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Physical therapy (also known as physiotherapy) is a 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 juristications, such as the Australian states, enjoy professional autonomy, with the ability to act as primary care providers and to determine — and be responsible for — a patient's management plan. Conversely, physiotherapists in some other juristictions work upon referral from, and largely under the direction of, other professionals (typically medical practioners).
The major conditions managed by physiotherapists can be broadly grouped into three categories: musculoskeletal, cardiopulmonary and neurological. Many areas of physiotherapy, e.g. rehabilitation or paediatrics, cross all three 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 juristictions, 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). 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 late Victorian England. In 1894 the British Medical Journal raised concerns about the practices of some masseuses and masseurs who were offering massage as a euphemism for sex. 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.
Quickly, the English example was followed by most of the collonial countries which adopted practices and regulatory systems suitable for their local conditions. In America, Australia, Canada and New Zealand 'authenitic' massage became synonymous with a discrete body of treatment modalities including electrotherapy (and later actinotherapy - the application of heat and light for healing purposes), remedial gymnastic exercise and, of course, massage and manipulation.
A concern to provide an authentic alternative to the massage parlours, and a desire to court medical approval, saw early physiotherapy pioneers adopt a biomechanical view of the body in health and illness - something that dominates the physiotherapy 'philosophy' even to this day.
Massage became a vital service in both world wars and much was learnt about the rehabilitation of injured servicemen from these unfortunate events. Physiotherapy grew rapidly after the First World War with spinal injury units, orthopaedic hospitals and chest clinics providing new challenges to the profession.
In most post-colonial 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, refine 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.
Treatment
Guided by the assessment findings, the physiotherapist will then develop and facilitate a treatment plan. Aside from the various physiotherapeutic teachniques involved in therapy, the treatment regimen 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 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 if 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.
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 latter stages. Postgraduate entry into physiotherapy in possible in some institutions, typically involving two years of study following the completion of a related (e.g. exercise physiology or science) undergraduate degree.
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. 35 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 an undergraduate student typically undertakes a science-related course (such as biology or physics) prior to gaining entry into a graduate program specialising in physical therapy in which they undertake their physical therapy training.
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, Pediatric, and Sports physical therapy.
Qualifications in the United States
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 189 accredited physical therapist programs in 1999. Of the accredited programs, 24 offered bachelor's degrees, 157 offered master's degrees, and 8 offered doctoral degrees. By 2002, all physical therapist programs seeking accreditation will be required to offer degrees at the master's degree level and above, in accordance with the Commission on Accreditation in Physical Therapy Education.
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, manifestations of disease, examination techniques, and therapeutic procedures. Besides classroom and laboratory instruction, students receive supervised clinical experience. Individuals who have a four-year degree in another field and want to be a physical therapist should enroll in a master's or a doctoral level physical therapist educational program.
Competition for entrance into physical therapist educational programs is very intense, 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.
See also
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