes of physiotherapists at Reed College in Portland, Ore.

By 1918. these two original programs were joined by 13 other education programs striving to train individuals to meet the needs of those with war wounds. On June 6, 1918, Sanderson saw the first reconstruction aides sail for Europe to begin their specialized duties to physically rehabilitate individuals wounded in the war.6

This first group of reconstruction aides included Inga Lohne Brauner, who was originally from Norway and then came to the United States and attended Teachers College at Columbia University. She had visited gymnasiums in Scandinavia and Kurope during 1915 and 1916 and returned to the United States to volunteer her services during World War I. She was appointed head aide at Walter Reed General Hospital and was the second reconstruction aide to report for duty. Brauner was in the first group to go overseas in 1918. Other group members included Dorothea Beck, who was the head reconstruction aide with the Reconstruction Corps at Camp Travis, Tex, and Fort McPherson, Ga, during 1918 and 1919; Hazel Furscott, who was a reconstruction aide at the US Army Letterman's Hospital in San Francisco from 1918 to 1920; Constance Green, who served as a reconstruction aide with the US Army in France; and Marguerite Irvine, who was another early reconstruction aide who devoted her professional career to the Army.[dagger] By 1919, 45 hospitals throughout the country had physiotherapy facilities and employed more than 700 reconstruction aides. Nearly 50,000 veterans, or almost half of those 125,000 Americans who were disabled during World War I, were said to have been treated at these facilities.4 Treatments consisted of exercises, including corrective exercises, passive exercises, sports and games, massage, hydrotherapeutic modalities, and assistive and adaptive equipment.

THE 1920s AND 1930s

Desiring to clearly differentiate themselves from reconstruction aides/physiotherapists, rehabilitation physicians changed their designation in 1920 from "physiotherapists" to "physical therapy physicians." They felt reconstruction aides/physiotherapists provided their needed services to treat the war wounded, but that they operated at the level of technicians and only under the physician's direction.

On the home front, physiotherapists were organizing local associations at the grass-roots level. These associations, which arose in Los Angeles, Calif, San Francisco, Calif, Washington, DC, New Haven, Conn, Chicago, Ill., and Portland, Ore, predated the national American Women's Physical Therapeutic Association (AWPTA) and were the hedrock on which the AWPTA was founded.

The historic first organizational meeting of the AWPTA occurred in New York at Keen's Chop House on January 15, 1921.6 Some 30 women attended. The purposes of the AWPTA as put forth in its constitution were to establish and maintain a professional and scientific standard for those engaged in the profession of physical therapeutics. The original charter membership category of the AWPTA was for those individuals who were reconstruction aides with at least 1 year's experience in the military. The original active member category was for those who were either graduates of recognized schools of physiotherapy or graduates of physical education programs who had training and experience in massage and therapeutic exercises and knowledge of either electrotherapy or hydrotherapy. Mary McMillan was elected the first President of the AWPTA by mail-in vote. The first issue of the association's official publication, The PT Review, appeared on March 1, 1921. Also in 1921, McMillan published Massage and Therapeutic Exercise, the first textbook written by a physiotherapist.
While the profession was originally composed of women and the association was established by women and named the AWPTA, in 1922 the association changed its name to the American Physiotherapy Association (APA) in recognition of the fact that men also practiced physiotherapy. There were a few male reconstruction aides who helped during the war effort in 1919.6

The poliomyelitis epidemics continued to rage throughout the country during the early 1920s. In August 1921, at the age of 39 years, Franklin Delano Roosevelt, who had been the Democratic Party's Vice-Presidential candidate in 1920 and who would later become President of the United States in 1933, contracted a severe case of poliomyelitis. The attack left him unable to walk without the assistance of a cane and lower-extremity long leg braces. The Meriwether Inn in Georgia was reported to have waters that might cure paralysis. In an attempt to help alleviate his disability, Roosevelt arrived at a cottage and began to swim in the warm waters. An article titled "Franklin D Roosevelt Will Swim to Health" appeared in the Atlanta Journal and chronicled Roosevelt's rehabilitation at the Inn. The article led many people with poliomyelitis and their families to Georgia Warm Springs for their therapeutic effects.7 Roosevelt bought Georgia Warm Springs in 1925 and proceeded to renovate and expand the facilities to provide a treatment center for those with poliomyelitis.7 The next year he established the Georgia Warm Springs Foundation, which in 1937 became the National Foundation for Infantile Paralysis and one of the major supporters of the physical therapy profession. The Georgia Warm Springs Foundation, a nonprofit organization, served as a focal point to generate public interest in poliomyelitis and in the physical rehabilitation of patients with poliomyelitis. The Foundation raised millions of dollars for the treatment of patients with poliomyelitis and for much needed poliomyelitis-related research.

Between 1930 and 1940, the United States saw an increase in the both the incidence and the magnitude of poliomyelitis outbreaks. Between May and November 1934, approximately 2,500 cases of poliomyelitis (almost 50 new cases a day) were treated at the Los Angeles County General Hospital alone.1 Physical therapy treatment continued to be centered around the use of exercises, massage, hydrotherapeutic modalities, heat and light modalities, and assistive and adaptive equipment. Home care evolved during this time as therapists provided their skills in rural homes, adapted equipment for patients, and provided braces and splints. In 1938, the "March of Dimes" coin collection was inaugurated by the National Foundation for Infantile Paralysis. It became a highly recognized and widely supported program across the country as the nation hoped to find a cure for poliomyelitis. The National Foundation for Infantile Paralysis also began distributing funds at the local level for various programs related to poliomyelitis.

In addition to the treatment of poliomyelitis, the late 1930s physical therapy practice continued to be dominated by the treatment of wounded World War II veterans. During this time, federal legislation recognized women physiotherapists as members of the Army Medical Department, which prior to that time had only recognized men.

The first Social Security Act, which later had a major impact on the provision of physical therapy services to the elderly in the United States, was passed by Congress in 1935 and was initially the old-age retirement system, which employees and employers financed through taxes.
In the mid 1920s, a group of physical therapy physicians had founded the American College of Physical Therapy, which then became the American Congress of Physical Therapy. By the mid 1930s, a group of these physicians had established the American Registry of Physical Therapy Technicians for the purpose of conferring a registered title to physiotherapists who passed the test. Registered physiotherapists remained technicians under the supervision of physicians.6
By 1937, physical therapy physicians had achieved recognition as a medical specialty. In an effort to further distinguish themselves from physiotherapists and in order to gain respect within the medical profession, physical therapy physicians began to call themselves "physiatrists."

APA hired its first paid staff member in 1934; membership grew to 710. A year later, the APA adopted its first "Code of Ethics and Discipline." The Association's active member category required members to have graduated from an approved school of nursing, passed an approved course in physical therapy for physical education and nursing graduates, and completed 1 year of practice within 2 years of graduation.

In reviewing the purposes of the APA in 1937, it is obvious that the technician mentality continued to dominate practice. The purposes of the Association were to:

* form a nation-wide organ which would establish and maintain a professional and scientific standard for those engaged in Physical Therapy;
* promote the science of Physical Therapy;
* aid in the establishment of educational standards and in scientific research in Physical Therapy;
* cooperate with, and to work only under the prescription of members of the medical profession;
* provide available Information for those interested in Physical Therapy;
* provide a central registry which will make available to the medical profession, efficiently trained assistants in Physical Therapy; and
* bind the several Chapters together.

In 1938, the APA established its first permanent office with the rental of space for The Physiotherapy Review in Chicago, Ill.

THE 1940s

Most of the developed world became embroiled in World War II between 1940 and 1945. Unlike World War I, World War II employed advanced technological developments enabling land, sea, and air maneuvers to be carried out in ways inconceivable before. Sixteen million people were engaged in battlefields throughout the world. As the United States prepared to enter the war, the US Army Medical Department once again became involved in plans for the reconditioning of those who would inevitably be wounded; the reconditioning was to include physical retraining, vocational rehabilitation, and psychological support.8 Drastic changes in the medical management of war wounds with penicillin and sulfa drugs and improvements in surgical techniques led to increasing numbers of individuals returning to the United States with disabling war wounds. Physical therapy practice at home and abroad was again dominated by the treatment of wounded veterans, including those with amputations, burns, cold injuries, wounds, fractures, and nerve and spinal cord injuries.6
Treatment up through the 1940's primarily consisted of exercise, massage, and traction. Manipulative procedures to the spine and extremity joints began to be practiced, especially in the British Commonwealth countries, in the early 1950's. Up until this point, there was no known practice of combination of exercise and manipulative therapy in existence. 4,5

1950-1990

In the 1950's, Physical Therapists started to move beyond hospital based practice. The majority continued to practice in hospitals through the 1960's. Physical Therapists now practice in a wide variety of settings, including outpatient orthopedic clinics, public schools, college/universities, geriatric settings (skilled nursing facilities), rehabilitation centers, hospitals and medical centers.

The 1990s represented a time when physical therapists needed to adjust to major changes in health care delivery system. Managed care, point-of-service plans, and other alternative organizational structures and concepts, such as "down-sizing," "reengineering," and "right-sizing" required increased ingenuity and adaptation by physical therapists across the country. The influence of insurance companies as determinants in the provision of services raised concerns by many and continues to this day. The impact of corporate ownership and physician ownership of physical therapy services often resulted in many compromises in the quality of physical therapy interventions and patient management.

Yet, the 1990s also saw growth in physical therapist practice in primary care arenas, work conditioning, work hardening, women's health, and many other niche practices. APTA purchased two additional buildings to meet their space and investment needs and hosted the 12th World Confederation for Physical Therapy Congress in Washington, DC, in 1995 to record-breaking crowds. In addition, the Association finally received representation on the AMA Coding Panel, enabling more appropriate development of codes to represent physical therapist practice. Relative value units for the codes were also developed that valued the higher skill levels of practice (eg, therapeutic exercises, functional training, etc) in a more equitable system. Prior to our representation, a hot pack was valued at almost the same level as therapeutic exercise.

The adoption of the model for physical therapist practice in 1997 and the Guide to Physical Therapist Practice published in 1999 clearly delineated the roles of present and future physical therapists. Examination, evaluation, diagnosis, prognosis, intervention, re-examination, and assessment of outcomes became the standard terminology guiding practice.26
The Association continued to grow and expand as the profession was touted by the media and corporate America as one of the top professions. Growth of education programs and massive numbers of graduates from physical therapist and physical therapist assistant programs would eventually lead to an imbalance of supply and demand as the profession entered the new millennium. A workforce study, undertaken in 1996 and completed in 1997, actually predicted supply exceeding demand; the marketplace changed for physical therapists and physical therapist assistants over a 5-year period. The pendulum began to swing slightly back to increasing demand in 2002.

THE NEW MILLENIUM

In 2001, a vastly revised version of the Guide to Physical Therapist Practice was published.27 Not only was its influence apparent in physical therapist education programs, but it has been increasingly valuable in the reimbursement and coding arenas. Physical therapists obtained evaluation and reevaluation codes in the CPT coding manual. Continued development of Part III of the Guide led to the development of an interactive CD-ROM version that included the specifics of all the tests and measures used in the physical therapist examination process along with the data indicating the reliability and validity of these examinations. That same year, the "Hooked on Evidence" project was developed to facilitate increasing practice based upon evidence, when available. Also influential was the 1990 establishment of the National Center for Medical Rehabilitation Research within the National Institutes of Health.28

In the political arena, 47 states have some form of direct access to physical therapist services involving examination/evaluation or intervention or both. Several states fought back attempts to remove manipulation from physical therapy practice acts. Medicare coverage was extended to physical therapists for electrical stimulation for urinary incontinence and wound care. The last years of the century brought additional challenges to the profession. A moratorium from 2004 through 2005 was placed on the $1,500 cap on Medicare coverage that was imposed on outpatient physical therapy and speech therapy services in 1999. APTA has worked tirelessly during each Congressional session to reduce the drastic impact the BBA has had on patient care.

Legislation was introduced in 2001 in the House of Representatives to allow physical therapist practice without referral under Medicare. Companion legislation was introduced in the Senate in 2002. The Medicare Payment Advisory Commission (MedPAC) is required to perform a study on the feasibility of direct access to physical therapy. A report is due to Congress no later than January 2005.

CONCLUSION

The practice of physical therapy in the United States has come a long way from its beginnings serving those with poliomyelitis and war wounds. Our practice is one with a rich history of almost 90 years of healing the generations; of tending to the needs of those with disease, disability, loss of function, and pain; and of preventing physical problems confronting so many people. The strength and continued durability of the profession throughout the most trying times are the qualities that have made this profession what it has been and what it will continue to be. Our practice history has been and will always be shaped by external forces and by scientific and technological advances in health service delivery. But at the same time, the profession will also be continuously shaped by the qualities of resilience, skill, and incredible dedication of those professionals whose primary aim is to improve the lives of those we serve.