Physical therapy is an evidence-based profession whose focus is on the restoration, maintenance, and promotion of optimal human physical function.¹ The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) has been embraced by the global physical therapy community as a key construct in describing the relationship between components of human function and health-related conditions.^2,3 Services provided by physical therapists may address all aspects of the ICF model including impairments in body structures and body functions, activity limitations, and participation restrictions. Physical therapists generally work with individuals with musculoskeletal, neuromuscular, cardiovascular, pulmonary, and integumentary dysfunction. In addition to direct patient care, physical therapists play a role in education, research, administration, and consultation as well as in preventive care and promoting optimal health and wellness.

The physical therapy profession in the United States has its roots as far back as the early part of the twentieth century. The polio epidemic in 1916 and World War I greatly facilitated the profession’s growth as the need for exercise specialists to treat those with muscle weakness and war-related injuries was evident. The Division of Special Hospitals and Physical Reconstruction was established in 1917 by the US Surgeon General to meet the human resource needs.^4,5 Reconstruction aides were trained in this system to treat those injured in war. Concurrently, the polio epidemic created the need for health care teams including physical therapists to examine and treat children with polio. These historical events established the foundation for the current day physical therapist (PT) professional.

The onset of World War II, as well as further outbreaks of polio, further advanced the demand for the rehabilitation professional and facilitated the development of professional practice throughout the 1950s and 1960s.⁶ The evolution of the profession in the latter half of the twentieth century and the early part of the twenty-first century cannot be separated from the changes in the educational and licensing requirements, as well as the growth of the professional association, all of which facilitated the advance of both practice and research.

The origin of physical therapist education began during World War I with 15 “reconstruction aid” training programs developed by the US Army.⁵ Around the same time, special training for those involved in the care of children with poliomyelitis or “infantile paralysis” was initiated in Boston by an Orthopedic Surgeon, Robert Lovett. Many women who trained within the Army system and those trained to treat children with poliomyelitis were the early leaders of the profession.

Educational requirements to practice as a physical therapist were elevated over the twentieth century. Minimum degree requirements evolved from certificate level programs in the early twentieth century, where training was primarily based in the hospital setting, to baccalaureate degree programs in the 1960s, housed primarily in academic colleges and universities.⁶ As physical therapy examination and interventions became increasing more complex to meet the growing needs of society, the transition to post baccalaureate minimum educational requirement followed in 2003. As of January 1, 2018, the professional doctorate degree (DPT) will be considered the minimum requirement.⁷ Today, there are more than 225 universities and colleges in the United States that offer a professional degree in physical therapy at the level of the clinical doctorate. These changes, in part, are the outcome of advances in medicine, technology and research, and the subsequent increase in the average life span. This in turn has resulted in a larger population in need of rehabilitation and physical therapy services. Additionally, the needs of a growing older population with comorbid and complex health conditions requires a clinician with critical thinking and problem-solving skills, who is prepared to examine and treat clients throughout their lifespan.

Physical therapists may complete residency or fellowship training following graduation to advance their skills in specialized areas of practice. In addition, physical therapists can become a certified specialist through demonstration of clinical competencies and formal testing. At present, the American Board of Physical Therapy Specialties recognizes eight areas of specialization: Cardiovascular and Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, and Women’s Health.

In 1921, the precursor to the present day professional association was established: the American Women’s Physical Therapeutic Association, by Mary McMillan, Chief Reconstruction Aide in the department of physiotherapy at Walter Reed Army Hospital. In 1922, with the inclusion of male members, the name of the association was changed to the American Physiotherapy Association. The goal of the association was to establish and maintain professional standards as well as advance study, disseminate literature, and address physical therapist training.⁸ Since 1921, the association has published the journal Physical Therapy, which is recognized as among the leading peer-reviewed journal in rehabilitation. In the late 1940s, the association changed names once again to its current name, the American Physical Therapy Association (APTA) with membership today totaling over 65,000 physical therapists and physical therapist assistants and 29,000 additional student members.⁹ The APTA is a member of the World Confederation of Physical Therapy (WCPT), which is the global organization representing the physical therapy profession.^*

The vision statement of APTA is “Transforming society by optimizing movement to improve the human experience.”¹⁰ The association’s strategic plan focuses on removing barriers to movement at the population and individual level as well as delivering value-based services using evidence and best practice with physical therapists as movement system experts.¹¹ Organizationally, today’s association is comprised of 51 chapters that includes all states and the District of Columbia and its governance structure includes a Board of Directors and a House of Delegates, whose voting members represent individual state chapters. Eighteen specialty sections also participate in the governance process; however, these are non-voting members in the House of Delegates. These specialty sections represent many different areas of physical therapist practice from special populations of patient care to education, administration, research, and policy.¹²

With encouragement from the APTA, state chapters began to seek licensure in their respective states such that physical therapist practice in most states was regulated by the late 1950s.¹³ In order to assess and standardize competencies, a national physical therapist examination was created in 1954, which was initially developed by the APTA. However, due to potential conflicts of interest, the Federation of State Boards of Physical Therapy was developed and now is responsible for developing and maintaining the National Physical Therapy Examination (NPTE) for physical therapists and physical therapist assistants. The purpose of the examination is to “protect the public by testing candidates on the minimum knowledge and education necessary for safe and competent entry-level work.”¹⁴

In order for candidates to be eligible to take the national licensure exam as well as be eligible to provide services to clients on Medicare, they must graduate from an accredited entry-level professional physical therapist program. These educational programs are accredited by the Commission on Accreditation of Physical Therapy Education (CAPTE).¹⁵ CAPTE is the only accrediting agency recognized by the US Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA) to accredit physical therapy programs. The role of CAPTE as a specialized program accreditor is to assess programs of study to ensure quality education for each student and ensure quality physical therapy services to the public. Program accreditation requires initial candidacy status and once accreditation status is awarded, regular self-study reports demonstrating continued compliance with the standards are required.

Due to increasing demands for physical therapy services, the physical therapist assistant (PTA) as a patient/client care provider was established in the late 1960s. PTA education typically includes a 2-year program of study from an accredited physical therapy assistant educational program. Following graduation, most states and jurisdictions require the candidate to pass the NPTE for PTAs to gain licensure or certification. The PTA carries out the plan of care developed by a licensed physical therapist. The PTA is under the direction and supervision of the physical therapist; however, state practice acts outline the specific role of the PTA, which may vary from state to state.^1,16

The APTA describes the scope of physical therapist practice as dynamic and having professional, jurisdictional, and personal components.¹⁷ The professional scope of practice is bounded by a unique body of knowledge, which is supported by educational preparation and by research evidence. The jurisdictional scope of practice is established by the state’s practice act licensing requirements. State practice acts may allow or restrict certain forms of treatment. One example of a practice area which is allowed by a number of states (in some cases with additional competencies) is dry needling; whereas other states do not allow dry needling under a physical therapy license. The personal scope of practice relates to the knowledge, skills, and abilities of the individual therapist, which is generally a subset of the professional and jurisdictional scopes of practice.

Descriptions of physical therapy practice, roles of PTs and PTAs, and settings in which physical therapists practice are described in APTA’s Guide to Physical Therapist Practice.¹ This resource is updated regularly to maintain currency and is available online. The Guide describes six elements of the physical therapist patient/client management model: examination, evaluation, diagnosis, prognosis, intervention, and outcomes. The examination begins with obtaining a history from a patient and a brief review of body systems as the physical therapist begins the process of clinical decision-making to identify the problem(s) relevant to physical therapy, as well as the possibility of consultation with, or referral to, another health care provider. The physical therapist then performs tests and measures as part of the physical examination to assist in assessing the patient’s functional status. Table 77–1 includes the 26 types of tests and measures utilized by physical therapists as identified by the Guide.

Evaluation is described as an ongoing process where a physical therapist integrates information gained from the examination, which is then used to determine a diagnosis and plan of care. The evaluative process continues through the episode of care as the physical therapist evaluates responses to interventions and progress toward goals. Diagnosis is used by physical therapists to categorize findings from the evaluative process to determine the most appropriate intervention strategies. Often, the diagnostic categories used by physical therapists will relate to the function of the individual, including the human movement system. Based on the diagnosis, the physical therapist makes a prognosis that includes a judgment of the optimal level of improvement and the time needed to reach that level. The prognosis includes a plan of care, which specifies the interventions to be used to assist in achieving the patient’s goals for physical therapy. Physical therapy intervention includes the treatment approach used in a patient’s plan of care. Categories of interventions utilized by physical therapists are listed in Table 77–2. The physical therapist chooses evidence-based interventions, which optimize the individual patient’s function in order to achieve appropriate goals. Evidence from clinical practice guidelines, systematic reviews, and randomized clinical trials for the effectiveness of different physical therapy interventions are available online via the Physiotherapy Evidence Database (PEDro) (www.pedro.org.au). The Orthopaedic Section of the American Physical Therapy Association has developed a number of clinical practice guidelines for physical therapist practice. These are available to the public at www.orthopt.org/content/practice/clinical-practice-guidelines.

Outcomes are used to describe a patient’s status and the results of physical therapy intervention. Measures of outcomes should relate to function and should be documented as part of every episode of care. Online resources such as the RehabMeasures Database (www.rehabmeasures.org) and PTNow (www.ptnow.org) provide the psychometric properties on a number of different instruments utilized by physical therapists as examination and outcome measures.

Physical therapists practice in settings such as hospitals, rehabilitation centers, outpatient clinics, home health, school systems, skilled nursing facilities, and athletic fields and facilities. Clinical decision-making is an essential function of a physical therapist. Regardless of setting, the physical therapist determines if the patient’s problem is within the scope of physical therapist practice, requires a referral to another health care provider, or can be managed solely by the physical therapist or within the context of a health care team.

Patients may be referred to physical therapy by physicians and other health care professionals as specified by individual State Practice Acts. In addition, all jurisdictions in the United States allow for some form of direct access where the physical therapist may be the first point of patient contact within the health care system for examination or treatment.¹⁸ In some states, direct access is not restricted, whereas in other states, direct access limitations are imposed under certain circumstances (e.g., preexisting medical diagnoses, number of visits). Communication between the physical therapist and the other members of the health care team is crucial for optimal patient management regardless of the patient’s entry point.