History of Physical Therapy Practice in the United States, The

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

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

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

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

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

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

THE BEGINNINGS

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

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

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