Movement & Exercise

Physical therapy or physiotherapy (often abbreviated to PT) is a physical medicine and rehabilitation specialty that remediates impairments and promotes mobility, function, and quality of life through examination, diagnosis, prognosis, and physical intervention (therapy using mechanical force and movements). It is carried out by physical therapists (known as physiotherapists in most countries).

In addition to clinical practice, other activities encompassed in the physical therapy profession include research, education, consultation, and administration. In many settings, physical therapy services may be provided alongside, or in conjunction with, other medical services.

Overview

Physical therapy (or Physiotherapy) involves the illnesses, or injuries that limit a person’s abilities to move and perform functional activities as well as they would like in their daily lives.^[1] PTs use an individual’s history and physical examination to arrive at adiagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies like X-rays, CT-scan, or MRI findings. Electrodiagnostic testing (e.g., electromyograms and nerve conduction velocity testing) may also be of assistance.^[2] PT management commonly includes prescription of or assistance with specific exercises, manual therapy and manipulation, mechanical devices such as traction, education, physical agents which includes heat, cold, electricity, sound waves, radiation, rays, prescription of assistive devices, prostheses, orthoses 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, orthopedics and pediatrics. Neurological rehabilitation is in particular a rapidly emerging field. PTs practice in many settings, such as private-owned physical therapy clinics, 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.^[3]

Physical therapists also practise in the non-patient care roles such as health policy,^[4][5][6][7] health insurance, health care administration and as health care executives.^[8][9] Physical therapists are involved in the medical-legal field serving as experts, performing peer review and independent medical examinations.^[10]

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.^[11][12]

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

United States

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. Physical Therapist education curricula in the United States culminate in a Doctor of Physical Therapy (DPT) degree,^[25] but many currently practising PTs hold a Master of Physical Therapy degree, and some still hold a Bachelor’s degree. Currently the education programs for physical therapy have changed. The Master of Physical Therapy and Master of Science in Physical Therapy degrees are no longer offered, and the entry-level degree is the Doctor of Physical Therapy degree, which typically takes 3 years.^[26] PTs who hold a Masters or bachelors in PT are encouraged to get their DPT because APTA’s goal is for all PT’s to be on a doctoral level.^[27][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.^[28] Curricula in the United States are accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). According to CAPTE, as of 2012 there are 25,660 students currently enrolled in 210 accredited PT programs in the United States.^[29]

The physical therapist professional curriculum includes content 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.

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 Alliance of Physiotherapy Regulators (CAPR), or simply known as The Alliance, offers eligible program graduates to apply for the national Physiotherapy Competency Examination (PCE). Passing the PCE is one of the requirements in most provinces and territories to work as a licensed physiotherapist in Canada.^[30] The Alliance has members which are physiotherapy regulatory organizations recognized in their respective provinces and territories:

• Government of Yukon, Consumer Services
• College of Physical Therapists of British Columbia
• Physiotherapy Alberta College + Association
• Saskatchewan College of Physical Therapists
• College of Physiotherapists of Manitoba
• College of Physiotherapists of Ontario
• Ordre professionnel de la physiothérapie du Québec
• College of Physiotherapists of New Brunswick/Collège des physiothérapeutes du Nouveau-Brunswick
• Nova Scotia College of Physiotherapists
• Prince Edward Island College of Physiotherapists
• Newfoundland & Labrador College of Physiotherapists^[31]

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.^[32] According to CAPTE, as of 2012 there are 10,598 students currently enrolled in 280 accredited PTA programs in the United States.^[29]

Curricula for the physical therapist assistant associate degree include:^[33]

• 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.

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.

United States

Job duties and education requirements for Physical Therapy Technicians or Aides may vary depending on the employer, but education requirements range from high school diploma or equivalent to completion of a 2-year degree program.^[34] O-Net reports that 64% of PT Aides/Techs have a high school diploma or equivalent, 21% have completed some college but do not hold a degree, and 10% hold an associate degree.^[35]

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.^[36] 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.^[37] 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.^[35][38]

Specialty areas

Because the body of knowledge of physical therapy is 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 physiotherapy

Cardiovascular and pulmonary rehabilitation respiratory practitioners and physical therapists offer therapy for a wide variety of cardiopulmonary disorders or pre and post cardiac or pulmonary surgery. An example of cardiac surgery is coronary bypass surgery. 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. Pulminary disorders, heart attacks, post coronary bypass surgery, chronic obstructive pulmonary disease, and pulmonary fibrosis, treatments can benefit^{[citation needed]} from cardiovascular and pulmonary specialized physical therapists.^{[39][verification needed]}

Clinical electrophysiology

This specialty area includes 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 providing therapy for such conditions in older adults.

Integumentary

Integumentary physical therapy includes the treatment of conditions involving the skin and all its related organs. Common conditions managed include wounds and burns. Physical therapists may utilize surgical instruments, wound irrigations, dressings and topical agents to remove the damaged or contaminated tissue and promote tissue healing.^[40] Other commonly used interventions include exercise, edema control, splinting, and compression garments. The work done by physical therapists in the integumentary specialty do work similar to what would be done by medical doctors or nurses in the emergency room or triage.

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^{[clarification needed]}, 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.^[39] 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 (similar to acupuncture), therapeutic exercise, neuromuscular techniques, muscle reeducation, hot/cold packs, and electrical muscle stimulation (e.g., cryotherapy,iontophoresis, electrotherapy) are modalities employed to expedite recovery in the orthopedic setting.^{[41][verification needed]} Additionally, an emerging adjunct to diagnosis and treatment is the use of sonography for diagnosis and to guide treatments such as muscle retraining.^[42][43][44] 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 limited variety of modalities to provide physical therapy for 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 mainly on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration.

Sports

Physical therapists are closely involved in the care and wellbeing of athletes including recreational, semi-professional (paid) and professional (full-time employment) participants. This area of practice encompasses athletic injury management under 5 main categories:

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, such as movement assessment
5. education – sharing of specialist knowledge to individual athletes, teams or clubs to assist in prevention or management of injury

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 collaborative sports medicine programs too (See also: athletic trainers).^[45]

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.^[46] Manual physical therapy has been demonstrated in multiple studies to increase rates of conception in women with infertility.^{[47][48][49][50]}

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 use of spine manipulation by physical therapists as a safe option to improve outcomes for low back pain.^[51] A 2015 systematic review suggested that spine manipulation and therapeutic massage are effective interventions for neck pain; it also suggested, however, that electroacupuncture, strain-counterstrain, relaxation massage, heat therapy and ultrasound therapy are not effective and thus not recommended for the treatment of neck pain.^[52]

United States

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.