米国における呼吸循環領域の理学療法教育―今後10年における日本人理学療法士のための臨床的意味

mp\fiit\ac32kig8e

504-510H

(2005ff)

Seminar

2

Cardiovascular

Clinical

and

Pulmonary

Physical

Therapy

Education

in

the

United

States

Implications

for

Japanese

Physical

Therapists

over

the

Next

Decade*

LawrenceP.

CAHALIN'*

Abstract

Cardiovascu!ar

and

pulmonary

diseases

are comrnon among many physical therapy

(PT>

patients

as

primary,

secondary, or even combined

diagnoses,

Despite

the

fact,

that

the

incidence

ofcardiovascular

disease

has

decreased

slightly,

the

incidence

and

prevulence

of

pulmonary

disease

and chronic cardiovascular

disease

is

increasing,

Both

disorders

are responsible

for

a substantial

degree

of morb{dity, mDrtality, and

disability.

Physical

therapists

are

in

a

pivotal

position

te

favorably

affect the morbidity,

disability,

and

possibly

mortality of

patients

suffering with

these

clisorders

via seeondary and

primary

prevention.

However,

few

North

American

physical

therapists

spe-eialize

in

this

area and

few

routinely assess

the

cardiovascular and

_pulmonary

systems

during

PT.

This

is

con-cerning since cardiovascular and

pulmonary

diseases

are

the

leading

causes of rnorbidity, mortality, and

disability

worlclwide,

The

results of a

questionnaire

survey of cardiovascular and

pulmonary

PT

education

in

the

USA,

Canada,

United

Kingdorn,

Australia,

and

New

Zealand

reveaied

that

cardiovascular and

pulmonary

education

in

the

USA

lags

behind

that

in

other countries and

in

the

USA

they

receive

far

less

attention

than

other

domains

of

PT

(e,g,

musculoskeletal and neuromuscular},

It

appears

that

PT

education

in

the

USA

is

not commensurate

with

the

health

care needs of

the

USA

er

the

world,

PT

for

patients

with

pulmonary

disease

is

routinely

pro-vided

by

Japanese

physical

therapists,

but

it

is

uncertain

if

Japanese

physical

therapists

provide

optimal care

to

patients

with cardiovascular

disease.

Greater

focus

on

the

health

care needs of each country and

the

world

is

needed

in

the

educational

programs

of

the

USA

and

Japan.

Providing

optimal academic and clinical

experi-ences

in

cardiovascular and

pulmonary

areas are

likely

to

ensure

that

PT

is

commensurate with

the

health

care

needs of

the

worlcl.

Not

providing

optimal

PT

academic and clinical experience

in

cardiovascular and

pulmonary

areas will allow others

less

qualified

to

fulfill

the

need

to

care

for

the

increasing

numbers of

individuals

through-out

the

world

diagnosed

with cardiovascular and

pulmonary

disorders.

Key

word:

physical

therapy

education, cardiovascular,

pulmonary

lntroduction

The

theme

of

the

40th

Congress

of

the

Japanese

Physical

Therapy

Association

(JPTA)

was "Clinicat

Sensitivity".

This

is

a critically

important

issue

as

physical

therapy

(PT)

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Correspondence/

Lawrence

P.

Cahatin

MA,

PT.

CCS,

Northeastern

University.

Department

of

Physical

Therapy,

6

Robinson

HalL

Boston,

Massachusetts

e2J15,

USA

(e-mail,

[email protected])

gresses

into

the

new millennium.

However,

defining

clinical

sensitivity

in

PT

is

diencult

because

of

different

cultures,

backgrounds,

interests,

responsibilities, and roles.

For

the

purpose

of

this

paper,

I

have

defined

clinical sensitivity as

being

sensitive to

the

educational and clinical needs of

phys-ical

therapists,

other

health

care

providers,

and

patients

emphasizing

the

trajectory of

the

physical

therapist

and

PT

profession.

I

will

focus

on

the

educational and clinical needs ef

physical

therapists,

other

heatth

care

providers,

and

patients

while emphasizing

the

career of

the

_physical

Cardiovascular

and

Pulmonary

Pbysical

1

will

hopefully

help

you

to avoid sorne of

the

mistakes

that

we

have

made

in

the

USA

in

the

areas of cardiac and

pul-monary

PT,

I

woutd

like

to

tell

you

a

true

story about cardiovascular

and

pulmonary

PT

in

the

USA.

While

telling

this

story

I

would

like

to

discuss

(1)

the

role of the

_physical

therapist

in

cardiovascular and

pulmonary

disease

-

worldwide and the

USA

dilemma,

(2)

pulmonary

PT

education

in

the

USA,

Canada,

UK,

Australia,

and

New

Zealand

and

how

pulmonary

education and clinical

practice

in

these countries relate to

Japan,

and

(3)

the

importance

and need

for

international

col-laboration

and "Clinical

_{Sensitivity".}

_I

would

like

te

address

each of these

primary

objectives and

begin

with

the

role of the

_physical

therapTst

in

cardiovascular and

pulmonary

dis-ease.

The

Rele

ef

the

Physical

Therapist

in

Cardiovascular

and

Pulmonary

Disease

The

role of

the

physical

therapist

in

cardiovascular and

pulmonary

disease

was very clearly

presented

in

an article

by

an

international

collaborative

group

of

physical

therapists

representing

12

different

countries

from

around

the

globei).

The

_purpose

of

this

articlewas to

highlight

the

high

preva-lence

and

incidence

of cardiovascular and

pulmonary

disease

in

industrialized

and non-industrialized countries and

the

major role and

impact

that

physical

therapiszs should

have

in

rhe examination and management of

persons

with

car-diovascular

and

pulmonary

diseasesi).

This

paper

hightighted

the

fact

that

heart

disease,

hyper-tension, stroke, smoking-related

lung

conditions such as can-cer and chronic obstructive

pulmonary

disease

(COPD),

and

diabetes

are

the

leading

causes of mortality, morbidity, and

disability,

However,

the

international

team of

_physical

ther-apists who wrote

this

paper

indicated

that

these

diseases

are not

leading

practice

areas

for

PT

in

their

respective

countriesi),

In

fact,

they

said

that

''This

essential area of

_physical

ther-apy

practice

<cardiovascular

and

puimonary

PT)

risks

sink-ing

into

oblivion as others

tess

qualified

attempt

to

fi11

this

void" and emphasized

the

fact

that

"physical

therapists

are

noninyas{ve

practitioners

who

have

the

ethical

responsTbili-ty

to

educate

health

care colleagues as welL as

the

public

about

the

power

of and

preference

for

noninvasive

inter-ventiens whenever

possible."i}

These

are extremely

imper-tunt

issues

as we continue

to

develop

clinical sensitivity

in

the

USA,

Japan,

and

the

world.

Other

issues

addressed

in

this

internationally

diverse

paper

included

(1)

historical

factors

that

have

contributed

te

the

relative

invisibility

of cardiovascuLar and

_pulmonary

PT,

(2)

rationale

for

carcliovascular and

pulmonury

PT

to

be

more

visible, and

(3)

strategies

to

make cardiovascular and

pul-Therapy

Education

in

the

United

States

505

monary

PT

more visiblei).

Each

of

these

issues

will

be

briefiy

discussed

belew.

Historical

Factors

Contributiug

to the

Relative

Invisibility

of

Cardiovascular

and

Pulmonar),

Physical

71}Leram,

in

the

Wbrld

The

historical

fuctors

that

have

contributed

to

the

tive

invisibility

of cardiovascular and pulmonary

PT

are

surned under

the

fragmented

rather

than

systematie

tion

of cardiovascular and

pulmonary

PT

and

include

the

(l)

developrnent

of chest

physical

therapy and

the

primary

focus

on secretion removal techniques

between

the

early

1900's

to

the

l950's.

(2)

development

of cardiac rehabiiitation

in

the

1960's,

{3)

frequent

separation of cardiac

from

putmonary

PT

and not a combined cardiopulmonary

PT

approach

from

the

1960's

to

the

_present

(4)

greater

academic

focus

on

loskeletal

and neurological

_physical

therapy

due

most

likely

to

the

poliomyelitis

epidemics and

injuries

of war

out

the

1900's,

and

(5)

lack

of allegiance

to

physician

groups

and relative

independence

from

physicians

throughout the

history

of

North

American

PTi'2).

All

of these

factors

have

separated cardiovascular and

_pulmonary

PT

and

have

ed

in

a separation ef cardiovascular and

pulmonary

ogy,

physiology,

and

the

clinical examinalion and

rnent of

patients

with

these

disorders.

These

factors

have

also separated cardiovascular and

_pulmonary

PT

from

other

domains

of

PT

and

have

made cardiovascular and

pulmonary

PT

less

visible.

The

result of such separation

is

a

fragmented

physical

therapist

and

PT

profession

that

have

evolved

in

aseparate

and

fragmented

manner.

Combining

cardiovascular and

monary

PT

_practice

with a

_greater

emphasis within

PT

catien and clinical

_practice

will

likely

stimulate a

ic

evolurion of cardievascular and pulmonary

PT

within

the

PT

profession.

Combined

examination and management skMs

in

both

cardiovascular and

pulmonary

PT

will

provide

the

heaith

care systerns of the world an

important

health

care

provider

{the

physical

therapist)

who

is

able to address

the

disablement

associated with

the

major

diseases

of

the

world

and

_possibly

prevent

or

postpone

the

development

ef

ability

due

to cardiovascular and

_puimonary

diseases.

The

interrelatedness

of the cardiovaseular and

_pulmenary

tems

demand

a comprehensive understanding of

beth

tems

by

every

physieal

therapist

which

is

Iikely

to

improve

the management of cardiovascular,

pulmonary,

or combined

cardiopulrnonary

disorders,

Furthermore,

developing

professional

relationships with

physician

and other

health

care

professional

groups

in

a

subservient manner

is

Iikely

to

promote

an

integrated

lution

ofcardiovascular and

pu]monary

PT

with needed

506

ge"utza\

apists

in

the

USA

have

limited

their

relationships with

cians

because

of a

_problematic

histery

of

physician

owned

PT

practices,

respiratory

therapists

in

the

USA

have

oped such a

physician

support system

that

has

enabled

the

respiratory

therapy

profession

to

be

quite

successful

in

the

USAZ),

Physical

therapists

werking within

the

lar

and pulmonary

domains

who

have

developed

such

subservient

_professional

relationships with

physicians

and

other

health

care

_{professionals}

have

censistently

been

cessful and

have

stimulated a cohesive evotving

ai

PT

practice culminating

in

_greater

responsibility and

tice

opportunities within

the

health

care arena3'5).

It

is

sible that

the

doctor

of

PT

(DPT)

which

has

been

readily

accepted as

the

terminal

degree

in

PT

in

the

USA

wM

ther

facilitate

non-subservient

PT-physician

relationships.

Attempts

to

correct the above

historical

problems

are

ly

to

make cardiovascutar and

pulmonary

PT

more visible.

Correcting

the abeve

problems

willrequire substantial

icat

sensitivity".

Rationale

for

Cardiovascular

and

PulmonaT:y

Physical

71hercury

to

be

bfore

Visible

The

rationale

for

cardiovascular and

pulmonary

PT

to

be

more visible

is

_quite

strong and

includes

(1)

the

escalating

cost of medical care,

{2)

the

fact

that

physical

therapists

are

licensed

health

care

proviclers,

(3)

the

noninvasive nature of

PT,

and

(4)

an expanding

literature

supporting exercise

apy and

physical

therapy as a

treatment

for

cardiovascular

and

pulmonary

disorders

that

has

the

potential

to

reverse

cardiovascular

disease,

enhance oxygen

transport

and

improve

cardiovascular and

pulmonary

function,

prevent

diovascular

and pulmonary

disorders,

and

improve

the

ability of cardiovascular and

_pulmonary

diseasei).

Strategies

to

Mahe

Cardiovascular

and

Pulmonary

Physical

Thercope,

Mbre

Visible

The

strategies to make eardiovascular and

pulmonary

PT

Table

1

Strategies

to

Make

Cardiovascular

E32tsrg8e

and

more visible are relatively simple,

but

very

important,

and

consist of several specific skills

listed

in

Table1i).

Of

these,

the

skill

in

articuiating the scope of cardiovascular and

put-monary

PT

practice

to

other

health

care

providers,

health

insurance

companies, and

legislators

via clinical

practice

and

research

is

most

important.

Cardiovascular

and

pulmonary

PT

witl

be

mest visible through communication with

physi-cians, nurses, other

health

care

_providers,

insurance

compa-nies, and

policy

makers.

The

forms

of communication are numerous and

perhaps

the

most effective mode of

commu-nication

is

through

publication

of

PT

research.

One

final

issue

that

was addressed

in

the

above

paper

by

the

internationally

_diverse

_{group of}

_physical

_therapists

_was

clinical education.

The

authors of this articlestated "The

PT

profession

must ensure

that

cardiovascular and

pulmonary

PT

develops

commensurate with global

health

care needs and

that

this

is

refiected

in

PT

academic curricuta across areas of

practice

and research"i).

However,

the

authors con-cluded

that

"In

part,

the

profession

has

failed

to

_provide

ade-quate

continuing education"i).

Greater

attentien

to

cardio-vascular and

pulmonary

disorders

in

PT

education will make

PT

education commensurate with

global

health

care needs

and

increase

the

visibility of cardiovascular and

pulmonary

PT.

To

summarize

the

Trnportant

issues

_presented

in

this

paper

published

at the

beginning

of

the

new millennium, cardiovaseular and

pulmonary

PT

should

be

more visible

based

on

(1)

the

overwhelming evidence-base of

the

effects exercise and

physical

therapy

on

disablement,

_(2>

the

aging

population

and

increasing

incidence

and

_prevalence

of

car-diovascutar

and

pulmonary

disease,

(3}

the

escalating costs

of medical care with the potential

fer

physical

therapists

to

provide

less

expensive

interventions

with a

focus

on

primary

prevention,

{4)

using

the

above strategies

to

promote

car-diovascular

and

pulmonary

PT

visibility, and

{5)

attempting

to

correct

the

above

historical

problems

that

have

separat-ed cardiovascular and

pulmonary

PT

from

other

domains

of

Pulmonary

_Physical

_Therapy

_More

_Visible

1,

Skill

in

articulating

the

scepe of

practice

as well as

the

benefits

and

limitations

of

their

care such

_that

others understand that cardiovascular and

pulmonary

PT

is:

a.

holistic,

evidence-based, and

has

long-term

benefits

b.

Iow

risk,

has

few

side efiects, and

is

cost-effective

c. not subservient

to

invasive

medical care or

biotechnology,

but

compliments

them

2.

Skill

in

initiating

and endorsing

health

and wellness campaigns

3.

Participate

in

_public

health

forums,

health

care

_policy

making,

health

fairs,

_public

health

events, and

health-related

organizations

4,

Participate

in

clisease

management

programs

5.

Be

visible

in

the media

&

practice

in

an eviclence-based manner

6.

Exploit

existing

technologies

&

develop

new ones

7,

Devetop

non-subservient

professionat

relationships with

_physicians

and other

health

care

_{professionals}

8.

Develop

a

greater

focus

in

cardiovascular and

pulmonary

PT

in

PT

education

9.

Develop

more clinical aenliations

in

cardiovascular and

pulmonary

PT

with well

trained

mentors

Cardiovascular

and

Pulmonary

Physical

PTi).

Therefore,

cardiovascular and

pulmonary

PT

shou]d

be

more visible via "clinical sensitivity''.

The

Uhited

States

Dilemma

The

_dilemma

in

cardiox,ascular and

pulmonary

PT

in

the

Unired

States

is

a simple

probtem,

but

with

dramaric

con-sequences

for

PT

due

to the

powerful

effects of supply and

demand,

In

the years

between

1950

and

1980

fewer

USA

physica] therapists were

interested

in

intensTve

care unit

(ICU}

care and cardiovascular or

pulmnnary

PT

{because

of

a

_greater

interest

in

musculosketetat, and neurological

I]T)

despite

the

continuing

poliomyetitis

epidemics and

the

res-piratory

complications associated with

poliomyelitis6).

As

a result,

fewer

physical

therapists were available to

manage

patients

in

the

ICU

or those

patlents

with

cardie-vascular and pulmonary

problems.

This

resutted

in

the

devei-opment of the respiratory

therapist

and

the

Respiratory

Therapy

AssociationL),

There

was a need tocare

for

patients

in

the

ICU

and

patients

with cardiovascular and

pulmonary

disorders

and respiratory

therapists

fulfitled

the

need.

This

is

a

perfect

example of suppty and

clemand

betzveen

the

PT

and respiratory therapy professions,

Unfortunately,

no

leg-islative

effbrts or practice actions were undertaken

by

the

American

Physical

Therapy

Association

_(APTA)

or the

IJSA

PT

educationat programs

te

keep

USil

physical

therapists

in

the

ICU,

Because

of the above

discordance

in

cardievascular and

pulmonary

PT

practice,

a

British

trained

physical

therapist

(May

Watrous}

working

in

the

USA

became

x,ery concerned

about the

USA

dilemma7),

May

Watrous

was very concerned

because

physical

therapists

had

been

criticized

for

ignoring

patients with acute or chronic chest

diseases

at a

time

when

increasing

numbers of

patients

having

chest

diseases

were

chattenging

the

health

professions.

Because

of

this,

she sent

asimple

questionnaire

survey

to

the

63

USA

PT

schoo]s

to

determine

the

pulmonary

educatien

provided

to

physical

therapists

in

19747).

She

found

that

a majority of

PT

schools

did

not offer a course

in

pulmonary

PT

and a number of

PT

schools

failed

to

teach

disease

specific

treatments

and allowed

too

littie

preparation

time

in

_puimnnary

PT7).

As

a resutt of rhe above study

)vlrs.

"iatrous

stated

"to

send even one

physical

therapist

out

poorly

prepared

zo

treat

patients

with chest

diseases

is

regrettabte/

to

have

schoots minimize

this

area

in

the

face

of

today's

need

is

deplorable"7).

She

also wrote that

''physical

therapists'

back-grounds

allow

them

to

Cl)

make a unlque contribution

to

the

welt-being of

patients

with chest

diseases,

(2}

teach

patients

how

to

prevent

chest

damage

and

physicat

deterioration,

and

(3)

bring

about maximum recovery within the

limits

of

the

cendition"7).

These

words were true then and even more

true

today

with

the

increasing

incidence

and

prevalence

of

Therapy

Education

in

the

United

States

507

lung

diseases

throughout

the

wortd.

Mrs,

Watrous

continued to address

her

concern

fur

monary

}'T

by

stating

"schools

of

PT

should

present

diovascular

and

_pulmonary

PT

as one of

the

most

tant,

interesting,

and stimulating thut our

profession

offers"

and "if we uontinue to

ignore

chest

PT

in

our

hospitals

and

schools, or

fail

to acquire excellence

in

our treatrnent skills.

a

fascinating

and rewarding area may

be

tost

te

the

PT

fession"7).

She

concluded with

''Worst

of alt,

the

chest

paticnt

who needs

PT

will miss

the

vital

help

we can

give"7).

Her

words again are criticat

to

teday's

physical

therapist,

to

the

PT

_profession,

and to t{)day's

_patients.

Furthermere,

in

the

LJSA,

the above statement regarding the pessibility of

ing

pulmonary

eare as a

PT

practice

area

has

ly

become

partly

true

and

it

may

become

completeLy true

if

specific actions are not

taken

by

USiX

physical

rherapists.

IJSA

PT

educationat

programs,

and

the

iXPTA.

Therefore,

the

specific actions rhat

USA

physical

therapists,

USiX

PT

education

programs,

and

the

APTA

must

perform

are

Ly

related

to

''clinical

sensitivity".

Pulmonary

PT

Education

in

the

USA,

Canada,

UK,

Australia,

and

New

Zealand

-Clinical

Implications

for

Japane$e

Physical

Therapists

Because

of

the

current status uf cardioi,ascular and

monary

PT

in

the

USA

discussed

above and

the

results of

the

1977

study

by

}v'Tay

Watreus,

",e studied

PT

education

in

the

USA

and several other

English

speaking countries to

determine

the

current status of

pulmonary

PT

educution

cornpared to that

in

1977Si.

t'Xlthough

)vtay

Watrous

did

not

study

{nternational

pulmonary

PT

education we

believed

it

of

greai

value

to

compare

putmonary

PT

education

between

the

LjSA

and other

Engtish

speaking countries.

Of

lar

importance

fer

this

puper

I

will

discuss

lhe

implications

this

data

has

fer

Jupanese

PT

and

international

"Clinical

Sensitivity".

Survey

quastionnaires

were sent to all

200

USA

P'1'

cational

_programs

and to the

PT

educational

pr"grams

in

Canada,

the

United

Kingdom

(UK),

Australia,

and

New

ZealandS).

The

response rates

from

Canada

and

the

[/K

wera

15%

and

l8%,

respectively.

The

response rate

irom

both

Australia

and

New

Zealand

was

50%

and

the

response rate

frorn

the

USA

",as

31%.

Analysis

ef the

_{questionnaire}

resutts

revealed

that

pulmonary

education

in

the

USt'X

was similar

among allof

the

5

regions of

the

IISA

(Nc)rtheastern.

Atlantic.

Southeustern,

CentraL

and

Western

regions} and

significantly

fewer

hours

of cardiopulmonary

PT

education

were

provided

to

USA

students compared

to

tal

ancl neuromuscular

PT

eduEation

(4.9

cardiopulmonary

508

Table

2

Instruction

rp"ptil\

rg32tsag8e

Time

in

Pulmonary

Physicat

Therapy

in1974

and

2003

Categories

Number

of

SchoolsReporting

Instruction

Time

in

1974

Y2

Hr.

IHr,

_2Hr,3

_Hr.

4

Hr.

No

or

More

Answer2oo3

Hrs"

L

2.

3,

4.

5.

6,

7.

8.

9.Ie,IL12.13.14.15.16.17.

A&P

Resp,

System

PFTsPsychosocial

Probs.

InterrelationsA

DrugslMech.

Vent.

Path,fProg.

Asthma

Asthma

Rx

Path/Prog.

Emphysema

Emphysema

Rx

Path,fProg.

Bronchitis

Bronchitis

Rx

PathJProg.

Bronchiectasis

Bronchiectasis

Rx

Path,

of

Acute

Condit.

Pre-IPost-Surgical

Condit,

Pre-IPost-Surgical

Rx

Special

Probs.AA

o4212117181213919122616o2218

4101019251516151414II881820195

6105oo459105532912911

54ooo5234111o2222

32l7ooo111613137672

911201614132015131624l72720131618

8,O'"2.41.42.55,O"LlLl1.31.41.11.3O.8O.8

**e,7

**3.e

**3.0O.8

Adapted

from

Watrous

ML.

Chest

Physical

Therapy

-

_A

_Survey

and a

Challenge.

Phys

Ther

1977:

57(2):

143-14Z

Hr.

=,

hour:

A&P

Resp.

= _{anatomy and physiology of}

_the

_{respiratory system:}

PFTs

=

_pulmonary

_function

_tests:

_Probs.

=

_problems:

Mech.

Vent

= _{mechanical ventilation:}

Path,fProg.

=

_{pathologyfprognosis;}

Rx

=

treatment:

Condit.

=

con-ditions.*..2003

Hrs

= mean number of

hours

of

instruction

reported

by

the

USA

Physical

Therapy

Programs

in

2oo3,

Mean

number of

2003

hours

for

these

questions

is

the

sum of

hours

from

two

or mere separate areas or conditions

{i.e.

number of

hours

of respiratory anatomy

instruction

+

number of

hours

of respiratory

_physiology

instruction).

A

_{Interrelations}

_{with other}

_health

_care

_{professionals}

_{such as}

physicians,

nurses, respiratory

therapists,

and aicles. AA

_Special

_problems

_{such as collapsed}

_Iobes.

it

hours

for

musculoskeletal and neuromuscular

PT:

p<

O.05}8).

Table2

has

been

slightly adapted

from

a

table

_published

by

May

Watrous

in

1977

and shows

the

instruction

time

in

pulmonary

PT.

The

original

table

that

Ms,

Watrous

pub-lished

is

in

the

middle and

left

side of

Table

2

and

lists

the

number of

PT

schools reporting

instruction

time

in

17

areas

in

1974

(with

the

number of schools effering

lf2

hour,

1

hour,

2

hours,

3

hours,

4

hours

or

More,

or

No

Answer),

The

last

column on

the

far

right of

Table

2

was added

to

the

originat

Watrous

table

and shows

the

mean number of

hours

of

instruction

time

in

each of the

17

categories

in

2oo3,

This

column shows

that

compared

to

1974,

the

num-ber

of

hours

spent educating

US

students about

Putmonary

PT

has

increased,

but

not

in

ull of the

17

areas

listed,

The

greatest

amount of

instruction

time

is

_in

_Anatomy

and

Physiology

and the

least

amount of

instruction

time

is

in

the

Pathotogy

of

Acute

Conditions.

This

is

concerning as are

many of the other categories showing

less

than

2

heurs

of

instruction

time

(a

total

of

11

out of

17

categories or

65%

of

the

Pulmonary

PT

categories

had

less

than

2

hours

of

instruction)S}.

Comparing

pulmonary

PT

education

in

the

USA

to

the

World

revealed

that

95%

less

time

is

spent

in

cardiovascu-lar

and

pulmonary

PT

education and only slightly more

hours

are

provided

in other

domains

of

PT

Education

_(e,g.

musculoskeletal and neuromuscular)

in

the

USA

compared

to

other

English

speaking countries,

We

atso

found

that

<1}

fewer

USA

credit

hours

are provided

in

anatomy and

phys-iology

of

the

respiratory system, mechanical ventilation and suctioning, and education and treatment of several

pul-monary

_patholegies

and

(2)

fewer

USA

students chose

pul-monary affiliations.

Another

important

aspect about our

study and

the

_poor

USA

response rate

is

that

many

USA

PT

education programs

likely

have

part-time

faculty

teach-ing

cardiopulmonary

PT

which was

likely

to

_<1)

_yield

the

poor

USA

respense rate and

(2)

give

students a

less

than

favorable

impression

of

this

domain

of

PT.

These

are

issues

that

my colleagues and

I

are very concerned about

for

car-diopulmenary

PT

and

the

PT

profession

in

the

_USA,

However,

some of

these

problems

do

not appear to

_be

is}

lated

to

the

USA

aloneS

iO},

In

2003

Roskell

and

Cross

published

their

findings

of

British

PT

student's

perceptions

of cardiopulmonary

PT9).

The

_purpose

of

the

study was to examine student

percep-tions of cardiopulmonary

PT

in

order

to

_possibly

recruit new

graduates

to

practice

in

cardiopulmonary

PT.

Fifteen

final

year

students

from

22

undergraduate

PT

schools

in

the

UK

(total

N=330)

were selected

to

answer

10

questions

about cardiopulrnonary

PT.

The

results of

this

study

found

that

Cardiovascular

and

Pulmonary

Physical

222

of

the

330

questionnaires were returned

(67%

response rate) revealing

that

80%

of

the

students

betieved

cardiopul-monary

PT

was of significant value,

but

that

only

6%

stat-ed an

intent

to

specialize9).

Also,

30%

of

the

students stat-ed that they were

less

competent

in

cardiopulmonary

PT

than

other specialties9).

These

results are clinically signifi-cant since

few

students

in

the

UK

intend

lo specialize

in

cardiopulmonary

PT.

The

same

is

likely

true

in

the

USA

and

is

likely

due

to

a

gap

between

education and

practice,

Roskell

and

Cross

as well as

Hunt

et alstate

that

students

lack

knowledge

of

the

`world

of work'

in

the

cardiopul-monary area which makes

it

necessary

for

universities

to

provide

opportunities

to

better

integrate

cardiopulmonary

education with cardiopulmonary

PT

practice

in

the

work-place9)iOi.

It

appears

that

what occurred

in

the

USA

cluring

the

1950's

to

l980's

is

now occurring

in

the

UK

with

British

physical

therapists

_practicing

in

other

domains

of

PT.

This

is

extremely

important

as we train

future

physical

thera-pists

around

the

globe.

Because

cardiovaseular and

pul-monary

PT

is

_practiced

by

so

few

North

American

physi-cal

therapists,

PT

students

in

the

USA

are exposed to

fewer

cardiovascular and

_pulmonary

clinical affiliations and

men-tors.

Therefore,

the

USA

and

PT

educational

programs

around

the

globe

must

become

more "clinicatly sensitive''

to

the

international

differences

in

academic

preparation

of

phys-ical

therapists

and

to

cardiopulmonary

PT

education.

International

clinical athliatiens arnong

different

countries are necessary and will

likely

facilitate

the

development

of

car-diovascular

and

pulmonary

PT

in

the

USA.

The

APTA

CIinical

Specialization

and

Clinical

Residency

Programsii)

are

likely

to

promote

cardiovascular and

pulmonary

PT,

but

greater

emphasis

is

needed

in

basic

cardiovascular and

pul-monary

PT

education

to

develop

greater

cardiopulmonary

interest

and numbers of cardiovascular and

pulmonary

elin-icians

who can serve as menters

in

clinical affiliations.

There

is

a need

for

greater

"clinical

sensitivity''within

the

PT

pro-fession

around

the

globe.

Clinical

Jmplications

for

Jdpanese

Physical

Therapists

The

previous

discussion

and

_{questionnalre}

survey resu]ts

have

important

clinical

implications

for

Japunese

physical

therapists.

The

major

implications

for

Japanese

physical

ther-apists

include

the need

to

continue to

₍₁₎

maintain a

pres-ence

in

the

ICU,

₍₂₎

make cardiovascular, pulmonary, and

other

domains

of

PT

visible

in

Japan,

(3}

exploit exist{ng

technologies

and

develop

new ones

in

cardiovascular,

pul-monary, and other

domains

of

PT.

and

(4)

develop

non-sub-servient

_professional

PT

-

physician

relationships.

Although

cardievascular and

pulmonary

PT

may not

be

particularly

high

profiLe

practice

areas

in

Japan,

the

pres-ence of

Japanese

physical

therapists

in

the

ICU

is

tikely

to

Therapy

Education

in

the

United

States

509

maintain

this

particular

practice

area as a

PT

practice

domain.

In

the

USA,

the

small number of

USA

physical

apists

in

the

ICU

resulted

in

the

deveiopment

of the

Respiratory

Therapy

profession

and the current

limited

tice of

USA

physical

therupists

in

the

ICU,

Maintaining

a

presence

in

the

ICU

is

therefore

]ikely

to

maintain

this

domain

of

practice

in

Japan.

Japanese

technology

has

influencecl

every aspect of

life

around the globe and combining

PT

with existing

nolegies will

likely

facilitate

PT

growth

in

_Japan

and the

world.

Coordinated

efforts

between

Japanese

physical

apists and

Japanese

technologists

to exploit existing

nologies and

develop

new ones will

likely

enable

Japanese

physical

therapists

to

be

world

leaders

in

rehabilitatien.

A

PT

-

technology relationship may

be

best

promoted

by

the

Japanese

PT

Association

(JPTA}.

The

JPTA

may also

facilitate

the

visibility of

PT

in

japan

by

standardizing

PT

educ:ation and considering

the

tions

of advanced

degrees

]ike

the

DPT.

The

DPT

may not

be

the

preferred

terminal

degree

in

Japan,

but

advancing

the

PT

_profession

through

advanced academic standards and

degrees

appears to

have

occurred

in

the

USA

and other

countries6).

Other

implications

for

Japanese

physical

therapists

inctude

the

need

to

₍₁₎

provide

optimaL clinical affiliations

for

Japanese

PT

student's,

(2}

narrow

the

_gap

between

PT

ory and

practice,

and

{3)

educate

the

world about

PT

tice

in

Japan.

Providing

PT

students with optimal clinical

affiliations and narrowing

the

_gap

between

PT

theery

and

practice

are

global

PT

problems

thut

must

be

re$olved,

The

wiclespread

PT

presence

in

the

ICU

in

_Japan

has

the

tial

for

optimal clinical affiliations which are

likely

to

row the

gap

between

PT

theory and

practice

in

the

diovascular

and

pulmonary

domains.

Establishing

tional

clinical affiliations

between

Japanese

clinical sites and

other countries of

the

worLd

is

Hkely

to

promote

the

opment of cardiovascular and

pulmonary

PT

around

the

globe,

Informing

the

wor!d about

PT

practice

in

Japan

is

a

very

irnportant

facter

that

will

further

facilitate

Japanese

research, clinical

practice,

and eclucation.

Informing

the

world

about

Japanese

PT

can

be

accomp]ished

in

many ways of

which clinlcal research and

innovative

PT

-

technotogieal

relationships are

the

most

likely

to

be

successful,

Clinical

sensTtTvity

to

PT

is

important

in

Japan

and

the

world.

Conclusion

The

theme of clinical sensitivity

is

important

for

PT

around

the

globe,

Being

sensitive to the educational and

ical

needs of

_physical

therapists, other

heaLth

care

proviclers.

and patients while emphasizing

the

trajectery

ef

the

ical

therapist ancl

PT

profession

are critically

important

51e

ge"fiza\

issues

in

_Japan,

USA,

and all countries where

PT

is

ticed.

Cardiovascular

and

pulmenary

diseases

are

the

major

causes of

disablement

throughout the world and

_physical

therapists

are capable of making a significant

irnpact

on

these

disorders.

However,

cardiovascuLar and

pulmonary

PT

has

poor

visibility worldwide when

it

shoutd

be

the most

visible

domain

of

PT

_practice.

A

variety of strategies exist

to

make cardiovascular and

pulmonary

PT

more visible of

which skill

in

communicating

the

favorable

effects of

PT

on

cardiovascular and

pulmonary

diseases,

increasing

the

focus

of cardiovascular and

_pulmonary

education, and

developing

PT

-

technologlcat

_professional

relationships are most

tant.

Increasing

elinicalsensitivity

in

PT

is

necessary to

mote

the

PT

profession,

cardiovascular and

pulmonary

PT,

and optimal patient care around

the

globe.

Not

increasing

ctinical sensitivity

in

PT

is

likety

to

allow others

less

ified

to

fulfill

roles that would

be

best

_perfermed

by

ical

therapists,

thus

_providing

suboptlmal care

to

_patients,

eg32tsag8e

o

2)

3)

4)

5}

6)

7)

8}9)]o)

11)

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E,

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D,

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WP,

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Cardiovascular/cHr-diopulmonary

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JS

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