Description of the Profession
Physical Therapy is a branch of the medical profession that combines manual (hands-on) therapy for muscles, joints, nerves, ligaments, and tendons. Additionally, exercise, strength assessments, progression, health care education for recovery as well as prevention, biomechanics analysis of movement patterns including walking and running, and the use of modalities (machines, medicines, tools) to assist in the healing process can all be utilized during a physical therapy visit. The “art” of therapy comes into play due to the ever-changing nature of an injury, and the individualization that each injury needs for proper recovery – taking into consideration co-morbidities, age, lifestyle, stage of injury, motivation, goals, personality and so much more.
Types of Physical Therapy
In the therapy world, there are various types of physical therapy. Achieve provides a combination of outpatient orthopedics, biomechanics and sports medicine. Here is a list of various ways to focus:
- Outpatient (can be divided into neuro, ortho, sedentary, active)
- Geriatric/Older adult
- Burn/Wound Care
- Niche’ focus like lymphedema, hand therapy, gait evaluation, amputee, chronic pain, etc.
Physical Therapists (PT) advance through a progression of schooling – bachelor’s undergraduate degree and then a doctoral program. Some schools offer a direct admit status, meaning that the student goes through 7 years (4 undergrad and 3 graduate) at the same school with the demand that a certain grade point average is maintained. For others, after undergraduate is complete, the application process begins for stand-alone doctoral programs and the acceptance rate is very competitive. Schooling includes a full array of the sciences as well as general education courses, then advancing in body and orthopedic specific courses such as anatomy, kinesiology, movement patterns, strength and conditioning, cardiology, exercise physiology, pharmacology and more.
After completing the degree (now is Doctorate across the board, with transitional programs available from Masters and Bachelors level degrees), continuing education courses are mandated by the national governing board, as well as each individual state. Courses can be taken to increase knowledge in diagnosis, assessment, treatment techniques, trending, and even courses on the psychology of injury, aging, and child development. Beyond the minimum requirements, most high level therapists will take 3-4 courses per year- some individual courses and others in succession for advanced certifications (such as ART, Maitland, etc.)
A patient needs to be “referred” over from a physician, whether cash pay or through insurance. In the state of IL they need a “script” that states that the MD has determined that the care is 1) medically necessary, 2) OK for the patient to tolerate physically, and 3) goals may be achieved by attending therapy in order for the PT to be covered under the state license and malpractice insurance. The MD often guides the PT in the diagnosis of the patient, any protocols that they will need to follow, important information on the injury or any scans (MRI, Xray, CT, Bone scan, etc.) that they have had leading up to the start of physical therapy. The PT, then, takes that information into consideration while evaluating the client including:
- Taking an in-depth history of injury and lifestyle
- Personality assessment (motivation factors, determination)
- Goal setting per the patient’s expectations
- Subset of population that they belong to (work/occupation, sport, school)
- Comorbidities (other medical ailments that can impact success in therapy such as cardiac issues, RA, diabetes, medications, bruising/clotting factors, etc.)
- The injury itself (tear, strain, stiffness, pain, dizziness, etc)
- The specific timeline of the injury (acute or recent and traumatic or chronic/longstanding)
- Time and dedication (student, mom of five children, busy job) – this will impact home program completion and attendance to therapy
- Degree of the injury (bad sprain versus a small spine tweak)
The evaluation includes the interview portion, the physical assessment (visually), palpation of the area of injury and other areas, movement analysis, strength evaluation flexibility examination, pain levels, ranges of pain, endurance level, and more.
Once the evaluation is completed, a full assessment of all objective, subjective, reported, visual and other measures are put into consideration to form goals and objectives for physical therapy. This includes how bad the issue or issues are, the prognosis for full recovery and the techniques that will be used during treatment sessions.
In the clinic, treatment can be categorized into the following:
- Manual therapy
- Soft tissue work (ART)
- Joint mobilizations
- Scar tissue removal (hands on, Graston)
- Nerve movement
- Manual stretching and flexibility
- Fascial plane work (MFR, etc.)
- Trigger point work (manual trigger point, Dry Needling, etc.)
- Movement analysis and cueing
- Gait and walk/run analysis
- Joint motion assessment (lifting shoulders, spine motion, bending)
- Pitching, kicking, swim stroke, etc.
- Manual resistance work
- Use of body weight and positioning
- Use of free weights
- Use of bands/resistance bands
- Use of exercise equipment
- Flexibility activities
- Static holding
- Dynamic motion
- Nerve tensioning
- PNF patterned motion
The therapist will communicate most of the time via fax with an extensive written document of the initial evaluation and measures. Throughout the course of treatment, PT’s often ask questions to the doctors and their staff about how visits went, approval for progression of exercises, and also reporting of goals met. With adolescent patients and athletes, parents are updated on how in-clinic work is going, and to communicate and get feedback on the home exercise program. With geriatric patients, often caregivers need to give feedback to the therapist, and vice versa for instructions to be followed or safety concerns. For the athlete or elite athlete, the communication train includes weekly if not per-session feedback to the athletic trainer, coaches, athletic director, and more. All communication is kept confidential, private and appropriate, and releases are given to patient or guardian to set the limitations of all communication.
Goals are set together, between the therapist and the patient, for the length, duration of session, intensity and commitment required to achieve maximum results in a safe and efficient manner. Unfortunately, insurance often limits or guides the frequency and duration of visits that are allowed. Some of this is known at the time of attaining insurance and other soft limitations are discovered when approval is needed. Many patients will start with insurance and then choose, because of the value of the therapy received, to transition to self-pay rates if insurance is limited.
In the clinical setting, each patient interacts with the front office manager and insurance guide at the clinic, the physical therapist themselves, a PT tech, and at some clinics a PT Assistant (PTA, whom cannot perform evaluations) or massage therapist. At higher-level clinics, interaction may also be with Exercise Physiologists, Athletic Trainers, and more.
In clinic treatment often includes the use of modalities. These can include:
- Electric stimulation (IFC, NMES, Russian, TENS, EMS)
- Phonophoresis (Ultrasound with medication)
- Iontophoresis (topical application of medication on patch)
- Moist heat (blood flow and muscle relaxation)
- Ice (for inflammation or pain control)
- Taping (Kinesio, SpiderTech, McConnel, supportive, specialty)
- And more.
Home Exercise Program
A great portion of the recovery process is the performance of exercises and activities at home, when the patient is not in the clinic. These may include rolling (trigger point, wood wheel, tennis ball, etc.), posture correction, endurance, strengthening, flexibility, desensitization, joint motion and return to activities. The performance of these prescribed activities is imperative in the success of the process as well as often for recovery between sessions.
The trained eye of a physical therapist combines movement analysis, understanding of sport- and occupational-specific activities, and then the dissection of the underlying causative issues and compensations that the patient is experiencing that are causing overuse, pain, fatigue, or other symptoms. Many companies create software to assist with this including video analysis, underwater swim stroke, picture or video comparisons, and more. In the end, the combination of the mind and eye of a trained and experienced therapist cannot be matched.
Referral to Ancillary medical and non-medical professions
Partner professions that often work hand-in-hand with the physical therapist include, but are not limited to:
- Physical Medicine and Rehabilitation doctors
- Surgeons/Orthopedic Doctors
- Pain Management Specialists
- Massage therapists
- Athletic Trainers
- Exercise physiologists
- Athletic directors
- Club or gym owners
- Personal trainers
- Strength and conditioning coaches
- Acupuncture professionals
- Shoe fitting professionals
- Equipment managers
- And so many more!
Once therapy is completed, the patient no longer needs to have hands-on treatment, guidance, or visual correction. They are then released to return to their sport, occupation, lifestyle, or other goals that they had set forth in therapy. Often, this process is a ramping or sorts, as therapy sessions wean down, return to lifestyle ramps up. Some may start with 3x week for therapy, and only 2 hours a week in their sport. As they go back to 4 days a week for 2-3 hours in sport, therapy will diminish to 1-2x week, or 1x week, and then 1x every other week if needed to check symptoms and success rate of return. Often patients, once discharged, will keep in touch with their therapist, using them to answer questions, return for evaluations, or even subsequent injuries if the experience as a positive one.