Physical therapy

Physical therapy or physiotherapy (sometimes abbreviated to PT) is the health care profession primarily concerned with the remediation of impairments and disabilities and the promotion of mobility, functional ability, quality of life and movement potential through examination, evaluation, diagnosis and physical intervention. It is carried out by physical therapists (known as physiotherapists in most countries) and physical therapist assistants (known as physical rehabilitation therapists or physiotherapy assistants in some countries). In addition to clinical practice, other activities encompassed in the physical therapy profession include research, education, consultation, and administration. Definitions and licensing requirements in the United States vary among jurisdictions, as each state has enacted its own physical therapy practice act defining the profession within its jurisdiction, but the American Physical Therapy Association (APTA) has also drafted a model definition in order to limit this variation, and the APTA is also responsible for accrediting physical therapy education curricula throughout the United States of America. In many settings, physical therapy services may be provided alongside, or in conjunction with, other medical or rehabilitation services, including occupational therapy.

Overview
Physical therapy involves the interaction between therapist(s), patients or clients, other health care professionals, families, care givers, and communities in a process where movement potential is assessed and diagnosed and goals are agreed upon. Physical therapy is performed by a therapist and sometimes services are provided by a physical therapist assistant (PTA) acting under their direction. Physical therapists and occupational therapists often work together in conjunction to provide treatment for patients. In some cases, physical rehabilitation technicians may provide physiotherapy services.

PTs are healthcare professionals who diagnose and treat individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions, illnesses, or injuries that limit their abilities to move and perform functional activities as well as they would like in their daily lives. PTs use an individual's history and physical examination to arrive at a diagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies. Electrodiagnostic testing (e.g., electromyograms and nerve conduction velocity testing) may also be of assistance. PT management commonly includes prescription of or assistance with specific exercises, manual therapy, education, manipulation and other interventions. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles, providing services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing therapeutic treatment in circumstances where movement and function are threatened by aging, injury, disease or environmental factors. Functional movement is central to what it means to be healthy.

Physical therapy is a professional career which has many specialties including sports, neurology, wound care, EMG, cardiopulmonary, geriatrics, orthopaedic and pediatrics. Neurological rehabilitation is in particular a rapidly emerging field. PTs practice in many settings, such as outpatient clinics or offices, health and wellness clinics, rehabilitation hospitals facilities, skilled nursing facilities, extended care facilities, private homes, education and research centers, schools, hospices, industrial and this workplaces or other occupational environments, fitness centers and sports training facilities.

Physical therapists also practise in the non-patient care roles such as health policy,   health insurance, health care administration and as health care executives. Physical therapists are involved in the medical-legal field serving as experts, performing peer review and independent medical examinations.

Education qualifications vary greatly by country. The span of education ranges from some countries having little formal education to others having doctoral degrees and post doctoral residencies and fellowships.

History
Physicians like Hippocrates and later Galenus are believed to have been the first practitioners of physical therapy, advocating massage, manual therapy techniques and hydrotherapy to treat people in 460 BC. After the development of orthopedics in the eighteenth century, machines like the Gymnasticon were developed to treat gout and similar diseases by systematic exercise of the joints, similar to later developments in physical therapy. The earliest documented origins of actual physical therapy as a professional group date back to Per Henrik Ling, “Father of Swedish Gymnastics,” who founded the Royal Central Institute of Gymnastics (RCIG) in 1813 for massage, manipulation, and exercise. The Swedish word for physical therapist is sjukgymnast = someone involved in gymnastics for those who are ill. In 1887, PTs were given official registration by Sweden’s National Board of Health and Welfare. Other countries soon followed. In 1894, four nurses in Great Britain formed the Chartered Society of Physiotherapy. The School of Physiotherapy at the University of Otago in New Zealand in 1913, and the United States' 1914 Reed College in Portland, Oregon, which graduated "reconstruction aides." Since the profession's inception, spinal manipulative therapy has been a component of the physical therapist practice.

Modern physical therapy was established towards the end of the 19th century due to events that had an effect on a global scale, which called for rapid advances in physical therapy. Soon following American orthopedic surgeons began treating children with disabilities and began employing women trained in physical education, massage, and remedial exercise. These treatments were applied and promoted further during the Polio outbreak of 1916. During the First World War women were recruited to work with and restore physical function to injured soldiers, and the field of physical therapy was institutionalized. In 1918 the term "Reconstruction Aide" was used to refer to individuals practicing physical therapy. The first school of physical therapy was established at Walter Reed Army Hospital in Washington, D.C., following the outbreak of World War I. Research catalyzed the physical therapy movement. The first physical therapy research was published in the United States in March 1921 in "The PT Review." In the same year, Mary McMillan organized the Physical Therapy Association (now called the American Physical Therapy Association (APTA). In 1924, the Georgia Warm Springs Foundation promoted the field by touting physical therapy as a treatment for polio. Treatment through the 1940s primarily consisted of exercise, massage, and traction. Manipulative procedures to the spine and extremity joints began to be practiced, especially in the British Commonwealth countries, in the early 1950s. Around this time when polio vaccines were developed, physical therapists have become a normal occurrence in hospitals throughout North America and Europe. In the late 1950s, physical therapists started to move beyond hospital-based practice to outpatient orthopedic clinics, public schools, colleges/universities health-centres, geriatric settings (skilled nursing facilities), rehabilitation centers and medical centers. Specialization for physical therapy in the U.S. occurred in 1974, with the Orthopaedic Section of the APTA being formed for those physical therapists specializing in orthopaedics. In the same year, the International Federation of Orthopaedic Manipulative Physical Therapists was formed, which has ever since played an important role in advancing manual therapy worldwide.

Education
Educational criteria for physical therapy providers vary from state to state and from country to country, and among various levels of professional responsibility. Most U.S. states have physical therapy practice acts that recognize both physical therapists (PT) and physical therapist assistants (PTA) and some jurisdictions also recognize physical therapy technicians (PT Techs) or aides. Most countries have licensing bodies that require physical therapists to be a member of before they can start practising as independent professionals.

Physical Therapists
The primary physical therapy practitioner is the Physical Therapist (PT) who is trained and licensed to examine, evaluate, diagnose and treat impairment, functional limitations and disabilities in patients or clients. Currently, most Physical Therapist education curricula in the United States culminate in a Doctor of Physical Therapy (DPT) degree, but many currently practising PTs hold a Master of Physical Therapy degree and some hold a Bachelor's degree. The World Confederation of Physical Therapy (WCPT) recognizes there is considerable diversity in the social, economic, cultural, and political environments in which physical therapist education is conducted throughout the world. WCPT recommends physical therapist entry-level educational programs be based on university or university-level studies, of a minimum of four years, independently validated and accredited as being at a standard that accords graduates full statutory and professional recognition. WCPT acknowledges there is innovation and variation in program delivery and in entry-level qualifications, including first university degrees (Bachelors/Baccalaureate/Licensed or equivalent), Masters and Doctorate entry qualifications. What is expected is that any program should deliver a curriculum that will enable physical therapists to attain the knowledge, skills, and attributes described in these guidelines. Professional education prepares physical therapists to be autonomous practitioners, that may work in collaboration with other members of the health care team. Curricula in the United States are accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). As of 2011, APTA reports that 222 out of 227 entry-level professional degree programs accredited in the United States are at the doctoral level. According to CAPTE, as of 2012 there are 25,660 students currently enrolled in 210 accredited PT programs in the United States.

The physical therapist professional curriculum is as rigorous as the traditional medical curricula and includes content and learning experiences in the clinical sciences (e.g., content about the cardiovascular, pulmonary, endocrine, metabolic, gastrointestinal, genitourinary, integumentary, musculoskeletal, and neuromuscular systems and the medical and surgical conditions frequently seen by physical therapists).

Curricula for the Physical Therapist professional degree include:
 * Screening to determine when patients/clients need further examination or consultation by a physical therapist or referral to another health care professional.
 * Examination: Examine patients/clients by obtaining a history from them and from other sources. Examine patients/clients by performing systems reviews. Examine patients/clients by selecting and administering culturally appropriate and age related tests and measures. Tests and measures include, but are not limited to, those that assess: a. Aerobic Capacity/Endurance, b. Anthropometric Characteristics, c. Arousal, Attention, and Cognition, d. Assistive and Adaptive Devices, e. Circulation (Arterial, Venous, Lymphatic), f. Cranial and Peripheral Nerve Integrity, g. Environmental, Home, and Work (Job/School/Play) Barriers, h. Ergonomics and Body Mechanics, i. Gait, Locomotion, and Balance, j. Integumentary Integrity, k. Joint Integrity and Mobility, l. Motor Function (Motor Control and Motor Learning), m. Muscle Performance (including Strength, Power, and Endurance), n. Neuromotor Development and Sensory Integration, o. Orthotic, Protective, and Supportive Devices, p. Pain, q. Posture, r. Prosthetic Requirements, s. Range of Motion (including Muscle Length), t. Reflex Integrity, u. Self-Care and Home Management (including activities of daily living [ADL] and instrumental activities of daily living [IADL]), v. Sensory Integrity, w. Ventilation and Respiration/Gas Exchange, x. Work (Job/School/Play), Community, and Leisure Integration or Reintegration (including IADL)
 * Evaluation: Evaluate data from the examination (history, systems review, and tests and measures) to make clinical judgments regarding patients/clients.
 * Diagnosis: Determine a diagnosis that guides future patient/client management.
 * Prognosis: Determine patient/client prognoses.
 * Plan of Care: Collaborate with patients/clients, family members, payers, other professionals, and other individuals to determine a plan of care that is acceptable, realistic, culturally competent, and patient-centered.
 * Intervention:Provide physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: a. Therapeutic Exercise, b. Functional Training in Self-Care and Home Management, c. Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration, d. Manual Therapy Techniques (including Mobilization/Manipulation Thrust and Nonthrust Techniques), e. Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment, f. Airway Clearance Techniques, g. Integumentary Repair and Protection Techniques, h. Electrotherapeutic Modalities,
 * Provide effective culturally competent instruction to patients/clients and others to achieve goals and outcomes.
 * Prevention, Health Promotion, Fitness, and Wellness: Provide culturally competent physical therapy services for prevention, health promotion, fitness, and wellness to individuals, groups, and communities. Apply principles of prevention to defined population groups.
 * Students completing a Doctor of Physical Therapy program are also required to successfully complete clinical internships prior to graduation.

In Canada
Canadian Physiotherapy programs are offered at 15 Universities, often through the university's respective college of medicine. In the past decade, each of Canada's physical therapy schools has transitioned from 3-year Bachelor of Science in Physical Therapy (BScPT) programs that required 2 years of pre-requisites university courses (5-year Bachelor's degree) to 2-year Master's of Physical Therapy (MPT) programs that require pre-requisite Bachelor's degrees. The last Canadian university to follow suit was the University of Manitoba who transitioned to the MPT program in 2012, making the MPT credential the new entry to practice standard across Canada. Existing practitioners with BScPT credentials are not required to upgrade their qualifications.

In the province of Quebec, prospective physiotherapists are required to have completed a college diploma in either health sciences, which lasts on average two years, or physical rehabilitation technology, which lasts at least three years, to apply to a physiotherapy program or program in university. Following admission, physical therapy students work on a bachelor of science with a major in physical therapy and rehabilitation. The B.Sc. usually requires three years to complete. Students must then enter graduate school to complete a master's degree in physical therapy, which normally requires one and a half to two years of study. Graduates who obtain their M.Sc. must successfully pass the membership examination to become member of the Ordre professionnel de la physiothérapie du Québec (OPPQ). Physiotherapists can pursue their education in such fields as rehabilitation sciences, sports medicine, kinesiology, and physiology.

To date, there are no bridging programs available to facilitate upgrading from the BScPT to the MPT credential. However, research Master's of Science (MSc) and Doctor of Philosophy (PhD) programs are available at every university. Aside from academic research, practitioners can upgrade their skills and qualifications through continuing education courses and curriculums. Continuing education is a requirement of the provincial regulatory bodies.

The Canadian Physiotherapy Association offers a curriculum of continuing education courses in orthopaedics and manual therapy. The program consists of 5 levels (7 courses) of training with ongoing mentorship and evaluation at each level. The orthopaedic curriculum and examinations takes a minimum of 4 years to complete. However, upon completion of level 2, physiotherapists can apply to a unique 1-year course-based Master's program in advanced orthopaedics and manipulation at the University of Western Ontario to complete their training. This program accepts only 16 physiotherapists annually since 2007. Successful completion of either of these education streams and their respective examinations allows physiotherapists the opportunity to apply to the Canadian Academy of Manipulative Physiotherapy (CAMPT) for fellowship. Fellows of the Canadian Academy of manipulative Physiotherapists (FCAMPT) are considered leaders in the field, having extensive post-graduate education in orthopaedics and manual therapy. FCAMPT is an internationally recognized credential, as CAMPT is a member of the International Federation of Manipulative Physiotherapists (IFOMPT), a branch of the World Confederation of Physical Therapy (WCPT) and the World Health Organization (WHO).

Physical Therapist Assistants
Physical therapist assistants may deliver treatment and physical interventions for patients and clients under a care plan established by and under the supervision of a physical therapist. Physical therapist assistants in the United States are currently trained under associate of applied sciences curricula specific to the profession, as outlined and accredited by CAPTE. As of August 2011, there were 276 accredited two-year (Associate degree) programs for physical therapist assistants In the United States of America. According to CAPTE, as of 2012 there are 10,598 students currently enrolled in 280 accredited PTA programs in the United States.

Curricula for the physical therapist assistant associate degree include:
 * Anatomy & physiology
 * Exercise physiology
 * Human biology
 * Physics
 * Biomechanics
 * Kinesiology
 * Neuroscience
 * Clinical pathology
 * Behavioral sciences
 * Communication
 * Ethics
 * Research
 * Other coursework as required by individual programs.

Physical Therapy Technicians or Aides
Some jurisdictions allow physical therapists to employ technicians or aides or therapy assistants to perform designated routine tasks related to physical therapy under the direct supervision of a physical therapist. Some jurisdictions require physical therapy technicians or aides to be certified, and education and certification requirements vary among jurisdictions.

In Canada
In the province of Quebec, physical rehabilitation therapists are health care professionals who are required to complete a three year college diploma program in physical rehabilitation therapy and be member of the Ordre professionnel de la physiothérapie du Québec (OPPQ) in order to practise legally in the country.

Most physical rehabilitation therapists complete their college diploma at Collège Montmorency, Dawson College, or Cégep Marie-Victorin, all situated in and around the Montreal area.

After completing their technical college diploma, graduates have the opportunity to pursue their studies at the university level to perhaps obtain a bachelor's degree in physiotherapy, kinesiology, exercise science, or occupational therapy. The Université de Montréal and the Université de Sherbrooke are among the Québécois universities that admit physical rehabilitation therapists in their programs of study related to health sciences and rehabilitation in order to credit courses that were completed in college.

In the United States of America
Job duties and education requirements for Physical Therapy Technicians or Aides may vary according to employer, but education requirements range from high school diploma or equivalent to completion of a 2-year degree program. O-Net reports that 64% of PT Aides/Techs have a high school diploma or equivalent, 21% have completed some college but hold no degree, and 10% hold an Associate's Degree.

Employment
Physical therapy-related jobs in North America have shown rapid growth in recent years, but employment rates and average wages may vary significantly between different countries, states, provinces or regions.

United States of America
According to the United States Department of Labor's Bureau of Labor Statistics, there were approximately 198,600 Physical Therapists employed in the United States in 2010, earning an average $76,310 annually, or $36.69 per hour, with 39% growth in employment projected by the year 2020. The Bureau of Labor Statistics also reports that there were approximately 114,400 Physical Therapist Assistants and Aides employed in the United States in 2010, earning an average $37,710 annually, or $18.13 per hour, with 45% growth in employment projected by the year 2020. To meet their needs, many healthcare and physical therapy facilities hire "Travel physical therapists", who work temporary assignments between 8 and 26 weeks for much higher wages; about $113,500 a year. Bureau of Labor Statistics data on PTAs and Techs can be difficult to decipher, due to their tendency to report data on these job fields collectively rather than separately. O-Net reports that in 2011, PTAs in the United States earned a median wage of $51,040 annually or $24.54 hourly, and that Aides/Techs earned a median wage of $23,680 annually or $11.39 hourly in 2011.

Specialty areas
Because the body of knowledge of physical therapy is extremely large, PTs usually specialize in a specific clinical area. While there are many different types of physical therapy, the American Board of Physical Therapy Specialties list eight specialist certifications. Most Physical Therapists practicing under a specialism will have undergone further training.

Cardiovascular & pulmonary
Cardiovascular and pulmonary rehabilitation respiratory practitioners and physical therapists treat a wide variety of cardiopulmonary disorders or pre and post cardiac or pulmonary surgery. An example of cardiac surgery is cabg. Primary goals of this specialty include increasing endurance and functional independence. Manual therapy is used in this field to assist in clearing lung secretions experienced with cystic fibrosis. Disorders, including heart attacks, post coronary bypass surgery, chronic obstructive pulmonary disease, and pulmonary fibrosis, treatments can benefit from cardiovascular and pulmonary specialized physical therapists.

Clinical electrophysiology
This specialty area encompasses electrotherapy/physical agents, electrophysiological evaluation (EMG/NCV), physical agents, and wound management.

Geriatric
Geriatric physical therapy covers a wide area of issues concerning people as they go through normal adult aging but is usually focused on the older adult. There are many conditions that affect many people as they grow older and include but are not limited to the following: arthritis, osteoporosis, cancer, Alzheimer's disease, hip and joint replacement, balance disorders, incontinence, etc. Geriatric physical therapists specialize in treating conditions in older adults.

Integumentary
Integumentary (treatment of conditions involving the skin and all its related organs). Common conditions managed include wounds and burns. Physical therapists may utilize surgical instruments, mechanical lavage, dressings and topical agents to debride necrotic tissue and promote tissue healing. Other commonly used interventions include exercise, edema control, splinting, and compression garments.

Neurological
Neurological physical therapy is a field focused on working with individuals who have a neurological disorder or disease. These can include stroke, chronic back pain, Alzheimer's disease, Charcot-Marie-Tooth disease (CMT), ALS, brain injury, cerebral palsy,l.g.b.syndrome, multiple sclerosis, Parkinson's disease, facial palsy and spinal cord injury. Common impairments associated with neurologic conditions include impairments of vision, balance, ambulation, activities of daily living, movement, muscle strength and loss of functional independence. Physiotherapy can address many of these impairments and aid in restoring and maintaining function, slowing disease progression, and improving quality of life. The techniques involve in neurological physical therapy are wide ranging and often require specialized training.

Neurological physiotherapy is also called neurophysiotherapy or neurological rehabilitation.

Orthopedic
Orthopedic physical therapists diagnose, manage, and treat disorders and injuries of the musculoskeletal system including rehabilitation after orthopedic surgery. This speciality of physical therapy is most often found in the out-patient clinical setting. Orthopedic therapists are trained in the treatment of post-operative orthopedic procedures, fractures, acute sports injuries, arthritis, sprains, strains, back and neck pain, spinal conditions, and amputations.

Joint and spine mobilization/manipulation, dry needling, therapeutic exercise, neuromuscular techniques, muscle reeducation, hot/cold packs, and electrical muscle stimulation (e.g., cryotherapy, iontophoresis, electrotherapy) are modalities often used to expedite recovery in the orthopedic setting. Additionally, an emerging adjunct to diagnosis and treatment is the use of sonography for diagnosis and to guide treatments such as muscle retraining. Those who have suffered injury or disease affecting the muscles, bones, ligaments, or tendons will benefit from assessment by a physical therapist specialized in orthopedics.

Pediatric
Pediatric physical therapy assists in early detection of health problems and uses a wide variety of modalities to treat disorders in the pediatric population. These therapists are specialized in the diagnosis, treatment, and management of infants, children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or acquired disorders/diseases. Treatments focus on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration. Children with developmental delays, cerebral palsy, spina bifida, or torticollis may be treated by pediatric physical therapists.

Sports
Physical therapists can be involved in the care and wellbeing of athletes including recreational, semi-professional (paid) and professional (full-time employment) participants. This area of practice encompasses complete athletic injury management under 5 main categories: Physical therapists who work for professional sport teams often have a specialized sports certification issued through their national registering organisation. Most Physical therapists who practice in a sporting environment are also active in sports medicine programs too.
 * 1) acute care - assessment and diagnosis of an initial injury;
 * 2) treatment - application of specialist advice and techniques to encourage healing;
 * 3) rehabilitation - progressive management for full return to sport;
 * 4) prevention - identification and address of deficiencies known to directly result in, or act as precursors to injury
 * 5) education - sharing of specialist knowledge to individual athletes, teams or clubs to assist in prevention or management of injury

Women's health
Women's health physical therapy mostly addresses women's issues related to the female reproductive system, child birth, and post-partum. These conditions include lymphedema, osteoporosis, pelvic pain, prenatal and post partum periods, and urinary incontinence. It also addresses incontinence, pelvic pain, and other disorders associated with pelvic floor dysfunction.

Palliative care
Physiotherapy in the field of Oncology and Palliative care is a continuously evolving and developing specialty, both in Malignant and non-malignant diseases. Rehabilitation for both groups of patients is now recognized as an essential part of the clinical pathway, as early diagnoses and new treatments are enabling patients to live longer. it is generally accepted that patients should have access to an appropriate level of rehabilitation, so that they can function at a minimum level of dependency and optimize their quality of life, regardless of their life expectancy.

Effectiveness
A 2012 systematic review found evidence to support the efficacy of spinal manipulation administered by physical therapists to patients. The same review found that physical therapy spinal manipulation seems to be safe and improves the outcome for individuals with low back pain.