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INTRODUCTION TO PART I

Part I of this textbook, “The Profession of Physical Therapy,” isdivided into three chapters:

• Chapter 1: Development of the Physical Therapy Profession• Chapter 2: The Physical Therapist Assistant as a Member

of the Health Care Team• Chapter 3: Physical Therapy Clinical Practice

In these three chapters, we will discuss the history of rehabilitationtreatments including therapeutic exercises, and the organization,history, values, and culture of the profession of physical therapy. Wewill also explore the differences in role, function, and supervisory re-lationship of the physical therapist (PT), the physical therapist assis-tant (PTA), and other health care practitioners and ancillary personnel.

PART

I

THE PROFESSION OF PHYSICAL THERAPY

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© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

© Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION




















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3

OBJECTIVES

After studying Chapter 1, the readerwill be able to:

■ Discuss the history of rehabilita-tion treatments (includingtherapeutic exercises) fromancient times through the 1900s.

■ Describe the history of thephysical therapy profession andits five cycles of growth anddevelopment.

■ Understand the values andculture of the physical therapyprofession.

■ Consider the American PhysicalTherapy Association’s missionand its goals (especially goalstwo and six) in regard tophysical therapists and physicaltherapist assistants.

■ Explain the organizationalstructure of the AmericanPhysical Therapy Association.

■ Discuss the benefits of belongingto a professional organization.

■ Name the other organizationsinvolved in the physical therapyprofession.

CHAPTER

1

Development of thePhysical Therapy

Profession

HISTORY OF REHABILITATION TREATMENTS INCLUDINGTHERAPEUTIC EXERCISES

It may be difficult to believe that some types of treatments utilized inphysical therapy today, such as therapeutic massage, hydrotherapy(water therapy), and therapeutic exercises, were used in antiquity—around3000 BC by the Chinese and around 400 BC by the Greeks and Romans.Therapeutic exercise and massage with aromatic oils were probably thefirst therapeutic modalities applied by the Greeks and Romans in a pur-poseful way to cure health problems. Written and pictorial records fromthe ancient civilizations of China, Japan, India, Greece, and Rome alsocontain descriptions and depiction of massage and exercise. Researchershave found evidence that the application of heat, cold, water, exercise,massage, and sunlight was often used to abate physical afflictions evenduring prehistoric times.

Ancient China, India, and Greece

Writings about therapeutic exercises came from the Taoists priests in Chinaand originated sometime before 1000 BC. These writings describe a typeof exercise called Cong Fu that was able to relieve pain and other symp-toms. The Cong Fu exercises consisted of body positioning and breathingroutines. They had very little motion and were unrelated to modern con-cepts of exercises. In India, the ancient Hindus also used certain types ofbody positioning as exercises to cure chronic rheumatism (arthritis).

Later, around 500 BC in ancient Greece, Herodicus, a Greek physician,wrote about an elaborate system of exercises called Ars Gymnastica1 or

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Around 180 BC, the ancient Romans1 adopted a formof therapeutic exercises that they called gymnastics. TheRoman gladiators and athletes used gymnastics in theRoman arenas and in popular exhibitions of athletics.Later, in the second century AD, Galen,1 the renownedphysician of ancient Rome, believed that moderate exer-cises strengthened the body, increased body tempera-ture, allowed the pores of the skin to open, and improveda person’s spiritual well-being (Figure 1-3). Galen1 wasalso an authority on trauma surgery and musculoskele-tal injuries. His extensive writings, advanced for his era,describe from a kinetic principle the roles of anatomyand physiology in human movement.

Europe and America from the 1500s tothe 1900s

In Europe around the 1400s, after the Middle Ages, ther-apeutic exercises2 were introduced in schools as physicaleducation courses. During the 1500s, the first printedbook on exercise, entitled Libro del Exercicio and written byChristobal Mendez of Jaen,2 was published in Spain.During the 1600s and 1700s, more books were writtenabout exercises. These works promoted moderate exer-cises, stating that exercises give the body agility and vigor

The Art of Gymnastics. Herodicus1 tried gymnastic exer-cises for his own health problems. He believed that hewas able to treat febrile conditions by using wrestling,walking, and massage. In the time of Herodicus, Greeksperformed exercises such as wrestling, walking long dis-tances, using a type of weights called halters (that resem-bled dumbbells), or riding (sitting or lying down) in ahorse-drawn carriage over rough roads. In ancient Greecearound 400 BC, Hippocrates, who is considered the fa-ther of medicine, recognized the value of muscle strength-ening using exercises (Figure 1-1). Hippocrates1 was thefirst physician in his time to recommend therapeutic ex-ercises to his patients because he understood the princi-ple of muscle, ligament, and bone atrophy (wasting) dueto inactivity. In regard to rehabilitation treatments,Hippocrates wrote about the utility of friction after liga-ment tears and dislocations, and recommended abdom-inal kneading massage and chest clapping massage toimprove digestion and relieve colds. Hippocrates was thefirst to use electrical stimulation, applying torpedo-fishpoultices for headaches. The torpedo fish has an electri-cal charge of approximately 80 volts to stun its prey. Alsoin the area of treatments, the Greek philosopher Aristotle1

recommended rubbing massage using oil and water as aremedy for tiredness (Figure 1-2).

4 | Part 1 | THE PROFESSION OF PHYSICAL THERAPY

Figure 1-1 Hippocrates

Source: © National Library of Medicine

Figure 1-2 Aristotle


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and also have the ability to cleanse the muscles andligaments of waste.2

In the United States, massage, hydrotherapy, and exer-cises were first introduced around the year 1700. Theserehabilitation treatments were based on ideas originatingmostly in England. They were further developed in the1800s and early 1900s.

In Europe in 1723, Nicolas Andry,3 a professor at theMedical Faculty in Paris, was the first scientist to relate themovements created by exercises to the musculoskeletalsystem. Andry is considered to be the “grandfather”3 of or-thopedics. He believed that exercises are able to cure manyinfirmities3 of the body. Nicolas Andry also postulated thatfencing was one of the few exercises that contributed to thedevelopment of all muscles, especially the muscles of thearms and legs. In Europe during the 1700s, attention wasgiven to the invention of exercise equipment. One piece ofequipment described around 1735 was a suspended rock-ing horse that had the same therapeutic benefits as a liv-ing horse, which few could afford to ride.

During the 1800s, Per Henrik Ling,4 a Swedish poet, fenc-ing master, playwright, and educator, contributed to thegrowth of physical exercise by initiating the gymnasticmovement. Ling was famous in Europe for developing, withthe help of Sweden’s King Charles XIII, a training school ingymnastics for the Swedish army. Ling’s therapeutic exer-cise, known as Swedish exercise, Swedish gymnastics, orSwedish movement, spread throughout Europe and America.Ling’s Swedish gymnastics movement included techniquesof Chinese martial arts called Tuina.4 These gymnastic

techniques, similar to Chinese manipulative therapy, wereadopted in the 1800s by Dr. Johan Georg Mezger ofHolland4 (a Dutch practitioner). Dr. Mezger gave this typeof manipulative therapy French names such as “effleurage,”“petrissage,” and “tapotement.” These techniques (describ-ing some of Ling’s movements) became known as theSwedish massage.

Around the 1860s, George H. Taylor, an Americanphysician5 from Vermont who was the medical directorof the Remedial Hygienic Institute in New York, intro-duced Ling’s Swedish gymnastics for the first time inAmerica. Swedish gymnastics became very popular inAmerican public schools and had a significant impactupon physical education classes. Ling’s exercises, con-sisting of passive and active movements, were also usedto treat chronic disease conditions. In addition, HenrikLing’s medical gymnastics contributed to the develop-ment of Swedish massage as a therapeutic activity.Although Ling’s system of exercise was effective, it re-quired the continuous personal attention of a gymnast.This was expensive for the patient because the gymnastcould work with only one person at a time. To solve thisproblem of economics, in 1864 Gustav Zander,6 aSwedish physician, invented different exercise machinesthat offered assistance and resistance to the patient.These machines eliminated the need for a gymnast ex-cept for getting the patient started and for infrequent su-pervision. Zander developed 71 different types ofapparatus for active, assistive, and resisted exercises, andfor application of massage. Zander Institutes were openedthroughout Europe and the United States.

Later, at the beginning of the 1900s, with the advent ofthe First World War (1917), “reconstruction aides” (whobegan physical therapy in the United States) usedZander’s machines as well as Ling’s Swedish movementfor the rehabilitation of disabled soldiers. In those earlytimes, physical therapy was performed in various spe-cialized rooms; one of the rooms was for “mechanother-apy” and contained Zander’s exercise machines. Zander’sapparatus seemed to work very well during the war.

At the beginning of the 1920s, after the passage of theRehabilitation Bill in New Jersey, orthopedic surgeons7 be-came enthusiastic about the future of rehabilitation and of“reconstruction aides or teachers of vocational and edu-cational forms of work that are therapeutic in purpose.”7(p.39)

An article written in February 1920 in the Journal ofthe Medical Society of New Jersey described moderndevelopments in rehabilitation, especially for “industriallyinjured”7(p.43) individuals. It was considered that “the sooneran industrially injured man gets safely back to work” the

Chapter 1 | Development of the Physical Therapy Profession | 5

Figure 1-3 Galen


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that muscle training exercises were the most importantearly therapeutic measures for polio treatment. Ten yearslater in 1926, Lovett’s idea was put into practice by his sen-ior assistant, Wilhelmine G. Wright. Wright12 developedthe training technique of ambulation with crutches (usingthe upper extremity muscles) for patients who had para-plegia or paralysis caused by polio. She also introduced themanual muscle testing procedure in physical therapy. In1928, Wright authored the book12 Muscle Function (whichshe started with Dr. Lovett), in which she described thesystematic method of manual muscle testing using palpa-tion, gravity, external manual resistance, and the arc of ac-tive movement. Wright believed in the importance ofmuscle testing on polio patients and the use of strongermuscles to compensate for the weakness of muscles af-fected by polio. Between 1917 and the early 1950s, sev-eral physical therapists and rehabilitation clinicians12

made changes to Wright’s method of muscle testing, tak-ing into consideration variables such as a patient’s fatigue,body position, and incoordination. These clinicians in-cluded Kendall, Brunnstrom, Dennen, and Worthingham.

Another example of the developments made to combatthe devastating effects of paralysis caused by the polioepidemic was Charles Leroy Lowman’s13 method of “hy-drogymnastics.” In California in 1924 he converted a lilypond into two treatment pools for the treatment of spas-ticity and paralysis caused by cerebral palsy. In the 1920sat Warm Springs, Georgia, Carl Hubbard13 (an Americanengineer) installed the first metal tank (known today as theHubbard tank) in a hospital for hydrogymnastics use. In1928, U.S. President Franklin D. Roosevelt,13 who hadpolio, used the hydrogymnastics therapy at Warm SpringsInstitute for rehabilitation. During late 1920s, Roosevelt de-veloped the institute known today as The Georgia WarmSprings Foundation, which has become an internationalpolio treatment facility.

In the area of exercise for vascular disease, in 1924 LeoBuerger (a urologist) and Arthur W. Allen (a surgeon) cre-ated the Buerger-Allen exercises14 for arterial insufficiencyin the legs. The exercises used the effects of gravity andposture and applied those to the vascular musculatureand blood circulation. Additionally, during the 1900s physi-cians began to treat back pain more efficiently. This wasdue to the use of X-rays to visualize and identify boneabnormalities and the dysfunction of curvature of thespine. An example of exercise development for back painwas Joel E. Goldthwait’s discovery that the reasons forbackaches were faulty posture15 and habits. As a result, in1934, Goldthwait and his colleagues wrote the bookEssentials of Body Mechanics. In regard to back pain and

better it would be for his morale and physical well-being. Inthe 1920s, this required the injured worker to receive “ac-tive, voluntary joint-motion and muscle-exercises.”7(p.44) Itis interesting that in the 1920s, orthopedic surgeons be-lieved that these forms of rehabilitation using active exer-cises were to be provided by a “reconstruction aide,” whowas described as a combination of “the school teacher”7(p.46)

and “the professional nurse.”7(p.46)

In the 1860s, electrical stimulation was first introducedin the United States as a therapeutic modality, having orig-inated in Europe and been used in France, England, andGermany. In the 1890s, the American Electro-TherapeuticAssociation was formed. Members included interested U.S.practitioners who promoted specialized training in elec-trotherapy, electrotherapeutic research, and the use of re-liable electrotherapeutic equipment. Also in the 1890s,Nikola Tesla8 introduced diathermy as an electrotherapeu-tic modality; however, it was not until the 1900s thatdiathermy’s beneficial role as a deep heating agent forjoints and the circulatory system was discovered.

In England around the beginning of the 1950s, a neu-rophysiologist (physician) named Herman Kabat9 uti-lized newly discovered neurological concepts of stretchreflex, flexion reflex, and tonic neck reflex to developneurological exercises called “proprioceptive facilitation.”Around 1968, Margaret Knott and Dorothy Voss ex-panded9 proprioceptive neuromuscular facilitation (PNF)as a form of physical therapy intervention for patientswith paralysis. As is done today, the PNF method wasrecommended and utilized for patients who had paral-ysis produced by stroke, cerebral palsy, or another neu-rological dysfunction. Additionally, regarding neurologicalexercises and rehabilitation, toward the end of the 1800s,H.S. Frenkel10 of Switzerland was able to improve anataxic (unstable) gait resulting from nerve cell destruc-tion by repetitive attempts at supervised ambulation.Frenkel did not rely on equipment, but instead markedthe floor for successive placement of the feet in walking(as we do today using Frenkel’s exercises). Frenkel advo-cated walking in groups of three to six patients with sim-ilar degrees of ataxia for long walking paths, insistingon repetitions.

In the United States during the 1900s, the area of ther-apeutic exercises was built up by physicians, physical ther-apists, surgeons, psychologists, and other scientists. Alltherapeutic exercises developed at the beginning of the20th century greatly influenced the growth of physicaltherapy interventions. Robert Lovett’s11 concept was an ex-ample of such growth and development. Lovett, a profes-sor of orthopedic surgery at Harvard, discovered in 1916


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exercises, in 1953, Paul C. Williams proposed a series ofpostural exercises, known today as the Williams exercises.These helped to strengthen the spine flexors and exten-sors and relieve back pain. Still in regard to exercises,around 1934, Ernest A. Codman, a Boston surgeon, intro-duced shoulder exercises known as Codman pendulumexercises. He pointed out that a diseased supraspinatusmuscle could relax if the shoulder is abducted in the stoop-ing position, allowing the arm to be under the influenceof gravity. In the 1920s and 1930s, additional develop-ments in the area of exercise were attributed to surgeons’findings that exercises could be helpful after surgery andthat customary bed rest should be eliminated.

In 1938, Daniel J. Leithauser,16 who performed appen-dectomies, was amazed to see that one of his patientswho did not follow the usual bed rest routines was ableto rapidly return to daily activities. Leithauser16 prescribedearly rising and physical activity for all postoperative ap-pendectomies and abdominal surgeries. By 1947, therewere many “convalescent centers,” in the United Stateswhere patients were prescribed “convalescent exercises”or “reconditioning exercises” to counteract the decondi-tioning effect and the abuse of rest. In these centers, pa-tients performed exercises in groups according to thedisability. There were ankle classes, shoulder classes, orwheelchair basketball for patients who had paraplegia.Special centers were also created for major disabilities; forexample, the centers for patients with amputations re-quired physical therapists to exercise the amputated ex-tremity early and through maximum range of motion toprepare it for the prosthesis.

In 1945, much of the greatest stimuli to the develop-ment of exercises came from an Alabama physician,Thomas DeLorme. Following his own knee surgery,DeLorme17 found that he could rapidly restore his quadri-ceps muscles to full strength by increasing the resistanceapplied to the exercising muscles. DeLorme’s methodfirst introduced the technique of progressive resistive ex-ercise (PRE),17 which is still used today.

During the second half of the 1900s, the area of ther-apeutic exercises in the United States was advancedtremendously by the arrival of isokinetic and biofeed-back exercises. For example, in 1967 the Cybex IDynamometer was introduced based on Hislop andPerrine’s concept of isokinetic exercise. Hislop andPerrine found that muscular performance can be re-duced to the physical parameters of force, work, power,and endurance, and that specificity of exercise shouldbe determined by an exercise system designed to con-trol each training need. Another type of exercise called

biofeedback was also introduced in the second half ofthe 1900s as a result of advances in scientific behav-ioral psychology and clinical electromyography.Furthermore, Williams’s back-flexion exercises werecomplemented in the 1950s and 1960s by RobinMcKenzie’s back-extension exercises that relieved pres-sure posteriorly on the spinal disk. Swiss ball exer-cises,18 developed by physiotherapists in Switzerland inthe 1960s, found their way to the United States in the1970s and became popular in physical therapy rehabil-itation in the 1980s.

HISTORY OF THE PHYSICAL THERAPYPROFESSION

The creation of the physical therapy profession centeredaround two major events in U.S. history: the poliomyelitisepidemics and the negative effects of World War I andWorld War II. The profession can be compared with a liv-ing entity, changing from an undeveloped, young occupa-tion in its formative years (1914 to 1920) to a firm,growing establishment in its development years (1920 to1940). As a mature profession, during its fundamental ac-complishment years (1940 to 1970), physical therapywas able to achieve significant organizational, executive,and educational skills. In the mastery years (1970 to1996), the profession acquired greater control, profi-ciency, and respect within the health care arena, growinglargely in the areas of education, licensure, specializa-tion, research, and direct access. From 1996 to 2005, inits adaptation years, physical therapy had to adapt, re-view, and make changes in its objectives and goals dueto political, social, and economic changes in the UnitedStates. Additionally, the profession went through rapideducational expansion and research growth, and signif-icant developmental and scientific goals were achieved.From 2006 to the present, in its vision and scientific pur-suit years, physical therapy has been emerging as a vig-orous participant in U.S. health care reform, having largeresponsibilities in the areas of research, education, andsociopolitical transformations.

The Formative Years: 1914 to 1920

Division of Special Hospitals and PhysicalReconstruction

In the United States, physical therapy had its beginningsbetween 1914 and 1919, in a time known as theReconstruction Era. Prior to the “Great War” (World War I),


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of therapeutic modalities including patient education.The other group of reconstruction aides was to becometoday’s occupational therapists. They provided trainingin the vocational skills that would help wounded soldiersreturn to work.

These forms of rehabilitation enabled soldiers to returneither to combat or to their civilian prewar lives.20

The division had almost a dozen small facilities set upin Europe and more extensive centers and hospitalsin New York Harbor; Lakewood, New Jersey; TacomaPark, Maryland (a suburb of Washington, D.C.); FortMcPherson, Georgia; and San Francisco, California. Eachhospital had a physical therapy unit containing a gymna-sium, a whirlpool room, a massage room, a pack room,and other rooms for mechanotherapy20 and “electricity”(electrotherapy). The mechanotherapy room was an ex-ercise room equipped with various apparatuses such aspulley-and-weight systems, trolleys, and ball-bearingwheels.

From its creation, the division recruited unmarriedwomen between the ages of 25 and 40 to be trained asreconstruction aides. Applicants who had certificatesshowing practical and theoretical training in any of thetreatments performed such as hydrotherapy, electrother-apy, mechanotherapy, or massage received priority andwere accepted first. Nevertheless, they still were givenadditional preparation in all other necessary treatments.

First Physical Therapists:MargueriteSanderson and Mary McMillan

The first reconstruction aides who made big contribu-tions to the physical therapy profession during theReconstruction Era were Marguerite Sanderson andMary McMillan. Marguerite Sanderson was a physio-therapist who graduated from the Boston Normal Schoolof Gymnastics and used to work with Dr. Joel Goldthwait,an orthopedic surgeon, who later became the chairmanof the War Reconstruction Committee of the AmericanOrthopedic Association. Because of her prior physio-therapy experience, in 1917, Dr. Goldthwait appointedSanderson as the first Supervisor of ReconstructionAides. Her role was to recruit and arrange for trainingof reconstruction aides and also send them to Europe tohelp the wounded soldiers. In 1922, Sanderson mar-ried and withdrew from active participation in theschool.

The training program for the reconstruction aides tookplace at Walter Reed General Hospital. The program atWalter Reed was assigned to a reconstruction aide named

most Americans regarded disability as irreversible, re-quiring little or no medical intervention. The war changedthis concept of irreversibility because of the large numberof young U.S. men returning home as disabled veterans.As mentioned prior, physical therapy was created be-cause of World War I and the poliomyelitis epidemics.These two devastating events in U.S. history brought agreat degree of disease and disability to U.S. society. Thefirst major outbreak of poliomyelitis occurred in NewYork State in 1916.19 The methods of treatment at thattime19 were bed rest, isolation, and splinting and castingof the person’s legs. Unfortunately, these forms of heal-ing increased the individual’s weakness in the legs andback, and as a result, the person required some form ofexercise and physiotherapy.

Prior and during World War I, support for people withdisabilities had been growing gradually.19 For examplethe Medical Department of the U.S. Army had two divi-sions that influenced the growth of physical rehabilita-tion in the United States, the Division of OrthopedicSurgery and the Division of Physical Reconstruction. Thenewly created Division of Physical Reconstruction wasneeded to apply physiotherapy treatments such as mas-sage and mechanical hydrotherapy to wounded soldiers.The Division of Physical Reconstruction drew its “train-ing corps” personnel from schools of allied health thera-pies and physical training.19 The Division of PhysicalReconstruction had three sections19: surgery (includinggeneral, orthopedic, and head surgery) and neuropsychi-atry, education, and physiotherapy (including gymnasi-ums and equipment).

In April 1917, the United States entered World War I.The U.S. Congress authorized the military draft andpassed legislation to rehabilitate all servicemen perma-nently disabled from war-related injuries. In August1917, the Surgeon General of the United States, WilliamGorgas, authorized the creation of the Division of SpecialHospitals and Physical Reconstruction.20 The role of thedivision was to give soldiers who were disabled “recon-struction therapy.” The people involved in the recon-struction therapy were newly trained physicalreconstruction aides. They consisted of a handful ofphysicians called orthopedists and 1200 young womencalled reconstruction aides. These people were the phys-ical therapy and occupational therapy pioneers20 whotreated the injured soldiers from World War I. The divi-sion included two different groups of reconstructionaides. One group who assisted physicians was to be-come today’s physical therapists. They provided exer-cise programs, massage, hydrotherapy, and other forms


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Mary Livingston McMillan (Figure 1-4). Mary McMillanwas a mature, educated woman who was born in theUnited States from Scottish ancestry. When she was 5 years old, her mother and sister died of consumption(tuberculosis). Mary was sent to live with relatives inLiverpool, England. Although acquiring a higher educa-tion was unusual at that time for a young woman, as anavid and eager learner Mary received a college degree inphysical education and a postgraduate degree in her cho-sen career, the science of physical therapy. MaryMcMillan’s physical therapy degree included topics such

as corrective exercises, massage, electrotherapy, after-care of fractures, dynamics of scoliosis, psychology, neu-rology, and neuroanatomy.20 In 1910, McMillan took herfirst professional position in Liverpool, England, workingwith Sir Robert Jones, nephew and professional heir ofthe great orthopedist Hugh Owen Thomas. Jones, an or-thopedic physician, was renowned for using the Thomassplint (invented by his famous uncle) and performingprogressive massage and orthopedic manipulations (in-vented by the French orthopedist Lucas-Championniereand British surgeon James B. Mennell). Lucas-Championniere and Mennell were pioneers of the prin-ciple that following an injury, early movement canenhance healing and prevent disability.

In 1916, McMillan returned home to her family inMassachusetts. Because of her education and experience,she was hired immediately at the Children’s Hospital inPortland, Maine, where for 2 years she was director ofmassage and medical gymnastics, treating children withscoliosis, congenital hip dislocations, and other childhoodorthopedic bone and joint abnormalities.20 In 1918, at therecommendation of Sir Robert Jones, Elliott Bracket, aBoston orthopedist and one of the organizers of the army’sReconstruction Program, asked McMillan to consider serv-ice with the U.S. Army. In February 1918, McMillan wassworn in as a member of the U.S. Army Medical Corps. Asa reconstruction aide she was assigned to Walter ReedGeneral Hospital in Tacoma Park, Maryland. Shortly after,in June 1918, due to her experience and education inEngland, McMillan was asked to go to Reed College in Portland, Oregon, to train reconstruction aide applicantsin the practical, hands-on segment of the War EmergencyTraining Program. With her contribution, Reed College’sphysical therapy curriculum became the standard by whichother emergency war training programs were measured.In January 1919, Mary McMillan was awarded the posi-tion of Chief Reconstruction Aide20 in the department ofphysiotherapy at Walter Reed General Hospital.

Between 1919 and 1920, the number of physical ther-apy reconstruction aides was reduced primarily becauseof a major postwar decrease in military hospitals (athome and overseas). The number of hospitals shrankfrom 748 to 49. Despite this cutback, the army’s commit-ment to maintain physical therapy as an important partof its medical services was established (Figure 1-5). In1920, Mary McMillan resigned her duties in the army be-cause she felt her work was essentially completed. Shereturned to civilian life in Boston as a staff therapist in anorthopedic office. In 1921, McMillan published her book,Massage and Therapeutic Exercise.


Figure 1-4 Mary McMillan, one of the founders and the firstpresident of the American Physical Therapy Association(WWI Era/1918/1919)

Source: Reprinted from Murphy W: Healing the Generations: A History of Physical Therapy and the American PhysicalTherapy Association. Alexandria, American Physical TherapyAssociation, 1995; Commemorative Photographs; APTA—75Years of Healing the Generations, with permission of theAmerican Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution isprohibited.

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reconstruction aides; the first year there were 274 mem-bers coming from 32 states.

The P.T. Review and Constitution

The official publication of the Association, which first ap-peared in March 1921, was called the P.T. Review.20 It waspublished quarterly and included the Association’s consti-tution and bylaws, professional interest articles, and evena column called “S.O.S.” for job classified advertisements.Today, the P.T. Review is called Physical Therapy. It is theofficial publication of the American Physical TherapyAssociation (APTA) and is a scholarly, peer-reviewed jour-nal. Also in 1921, the first textbook written by a physio-therapist (Mary McMillan) was published.

The first edition of the P.T. Review reported the full textof the constitution and bylaws of the Association. Thebasic reasons for the Association’s existence, as describedin its constitution,20 were to have professional and scien-tific standards for its members, to increase competencyamong members by encouraging advanced studies, topromulgate medical literature and articles of professionalinterest, to make available efficiently trained members, andto sustain professional socialization.20 The Association’sbylaws specified three categories of membership in theAssociation: charter members, who were the reconstruc-tion aides in physiotherapy; active members, who weregraduates of recognized schools of physiotherapy or phys-ical education; and honorary members, who were grad-uates of medical schools.

American Physiotherapy Association

At its first conference in Boston in 1922, the Associationchanged its name to the American PhysiotherapyAssociation because although its members were all women,they recognized that men also practiced physiotherapy. Atthat time, there were a few male reconstruction aides whoprovided physiotherapy services during World War I.

In 1922, new schools of physiotherapy were opened atHarvard Medical School and in New York City. The grad-uates of these schools were called physiotherapists. By1923 the membership in the Association had risen appre-ciably, and Mary McMillan stepped down as president,giving way to a new president, one of the former recon-struction aides, Inga Lohne.20

In 1926, the Committee on Education and Publicitywas formed to draft the minimum standard curriculum forschools offering a complete course in physical therapy.The committee’s report, which was published in 1928,20

The Development Years: 1920 to 1940

The Development of ProfessionalOrganization

During her work as a reconstruction aide, MaryMcMillan was convinced that physical therapy had avital future role in America’s health care. Before resign-ing her duties in the army, McMillan wanted to maintaina nucleus of trained people who were capable of carry-ing out such a role. She contacted 800 former recon-struction aides and civilian therapists and received 120enthusiastic responses. On January 15, 1921, at Keene’sChop House, an eatery in Manhattan, New York,20 MaryMcMillan and 30 former reconstruction aides organizedthemselves into the first association of physical thera-pists. The organization was called the AmericanWomen’s Physical Therapeutics Association (AWPTA).Mary McMillan was elected president. The role of theAWPTA was to establish and maintain professional andscientific standards for individuals who were involvedwith the profession of physical therapeutics.19 Themembers of the AWPTA19 were graduates of recognizedschools of physiotherapy and of physical educationprograms trained in massage, therapeutic exercises,electrotherapy, and hydrotherapy. The executive com-mittee of the AWPTA represented geographically diverse


Figure 1-5 Reconstruction aides treat soldiers at Fort SamHouston, Texas in 1919 (WWI Era)

Source: Reprinted from Murphy W: Healing the Generations: A History of Physical Therapy and the American PhysicalTherapy Association. Alexandria, American Physical TherapyAssociation, 1995; Commemorative Photographs; APTA—75Years of Healing the Generations, with permission of theAmerican Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.

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was recommending a 9-month course with 33 hours ofphysical therapy–related instruction per week for a totalof 1200 hours. The entrance requirement was graduationfrom a recognized school of physical education or nursing.In 1930, there were 11 schools20 that met or exceededthe minimum standards set by the committee. By 1934,there were 14 approved physiotherapy schools20 includ-ing higher standard educational institutions such asHarvard Medical School in Boston, Massachusetts,Stanford University Hospital in Stanford, California, andthe College of William and Mary in Williamsburg, Virginia.

In the early years, the American PhysiotherapyAssociation tried to stay side by side with the medical pro-fession. During the 1920s and 1930s, physical therapyphysicians became organized21 in order to belong to theAmerican Medical Association (AMA). The AMA recognizedtheir efforts and educated other physicians about the valueof physical therapy in rehabilitating World War I veterans.As a result, in 1925, a group of physical therapy physiciansfounded21 the American College of Physical Therapy(ACPT). Later that year, the ACPT joined the AMA andchanged its name to the American Congress of PhysicalTherapy. Physical therapy physicians decided to call them-selves “physiatrists.” Although, their name was not offi-cially changed until 1946, the physiatrists established theAmerican Registry of Physical Therapy Technicians to sep-arate the physiotherapists from the medical profession.

In 1930, the American Physiotherapy Association wasincorporated and decided to work with the AMA to cre-ate standards of education for physiotherapists, to en-courage the regulation of physical therapy practice bylaw, and to cooperate with, or under the direction of, themedical profession to provide a central registry for phys-iotherapists.22 Consequently, by the 1930s, due to pres-sure from the AMA, registered physiotherapists werecalled technicians and settled to work under the referralof physical therapy physicians. It seems, however, thatmembers of the AMA were concerned that the publicmight consider physiotherapists to be physicians, be-cause their designation as physiotherapists ended in“ists,” the same as radiologists, orthopedists, and so on.The AMA wanted no confusion in regard to medicalschool education of physiatrists as compared to physio-therapists. Finally, in the 1940s the name physiotherapistschanged to physical therapists.

Poliomyelitis and the Great Depression

By the 1930s, members of the American PhysiotherapyAssociation were confronted with two calamities20 in U.S.

life—the growing severity of poliomyelitis and its result-ing infantile paralysis (which began in the summer of1916) and the Great Depression of 1929 (Figure 1-6).The poliomyelitis epidemic started in 1916 and contin-ued into the 1930s and 1940s. As an example of thehigh incidence and magnitude of this disease, betweenMay and November 1934, approximately 2500 cases ofpoliomyelitis were treated at just one hospital,19 the LosAngeles County General Hospital. The fact that thePresident of the United States, Franklin DelanoRoosevelt, was treated for poliomyelitis by physiothera-pists generated large public recognition of the physicaltherapy profession. At that time, physical therapy for po-liomyelitis consisted of hydrotherapy, exercises, mas-sage, heat and light modalities, and assistive andadaptive equipment.19 For home care, especially in ruralareas, the physiotherapists provided “homemade” bracesand splints.

In 1929, the Depression closed many hospitals andprivate medical practices, substantially reducing the num-ber of physical therapy services.

Because the country was looking for a cure for po-liomyelitis, in 1937, the National Foundation for InfantileParalysis was founded. The foundation, using federal


Figure 1-6 Physical therapists and physicians work to-gether to treat children at a New York poliomyelitis clinicin 1916 (WWI Era).

Source: Reprinted from Murphy W: Healing the Generations: AHistory of Physical Therapy and the American PhysicalTherapy Association. Alexandria, American Physical TherapyAssociation, 1995; Commemorative Photographs; APTA—75Years of Healing the Generations, with permission of theAmerican Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.

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The course at Walter Reed consisted of six months ofconcentrated didactic instruction followed by six monthsof supervised practice at a military hospital.

The physiotherapists graduating from the EmergencyTraining Course were no longer called reconstruction aidesbut instead were physiotherapy aides. In 1943, the U.S.Congress passed a bill stating that graduates of theEmergency Training Course should be called physical ther-apists. Inadvertently, with the change of their titles, physicaltherapists started to have increased recognition and wide-ranging responsibilities. These new tasks were related tothe treatment of wounded veterans including rehabilitation

funding and money from charitable organizations such asthe March of Dimes, opened new facilities and lent equip-ment to families and hospitals for polio aftercare. TheNational Foundation for Infantile Paralysis also financiallycontributed to the development of physical therapy edu-cation and the growth of physical therapy schools.Physical therapists who had no work during the GreatDepression were able to pick and choose positions. Theywere needed to work in diagnostic clinics, outpatient cen-ters, orthopedic hospitals, convalescent homes, schoolsfor children with disabilities, and restorative services.

In 1937, although the physiotherapists were still domi-nated by their technician mindsets, their plans for the fu-ture were progressive, and included unity, research, andprovision of educational standards. For example, the aimsof the American Physiotherapy Association in 1937 were19:

• To form a nationwide organization that would es-tablish and maintain professional and scientificstandards for its members

• To promote the science of physical therapy• To aid in the establishment of educational stan-

dards and scientific research in physical therapy• To cooperate with, and to work only under the pre-

scription of members of the medical profession• To provide available information to those inter-

ested in physical therapy• To unite several chapters• To create a central registry (available for the med-

ical profession) that will make physiotherapists theonly “trained assistants”19(p.6) in physical therapy

The Fundamental Accomplishment Years:1940 to 1970

The Professional and EducationalDevelopments of Physical Therapy

During World War II, the American PhysiotherapyAssociation continued to grow under its experienced pres-ident, Catherine Worthingham.20 She was the first phys-ical therapist to hold a doctoral degree in anatomy andserved as president of the Association from 1940 to 1945.The governance of the American Physiotherapy Associationchanged substantially to accommodate increased growthand responsibilities and a more national approach. Inthe summer of 1941, six months before the bombing ofPearl Harbor, the first War Emergency Training Courseof World War II was initiated at Walter Reed GeneralHospital. Emma Vogel20 directed the Walter Reed GeneralHospital program to train physical therapists (Figure 1-7).


Figure 1-7 Emma Vogel directed the Walter Reed GeneralHospital program for physical therapists. After the outbreakof World War II, Vogel was deployed to direct the WarEmergency Training courses at 10 Army hospitals (PostWWI through WWII Era).

Source: Reprinted from Murphy W: Healing the Generations: A History of Physical Therapy and the American PhysicalTherapy Association. Alexandria, American Physical TherapyAssociation, 1995; Commemorative Photographs; APTA—75Years of Healing the Generations, with permission of theAmerican Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.

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for amputations, burns, cold injuries, wounds, fractures,and nerve and spinal cord injuries. Additionally, immedi-ately after the war, the U.S. government allocated $1 mil-lion for the enhancement of prosthetic services. This gavephysical therapists the opportunity to participate in theteaching and training programs of the 25-year-old ArtificialLimb Program at the University of California at Berkeley,New York University, and the University of California at LosAngeles. Furthermore, in 1946, because of the passing ofthe Hill-Burton Act and founding of a nationwide hospital-building program, physical therapists increased theirhospital-based19 practice. The work of physical therapistsexpanded even more in the 1950s with the outbreak ofthe Korean War.

In 1944, the American Physiotherapy Associationmembership voted for a separate internal legislativebranch called the House of Delegates.20 The House ofDelegates had the same legislative powers as it doestoday—to amend or repeal the bylaws of the Associa-tion. In 1946, physical therapy physicians practicingphysical medicine officially changed their specialty nameto physiatrist. In the same year, the AmericanPhysiotherapy Association changed its name to its cur-rent one, the American Physical Therapy Association(APTA). By 1959, membership in the American PhysicalTherapy Association had increased to 8,028 physicaltherapists.

In 1947, the length of physical therapy schools’ curric-ula increased from 9 months to 12 months. By the 1950s,there were 31 accredited schools in the United States, 19of them offering 4-year integrated bachelor degreeprograms. By 1959, most of the states had licensure lawsadopting the Physical Therapy Practice Act. In 1951, theJoint Commission on Accreditation of Hospitals wasformed, raising the standards for institutional staffingand health care.

The Polio Vaccine and the Journal of theAmerican Physical Therapy Association

Because new cases of polio were seen every year, phys-ical therapists were called upon from all over the coun-try to help either part-time or full-time as volunteersdealing with polio epidemics. In 1952, there were 58,000cases of poliomyelitis in the United States. Between 1948and 1960 nearly 1000 physical therapists participated inthe polio volunteer program. In 1954, 63 physical thera-pists were dispatched to 44 states to help with clinicalstudies of the polio vaccine developed by Jonas Salk. Aftersuccessful clinical trial inoculations of 650,000 children,

the Salk vaccine was determined to be safe and was ap-proved for commercial production in 1955 by the Foodand Drug Administration. Finally, in 1955, a massivenational vaccination program started using the Salkvaccine. As a result, poliomyelitis cases were virtuallyeradicated.

Jessie Wright, PT, MD, was one of the physical thera-pists who helped with polio clinical studies by evaluatingpatients’ strength. In 1954, Wright and her staff intro-duced the abridged muscle grading system. Wright, whospecialized in physical medicine and rehabilitation at theUniversity of Pittsburgh, Pennsylvania, was a visionary inregard to helping patients achieve function. Wright be-lieved that “the first goal of physical therapy was to relaxtight muscles”11(p.77) allowing complete range of motionin the joints and as a result giving the patient “functionaluse of residual power, helpful body mechanics and as-sistive devices.”11(p.78)

The role of the physical therapist in the 1950s ex-panded19 from a technical position to that of a profes-sional practitioner. Private practices expanded and, in1957, the Physical Therapy Fund was established to fos-ter scientific, literary, and educational programs.20

Physical therapists’ licensure started in 1913 inPennsylvania and in 1926 in New York; it expanded dur-ing the 1950s and by 1959,20 45 states and the territoryof Hawaii offered licensure.

In 1964, the APTA formed a committee on research inorder to improve the development of scientific inquiry. Inregard to dissemination of information (including scien-tific discovery) among the members of physical therapyprofession, just 2 years earlier (1962), the APTA changedthe name of the official journal, the P.T. Review to theJournal of the American Physical Therapy Association. In1963 the journal modified its format and expanded itscontent with the help of its editor, Helen Hislop.20 In1964 the journal changed its name to the Journal ofPhysical Therapy. Later, the name was change to PhysicalTherapy.

The Beginning of Physical Therapy Assistants

In the 1960s the U.S. population was changing, primarilybecause of the doubling of the number of elderly, but alsobecause people were becoming more health conscious. Aswith other health professions, physical therapy was ex-panding rapidly with a high demand for physical therapyservices. In addition, the change in physical therapy insur-ance reimbursement (through diagnostic related groups in-troduced by Medicare) and the enactment in 1965 and


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president of the Affiliate Assembly was CherylCarpenter-Davis, PTA, MEd.

The Expansion of the Physical Therapy Profession

During the 1970s and 1980s, the physical therapy professioncontinued to grow and expand. Because of the establish-ment of the Occupational Safety and Health Administration(OSHA) by the Department of Labor, physical therapy prac-tices related to prevention, work management, and job in-juries and compensation also developed. This contributed tophysical therapists’ advancement of practice from hospital-based to private. In 1972, Congress added physical therapyservices to the Social Security Act as services that were to bereimbursed20 when they were furnished by an individualphysical therapist in his or her office or in the patient’s home.In 1975, the Individuals with Disabilities Education Act(IDEA) was passed. This helped physical therapy expandinto treatment of children with disabilities in public schools.

In 1971, the AMA dissolved the American Registry, andby 1976, all states had physical therapy licensure laws inplace. In 1981 and 1982, the House of Delegates adoptedthe policy that physical therapist practice that was inde-pendent of practitioner referral was ethical19 (as long asit was legal in that specific state). This separated physi-cal therapists from the physician’s control, giving themthe right to practice without a physician’s referral.

During the early 1970s, the American Physical TherapyAssociation formed sections for state licensure and regula-tions, sports physical therapy, pediatrics, clinical electro-physiology, and orthopedics. The state licensure andregulations section later became the health policy, legisla-tion, and regulation section. In 1976, the first combinedsections meeting took place in Washington, D.C. In 1977,the American Physical Therapy Association, through theCommission on Accreditation in Physical TherapyEducation, became the sole accrediting agency for all edu-cational programs for physical therapists and physical ther-apist assistants in the United States, Canada, and Europe.

In 1978, the American Board of Physical TherapySpecialties was created by the American Physical TherapyAssociation to allow members a mechanism to receivecertification and recognition as a clinical specialist in acertain specialty area. During the late 1970s, the sectionson obstetrics and gynecology (now called women’shealth) and on geriatrics were created. By 1985, theAmerican Board for Physical Therapy Specialties—Certified Cardiopulmonary Specialists was formed, givingcardiopulmonary specialist certifications. Shortly, other

1966 of Medicare and Medicaid programs created an evengreater demand for physical therapists. As a result, in1967 the American Physical Therapy Association adopteda policy statement that set the foundation for the creationof the physical therapy assistant and the establishmentof educational programs for the training of physical ther-apy assistants. The policy statement adopted by the Houseof Delegates recommended the following20:

• The American Physical Therapy Association hadto establish the standards for physical therapyassistant education programs.

• A supervisory relationship existed between thephysical therapist and the physical therapyassistant.

• The functions of assistants were to be identified. • Mandatory licensure or registration was

encouraged.• Membership in the American Physical Therapy

Association was to be established for the assistants.

By 1969, the occupational title changed from physicaltherapy assistant to physical therapist assistant. Also,training programs were to be called physical therapist as-sistant programs. At that time there were already twocolleges in the country that enrolled students in their pro-grams: Miami Dade Community College in Miami, Florida,and St. Mary’s Campus of the College of St. Catherine inMinneapolis, Minnesota.

Mastery Years: 1970 to 1996

The Societal Developments of Physical Therapy

In 1969, the first 15 physical therapist assistants grad-uated with associate degrees from Miami Dade Collegeand College of St. Catherine. By 1970 there were ninephysical therapist assistant education programs, mostlydue to federal financial assistance to junior colleges.In the same year, the American Physical TherapyAssociation offered temporary affiliate membership tophysical therapist assistants. By 1973, eligible physi-cal therapist assistants were admitted as affiliate mem-bers in the national association, having the right tospeak and make motions, to hold committee appoint-ments, and to chapter representation in the House ofDelegates. In 1983, physical therapist assistants formedthe Affiliate Special Interest Group, and in 1989 theHouse of Delegates approved the creation of theAffiliate Assembly, which gave physical therapist assis-tants a formal voice in the Association. The first


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specialty certifications followed such as orthopedic, pe-diatric, electrophysiology, neurology, and sports. In 1983,the APTA purchased its first four-story building inAlexandria, Virginia.

In 1990, the Americans with Disabilities Act assuredthe involvement of physical therapists as consultants toguarantee every individual with disabilities rightful ac-cess to all aspects of life. Many major changes occurredduring the 1990s; managed care, point of service plans,and other alternative organizational structures such ashealth economics resources also impacted physical ther-apy delivery. Nevertheless, physical therapy practice de-veloped in the areas of work conditioning, women’shealth, and work hardening.19

During the last two decades of the 20th century, the fol-lowing major developments occurred in the physical ther-apy profession:

• In 1980, the House of Delegates established itsgoal to raise the minimum entry-level educationin physical therapy to a postbaccalaureate degree.

• During the early 1980s, the sections on veteransaffairs, hand rehabilitation, and oncology wereestablished.

• In 1986, the PT Bulletin was initiated. In thesame year, setting goals and objectives becamepart of the American Physical TherapyAssociation’s annual self-review process.

• In 1989, the House of Delegates approved theformation of the Affiliate Assembly, composedentirely of physical therapist assistant members.In this way, physical therapist assistants had aformal avenue to come together and discuss is-sues that directly concerned them.

• By 1988, direct access was legal in 20 states,providing patients and clients the ability to seekdirect physical therapy services without first see-ing a physician.

• The academic preparation of physical therapistschanged from a bachelor’s degree to postbac-calaureate degrees. By January 1994, 55 percentof physical therapy education programs were atthe master’s level.

• In 1995, the American Board of Physical TherapySpecialties inaugurated nationwide electronic test-ing and the American Physical TherapyAssociation celebrated the 75th anniversary of theassociation and the physical therapy profession.

• Also in 1995, the APTA hosted the 12th WorldConfederation for Physical Therapy Congress in

Washington, D.C. The Congress had record-breaking crowds.19

• In 1995, the American Physical TherapyAssociation received representation on the AMACoding Panel, facilitating a better development ofphysical therapist practice codes.

Adaptation Years: 1996 to 2005

The Balanced Budget Act and the APTA Events

In August 1997, President Clinton signed the BalancedBudget Act (BBA) to eliminate the Medicare deficit. TheBalanced Budget Act, which took effect in January 1999,applied an annual cap of $1500 (for both physical therapyand speech therapy services) per beneficiary for all outpa-tient rehabilitation services. As an effect of the BalancedBudget Act and its resultant reduction in rehabilitationservices to Medicare patients, many new graduate phys-ical therapists and physical therapist assistants could notfind jobs. Also, some experienced physical therapists andphysical therapist assistants suffered an appreciable de-crease in income and in the number of working hours.Due to pressure from the Association, its members, pa-tients, and the general public, in November 1999President Clinton signed the Refinement Act, which sus-pended the $1500 cap for 2 years in all rehabilitation set-tings starting on January 3, 2000. Nonetheless, theBalanced Budget Act was detrimental to the treatment ofmany Medicare patients and also created a hardship forphysical therapists and physical therapist assistants for atleast 3 years. An American Physical Therapy Associationsurvey23 in October 2000, found that as a result of theBalanced Budget Act, physical therapist assistants werehurt the most, with an unemployment rate of 6.5 percent.The physical therapists also reported that their hours of em-ployment had been involuntarily reduced. In March 2001,the same survey discovered that the unemployment rateamong physical therapist assistants had improved, goingdown to 4.2 percent. Physical therapists also reported animprovement, with the reduction in working hours only10.8 percent. The reduction in the number of working hoursfor physical therapist assistants was even greater than thephysical therapists, at 24.5 percent in October 2000; inMarch 2001 it went down to 19.8 percent.

During 2005, the effects of the Balanced Budget Act of1997 were still influencing the future of rehabilitationservices. On February 17, 2005, the American PhysicalTherapy Association stated in a news release that “Seniorcitizens across the country are looking to the 109th


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Professional Education: Version 2000. In 2001, the Associa-tion introduced the second edition of the Guide to PhysicalTherapist Practice and worked hard to maintain physicaltherapists’ rights in certain states to perform manipula-tions and provide orthotics and prosthetics within thescope of physical therapy practice. The Associationlaunched Hooked on Evidence on the Web in 2002 to helpclinicians review the research literature and utilize the in-formation to enhance their clinical decision making andpractice. In January 2002, all physical therapy educationalprograms changed to the master’s level. In the same year,Pennsylvania became the 35th state to achieve direct ac-cess, and the American Physical Therapy Association re-leased the Interactive Guide to Physical Therapist Practice.In 2003, the Association built support in Congress for theMedicare Patient Access to Physical Therapists Act to allowlicensed physical therapists to evaluate and treat Medicarepatients without a physician’s referral.

Vision and Application of ScientificPursuit Years: 2006 to Today

From 2006 to today, the roles of physical therapists have be-come more dependent on the application of the scientificmethod in clinical practice and finding new evidence-basedapproaches for disease prevention and health promotion.Physical therapist assistants were delegated with impor-tant responsibilities as the only individuals permitted to as-sist physical therapists in selected interventions (under thedirection and supervision of physical therapists).

The American Physical Therapy Association’s Vision 2020

The American Physical Therapy Association’s 2020 Visionincludes the following25:

By 2020, physical therapy will be provided by physicaltherapists who are doctors of physical therapy, recog-nized by consumers and other health care professionalsas the practitioners of choice to whom consumers havedirect access for the diagnosis of, interventions for, andprevention of impairments, functional limitations, anddisabilities related to movement, function, and health.

APTA Vision Statement for Physical Therapy 2020 in-cludes the following25:

➤ “Physical therapy will be provided by physical ther-apists who are doctors of physical therapy and whomay be board-certified specialists.

➤ Consumers will have direct access to physical thera-pists in all environments for patient/client manage-ment, prevention, and wellness services.

Congress to keep much needed rehabilitation servicesavailable under Medicare.”24 Rehabilitation providers andpatients urged Congress to pass the Medicare Access toRehabilitation Services Act of 2005 to eliminate the threatthat seniors and individuals with disabilities would haveto pay out of pocket for rehabilitation or to alter thecourse of their rehabilitation care. This act was consideredsignificant to repeal the cap that was originally institutedthrough the Balanced Budget Act (BBA) of 1997. From1997 to the beginning of 2005, Congress enforced amoratorium three times that delayed implementation ofthe cap. On December 31, 2005, the moratorium expired.As a result, on January 1, 2006, the Medicare cap wasreimplemented by the Centers for Medicare and MedicaidServices (CMS). From January 1, 2006, to December 31,2006, the dollar amount of the therapy cap was $1,740for physical therapy and speech language pathology com-bined and $1,740 for occupational therapy.

The American Physical Therapy Association has beenworking diligently during each Congressional session toreduce the drastic impact the BBA has had on patientcare. Although the therapy cap went into effect in 2006,because of the pressure from the American PhysicalTherapy Association, clinicians, and consumer groups,Congress authorized Medicare to allow exceptions forbeneficiaries who needed additional rehabilitation serv-ices based on diagnosis and clinicians’ evaluations andjudgments. Consequently, Congress acted to extend theseexceptions through December 31, 2009. On January 1,2010, without Congressional action, authorization for ex-ceptions to the therapy caps expired. The AmericanPhysical Therapy Association states on its website that“on March 23rd, 2010, President Obama signed H.R.3590, the Patient Protection and Affordable Care Act,making it law.” This Act includes a health care reformpackage that extends the therapy cap exception processuntil December 31, 2010. For details of the Act and moreinformation, visit the APTA’s website at: www.apta.org

APTA Events

In 1999, two significant events affected the AmericanPhysical Therapy Association: the suspension of the $1500Medicare cap and the publication of the Normative Modelof Physical Therapist Assistant Education: Version 1999,which guides physical therapist assistant education pro-grams. In 2000, the Association adopted the new“Evaluative Criteria for the Accreditation of Education forPhysical Therapist Assistants,” launched PT Bulletin online,and published the Normative Model for Physical Therapist


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➤ Physical therapists will be practitioners of choice inpatients/clients’ health networks and will hold allprivileges of autonomous practice.

➤ Physical therapists may be assisted by physicaltherapist assistants who are educated and licensedto provide physical therapist directed and super-vised components of interventions.

➤ Guided by integrity, life-long learning, and a com-mitment to comprehensive and accessible healthprograms for all people, physical therapists andphysical therapist assistants will render evidence-based services throughout the continuum of careand improve quality of life for society.

➤ Physical therapists and physical therapist assistantswill provide culturally sensitive care distinguishedby trust, respect, and an appreciation for individualdifferences.

➤ While fully availing themselves of new technologies,as well as basic and clinical research, physical thera-pists will continue to provide direct patient/client care.

➤ Physical therapists and physical therapist assistantswill maintain active responsibility for the growth ofthe physical therapy profession and the health ofthe people it serves.”

The terminology used in the vision sentence/statementrelate to the following25:

• Autonomous physical therapy practice environ-ments include all physical therapy practice set-tings where physical therapists accept theresponsibility to practice autonomously and col-laboratively to provide best practice to the patient/client. Such physical therapist practices are char-acterized by independent, self-determined, pro-fessional judgments and actions.

• Direct access means that throughout his or herlifetime, every consumer has the legal right to di-rectly access a physical therapist for the diagno-sis of, interventions for, and prevention ofimpairments, functional limitations, and disabili-ties related to movement, function, and health.

• The Doctor of Physical Therapy (DPT) is a clini-cal doctorate degree (entry-level) that reflectsthe growth in the body of knowledge and ex-pected responsibilities that a professional physi-cal therapist must master to provide bestpractice to the consumer. All physical therapistsand physical therapist assistants are obligated toengage in the continual acquisition of knowl-edge, skills, and abilities to advance the scienceof physical therapy and its role in the delivery ofhealth care.

• Practitioner of choice means physical therapistswho personify the elements of the Vision 2020and are recognized among consumers and otherhealth care professionals as the preferredproviders for the diagnosis of, interventions for,and prevention of impairments, functional limita-tions, and disabilities related to movement, func-tion, and health.

• Evidence-based practice means access to, andapplication and integration of evidence to guideclinical decision making to provide best practicefor the patient/client. Evidence-based practice in-cludes the integration of best available research,clinical expertise, and patient/client values andcircumstances related to patient/client manage-ment, practice management, and health carepolicy decision making. Plans for evidence-basedpractice include enhancing patient/client man-agement and reducing unwarranted variation inthe provision of physical therapy services.

• Professionalism means that physical therapistsand physical therapist assistants consistentlydemonstrate core values by aspiring to andwisely applying principles of altruism, excel-lence, caring, ethics, respect, communication,and accountability, and by working together withother professionals to achieve optimal health andwellness in individuals and communities.

Achieving Direct Access

Direct access means the ability of the public to directly ac-cess a physical therapist’s services such as physical ther-apy evaluation, examination, and intervention. Directaccess eliminates the patient’s need to visit his or herphysician to ask for a physician’s referral. Licensed phys-ical therapists are qualified to provide physical therapyservices without referrals from physicians. Direct accessdecreases the cost of health care and does not promoteoverutilization. The American Physical TherapyAssociation assigned direct access to physical therapistsas a high priority in the Association’s federal governmentaffairs activities. In 2005, the Medicare Patient Access toPhysical Therapists Act was introduced in the House ofRepresentatives, and its companion bill in the Senate. Theact and the bill recognized the ability of licensed physicaltherapists to evaluate, diagnose, and treat Medicare ben-eficiaries requiring outpatient physical therapy servicesunder Part B of the Medicare program, without a physicianreferral.


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therapist or physical therapist assistant students are wel-come as student members of the Association.

The Association describes the following 12 specificbenefits for student members27:

How Will APTA Membership Jump-Start YourCareer?

1. Enjoy significant members-only savings onAPTA’s products, services, and conferences.

2. Explore new topics and research you won’tfind in the classroom through podcasts,newsletters, and more.

3. Get solid advice from people who have beenin your shoes through APTA’s mentoring programs.

4. Find the right job—studies have shown thatwhen they have the option, employers preferto hire APTA members.

5. Become involved in professional issues anddebates by participating in the StudentAssembly and student special-interest groups.

6. Stay current through News Now, PT in Motion,PTJ Online, Student Assembly Pulse, andother publications.

7. Connect with students, educators, and clini-cians now and build lifelong contacts andfriendships you can rely on for years.

8. Explore APTA’s 18 special-interest sectionsnow and know exactly where your interestslie when you embark on your new career.

9. Build leadership skills and make a difference—take on active volunteer roles in the StudentAssembly and your state chapter.

10. Protect your future with APTA-endorsedplans and programs for professional liability,education loans, and more.

11. Save 50% upon graduating when you convertto PT or PTA membership—APTA’s gradua-tion gift to you.

12. Do your part to ensure the best possible fu-ture for the profession.APTA is the voice ofphysical therapy, actively representing theprofession on Capitol Hill, in state legisla-tures, and with regulators.

The American Physical Therapy Association.Membership& Leadership. 12 Great Reasons to Be a Member! TheAmerican Physical Therapy Association Web site.Available at: http://www.apta.org.Accessed March 2010.

PTA Caucus

In June 2005, the National Assembly of Physical TherapistAssistants (PTAs) was dissolved and the Physical TherapistAssistant (PTA) Caucus was formed. The National Assemblyof PTAs was formed in 1998 as the Affiliate Assembly. ThePTA Caucus’s purpose was to more fully integrate PTA mem-bers into the APTA’s governance structure and increase PTAs’influence in the Association.26 The PTA Caucus representsthe physical therapist assistants’ interests, needs, and is-sues in the APTA governance.26 The caucus includes a chiefdelegate and four delegates representing five regions.26

Additionally, there are 52 PTA Caucus members represent-ing 52 chapters.26 Each PTA Caucus representative is electedor selected by their state chapter. The PTA Caucus also electsone chief delegate and four delegates (representing five re-gions) to the APTA’s House of Delegates (HOD). The PTACaucus representatives work with their chapter delegatesand provide input to the delegates to the HOD and the ad-visory panel of PTAs. Each delegate has the ability to speak,debate, and make and second motions providing represen-tation in the HOD for a particular region of the country.

MEMBERSHIP IN THE APTA

The American Physical Therapy Association (APTA) is thenational organization that represents the profession of phys-ical therapy. Membership in the Association is voluntary.Active members of the Association are physical therapists,physical therapist assistants (also called affiliate members),and physical therapist and physical therapist assistant stu-dents. Other Association members are retired members,honorary members (people who are not physical therapistsor physical therapist assistants but who made remarkablecontributions to the Association or the health of the public),and Fellow members (called a Catherine WorthinghamFellow of the American Physical Therapy Association). TheFellow member is an active member for 15 years who hasmade notable contributions to the profession. As of 2010,the American Physical Therapy Association membershipconsisted of approximately 72,000 physical therapists, phys-ical therapist assistants, and students members. The APTAincludes 52 chapters operating in the United States and itsterritories. Each chapter offers a variety of events, profes-sional development activities, and other opportunities formembers’ interaction.

The requirement for membership in the AmericanPhysical Therapy Association is to be a graduate of anaccredited physical therapist or physical therapist assis-tant program or to be enrolled in an accredited physicaltherapist or physical therapist assistant program. Physical


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As of 2008, most members of the American PhysicalTherapy Association were females, with an average ageof 42.9 years.28 Members averaged 17.4 years workingas a physical therapist, with some members practicing forup to 31 years and some for less than 1 year.

As of 2007, the American Physical TherapyAssociation’s demographic profiles29 for physical thera-pist assistant (PTA) members indicate that most of thePTAs were female (78.5 percent). In regard to age, in2007, the highest percentage (16.4 percent) were be-tween 35 and 39 years old, the second highest (15 per-cent) were between 45 and 49, and the lowestpercentage (0.4 percent) were over 65 years of age.29 In2007, 73.3 percent of all PTA members were workingfull-time, and 11.5 percent were working part-time.29

Others were either full-time or part-time self-employed(6.4 percent), seeking full-time or part-time employment(5.6 percent), or retired (0.3 percent). In regard to edu-cation, in 2007, 68.2 percent of PTAs had associate de-grees, 26.7 percent had baccalaureate degrees, 3.7percent had master’s degrees, and 0.2 percent had doc-torate degrees (not DPTs or tDPTs).

The APTA’s Mission

The Association is the principal membership organiza-tion that stands for and promotes the profession ofphysical therapy. Its mission is to “further the profes-sion’s role in the prevention, diagnosis, and treatmentof movement dysfunctions and the enhancement ofthe physical health and functional abilities of membersof the public.”30 As of October 2009, the AmericanPhysical Therapy Association amended its goals to eightencompassing the Association’s major priorities towardrealization of the ideals set forth in Vision 2020.Although the Association’s goals are not ranked, goalsone and two state the significance of physical thera-pists being universally recognized and promoted as the“practitioners of choice for persons with conditionsthat affect movement and function,”31 and “providersof fitness, health promotion, wellness, and risk reduc-tion programs to enhance quality of life for personsacross the life span.”31 Physical therapist assistants’roles are included in the Association’s goal six, whichstates that physical therapists and physical therapistassistants “are committed to meeting the health needsof patients/clients and society through ethical behavior,continued competence, collegial relationships withother health care practitioners, and advocacy for theprofession.”31

APTA Components

The components of the American Physical TherapyAssociation are chapters, sections, and assemblies. TheAssociation has 52 chapters including chapters in the 50states, the District of Columbia, and Puerto Rico.Membership in a chapter is automatic. Members mustbelong to the chapter of the state in which they live,work, or attend school (or of an adjacent state if moreactive participation is possible). Chapters are significantfor governance at the state level and for contributing toa national integration of members in the Association.The American Physical Therapy Association has 18 sections.They are organized at the national level, providing anopportunity for members with similar areas of interestto meet, discuss issues, and encourage the interests ofthe respective sections. The sections usually have anannual combined sections meeting in February.

The Association has two assemblies: the PTA Caucus(which was the National Assembly for the PTAs) andthe Student Assembly. The assemblies are composedof members from the same category and providemeans for members to communicate and contribute atthe national level to their future governance. One ofthe important positions expressed in 2004 by theNational Assembly for the Physical Therapist Assistantswas that the physical therapist assistant is the only ed-ucated individual whom the physical therapist may di-rect and supervise for providing selected interventionsin the delivery of physical therapy services. The PTACaucus is benefiting from and also reinforcing the PTArole in the APTA. A recent meeting in 200932 identifiedthe PTA members as a valuable resource of the Associa-tion, allowing for further leadership.

The House of Delegates and the Boardof Directors

The House of Delegates (HOD) is the highest policy-making body of the APTA. It is composed of delegatesfrom all chapters, sections, and assemblies, as well asthe members of the board of directors. The HOD iscomposed of chapter voting delegates; section, assem-bly, and PTA caucus nonvoting delegates; and consult-ants. The number of voting chapter delegates isdetermined each year based on membership numbersas of June 30. The annual session of the APTA is themeeting of the House of Delegates. It usually takes placeevery year at the Association’s Annual Conference andExhibition in June.


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of the speaker for the unexpired term. In this situation, theoffice of the vice speaker will be vacant.

APTA’s Headquarters

The Association’s headquarters are in Alexandria, Virginia.The Association’s personnel are available online atwww.apta.org and at the toll-free number (800) 999-2782. The address of the Association is 1111 North FairfaxStreet, Alexandria, VA, 22314-1488. In 2003 the AmericanPhysical Therapy Association’s headquarters in Virginiawas named by Washingtonian magazine as “One of theBest Places to Work.”

Other Organizations Involved with Physical Therapy

Commission on Accreditation in PhysicalTherapy Education

The Commission on Accreditation in Physical TherapyEducation (CAPTE) grants specialized accreditation statusto qualified entry-level education programs for physicaltherapists and physical therapist assistants. The commis-sion is a national accrediting agency recognized by theU.S. Department of Education and the Council for HigherEducation Accreditation. The APTA and CAPTE work to-gether to ensure that persons entering educational pro-grams for physical therapists and physical therapistassistants receive formal preparation related to current re-quirements for professional practice. CAPTE accreditsprofessional (entry-level) programs in the United Statesfor the physical therapist at the master’s and doctoral de-gree levels and programs for the physical therapist assis-tant at the associate degree level. CAPTE also accreditstwo physical therapist education programs in Canada andone in Scotland.

CAPTE states that its mission is “to serve the public byestablishing and applying standards that assure qualityand continuous improvement in the entry-level prepara-tion of physical therapists and physical therapist assis-tants, and that reflect the evolving nature of education,research, and practice.”33 CAPTE consists of three panels:the Physical Therapist Review Panel, Physical TherapistAssistant Review Panel, and Central Panel. Appointmentto CAPTE is done through the APTA staff, who providesthe APTA board of directors with a list of all individuals33

qualified for open positions who consent to serve. CAPTEreviews the list and makes recommendations of thoseindividuals who best meet CAPTE’s needs. The board of

The role of the board of directors is to carry out themandates and policies established by the House ofDelegates and to communicate issues to internal and ex-ternal personnel, committees, and agencies. The board ofdirectors of the APTA is composed of 15 members—6officers and 9 directors. Members of the board assumeoffice at the close of the House of Delegates at whichthey were elected. A complete term for a board memberis 3 years. Only active members of the American PhysicalTherapy Association in good standing for at least 5 yearscan serve on the board of directors. No member is al-lowed to serve more than three complete consecutiveterms on the board or more than two complete consec-utive terms in the same office. The board meets at leastonce a year, and the executive committee meets at leasttwice a year.

The six officers of the APTA are the president, vice pres-ident, secretary, treasurer, speaker of the House ofDelegates, and vice speaker of the House of Delegates.The president of the APTA presides at all meetings of theboard of directors and the executive committee and servesas the official spokesperson of the Association. The pres-ident is also an ex officio member of all committees ap-pointed by the board of directors except the ethics andjudicial committee. The vice president of the APTA as-sumes the duties of the president in the absence or inca-pacitation of the president. In the event of vacancy in theoffice of president, the vice president will be the presi-dent for the unexpired portion of the term. In this situa-tion, the office of the vice president will be vacant. Thesecretary of the APTA is responsible for keeping the min-utes of the proceedings of the House of Delegates, theboard of directors, and the executive committee; for mak-ing a report in writing to the House of Delegates at eachannual session and to the board of directors on request;and for preparing a summary of the proceedings of theHouse of Delegates for publication. The treasurer of theAPTA is responsible for reporting in writing on the finan-cial status of the Association to the House of Delegatesand to the board of directors on request. The treasureralso serves as the chair of the finance and audit commit-tee. The speaker of the House of Delegates presides atsessions of the House of Delegates, serves as an officer ofthe House of Delegates, and is an ex officio member of thereference committee. The vice speaker of the House ofDelegates serves as an officer of the House of Delegatesand assumes the duties of the speaker of the House ofDelegates in the absence or incapacitation of the speaker.In the event of a vacancy in the office of the speaker of theHouse of Delegates, the vice speaker succeeds to the office


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directors considers the recommendations of CAPTE andmakes final decisions33 for appointments to CAPTE. Theterm of appointment is 4 years.

American Board of Physical TherapySpecialties

The American Board of Physical Therapy Specialties(ABPTS) is the governing body for certification and re-certification of clinical specialists by coordinating and su-pervising the specialist certification process. The ABPTSis composed of nine individuals34: six individuals ap-pointed by the ABPTS for 4-year terms, one member ofthe APTA board of directors (BOD) appointed by the APTABOD for a 1-year term, one consumer representativeappointed by the BOD for a 2-year term, and one testsand measurement expert appointed by the ABPTS for a2-year term.

The specialist certification program was established in1978 by the APTA to provide formal recognition for phys-ical therapists with advanced clinical knowledge, experi-ence, and skills in a special area of practice, and to assistconsumers and the health care community in identifyingthese physical therapists. The APTA describes specializa-tion as a process by which a physical therapist increaseshis or her professional education and practice and de-velops greater knowledge and skills related to a particu-lar area of practice. Specialist recertification is a processby which a physical therapist verifies current competenceas an advanced practitioner in a specialty area by in-creasing his or her education and professional growth.

The Specialty Council on Cardiopulmonary PhysicalTherapy was the first to complete the process, and the car-diopulmonary specialist certification examination was firstadministered in 1985. Since then, seven additional spe-cialty areas were established: Clinical Electrophysiology,Geriatrics, Neurology, Orthopedics, Pediatrics, Sports, andWomen’s Health Physical Therapy.

The purposes of APTA’s Clinical Specialization Programare as follows34:

➤ To contribute to the identification and developmentof appropriate areas of specialty practice in physicaltherapy.

➤ To promote the highest possible level of care for in-dividuals seeking physical therapy services in eachspecialty area.

➤ To promote the development of the science and theart underlying each specialty area of practice.

➤ To provide a reliable and valid method for certifica-tion and recertification of individuals who have

attained an advanced level of knowledge and skillin each specialty area.

➤ To help the consumers, the health care community,and others in identifying certified clinical specialistsin each specialty area.

➤ To serve as a resource in specialty practice forAPTA, the physical therapy profession, and thehealth care community.

Federation of State Boards of Physical Therapy

The Federation of State Boards of Physical Therapy(FSBPT) develops and administers the National PhysicalTherapy Examination (NPTE)35 for both physical thera-pists and physical therapist assistants in 53 jurisdictions:the 50 states, the District of Columbia, Puerto Rico, andthe Virgin Islands. The purpose of the FSBPT is to protectthe public by providing leadership and service that en-courage competent and safe physical therapy practice.35

The exams assess the basic entry-level competence forfirst time licensure or registration as a physical therapistor physical therapist assistant within the 53 jurisdictions.FSBPT’s vision35 is that the organization will achieve ahigh level of public protection through a strong founda-tion of laws and regulatory standards in physical ther-apy, effective tools and systems to assess entry-level andcontinuing competence, and public and professionalawareness of resources for public protection.

For physical therapist and physical therapist assistantgraduates who are candidates to sit for the NPTE, thefederation offers a Candidate Handbook that includes allthe necessary information about the exam and exam ad-ministration. The handbook can be viewed or down-loaded online at www.fsbpt.org. The federation has beenworking with the state boards within its jurisdiction to-ward licensure uniformity supporting one passing scoreon the NPTE. This uniformity in scores assists physicaltherapists and physical therapist assistants to work acrossstates.

In 2004, the FSBPT developed for purchase an on-line Practice Exam and Assessment Tool (PEAT) to helpphysical therapist and physical therapist assistant can-didates prepare for the NPTE. The online PEAT allowsthe candidates to take a timed, multiple-choice examsimilar to the NPTE and receive feedback on it. Whenreceiving feedback, the candidates have access to the correct answer rationale and the references usedfor each question. Physical therapist assistant candi-dates can purchase a PTA PEAT that has two different150-question exams.


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policy decision makers. The purpose of the PT-PAC is“to further the legislative aims of APTA.”36 The tasks ofthe PT-PAC are36:

➤ “To raise funds to contribute to campaigns of candi-dates for national and state office with attention tophysical therapists as candidates for public office

➤ To encourage and facilitate APTA member participa-tion in the political process”

Follow-Up to Direct Access and Education

As of 2010, 45 states and the District of Columbia al-lowed direct access. In these states, the advanced pro-fessional training and expertise of physical therapists arerecognized, allowing patients/clients to visit and receivephysical therapy interventions directly from physical ther-apists without needing a referral.

In regard to physical therapist and physical therapist as-sistant education, as of January 28, 2010, there were37:

• 203 DPT (Doctor of Physical Therapy) accreditedphysical therapist education programs

• 9 MS/MPT accredited physical therapist educa-tion programs (which are changing to DPT)

• 9 developing DPT physical therapist educationprograms

• 252 PTA accredited physical therapist assistanteducation programs

• 46 developing PTA physical therapist assistanteducation programs

Outside of the United States there were three physicaltherapist accredited programs, two in Canada and one inScotland.

APTA’s Position in Regard to Licensure

In regard to licensure, the American Physical TherapyAssociation (APTA) requires that all physical therapistsand physical therapist assistants should be licensed orotherwise regulated in all U.S. jurisdictions. State regu-lation of physical therapists and physical therapist as-sistants should require at a minimum graduation from anaccredited physical therapy education program (or inthe case of an internationally educated physical thera-pist, an equivalent education) and passing an entry-levelcompetency exam; should provide title protection; andshould allow for disciplinary action. In addition, physi-cal therapists’ licensure should include a defined scopeof practice. Relative to temporary jurisdictional licen-sure, the APTA supports the elimination of temporaryjurisdictional licensure of physical therapists or tempo-rary credentialing of physical therapist assistants for pre-viously non-U.S.-licensed or non-U.S.-credentialedapplicants in all jurisdictions.

Political Action Committee

The physical therapy political action committee (PT-PAC) of the American Physical Therapy Association isa vital aspect of the Association’s success on CapitolHill in Washington, D.C. PT-PAC ensures that future leg-islative actions on Capitol Hill are helpful to physicaltherapy practice. Physical therapist and physical ther-apist assistant members make donations to the politi-cal action committee. The PT-PAC committee usesmembership donations to influence legislative andpolicy issues through lobbying efforts directed toward


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