A History of Physical Therapist Education Around the World
2012; Lippincott Williams & Wilkins; Volume: 26; Issue: 1 Linguagem: Inglês
10.1097/00001416-201210000-00005
ISSN1938-3533
Autores Tópico(s)Occupational Therapy Practice and Research
ResumoINTRODUCTION The roots of the physical therapist education reach back through the ages. The development of physical therapy as an autonomous profession based on current scientific knowledge was in large part due to Per Henrik Ling of Sweden. In 1813, he founded the Royal Central Institute of Gymnastics (RCIG) in Stockholm for the training of gymnastic instructors. With the founding of RCIG, Ling provided a professional identity for the physical therapist. Thereafter, physical therapist education evolved in different ways around the world. In the United Kingdom, it was through the Society of Trained Masseuses. In Norway and Finland, it was influenced by the work of Ling, with an emphasis on massage training. In the United States, it was as a result of the polio epidemics and the need to treat those wounded during World War I. The World Confederation for Physical Therapy (WCPT) has established standards and guidelines for physical therapist entrylevel education that are globally relevant and available to all on its Web site. They include the "WCPT Policy Statement: Education" and the 5 WCPT guidelines related to physical therapist professional entry-level education ("WCPT Guidelines for Physical Therapist Professional Entry-Level Education"; "WCPT Guideline for Qualifications of Faculty for Physical Therapist Professional Entry-level Education Programs"; "WCPT Guideline for the Clinical Education Component of Physical Therapist Professional Entry-level Education"; "WCPT Guideline for Curricula for Physical Therapists Delivering Quality Exercise Programs Across the Life Span"; and "Guideline for a Standard Evaluation Process for Accreditation/Recognition of Physical Therapist Professional Entry-level Education Program"). Consideration of physical therapist education across member organizations in each of the 5 WCPT regions clearly demonstrates that major diversity exists in physical therapist entry-level professional education around the world. THE ROOTS The roots of the profession of physical therapy may have begun as early as 3,000 BC, with evidence that the Chinese practiced massage. Hippocrates (460-377 BC) made reference to friction massage.1 The use of therapeutic exercise and massage in the 16th century occurred when the Greeks realized that physical health and spiritual health were inseparable. An Italian physician, Gerolamo Mercuriale, used exercise both hygienically and curatively in the 1500s.2 In Sweden in the early 19th century, Pehr Henrik Ling combined massage and rhythmic exercises for health benefits.3 In the 17th, 18th, and 19th centuries, there are references to correcting childhood deformities with splinting, massage, and prosthetics; treating patients with a stroke by reawakening the weakened control of the brain through motion; and using a regime of gymnastics and massage to treat scoliosis.4 BEGINNINGS OF PHYSICAL THERAPIST EDUCATION IN SWEDEN The profession of physical therapy developed in Sweden first as an autonomous profession based on the scientific knowledge of the day due to Pehr Henrik Ling (Figure 1), who has been called the "Father of Swedish Gymnastics." Ling, originally a graduate of the Vãxjö gymnasium (1792) and a fencing master, went on to study theology at Lund and Uppsala Universities. While traveling abroad after graduation, he met a Chinese individual (Ming) who instructed Ling in martial arts and tui na. Ling acquired further knowledge in England, Germany, and France that expanded Ming's special "gymnastics" or exercises and were aimed at enhancing stamina, strength, and flexibility—requisites for Ling's fencing. Ling returned to Sweden as a result of overuse injuries and "rheumatism" and healed himself using the exercises that he had acquired. He was appointed as a fencing master at Uppsala. Appreciating how the exercises had restored his health, he understood the importance of using exercises for the health of others. Thus, Ling began studies of anatomy and physiology and eventually completed the doctor (meaning "physician" at this time) training curriculum. He categorized his system of gymnastics, exercises, and maneuvers into 4 specific areas: medical (physical therapy), military (primarily fencing), pedagogical (physical education), and aesthetic. Ling then attempted to garner the support of the Swedish government for his approach, which was not immediately forthcoming. Finally, in 1813, he founded the Royal Central Institute of Gymnastics (RCIG) in Stockholm for the training of gymnastic instructors with the cooperation of the Swedish government.5Figure 1. Pehr Henrik LingAlthough there were other European contemporaries involved in the early days of the profession of physical therapy, it was Ling who is credited with creating the identity of the physical therapist. With the founding of RCIG, Ling provided not only a professional identity for the physical therapist, but also the first formally state-sanctioned education program. Until about 1827, RCIG also was the only institution that offered education and also mechanical treatments.6 The examination that students took in the early days upon completion of the RCIG program covered the 3 areas of medical, military, and pedagogical learning, and these men were then capable of working outside of their regiments as physical therapists and physical educators. The title given to those who passed the examination was "Director of Gymnastics," and they were in charge of an institute curing sick people with the use of physical therapy. In 1887, Sweden's National Board of Health and Welfare officially sanctioned these directors and allowed them to apply for authorization from their Board.6 Of interest is the fact that the profession in Sweden was originally one for men who were noblemen or a member of the upper bourgeoisie, and women did not become part of the profession until 1864. Male students had to possess an officer's degree or equivalent for admission to RCIG, whereas female students had only to complete compulsory school. In addition, the education for male students was 3 years in length, whereas the education for female students was only 2 years since women were not required to take military gymnastics. For qualified doctors, the education was only 1 year.6 Graduates of the RCIG program spread out to present their new science of physical therapy that cured and prevented diseases and disabilities to lay audiences, physicians in many other countries, and to many health spas and resorts throughout the 20th century. This new model of "mechanical Medicine/medical Gymnastics" attracted many to RCIG, including Lieutenant Jonas Henrik Kellgren from London. His son-in-law, Edgar F. Cyriax, was an RCIG-trained physician in London whose medical degree thesis was titled, "The Elements of Kellgren's Manual Treatment." Kellgren's grandson was James Cyriax, who physical therapists recognize and is credited as the founder of orthopedic medicine.6 In 1864, RCIG underwent a major reorganization, which led to its monopoly on the education of physical therapists. Even the government in Sweden declared that in order to practice physical therapy, anyone, including MDs, had to pass the official RCIG examination. Thus, for a doctor to become a specialist in physical therapy (doctors of gymnastics/physical therapy), they had to complete the gymnastics/physical therapy training at RCIG.6 It also must be noted that for almost 100 years (1830s-1940s), major conflicts existed between Swedish physical therapists and physicians, especially orthopedists. The overlap of mechanical interventions was apparent, and resolutions of the conflicts did not really occur until the orthopedists "took up the knife" in place of mechanical medicine.6 In 1934, a Swedish physician, Patrik Haglund (Figure 2), divided the education of physical therapists into 2: physical educators and physical therapists. The Carolingian Institute, the new name for the RCIG, became responsible for physical therapist education. Physical therapists no longer received education in physical education, and physical educators no longer received education in physical therapy. The faculty of medicine at the Carolingian Institute was responsible for the education of physical therapists and compulsory education was all that was required for admission to the physical therapist program. On the other hand, physical educators had to possess qualifications that were equivalent to those for admission to the university. Thus, physical education became superior to physical therapy, requiring 2 years of education, whereas physical therapist education was only 1½ years. The scientific basis of physical therapy also was minimized by Patrik Haglund. Haglund was one of the early orthopedic surgeons in Sweden and held the first chair in orthopedics in 1913. He was a part of the early group of young surgeons who broke away from mechanical medicine. Haglund did not want men, particularly men of the upper class, to become physical therapists. He felt women would not have the same aspirations as men and would therefore act less autonomously. This sad portion of education history in Sweden is probably no different than what happened in other parts of the world. In Sweden, almost 100 years of a strong physical therapy history and identity seemed to have been lost.6Figures 2 and 3: Outpatient therapy in the Polyclinic of the Royal Central Institute of GymnasticsFigure 4. Patrik HaglundCurrently, the Swedish association has their own education department. There are 7 physical therapist schools in the country, graduating about 550 students per year. The physical therapist education is a 3-year program that leads to a Bachelor of Science Degree. Opportunities for continuing education exist, including pursuit of master's and doctoral degrees.7 BEGINNINGS OF PT EDUCATION IN THE UNITED KINGDOM By the late 19th and early 20th centuries, the profession began to come into its own in many parts of the world. In the United Kingdom, the Society of Trained Masseuses, composed of trained nurses, established a certification program for massage. The required exam consisted of anatomy and theory questions, and a practical massage on a living model. Along with the massage certification program, training programs for nurses were primarily in hospital-based programs. In 1900, the society became the Incorporated Society of Trained Masseuses (ISTM).8 As early as 1903, training and examination in remedial exercises based on those used in Sweden became a course offered to members of the ISTM at the Chelsea Physical Training College. In 1910, a full examination was given in Swedish remedial exercises under the auspices of the ISTM. In 1913, all students who prepared for the massage examination actually had to see and provide treatment to patients in hospitals, infirmaries, or their equivalent. New schools in London (including the Swedish Institute and Clinque, the Training College for Massage and Remedial Gymnastics, and the Swedish Training Schools for Remedial Exercises and Massage) opened under the auspices of women doctors that trained students for the examination in Swedish remedial exercises.8 With the outbreak of World War I, Britain's surgeon general established a corps of 50 certified masseuses. In the ensuing 4 years, the corps maintained a supply of trained personnel, but the standard of training was fraught with difficulties. In 1915, lectures and demonstrations on medical electricity were added by the ISTM, and the first examination in medical electricity was given in that same year. In June of 1920, the ISTM became "The Chartered Society of Massage and Medical Gymnastics." Throughout the 1920s, the Society attempted to raise the standard of training for its members. By 1927, one could not sit for the massage examination alone, but had to hold the dual qualification in massage and Swedish remedial exercises to become a member of the Society.7 In the 1930s, the Society also added light, electrotherapy, and hydrotherapy to the certification examination.8 During the next decade, a new, lengthened, more academic curriculum was developed. Interestingly, some of the specialized areas of work of Society members at this time included maternity exercises, training after amputation, work with slings and pulleys, exercises for chest conditions, treatment of paralysis, return-to-work exercise programs, and dexterity exercises for hands. In 1942, the Society changed its name to the "Chartered Society of Physiotherapy."8 After World War II, education in the training schools was extended to 3 academic years and teachers' training was revised. The Society provided refresher courses for its members returning from battlefronts. Three new schools for both male and female students received Society approval, and 3 existing schools for women allowed men to enter.8 The evolution of physical therapist education in the United Kingdom parallels the establishment of the profession and its education in Australia and in many of the other historically British colonies.3 The School of Physiotherapy at the University of Otago in New Zealand was founded in 1913. Currently, 35 physical therapist schools thrive in the United Kingdom, with about 1,700 students enrolled per year. The physical therapy course of study varies. In England, the program is 3 years in length (with a minimum of 3,000 hours). In Scotland, Wales, and Northern Ireland, the program is 4 years in length, with studies resulting in a BSc (Hons) degree. Students have the opportunity for further study at both master's degree and PhD levels.7 BEGINNINGS OF PT EDUCATION IN OTHER EUROPEAN COUNTRIES Norway The evolution of physical therapy in Norway is linked to Swedish history and was closely aligned with the development of orthopedics in Norway. Simultaneous to the birth of the orthopedic tradition in Norway, Ling founded his RCIG in Sweden, and Swedish graduates of Ling's program brought medical gymnastics to Norway. The establishment of the first orthopedic institute occurred in Norway in 1838. Approximately 9 years later, the third physician in charge of the orthopedic institute also was a graduate of the RCIG in Stockholm, Sweden. Under his influence, the orthopedic institute in Oslo paved the way for physical therapist education in Norway, which formally began in 1897 (written communication, M. Haneborg and V. Rekv, June 2011). While massage remained an important part of the physical therapist's education, the profession retained its distinct designation as "physiotherapists" and not masseurs. As early as 1916, the Norwegian Medical Association established a council that authorized graduates to exercise their profession as physical therapists and masseurs. In 1936, public authorization was granted to physical therapists educated at any institution approved by the Ministry. Legislation in 1956 gave physical therapists the right to practice their profession as "physiotherapists and Mensendieck therapists." In 1976, the first state physical therapist educational institution opened in Bergen, Norway's second-largest city. Physical therapist education institutions were granted college status in 1982 (written communication, M. Haneborg and V. Rekv, June 2011). Currently, 5 physical therapist schools exist in Norway, graduating about 300 students per year. Physical therapist education in Norway is a 3-year diploma course at a physical therapist college. In addition, mandatory supervised clinical practice of 1 year is required, elevating the level of education. Postgraduate physical therapist education exists in Norway at the master's degree.7 Finland The beginning of physical therapist education in Finland resembles Sweden and Norway, but with significant differences. The first private education and medical gymnastic institute was started in 1869 in Helsinki to educate female teachers. In 1882, medical gymnastics was an elective and later obligatory subject for gymnastic teachers' education at the University of Helsinki. In 1908, medical gymnastic education spanned 3 years and was based on Ling's model of physical therapist education in Sweden (written communication, K. Partanen and M. Keskinen, May 2011). Surprisingly, medical gymnastic education was abolished in 1942; however, the end of the Finnish Winter War (1939-1940) and the ongoing World War II (1941-1944) were creating a need for rehabilitation for the war wounded. The Finnish defense forces held quick courses for masseurs to help to meet the pressing need for rehabilitation of those injured in the wars. The Finnish Society of Physiotherapists was established in 1943, with its first objective to begin education programs again. Development of Finnish legislation in 1945 and 1946 concerning the profession of physical therapy improved physical therapists' education, duties, and rights (written communication, K. Partanen and M. Keskinen, May 2011). Finally in 1945, the college of medical gymnastics was established at Invalidisäätiö (a foundation established in 1940 to organize the treatment, rehabilitation, and education of people who had been disabled in the Winter War). While re-establishing physical therapist education was an important milestone in Finland at this time, it did shift the program from university-level to college-level education. Admittance to the program required at least a secondary school background. Key areas of study were orthopedics and war injuries. From the 1960s on, education programs developed in other Finnish cities. Education occurred within nursing colleges during that time, and eventually moved to the polytechnic school system in the 1990s. Physiotherapy strengthened its position in the academic world as an independent scientific discipline and secured the continuity of a universitybased education.10 (written communication, K. Partanen and M. Keskinen, May 2011. Currently, 17 physical therapist schools exist in Finland, with 380-420 new students per year. The physical therapist education is at the higher level in the polytechnic schools. Graduates earn an academic degree/diploma after 3½ years of studies (5,600 hours), which corresponds to 140 Finnish credit units. The Finnish Physical Therapy Association follows the planning, content, and implementation of entry-level professional education in physical therapy in order to ensure, among other things, that the education provided meets international criteria. Continuing education and master's and doctoral degree levels of education are available.7 BEGINNINGS OF PT EDUCATION IN THE US In contrast to the history elsewhere, the history of physical therapist education in the United States followed a slightly different developmental course. Physical therapy origins evolved around 2 major historical events: the poliomyelitis epidemics within the United States in the 1890s and the effects of World War I upon US citizens, creating a need for rehabilitation. The latter, as previously noted, also was an impetus to the development of physical therapist practice and physical therapist education in Europe. Prior to World War I, support for those with disabilities in the US had been growing gradually at both the private and governmental levels. A report from the Division of Orthopedic Surgery of the Medical Department of the United States Army in the 1920s called for the establishment of hospitals for the reconstruction of soldiers with disabilities.11 The physiotherapy section of the US Army report indicated the need for massage and mechanical hydrotherapy, and more importantly, for a national training corps of personnel (therapists). The report11 suggested that the personnel be drawn from schools of physical training and allied therapies. As a follow-up, several schools were chosen: the Boston School for Physical Education; the New Haven Normal School in Connecticut; the Normal School for Physical Education in Battle Creek, Michigan; Posse Normal in Boston, Massachusetts; the Teacher's Physical Education Program at Oberlin College, Ohio; and the Physical Education Department of Leland Stanford Junior University in California. The report also suggested that schools develop standards and that the trainees be designated "physical reconstruction aides."12 After the United States entered World War I, Frank Granger, MD, (chief of orthopedics at Massachusetts General Hospital) and Joel Goldthwait, MD, (chairman of the War Reconstruction Committee of the American Orthopedic Association) studied the British system of treating the disabled, a system largely conceived by Robert Tait McKenzie, MD. Granger and Goldthwait were sent to Europe by the surgeon general to investigate how the war-wounded were being treated in England and France. Upon their return to the United States, they developed a plan to meet the needs of the over 200,000 US troops wounded at the battlefront. The plan put together by Granger and Goldthwait established 2 different groups of reconstruction aides. One group was to assist the physicians as reconstruction aides/physical therapists and provide exercise programs, hydrotherapy and other modalities, and massage for these patients. The other group had been working in civilian and insane asylums since about the 1840s, and they were designated as reconstruction aides/occupational therapists.4 Marguerite Sanderson, who had been working with Goldthwait, established a training program for reconstruction aides at Walter Reed General Hospital. Mary McMillan joined Marguerite Sanderson to head the Walter Reed program. McMillan, who was born in the United States but raised in England after the death of her mother, had completed a bachelor's degree in physical culture and corrective exercises. Finding this study incomplete, she went to London for special courses in neuroanatomy, neurology, and psychology, and accepted a position in a children's hospital. With the outbreak of World War I, she returned to the United States. In 1918, McMillan took a leave of absence from the Army to train 2 emergency classes of reconstruction aides at Reed College in Portland, Oregon, a program that was started in 1914.4 By 1918, these 2 original programs were joined by 13 other professional education programs striving to train individuals to meet the needs of those with war wounds.4 Treatments consisted of exercises (including corrective exercises, passive exercises, sports, and games), massage, hydrotherapeutic modalities, and assistive/adaptive equipment. The first organizational meeting of the American Women's Physiotherapeutic Association occurred in New York City on January 15, 1921,4 and Mary McMillan was elected the first president. While the profession was originally composed of women and the association was established by women, in 1922 the association changed its name to the American Physiotherapy Association (APA) in recognition of the few male reconstruction aides who helped during the war effort in 1919.4 In 1934, APA's "active member" category required members to have (1) graduated from an approved school of nursing; (2) completed an approved course in physical therapy for physical education and nursing graduates; and (3) completed 1 year's practice within 2 years of graduation. In 1946, due to the decision of physical therapy physicians to call themselves "physiatrists," the American Physiotherapy Association took the opportunity to officially change its name to the American Physical Therapy Association. Also in 1946, the first section, the Schools Section, began to meet.4 The role of the physical therapist progressed increasingly from that of a technician to that of a professional practitioner. Thus, during this phase, physical therapist education was characterized by both hospital-based and college/university-based programs. Interestingly, education was primarily at the post-baccalaureate certificate level, generally requiring 3 years of college for admission and approximately 9 months of physical therapist education. Beginning with the first 2 programs, (Walter Reed General Hospital and Reed College), education programs grew to 6 in 1928 and to 34 by 1955.4 From the late 1950s to the late 1970s, physical therapists in the United States moved from hospital-based programs to academic environments, with increasing curricular content in physical therapist education and increased hours of clinical affiliations. In 1979, the average physical therapist bachelor's degree program required approximately 142 credit hours for completion. In 1977, there were 84 programs in the US providing physical therapist education. By 1978, 92% of these programs were at the bachelor's degree level and 8% at the master's degree level.4 The evaluative criteria for physical therapist education programs required the bachelor degree in 1978.13 The following year, the American Physical Therapy Association House of Delegates adopted the position that entry-level education for the physical therapist be a post-baccalaureate degree.4 Eight percent of the 85 physical therapist education programs were at the master's degree level. New evaluative criteria were published in 1996 that required a post-baccalaureate degree by 2002 for entry-level programs. Of the 159 physical therapist education programs at that time, 28% were at the baccalaureate level, 70% were at the master's degree level, and 2% were at the Doctor of Physical Therapy (DPT) level. The last of the bachelor degree programs converted to the post-baccalaureate degree in 2001. The transition of physical therapist entrylevel professional education to the DPT degree level in the US occurred from 2001 on. The first 4 programs (Creighton University, University of Southern California, Slippery Rock University, and New York University) were accredited between 1995 and 1998. By 2004, 55% of the programs were at the DPT level, and the new evaluative criteria of the Commission on Accreditation of Physical Therapy Education (CAPTE) stated that the DPT was the preferred degree.14 As of 2011, 207 of 212 physical therapist entry-level professional education programs are at the DPT level. Four of those programs that are not yet at the DPT level are in the process of converting. CAPTE has added a criterion that, as of 2015, only programs that award the DPT will be accredited. WORLD STANDARDS While the history of physical therapist education around the world includes similarities and differences, the World Confederation for Physical Therapy (WCPT) has sought to establish standards to guide educational programs in an attempt to assure the graduation of the highest quality practitioner around the world. WCPT Policy Statement: Education To that end, WCPT adopted a Declaration of Principle in 1995 that was revised in 2003 and changed to a Policy Statement, with minor revisions in 2011 (Table 1).15Table 1: WCPT 2011 Revised Policy Statement Regarding PT EducationWCPT Guidelines From 2003 through 2011, as a result of charges from member organizations during the general meetings, the WCPT Executive Committee developed a series of guidelines to facilitate the delivery of high-quality education experiences in physical therapist professional entry-level education. The guidelines were developed for and with input from member organizations of WCPT. The intent was that they may be used by countries where physical therapy associations and education programs do not currently exist and where the profession is not represented. WCPT anticipates that different countries will use the guidelines to varying extents depending on their needs. Individual WCPT member organizations and program developers may modify and interpret the guidelines within the context of their situation, while aiming to maintain the quality education opportunities the guidelines are designed to facilitate. Currently, 5 guidelines related to physical therapist professional entry-level education have been developed: (1) WCPT Guidelines for Physical Therapist Professional Entry-Level Education; (2) WCPT Guidelines for Qualifications of Faculty for Physical Therapist Professional Entry-level Education Programs; (3) WCPT Guidelines for the Clinical Education Component of Physical Therapist Professional Entry-level Education; (4) WCPT Guidelines for Curricula for Physical Therapists Delivering Quality Exercise Programs Across the Life Span; and (5) Guideline for a Standard Evaluation Process for Accreditation/Recognition of Physical Therapist Professional Entry-level Education Program. (1) WCPT Guidelines for Physical Therapist Professional Entry-Level Education.16 As a result of a motion presented by the North American/Caribbean Region to the WCPT General Meeting in 2003, the WCPT Executive Committee undertook the task of developing guidelines for professional education with input from member organizations around the world. Table 2 presents introductory material including the purpose, background, target audiences, and application of these guidelines.Table 2: WCPT Guidelines for Physical Therapist Professional Entry-Level Education: Introductory MaterialThe full document "WCPT Guidelines for Physical Therapist Professional Entry-Level Education" contains the areas found in Table 3, with detailed information provided in each area (you can see this by going to http://www.wcpt.org/node/29550 and clicking "download").Table 3: WCPT Guidelines for Physical Therapist Professional Entry-Level Education: Outline(2) WCPT Guideline for Qualifications of Faculty for Physical Therapist Professional Entry-Level Education Programs.17 This guideline on qualifications of faculty was produced to support member organizations intent on meeting the WCPT guideline for physical therapist professional entry-level education through the development of physical therapist professional entry-level programs. It was presented to the 2011 WCPT General Meeting as a reference document. The Guideline puts forth the need of faculty members to bring their students from a
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