Will the Legacy of Our Past Provide Us With a ... - Physical Therapy

Will the Legacy of Our Past Provide Us With a Legacy
for the Future?
Marilyn Moffat
PHYS THER. 1994; 74:1063-1066.
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The 1993 APTA Presidential Address
Will the Legacy of Our Past Provide Us
With a Legacy for the Future?
This APTA Presidential Address was presented at the Annual Conference of the
American Physical Therapy Association, Cincinnati, Ohio, fune 12, 1993-
Marilyn Moffat
Mr Puller,* colleagues, distinguished
guests—it is indeed my pleasure to
open this meeting of the American
Physical Therapy Association in Cincinnati,
Ohio, marking the 72nd year
in the history of the Association.
This is a most historic year in the life
of the profession of physical therapy
because it does mark the 75th anniversary
of the founding of the first education
program for the training of physical
therapists in this country. Thus, the
central theme about which this address
will be based is: Will the legacy
of our past provide us with a legacy
for the future? To answer that question,
we must look at the evolution of
our profession, from what appeared to
us as technical status, to somewhere in
between, and now to the brink of
professionalism. And at the same time,
we must introspectively review the
most positive aspects of what physical
therapy is all about, critically examine
those divergent paths that will eventually
thwart our dreams and aspirations
of professionalization if we continue to
pursue them, and idealistically charter
a course to enable us to soar to the
heights that this profession should
attain.
Our history related to practice shows
that we evolved because of the necessity
of providing treatment to those
individuals who were wounded during
World War I and to those who suffered
from the paralytic effects of poliomyelitis.
Although perhaps looked upon as
technical workers, the Reconstruction
Aides, who were the first physical
therapists, were much, much more
than that. Seventy-five years ago they
were for the most part graduates of
gymnasia or nursing programs and
thus were really postbaccalaureate
certificate individuals. After their war
service, they embarked into many
varied practice arenas, including hospitals
and private practices. They were
recognized by their medical colleagues
for their expertise, and they—and they
alone—provided "physiotherapeutic"
services to their patients.
Our history related to education shows
that for over 30 years our education
was in hospital-based and postbaccalaureate
certificate programs in institutions
of higher education. Of note was
the fact that those who taught in the
increasing numbers of physical therapy
education programs that developed
M Moffat, PhD, PT, FAPTA, is President, American Physical Therapy Association, Ludlam Ln, Locust
Valley, NY 11560 (USA).
*The late Lewis B Puller, Jr, Pulitzer-Prize-winning author of Fortunate Son, was the keynote
speaker at the Opening Ceremonies of the 1993 Annual Conference.
[Moffat M. The 1993 APTA Presidential Address. Will the legacy of our past provide us with a legacy
for the future? Phys Ther. 1994,74.1063-1066]
after World War I did so because of
the strong education base that they
had had with their "prephysiotherapy"
background. This strongly based educator
dominated physical therapy education
programs throughout the first
40 years of our history.
What has happened to physical therapy
education and practice since that
time must be reviewed with an openness
and honesty that makes us capable
of assessing what appropriate
change is necessary to ensure a legacy
for those who follow us. First, let us
look at education. Somewhere in the
1960s we decided that we needed
academic legitimacy, so we embarked
upon a program to make the baccalaureate
degree the minimum degree
for physical therapist education. As
one could easily expect, the minimum
became the norm. Thus, when 20
years later we tried to return to the
postbaccalaureate mode, great resistance
occurred both within and without
the physical therapy educational
community. And 14 years after our
decision to move to postbaccalaureate
education, we are still struggling with
where physical therapy education
should be. Many of our faculty within
our educational arenas do not have
the strong pedagogical background
for their teaching responsibilities and
for their roles in higher education
that our predecessors had. And in
spite of the problems in academia,
our programs continue to rival doc-
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toral programs in quantity of material
and quality of material, yet we continue
to award baccalaureate or master's
degrees for programs that are so
much more than that.
Let us next look at practice. Physical
therapy practice certainly has seen
some drastically changing patterns in
its more recent history. From the early
treatment of the war wounded to the
massive muscle reeducation required
during the poliomyelitis epidemics, the
practice of physical therapy appears to
be moving further and further away
from the skills and from the types of
services rendered that had made us
unique. These are the same kinds of
skills and services that made Lt Puller
always remember his physical therapist
and that made him forever aware of
the long-lasting effects of his physical
therapy intervention. These are the
same kinds of skills and services that
are not duplicated or rendered by
others. What has and where have we
gone awry? Although I firmly believe
that many, many physical therapy practitioners
are attempting to do the best
possible, I am increasingly dismayed
when I hear the following types of
comments.
From a colleague in New York came
the statement that a patient had been
referred to her office for spinal stenosis.
Upon taking the history, my colleague
found that this patient had
been previously seen by another
physical therapist who was a participating
physical therapist in a large
New York City health maintenance
organization (HMO) and who had
seen her initially for 30 visits. Further,
the patient's treatment had consisted
of one exercise, and hot packs and
ultrasound to the left thigh because
that is where the pain was—remember,
this patient had a diagnosis of
spinal stenosis. After completing that
course of 30 visits, the patient was
then given authorization for transcutaneous
electrical nerve stimulation
(TENS) and had 25 more visits with
the same physical therapist, who now
applied TENS instead of hot packs
and ultrasound and one exercise. This
patient had 55 visits of something that
I will not even deign to call physical
therapy. Yet this patient's insurance
paid for physical therapy, and the
therapist collected for this, what I
might term, disservice.
From another colleague in South Dakota
came the story of her mother,
who lived in another state and who
had undergone a total knee replacement.
Discharged from the hospital on
crutches with a continuous passive
motion machine and some home
exercises, the patient kept her leg in
extension while doing most activities
of daily living. Five weeks postdischarge,
the physician finally recommended
outpatient physical therapy,
which included exercises and mobilization
techniques. The manual therapy
techniques used rendered the patient
nonambulatory for 2 days after each
treatment. These were certainly not the
Grade II techniques that might have
served as neuromodulators of pain.
After 8 weeks of excruciatingly painful
therapy and only 10 degrees of increased
range of motion, she finally
sought her daughter's advice. Upon
examination, pain, difficulty moving
about, poor balance, decreased step
length, and asymmetrical gait were all
noted, as well as a completely atrophied
gastrocnemius muscle. With an
intensive, progressive home program
of appropriate strengthening, appropriate
stretching that the patient now
happily did herself, gait instruction,
stair climbing, and functional skills
training, this woman is back to her
previous busy, productive life. It is
difficult to justify mobilization techniques
that render the recipient so
debilitated as to question the efficacy
of those techniques, and it is equally
as difficult to justify those particular
manual techniques with a joint replacement
when the capsule has not
completely grown back.
From another colleague in Illinois
came the case of a patient who had
undergone a total hip replacement and
who was referred to this therapist for
home health care 9 days after the
surgery. Upon arrival at the house, my
colleague noted quite apparent shortness
of breath. She referred the patient
back to the physician, who evaluated
her and immediately performed an
angiogram, which revealed three totally
occluded vessels. Open-heart
surgery was performed within 2 days,
and 1 week later she was told by the
nurse in the hospital to attend the
cardiac rehabilitation class. In class,
she was unable to stand from the
chair, and when asked why by the
nurse, they finally realized that she had
also just undergone a total hip replacement
3 weeks before. Then the difficulty
began—the orthopedic physical
therapist would not see her because of
her cardiac involvement, and the cardiac
physical therapist was unable to
provide the care for her hip.
From another colleague in Texas
came the saga of a patient with an
on-the-job neck injury who had been
treated by a physical therapist authorized
by workers' compensation. The
patient was seen for 1V2 years by the
physical therapist, and the treatment
consisted of hot packs, ultrasound,
massage, traction, and electrical stimulation.
Upon being evaluated by my
colleague, V/z years later, this patient
was placed on a progressive physical
therapy exercise program of strengthening
and stretching, was given instructions
in activities of daily living,
was taught appropriate postural alignment,
was provided with an appropriate
pillow for sleeping, and was seen
once per week for 4 weeks when she
returned to full-time employment.
And from yet another colleague in
New Mexico came the history of a
patient who was referred to her
clinic. The patient, who had a firm
roentgenographic diagnosis of a
spondylolisthesis, had previously been
seen by another physical therapist.
The previous therapist had taken a
course that told him that extension
exercises were the way to treat back
problems. Without fully assessing the
pathophysiological and anatomical
changes in spondylolisthesis, he embraced
the extension approach and
administered only those movements
for this patient. Needless to say, the
patient did not improve and did experience
worsening of symptoms. Upon
the new referral to my colleague, the
patient was placed on an exercise
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program appropriate for the condition
and made steady improvement.
To put aside the patient examples for
a moment, I should like to have us
look at other facets of what have appeared
to be changing patterns of
physical therapy practice, which must
be carefully evaluated in this era of
fiscal constraint and this era of increasing
scrutiny of our services.
Have we adjusted our charges to a
client or patient so that if the care is
rendered under our supervision by a
physical therapist assistant, the cost is
lower than if the care is rendered by
the physical therapist? The history of
the reasons for the development of
assistant-level supportive personnel in
health care began in the 1960s. I
might point out that the physical therapist
assistants who are with us tonight
are celebrating the 20th anniversary
of their involvement in the
American Physical Therapy Association
as affiliate members. The raison d'etre
of the physical therapist assistant was
predicated on the development of
persons who could be educated more
quickly and was put forth as a means
of decreasing the cost of health care
in the United States. We might ask
ourselves whether this happened in
physical therapy?
Does mobilization with movement of
a joint Vi6 of an inch in and of itself
constitute physical therapy?
Does the use of high-tech equipment—which
is in the purview of the
salesperson who sells the equipment,
is in the purview of the exercise physiologist,
and is in the purview of the
athletic trainer—in and of itself constitute
physical therapy?
Does multiple modality use and nothing
else constitute physical therapy?
To these and many other similar
questions, I would say "no." It is no
wonder that the government looks at
us as only purveyors of hot packs and
ultrasound. And although I am fully
aware that coding systems have not
been representative of what we do,
the billing for two modalities—hot
packs and ultrasound—is well ahead
of the billing for therapeutic exercise,
kinetic activity, and the like.
And then we wonder why physical
therapy has been termed a "luxury
service" in the health care reform
arena. We wonder why insurance
companies question the efficacy of
what we do. We wonder why medicine
does not value our services in
the way we think they should. What is
the legacy that we are leaving?
Although these are but a few of a
myriad of examples and questions, we
must begin to look at what we are
providing in the name of physical
therapy to those patients and clients
we serve. The fringe has become in
vogue, and physical therapists spend
exorbitant amounts of money pursuing
the Holy Grail in physical therapy. The
gurus of physical therapy today, with
their slick presentations, have physical
therapists change their approaches
every other year. How often I have
heard the statement that a "noted
physical therapist" has "the answer"
this year, yet 2 years later I hear that
"the answer" has now been changed
to another pontification from on high.
Further complicating changes in physical
therapy practice are the delivery
modes occurring across this country,
which also will affect whatever legacy
that we might leave.
Corporate takeovers of physical therapy
practices, that is, the big-business
ventures, across this country are so
established to maximize the profits
for their investors. At first, it is difficult
to understand why anyone would
want to sell his or her practice to
anyone other than another physical
therapist. And yet, as we survey many
practitioners who have felt the need
to keep up with the high tech and the
incredible outlay of money that
equipment necessitates, it is understandable
why therapists have been
leveraged far beyond what they
should be, and thus opt to eliminate
that financial albatross from around
their neck. It is also understandable
when one reaches the age of thinking
about retirement with no other physical
therapist wanting to take over or
buy his or her practice, unlike other
professions that have younger individuals
waiting to buy into such wellestablished
programs.
Referral-for-profit practices will continue
to affect the legacy that we
might leave. Professional integrity,
professional judgment, and professional
autonomy are all potentially
compromised in these arrangements.
In addition, health care reform in this
country is already being set by American
businesses and the insurance
companies and not by the federal
government, in spite of all of the time
that has been spent talking and planning
for reform. Increasingly, every
major health insurance provider in
this country offers its own HMO plan,
which is much cheaper than its feefor-service
plan. Employees in company
after company in the United
States are being forced to adopt these
plans in order to have affordable
insurance. And what have they done
to physical therapists and to the practice
of physical therapy? Practitioners
from across the country are relating
the same situation. They are now
closed out of these HMOs because
they did not sign up early enough. Of
note is the fact that one major HMO
in Manhattan has two physical therapists
as its providers in a city of over
8 million people. Does it indicate to
us the extent and the quality of the
physical therapy care that this HMO
intends to provide?
The legacy of the evaluative, handson,
cerebrally produced care is being
lost from physical therapy. The ability
to look at, totally assess, and appropriately
treat that whole person is sliding
into the hands of others. The examples
are legion. If we are to preserve
that exciting, challenging approach to
care that our legacy has so richly
provided, then we must come to grips
with the preservation of that legacy in
the face of many odds. Physical therapy
practitioners must carefully assess
the what, the how, and the why of the
services we render.
Are we ready to truly stand up and
fight for the rightful place of physical
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Physical Therapy/Volume 74, Number 11/November 1994

therapy as a necessary health service
in this country for both prevention
and treatment? Are we ready to
change our approach to delivery of
services so that the consumer demands
our services because we have
something unique to offer to that
client or patient? Are we willing to
put forth the funds that are necessary
to inform the public in the way that
other practitioners are so doing? Are
we willing to return to that legacy of
treating the whole person, whether it
be patient or client, rather than treating
a knee, or a back, or a shoulder,
or a hand? How can we continue to
treat the hip fracture without treating
the person who has sustained that hip
fracture, who probably also has osteoarthritic
changes in his or her
body, may be osteoporotic, may have
some degenerative disk disease, and
may need some cardiovascular conditioning?
Do we discharge that person
from our inpatient care without appropriate
follow-up, and, as importantly,
do we discharge that person
from outpatient care without appropriate
instruction in prevention of the
long-term problems associated with
the other concomitant problems that
the patient may have?
Are we willing to revamp the kinds of
treatment we provide so as to diminish
the costs to the patient or client, at
the same time making the patient an
active participant in his or her treatment
regimen? Are we willing to fight
for the right to determine the number
of treatments that truly are appropriate
for a given disease or disability
and for our right to determine how
they should be spread out? No physician
should tell any of us that we
have to see a patient three times a
week for 3 weeks when we know that
the patient will be better served if we
see him or her once a week for 7
weeks.
As many of you know, I have been a
major proponent of change when it is
in the best interests of the consumer
of our services and in our best interests.
I have looked back at our history
of change within this profession, and
I can admire and be ever grateful for
those who have provided a legacy for
us. Sister Kenny revolutionized the
approach to patients with poliomyelitis
when she advocated warm wraps,
muscle reeducation, and an awareness
of the disastrous effects of overfatigue
of muscles affected by the virus. Edith
Buckwald Lawton offered new hope
to patients with spinal cord lesions
when she began to look at ways to
have them cope with activities of daily
living in ways not thought possible
before. Signe Brunnstrom made us
look carefully at the stages of recovery
from a cerebrovascular accident by
her meticulous documentation of her
patient observations. Marian Williams,
Catherine Worthingham, and Florence
Kendall made major changes in how
we assessed muscle capability. Margaret
Rood took the treatment of patients
with cerebral palsy to an entirely
different plane when she
discarded the traditional orthopedic
management of these patients and
began to treat their bodies using
principles of neurophysiology. Our
legacy has been a rich one, and
change has been a part of that legacy.
But the changes never lost sight of
the unique contributions that we in
physical therapy may make to the
patient or client, from pediatrics to
geriatrics, from physical therapy intervention
for disease and disability to
maintenance of wellness and prevention
of ill health.
Thus, a legacy is anything handed
down to us from the past from a
predecessor and therefore is something
we will hand down to the next
generations of physical therapists and
physical therapist assistants in this
country. Will this legacy ensure that
the caring, multifaceted aspects of
treatment that we have so capably
rendered for many years continue to
be the legacy that we pass on? Or will
the kinds of examples continue to
erode the very foundations of our
profession? To paraphrase a quote
from Lew Puller's autobiography Fortunate
Son, "Physical therapy must
instill in us a pride and professionalism
more closely akin to a calling."
The choice is up to each and every
one of us—and for all of us, that
choice should be easy. We must lead
the profession through uncharted
paths, yet we must continue to walk
in the paths of those who have provided
the legacy of which we may be
justly proud. I should like to conclude
this address with a poem written by
Dr Bella J May and Dr Betty Landen in
1980 entitled "An Ode to the Future—With
Echoes From the Past":
The past is full of memories
Of triumphs and defeats;
Today is full of challenges
That we have yet to meet.
Tomorrow still is waiting,
We hope for our success;
But that bit of future history
Will put us to the test.
The test of our direction
Of where we hope to be,
The test of how we get there,
It's up to you and me.
Some of us are dreamers,
Some are action bent,
Some of us are laggards,
Some just malcontent.
How do we get together
To chart our future course?
Wherein are our differences?
What is our recourse?
We'll never walk in perfect step,
It wasn't meant to be;
But unless we walk in some accord,
We're like lemmings to the sea.
To blunder blindly off the cliff
In pursuit of Camelot
May be a new experience,
But progress it is not.
For if in our endeavors
Our cause should cease to be,
Who will ever miss it
Except for you and me.
We need to stop and listen
To the echoes of the past,
To where we were and where we are
So what we build will last.
Will the paths down which we're
heading
Eventually lead to light?
Or will those who come behind us
Encounter falling night?
The answer is up to us,
Our construction, our design;
If we build on firm foundation,
It will stand the test of time.
Physical Therapy/Volume 74, Number 11/November 1994 1066/75
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Will the Legacy of Our Past Provide Us With a Legacy
for the Future?
Marilyn Moffat
PHYS THER. 1994; 74:1063-1066.
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