Physical therapy

This article concerns itself with the health profession. For the band by the same name, see Physical Therapy (band)

Physical therapy (also known as physiotherapy) is an allied health profession concerned with the assessment, diagnosis, and treatment of disease and disability through physical means. It is based upon principles of medical science, and is generally held to be within the sphere of conventional (rather than alternative) medicine. Physiotherapy is practiced by physiotherapists (also known as physical therapists, e.g. in the United States), though aspects may also be practiced under supervised delegation by physiotherapy assistants or other health professionals.

Scope of practice

Physiotherapists' scope of practice varies considerably across the world, both in terms of the degree of professional autonomy enjoyed and the range of conditions managed.

Physiotherapists in some jurisdictions, such as the Australian states, Canada, and most of the United States, enjoy professional autonomy, and have the ability to act as primary care providers and to determine—and be responsible for—a patient's management plan. Physiotherapists in some other jurisdictions work primary upon referral from other professionals (typically medical practitioners).

The major conditions managed by physiotherapists can be broadly grouped into four categories: musculoskeletal, cardiopulmonary, integumentary, and neurological. Many areas of physiotherapy, e.g. rehabilitation or pediatrics, cross all four areas. Depending on the local healthcare system, physiotherapists may be involved in all areas, or may only manage certain aspects (e.g. in some United States jurisdictions, respiratory therapists manage many aspects of cardiopulmonary therapy).

Depending on the structure of the local healthcare system, physiotherapists may function either privately (e.g. in a private clinic) or publicly (e.g. in a hospital or community setting). An advancement of technology has also allowed physiotherapists to treat patients via "telehealth". Examples include cardiac rehab and online treatment of musculoskeletal injuries. Furthermore, physiotherapists may work as generalists managing a wide range of conditions, or may specialise in certain fields. The process of determining career structure and specialisation varies geographically.

History of physiotherapy

Physiotherapy has its origins in ancient times with the advent of joint manipulation and massage (manipulation of soft tissues) in China circa 3000 BC. Hippocrates in 460 BC described massage and hydrotherapy. In 1894 the British Medical Journal raised concerns about the practices of some masseuses and masseurs who were offering massage as a euphemism for immoral services. The BMJ called for an institution to be formed to regulate massage practice. The Society of Trained Masseuses was formed by well-meaning nurses and midwives who were keen to see their massage practices authenticated.

A concern to provide an authentic alternative to the massage parlours, and a desire to court medical approval, saw early physiotherapy pioneers adopt a view of the body based on biomechanics and kinesiology in health and illness - something that dominates the physiotherapy 'philosophy' even to this day.

Massage and remedial gymnastics became a vital service in both world wars and much was learned through the rehabilitation of injured servicemen from these unfortunate events. Physiotherapy grew rapidly after the Second World War with spinal injury units, orthopaedic hospitals and chest clinics providing new challenges to the profession.

In many countries, physiotherapy has become the largest allied health profession, and third only behind medicine and nursing in the number of graduating health care students.

Assessment

A physiotherapist will initially conduct a subjective examination (interview) of a patient's medical history, and then go on to the objective assessment (physical examination). The subjective examination is guided by the presenting system and complaint, and the objective assessment is in turn guided by the history.

This semistructured process is used to rule out serious pathology (so called red flags), establish functional limitations, establish the diagnosis, guide therapy, and establish a baseline for monitoring progress. As such, the objective exam will then use certain quantifiable measurements to both guide diagnosis and for progress monitoring. These depend upon the system (and area) being managed, e.g. a musculoskeletal exam may involve, inter alia, assessment of joint range of motion, muscle power, motor control and posture, whilst a cardiopulmonary assessment may involve lung auscultation and exercise physiology testing.

In some countries a physiotherapist may order diagnostic imaging tests such as x-rays and MRIs to obtain more information about a patient's presenting condition and determine the treatment plan including referral to other practitioners. Physiotherapists may also perform electromyography and nerve conduction testing to aid in the diagnosis of muscle and nerve disorders.

Treatment

Guided by the assessment findings, the physiotherapist will then develop and facilitate a treatment plan. Aside from the various physiotherapeutic techniques involved in therapy, the treatment regime may include prescribing and advice regarding assistive walking devices; should consider functional progress; and include ongoing review and refinement. Patient education is a key aspect of all treatment plans.

It is difficult to explore the many aspects of physiotherapeutic treatment options, especially considering their ongoing development in the face of an increasing research base. Nonetheless, some examples of treatment options are listed below.

Musculoskeletal physiotherapy

Various therapeutic physiotherapy modalities are available, including exercise prescription (strength, motor control, stretching and endurance), manual techniques, soft tissue massage, and various forms of so-called "electrophysical agents" (such as cryotherapy, heat therapy, iontophoresis and electrotherapy).

Despite ongoing research giving a clearer picture regarding the use of various modalities in specific conditions, the benefits of electrotherapy are widely debated.

The practice of physical therapy should not be defined by the use of modalities but rather the integration of examination, history, and analysis of movement dysfunction.

Cardiopulmonary physiotherapy

Cardiopulmonary physiotherapists work with patients in a variety of settings. They treat acute problems like asthma, acute chest infections and trauma; they are involved in the preparation and recovery of patients from major surgery; they also treat a wide range of chronic cardiac and respiratory conditions like Chronic Obstructive Pulmonary Disease (COPD), cystic fibrosis (CF) and post-myocardial infarction (MI). They work with all ages from premature babies to older adults at the end of their life. Physiotherapists are pioneering new management techniques for non-organic respiratory problems like hyperventilation and other stress-related disorders as well as leading the development of cardio-pulmonary rehabilitation and non-invasive ventilation.

Cardiopulmonary physiotherapists use physical modalities to treat people. This may involve using manual techniques to clear infected mucus from a person's chest, or using non-invasive ventilation to help a person breathe, or prescribing exercises to improve a patient's functional exercise capacity.

Neurological physiotherapy

Treatment in neurological conditions is typically based upon exercises to restore motor function through attempting to overcome motor deficits and improve motor patterns. To achieve this aim various theoretical frameworks have been promoted, each based upon inferences drawn from basic and clinical science research. Whilst some of these have remained static, others are designed to take into account new developments, perhaps the most notable example being the "movement science" framework. The various philosophies often generate considerable debate.

Integumentry physiotherapy

Treatment of conditions involving the skin and related organs. Common conditions include wounds and burns. Treatment interventions include debridement of wounds/burns, dressings, scar prevention and reduction.

Physiotherapy education

As with many aspects of the profession, essential physiotherapy training varies considerably across the world. As a general rule, physiotherapy studies involve a minimum of four years tertiary education. Some examples are described here.

In Australia, an undergraduate physiotherapy degree is typically undertaken over a four-year period, with the early components being predominantly theoretical and with an increasingly clinical focus throughout the later stages. Postgraduate entry into physiotherapy is possible in some institutions, typically involving two years of study following the completion of a related (e.g. exercise physiology or science) Bachelor degree.

In Canada, all entry-level programs will be at a Masters level by 2010, and most are already at the Masters level, meaning that applicants to the program must have an undergraduate degree to apply. Entry-level physiotherapy education in Canada takes place in one of the 13 university programs listed below. Many programs also offer graduate programs in physiotherapy, rehabilitation, or related disciplines at the masters or doctoral level. Many physiotherapists may advance their education at these levels in such Clinical Practice Areas as cardiorespirology, geriatrics, neurosciences, orthopaedics, paediatrics, rheumatology, sports physiotherapy, and women's health.

In New Zealand, there are currently two schools of physiotherapy offering four-year undergraduate programs. Many New Zealand physiotherapists work in the private health care system as musculoskeletal physiotherapists and the curriculum reflects the need to prepare graduates for autonomous practice. Students follow an educational program similar to Australia with an emphasis on biomechanics, kinesiology and exercise. Postgraduate study typically involves two years of subject specific learning.

In the UK university degrees tend to be three rather than four years in length, as historically British students specialise earlier in their education than in most developed countries. Thirty-five universities and tertiary level institutions train physiotherapists in UK. In the UK the vast majority of physiotherapists work within the National Health Service, the state healthcare system.

In the United States a student completes an undergraduate degree prior to gaining entry into a graduate program specialising in physical therapy (Masters or Doctorate) in which they undertake their physical therapy training. Most educational institutions in the United States have transitioned or are transitioning to an entry-level Doctor of Physical Therapy degree for entry-level physical therapy practice.

In the United Arab Emirates[1] the Bachelor Of Physiotherapy (BPT) consists of a 4 year undergraduate degree program. In the first year of the program they are introduced to pre-clinical subjects such as Anatomy, Physiology, Biochemistry, Human Behaviour & Socialisation & Basic Medical Electronics & Computers. The students also get hands on experiences in cadaveric dissections while learning Human Anatomy during the first year of the program. The students progressively are introduced to supervised clinical practice and the integrated curriculum offers the best learning experiences in addition to extensive inhouse elearning programs. The course offers Case Based Learning experiences and focusses on Evidence Based Practices. The program culminates with a six month internship ending with a research project work.

In South Africa the degree (B.PhysT, B.Sc Physio or B.Physio) consists of four years of general practice training, involving all aspects of Physiotherapy. Typically, the first year is made up of theoretical introduction. Gradually, time spent in supervised practice increases until the fourth year, in which the student generally spends about 80% in practice. In the fourth year, students are also expected to complete Physiotherapy research projects, which fulfills the requirements of an Honours degree. Professional practice and specialization can only be entered into after a state governed, compulsory year of community service is completed by the student after graduation.

In India, an undergraduate physiotherapy degree (Bachelor of Physiotherapy - BPT) typically consist of four years of course study and six months of internship, irrespective of universities the first year of an undergraduate course focus on theorotical and laboratory based studies. The later stages increasingly have a clinical focus. There are more than fifty universities that offer under graduate and post graduate physical therapy courses in India. Postgraduate entry into physiotherapy in many institutions is based upon entrance examinations. Post graduate courses (Master of Physiotherapy - MPT) involve two years of subject specific dissertational study.

Following basic physiotherapy training, experienced practitioners may undertake further study towards certification as a specialist practitioner. For example, in the United States, experienced physical therapists may apply to take a specialty exam to earn board certification in any of seven sub-specialty areas: Cardiovascular and Pulmonary, Clinical Electrophysiologic, Geriatric, Neurologic, Orthopaedic, Paediatric, and Sports physical therapy.

Qualifications in the United States

Physical Therapists must have a graduate degree from an accredited physical therapy program before taking the national licensure examination. Most educational programs now offer the Doctor of Physical Therapy (DPT) degree. All states (in the United States) require physical therapists to pass a licensure exam after graduating from an accredited physical therapist educational program before they can practice.

According to the American Physical Therapy Association, there were 209 accredited physical therapist programs in 2006. Of the accredited programs, 61 offered master's degrees, and 148 offered doctoral degrees.

Physical therapist programs start with basic science courses such as biology, chemistry, and physics, and then introduce specialized courses such as kinesiology, biomechanics, neuroanatomy, human growth and development, pathology, diagnostics, physical examination techniques, and therapeutic procedures. Besides classroom and laboratory instruction, students receive supervised clinical education.

Physical therapist education is rigorous, so interested students should attain superior grades in high school and college, especially in science courses. Courses useful when applying to physical therapist educational programs include anatomy, biology, chemistry, social science, mathematics, and physics. Before granting admission, many professional education programs require experience as a volunteer in a physical therapy department of a hospital or clinic.

Physical therapists should have strong interpersonal skills to successfully educate patients about their physical therapy treatments. They should also be compassionate and possess a desire to help patients. Similar traits are also needed to interact with the patient's family.

Physical therapists are expected to continue professional development by participating in continuing education courses and workshops. A number of states require continuing education to maintain licensure.

Many physical therapists pursue board certification in one of seven specialty areas (orthopaedic, pediatric, neurologic, sports, electrophysiologic, geriatric, and cardio-pulmonary.) Board certified specialists have demonstrated expertise in the clinical content area.

References

World Confederation for Physical Therapy

World Confederation for Physical Therapy

Physiotherapy Associations