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

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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- 72/1063 Physical Therapy/Volume 74, Number 11/November 1994 Downloaded from http://ptjournal.apta.org/ by guest on January 11, 2014
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 Physical Therapy/Volume 74, Number 11/November 1994 1064/73 Downloaded from http://ptjournal.apta.org/ by guest on January 11, 2014
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Will the Legacy of Our Past Provide Us With a ... - Physical Therapy

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