アメリカの理学療法の現状と将来

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mp\asza\

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17tsng6e

_509--523fi

_(19905)

The

25th

Congress

of

JPTA

Special

Lecture

Present

Status

ofPhysical

Therapy

in

the

and

Future

Directions

United

States

Jane

S.Mathews'

Introduction

I

wish te thank the

Japanese

Physical

Therapy

Association

(JAPA)

for

inviting

me here to speak

at your annual meeting, Iam most honored tobe your guest and Iwant you toknow thatI

find

your country, your culture, and your people among the most gracious and

hospitable

in

the world.

When Professor Miyamoto firstcontacted me, he requested that Iaddress my remarks to the _present status of Physical Therapy

(PT)

in the United States

(US),

and

discuss

some of the

future

direc-tions in which

the

_profession and the

American

Physical Therapy Association

(APTA)

isheading, I will do so

by

organizing my remarks

in

three

major categories of practice, education, and research as theseare

the

major components of allof our

ac-tivity and _planning. Ineach category, Iwill discuss

on!y the mal'or trends and issuesas time

does

not permit extensive detaiL IfIappear to be overly

cencise, _please accept my apologies

but

I

am

cer-tain yQu are rnost

interested

in

the

major

issues,

Before proceeding to the present status, Iwish to present a

brief

historical

_perspective of the

APTA

from

its

inception

in

thehope Ican _provide a

con-text inwhich and through which we address major issues,_problems and future_planning forour

profes-sion inthe

US.

Historical

Perspeetiye

of

APTA

Physical

Therapy

had

its

official

beginning

in

the

'President, _{the American Physical} Therapy Association

US

during

World

War

I

when two physicians

in

the

Othce

of the

Surgeon

General

were

instrumental

in

setting up _programs totrainReconstruction

Aides,

our

initial

title.

The

Reconstruction

Aides

were

trained _prirnarilyto treatand assist the

US

military personnel who were wounded or

disabled

on

the

battlefields

of thatwar.

In

1921,

several _years after

World

War

I

ended, a

small

_group

of those

Reconstruction

Aides

met

in

New York City and organized what was initially called the

American

Women's Therapeutic

Associa-tion. In 1922, the name of the organization was changed to the

American

Physiotherapy Associa-tion,and, somewhat Iater,totheAPTA.

In

the firstdecade of

its

existence, the APTA

di-rected'ats attentien tothe development of minimum

standards

for

PT

educational _programs and the firststandards were

published

in 1928. In 1929, the APTA Education Committee initiateda site

yis-iting

_procedure

for

the educational _programs as a

means of deterfriiningwhether the _programs met the standards forapproval.

I

want

to

share aqttote

of one of our early leaders which appeared in a 1927 issueof the

(then)

Physiotherapy Review as itrefiects the status of PT at.that time. The _quote

is

as follows:",..We

must stick to our own field,

which

is

the carrying out of

_{prescriptions}

_given

by

doctQrs,and not diagnosing, prescribing, or inany way experimenting

in

the treatment of disease,,." Pleaseremember thisquote when Idiscusscurrent trendsand issuesand _you will see hew

far

our

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slo

ff7whikY

In

our second

decade,

the

1930s,

the

Association

published a

list

of eleven approved schools and,

in

1933, made the initialoverture to the American

Medical

Association

for assistance

in

that process.

The

result culminated

in

1936

with the very

first

set of "Es$entials

for

an

Acceptable

School

for

Phy-sical

Therapy

Technicians".

At

that time,all

ex-isting

educational programs were

headed

by a

"medical

director",

a physician,and second

in

au-thority was a

"technical

directori',a _physical

thera-pist,By 1938 there were fourteen approved scheols with a combined totalof

151

students, and with

curricula ranging

in

length

ef time

from

nine to twenty-two months.

I

shouLd also tellyou that tho$e

1936

Essentials

had

two basic _program ad-･

mission requirements:

1)

2

years or

60

semester

hours

of college with physics and

biology,

and 2)

the applicant must

have

graduated

from

an

ac-credited $chool of

_physical

education or nursing. By 1940, the beginning of the APTA's third decade, there were sixteen accredited _programs in

'PT,

and approximately a totalof 135 graduates

'

each _year.

With

trie

beginning

of the US

involve-ment

in

World

War

II

in

1941,

a shortage was

ide-ntified and the

Association

participatedagain with

the US OMce of the

Surgeon

General to develop

new trainingprograms.

As

a result,

by

l948

there

were 25 educational programs,

17

of whicri

by

that time led to

Bachelor

of Science

de-grees rather than certificates.

Also,

in

1944,

our firstnational Association headquarters office was established

in

New

York

with the

hiring

of our

first

Executive

Director,

In

1949,

thePhysical Therapy

Review,

our

journal,

began

publicationon a

month-lybasisand our Association headquarters staff was

expanded

to

three

empleyees.

By

that

time,

there

were 4,104 APTA members, 55 chapters in 42 states _plus Puerto Rico,Hawaii, and the

District

of

Columbia, and, by the end of that

decade,

there were some 20 educational

ingtitutions

offering post-professional or graduate

degrees

to

those practi-tionersiwho already had completed a baccalaureate

'

degree with a major inPT.

ag

17

_Uag

6

･ng-In

thefourth

decade,

the 1950s,APTA attempted toobtain an updating and revision of the 1936 Es-sentials for educational _programs, but the

Ameri-can Medical

Association

was unreceptive.

Howev-er,out ofthatendeavor,

the

APTA

obtained greater

participation

inthe accreditation _processon a more

coliaborative

basis

than

had

existed priorto that time.

The

1960s

were most eventful

for

the

Associa-tion.

Our Federal

_government

enacted major secial

and health legislationincluding Medicare, a

health

insurance

program

for

citizens

65

years or older,

Medicaid,

a state-administered health benefit

pro-gram with costs shared among

Federal,

state and

local

governrneilts,and programs to educate and

train multiple types of

health

care providers

in-cluding

Physical

Therapists.

All

of the new

legisla-tiongreatly

increased

the

dernand

for

PTs

and our

Association

respon.ded

by

creating our technical

levelpersonnel, the Physical Therapist

Assistant

(PTA).

These are individualsprepared

in

two-year,

community college programs leadingto an

tt

ate of

Science

degree.

Ishould note thateven now,

23 years later,the

PTA

and the

PTA's

role and

rights wathin the

APTA,

are stillsubject to

contro-versy within the Association.

In

the

late

1960s,

another attempt was made to

obtain an update of the

1936

educational

Essen-tials,again tono avail, That spurred the beginning of what resulted

in

the mid-1970s

in

an

APTA

tt

House of Delegate,saction toseek recognition as an educational accrediting age'ncy

independent

frorn

the

American

Medical Association.

AIso

in the

1970s,

after the priorrelocation of our

APTA

head-quarters to Washington, D.C,, the Association

became

much mere

involved

in

governmental

affairs inlobbying.

Also

_in

the 1970s, what isnow

known

as the Foundation forPhysical Therapy Research was es-tablishedto raise monies

-for

stimulating research and advancing our profession through reseatch,

doctoral

training funding, and various other

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Present Statusof PhysicalTherapy inth

increasing}y more sophisticated as an organization and as a _profession.

Professional

_practice

had

changed and expanded dramatically by that time

and,

in

1979, to respond to

those

changes in PT

roles, functions,scope of _practiceand _practice set-tings,the House of Delegates enacted a _policythat

has _proved to be extrem61y controversial. That

policy

is

the one which targetedthe_goal of making

the

transition

to

post-baccalaureate

degree

profes-siona! education _programs by 1990,

(I

will

be

dis-cussing this

in

more

detail

when

in

address

the

issuesand trendsineducation,)

So much has happened inthe _past decade Iwill

'

not even attempt

-to

listthe events as most will be

'

evident as Idescribe the_present status of PT prac-tice,education, and research, However, as of 1990 the

APTA

has

a totatmembership of approximate-ly50,OOO _physical therapists._physicaltherapist

as-sistants, and students in both types of programs.

Since 1983 we have owned our own nationat head-quarters

building

in Alexandria, VA, and our na-tionalstaff now numbers approximately 110 em-ployees. Our totalAssociatiQn budget for !990

ap-proximates

$15,OOO,OOO

which

is

allocated to

ex-penditures

for

a broad array of

Association

ac-tivities.

This year the

APTA

will be celebrating

its

69th

anniversary and IfearIhave done a greatinjustice

by

merely skimming the surface of our evolutienary

events, Perhaps Ican now fi11insome detail

by

describing

the

current issuesand trends inPT in the US.

The

Current

Status

of

Practice

The

rnajor trendsand issuesinpracticerelate _to

the following: 1) the exponentially increasing

demand

for

PT services, and the growing

discrep-ancy between demand and supply; 2) the

ob-tainment of direct access }egislation;

3)

the Aesociation'sproblem with referral-for-profit prac-ticesettings; 4) themajor governmental affairs

ac-tivities;

and 5)

the

ever-changing roles,

functions,

and scopes of practice for PTs including formal

e United Statesand Future Directions 511

Board certification

in

PT speciality ar,eas.

'

'

1. TPedemandlsupplyissue

In the

US,

there

is

a widespread perception of a

"shortage"

of PT _personnel, The term "shortage'' has not been defined and we do not really know

that a

'`shortage",

_per se, exists, However, we

do

khow that there isindeed a discrepancy

between

the

numbers of _graduates

from

our _{preparational} programs and the numbers of vacant _positions

service settings are seeking

to

fiII.

All

types

of prac-tice settings are seeking to recruit PTs, but hospi-talsappear to

be

having the _{greatestproblern,}not only in recruitment but in retention of PTs. Our

'

-pre-professional

educational _programs are

'

ing between 4,OOO and 5,OOO _physical therapist$

'

each year, and our

Physical

Therapist

Assistant

programs

are

_producing

between 1.200 and 1,400

PTAs, annually. Yet,the demand forPT personnel

issuch thatwe do not meet thatdemand. This

has

infiuencedthe APTA tolook at all _possible alterna-tivesfor remedying the _problem, We are seeking funding to increasethe supply ot faculty;funding

to

increase

the number of students per class where

'

possible;and

funding

for

s,tudent scholarships.

The

APTA

has

also

developed

special programming to

encourage those

PTs

who

have

dropped

out of prac-ticeto reenter a career path.

The

first

such

pro-gram was

held

at our

Annual

Conference

in

Nash-ville,

Tennessee

last

year and these will continue

ba$ed

on theoverwhelming positive response.

There are external agencies among those who

accuse the

APTA

of "controlling"

the supply of

PTs, However, nothing coulcl be further from the truth. For example, between 1980-1985, the number of educational _programs increased by 20

percent, and between 1985-1988,

by

30 percent

In

the same periods of time,our nurnbers of new

PT

graduates

increased

by

72

percent and

17

percent, respectively.

In

fact,

beth

the number of accredited educational _programs and new _graduates annually

have

been

on a linearprogression formany years,

Aiso,an APTA study of hospital-basedPTs

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512

ve#asrk?

ed

PTs

in

hospitals

as well as thosewho left

hospi-tal

settings

to

_practiceelsewhere.

Findings

indicate

that variables inthe_practiceenvironment are most

influential･intherecruitment and retention process.

I should also teU _you that

APTA

membership survey

data

between

1978

and 1987, evidence

shifts in _practice settings. As of

1978,

approxi-mately

42

_percent of

(respondent)

PTs in the U.S.

chose to practice

in

hospital

settings. The most rapidly increasing _preferred setting, according to our $urveys, is_{privatepractice,}

The personnel demand/supply dilemma isa socie-talissueand a very risky one

for

our

Association.

We must continue tobe creative and innovativein

finding

ways to

be

responsive tosocietal needs.

As

an Association,we allecate approximately one-half

million

dollars

a year to publicrelations activities tomarket therole and

importance

of

PT.

Howeverl

ifwe have insuMcient means to follow through

with those

lmplied

promises tothe _public,we will

find

ourselves ingreat

jeopardy

as a profession.

2I Directaceess legislation

This

trend

is,without

doubt,

the most substantial

indicatienof our _public credibility as a profession.

In

the US, _physical therapists are credentialed

through individual state licensingstatutes which describe _{qualifications}topractice,

define

thescope

of _practice,and establish regulations _togovern prac-tice.Thi$ i$very differentfrom a certification

pro-cess of a _professienalassociation. The major

differ-ence

in

the

US

relates tothe

fact

thatstate licensu-re and associated regulatory functionsare

atttono-mous tothe state,

a.e.,

NOT a functionofthe

profes-sional association OR theFederal _government. The

second major differenceisthat state licensure

de-rives

from

statutes and common law,and thus pro-vides a legalbasisfor practice whereas entry-level certification

by

a _professienalbody does not. The APTA, through itsstate chapter components,

cer-tainly

attempts to

influeBce

and change state

legis-lation,but the national Association has no

direct

control over that _particularform ef credentialing

ng

l7

_Uag

6

g-for_practice.

Our early

(1930s)

state _practiceacts were per-missive

in

that one did not need tomeet the

re-quirements of the practice act topractice

PT.

Over

time,

allstate

legislation

for

licensurebecarne

man-datory meaning that,

in

order topractice

in

an indi-vidual state, a

P.T,

MUST

meet

licensure

require-ments.

Also,

inour early days,thestate laws requir-ed thatwe _practiceONLY with a prescription from a licensed

_physician,

surgeon, or dentist.

Subse-quently,

during

the

196es,

changes

in

those

legisla-tive acts required only a referral. You may

be

in-terested

to

know,

that

in

my

36

_years as a

P.T.I

have not experienced a

detailed

_prescriptionor

spe-cific orders. Ihave been accustomed to referrals thatustial!y say "evaluate

and treat".

The directaccess movement had itsorigins ina

1974

APTA

House

of

Delegates

motion, which

I

in-troduced, that charged the

Association

to exp]ore

the notion of PT evaluation and treatment without

practitioner referral. Aftermany taskforcereports and activity that culminated in the

first

direct

access

iegislation

in

the

State

of Maryland

in

1979,

The

concept of "direct

access" means that patients or clients can enter the

health

care system by going

to

a

PT

service

directly

without the

require-ment of physicianreferraL

As

of

1990,

we now

have

some 25 states in the

US

which

have

direct

access legislation,The legis-lationvaries frem

being

open-ended with no condi-tions,as is

the

case inmy $tate of

Massachusetts,

to other states which have certain _quaiifying

condi-tionssuch as centinuing edu.cation or experiential time requirements.

An

associated problem has

been

thatof third-party_payer of

health

insurance

reimbursement

for

direct

access clients. Even the Iatteris

being

resolved

by

certain states, such as

North Carolina,in which the healthinsurance com-missioners,

in

conjunction with the state attorney

generaL notified insurance companies in the state

that they must

indeed

reimburse for directaccess

PT clients because the state

_practice

act now

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Present Status of Physical Therapy inth

Another

problem associated with the direct

access legislationrests among our PT colleagues in the

US

who

feel

more comfortable with specific

in-structions from _physician, That isunfortunate,

be-cause there

is

nothing

in

the

direct

access legisla-tion that says a

P.T.

must practice

in

that mode.

For

those

therapistswho prefer that

kind

of

struc-tured practice,they,can continue

it;

however,

the

legislation

enables their colleagues who consider

themselves capable of

direct

access modes to pursue that.

The

movement

is

growing, and Ithink

it

isone

of the most critical movements on our _pathway to

full

recognition as _{professionals.}

3.

Rreferral-for-profitsettings,

This

issue

initially

eme'rged as an

issue

associat-ed with physician owned physical therapy setting

(POPTS)

in

the early

1980s,

The

APTA

House

of Delegates enacted motions in opposition to those

situations,,mainly

because

it

felt

thatclients, physi-cal therapists,AND the _professionwere vulnerable

to_potentialexploitation. Subsequently, theevents in the US health care system and the

increasing

over-supply of _physicians created a _problem that

was no _longer as simplified as POPTS inthatit

ex-tended toa

broad

variety of profit-making

arrange-ments, theextent of which we still cannot

identify.

The

'APTA

has been instrumental in bringing this

issue

to visibility at our

Federal

legislative

issue,

but no specific action

has

yet

been

taken.

As

the

physician supply

in

the

US

has

increased,

their desireto rnaintain the same standard of

income

as

in

earlier _yearsof _practice

has

also

increased.

As

Americans,

we loveto"hype" _the

competitive marketplace, The fact

is,

however, that the health

care system, particularly medical _practice, has

never

functioned

in

a trulycornpetitive way

in

the

US

economy,

There

has

'been

study after study by American health economists which show that,

when physician supply

increases

in

a given locale, costs or pricesforcare increaseas each tryto

main-tain

their

accustomed standard of living.

e United

States

and Future Directions

513

This,too,

is

a _phenemenon of referral-for-profit,

An exampie inour nation would be thatof a _group

of orthopedic _physicians who,

for

many _years,had

been referring to _private PT _practices in their

locale, who decide that the better part of

Wisdom

is

toemploy theirown physical

thera-pist(s),

We

have

evidence, that,when that occurs,

physicians

refer their

_patients

to PT, made

deci-sions about when clients are terminated

from

PT, and,

in

general, participate

in

a closed systern that

reaps excessive profitsto them,

The

other side of

that equation, and definitelycontributing

to

the referral-for-profit _problem, are those_physicai thera-pistswho opt for employment by,_physicians and letthemselves, their_profession,and theirclients be subject toexploitation.

4. Ma.jorgovernmental relations activities Most of these are undertaken

by

our

govern-mental relations staff at headquarters inrelation to

Federal

legislation

as well as state-level

!egislation.

They relate to

_previous

_practice

issues

discussed

such as directaccess and methods for reimburse-ment, but most specifically relate to attempts to modify and change reirnbursement and regulation

requirements at the Federal level.

_Although

we

have

had

moderate success with commercial or

not-for-profit

health

insurance

agencies at the state

level,our major hurdles relate to

Federal

health

in-surance such as the

Medicare

program which still

requires medical referrals.

A

major goal of our

As-sociation relates toreimbursement

issues

because,

it

is

our sense, that

if

we can change

Medicare

re-ferral

regulations, thestates will accommodate very

soon,

5. Changing roles, functions

&

_practice inPT

These changes are, most certainly, the "p;ime movers" forall other changes inpractice, educatien, and research, In the US, PT has become a profes-sion of diverseopportunity.

PTs

are

in

_private pra-ctice, hospital,nursing home, school, sports injury, home care, neurodevelopmental settings,

fitness

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514

ff\esza,+.

nics, and _probably others which I have failedto delineate.We are indeed reimbursed by third-party payers

i.n

one

ferm

or another and,

due

to that,

have

publicrecognition of the value of eur profes-sional contributions tosociety.

But,

simultaneously, as we receive thatcredibility

and validity as

health

care professionals, we have

an increasingresponsibility _to

develop

measures of accountablity and qua}ityassurance.

We

are

con-tinuously and increasingly receiving _pressure to document and substantiate the erncacy of our ther-apeutic interventionsand rightly so. Ibelievethat thereisa distinctdifferencebetween being licensed

and

being

accountable

for

what

the

profession

is

li-censed to

do.

This

is

a complex problem that we,

in

the

US

have

not yet soived and we need togive

greater

attention to

it,

particularly

in

regard tothe

types of app!ied clinical research which

substanti-ates the eMcacy of our interventions.

In

addition,

formal

Board certification

in

PT spe-cialization areas

is

relatively new to our

Associa-tion. We now have seven specialization areas

of-ficially

recognized

by

our

APTA

House

of

Delegates

which include: Cardiopulrnonary, Pediatrics,

Clini-cal

Electrophysiology,

NeurologY,

Sports

Physical

Therapy,

Orthopedics,and Geriatrics. Allbut

Ger-iatrics

have

reached the stage where they

have

i-dentified the advanced competency required and

are administering annual examinations for eligible candidates.

The

first

Board

certified specialists

(3)

were the cardiopulmonary specialists recongized

in

1985.

Since

then,some

i55

others

have

met the

re-quirements

in

the

first

six specializatiens

identified.

As thismovement continues and grows, we will see

massive changes in the recruitment _practicesof

both

heatth

care

facilities

and educational

institu-tionswithin the

_.US,

as well as changes in the

re-imbursement requirements of our health

insurance

agencies atstate and

Federal

levels.

I

truly

believe

that,at

least

in

this one arena, we will

indeed

follow the model of medicine inthat, as increasing

numbers of

PT

specialists are available

in

our

US

health care

･marketplace,

both

facilitiesand

educa-ee

17

tsts'

6

tienarinstitutions will begin targetingrecruitment

te those persons.

If,

as professional physical

pists,we trulyvalue excellence,

then

I

believe

that

we must give formal recognition to specialists

within our profession very serious consideration. In fact,at

least

in

the

US,

I

believe

we will

ally encounter situations where third-party payers

or health insurerswill NOT reimburse unless they

have

guarantees thata

Board

certified

PT

specialist

(in

whatever area) isthe team leaderforthe given

arena of clientele.

The

CuTrent

Status

of

Education

The

predominat issue

in

our educational settings

i$,

without question, the transition to

baccalaureatedegreeprofessionalpreparation,

sociated with thisare several sub-issues which are sufficient}y

important

or criticaltoaddress.

'

1. The post-bacealaureate

clegree

transition

As of the most recent

data

from

the

APTA,

we

have some 125 accredited entry-level

_professional

education programs

located

within some

116

tutiens,with approximately 10 _programs in the process of

development,

Some

38

percent of

these

eXisting programs are already leading _{to the}

Master's

degree

or

have

been

approved tomake the

transitionto the post-baccalaureate degree. Frgm

data

gathered periodieallyfrom our educational programs,

it

appears that,as of

this

year,

1990,

some 45

_percent

wil]

have

made the transitiofiand

others will

follow

very soon thereafter.

This

educational policy

has

been one of themost

controversiar issuesIhave experienced during my

activity inthe APTA. Itisinteresting,inthat it

was not an issuewhen the motion tomove inthis directionwas enacted by our House of Delegates in

1979;

it

only became an issuewhen

APTA

was

ognized as thesole accrediting agency for our cational _programs

in

1983.

At

thatpoint,many ternal groups perceived that our sele, accrediting

body status would be a mechanism to

"force"

tran$i-NII-Electronic Library Service

'

Present Status of Physical Therapy in

tion.

As

of October, 1989, our data

indicate

that we

have

125

accredited

PT

education _programs,

38

percent of which leadtoa M'aster's

degree,

and the remainder of which lead to a baccalaureate degree, There are various models forthe preparatl'onal

pro-grams thatleadto a Master'sdegree.

Sorne

require completion of a

baccalaureate

degree

with a majbr

in

something other than PT

_prior

to application; others

include

threeyears of undergraduate

(bacca-laureate

level)work and three

_years,

includingthe

fourth

_year of the baccaulaureate degree,of

profes-sional study concentration; a

few

require three years of _general studies and _{prerequisites}at the un-dergraduate level _plus two _years of _professional concentration.

We

anticipate that,

by

the mid-1990s, over

half

of

our eductional

_programs

will have made the

transi-tion

but

it

is

dirnculty

topredict.

In

the

US,

educa-tionalinstitutions,both public and _private,tend to

be

very autonomQus and will not accept

dictates

from

external _groups such as

professional

associa-tions. Also,there have been mahy misconceptions about the entry-level _{professionalprograms} leading toa _graduate degree, Some university administra-tors

have

anticipated significant

increases

in

pro-gram costs and resources, which are not necessarily thecase.

Others

have assumed thatenrollrnents er

class sizes will

decrease,

thus

decreasing

the number of

PT

graduates entering the

health

care

marketplace each _year. That

has

not

_proved

tobe the case, On the centrary, many _programs have

actually proposed increasesin class size as _part of

the transitionnegotiations. Inthe US our applicant pools

for

our programs are largeinnumber and of very high quality in regard to their academic

records.

In

fact,

admission to

PT

programs

is

so

highly

competitive that

it

is

now as

diMcult,

or in

some

instances

more

diMcult

to

be

admitted to a

PT educational _program than to a medical school.

One

very valid _problem associated with the tran-sition isthe continuing cliMcultyinrecruiting and

retaining

faculty.

In

the

1987

APTA

membership

the United Statesand Future Directions 515

survey

data,

!ess

than one and one-half _percent of

respondents had obtained

doctoral

degrees

and, of those who

held

doctoral

degrees,

some

forty-two

percent were NOT in academic

_positions,

The

numbers are gradually increasing as more and

more physical therapistscurrently

in

academic

tingsor _planning on academic careers are _pursuing

doctoral

degrees.

I

note that most current

tisements

for

faculty

positions state that the

doctoral

degree

is

preferred,

but

the master's

degree

will be acceptable

_provided

the applicant

has

cient experiential _{qualifications.}

As

we tryto

increase

thesupply of _phygical

pists,increasing the size of enrollments in tionalprograms appears to be the short term, as

well as, the long term solution, Itrequires

far

less

additional resources

(e.g.

space,

faculty,

equipment, etc.) toexpand an existing _program than to focus

upon

developing

new educational _programs.

Also,

enrolling additienal- students

in

established grams will _{produce graduates}

in

a shorter _periodof

time as establishing new

_programs

usually takes

four tofiveyears beforegraduates are available to the practicemarketplace,

Financia}assistance forpre- and post-professional

students

i$

not abundant. There are some ship and loan _programs, and a new tread

is

the

creasing number of "service scholarships" made

available

6y

facilities

in

attempts to recruit new graduates.

For

example, a

facility

may offer a dent

from

$5,OOO

to

$15,OOO

a _year

in

scholarship

funds provided that the

PT

student rnakes a mitment

to

enter

the

employ of that facilityuppn graduation, Inaddition, fortherapistswho are

suing doctoral e6ucation,

the

APTA _provides an annual _grant plus funding to the Foundation for

Physical

Therapy,

Inc,

for

doctoral

traineeships.

Another trend inour eductienal

Programs

isthat

of increasing curricula emphasis on

theory,

search, clinical decision analyses and

solving.

These

emphases are not totallynew to

curricula, but have been increasingas P,T.sassume

associa-NII-Electronic Library Service

516

veijfi211*

ted

with

the

direct

access

legislation

_previously

de-scribed.

The

Current

Status

of

Research

During

the past two

decades,

there has been a

marked increase among

P.T.s

in

the US regarding

their

value commitment to, and understanding the importance of, research thatsubstantiates our

ther-apeutic interventions.

As

the

costs of health care inour country

contin-ue toincrease,legislatorsat all levels,third-party payers/health

insurance

carriers, and various

types

of managed healthcare systems are _pressuring the

professionto _provide documentation of the eMcacy of our clinical _procedures and modalities, There is no question that applied clinical research

is

one of mo$t critical_presentneeds.

As previously mentioned, the Foundation for Physical

Therapy,

Inc.has been a major

impetus

for stimulatlng research during the _past decade. However,

its

fund-raisingsources are limited, com-pared te the needs. The APTA iscurrently en-gaged in a major effort te identify,and interact with, sources of research funding within

govern-mental agencies as well as with private

founda-tions.

We

are also

beginning

the

clevelopment,

under the auspices of the Foundation, ef

Clinical

Research

Centers

based at university sites in the us.

It

is

my _personal opinion that,

if

we allocated major resources for basicand applied PT research, that would ultimately _provide us with sub-stantiation of the eMcacy of our clanical methods, our credibility as

bona

fide

professionalwould

be

established. Also,such

documentation

of the effec-tivenessof

PT

treatment would _give us a powerful

stance in our interactions with legislators,_ptiblic

'

and private hea!th insurance carriers, regulatory agencies, and highereducation

institutions.

Future

Directions

Ihave

_ju$t

_provided a briefoverview of the cur-rent status of PhysicalTherapy _practice,education,

eg

17

_tseg

6

-and resear6h

in

the

US.

In

conclusion,Iwill now

list

the

future

directions

that appear te be

inevita-ble,

First,Ianticipate that,by the turn of the centry,

the pre-prefessional education programs will

be

making thetransitionto

doctoral

degrees.

The

ex-ponential rate at which our professional

body

of

knowledge

and technology

is

expanding, and the

expanding role and responsibility of the Physical

Therapist

in the US health care system, will be

major influenceson changing our educational

pro-grams.

Second, Ianticipate that,within another de6ade, our profession will

have

ebtained

direct

access

leg-islationineach state and thatwe will

be

reimbursed

for

direct access care to clientslpatients without

major restrictions.

The

APTA,

at

both

state and

national levels,has been investing major effort

toward thisend and will continue to

do

so.

Third, I anticipate a significant

increase

in

the number of physical therapistswho will seek to become certified ina PT speciality area through the process'esestablished by the

American

Board

of Physical Therapy

Specialities.

As

increasing

num-bers

of

Board

certified specialists are available,

I

be-lievethey will

be

rendered recruitment _preferences by educational

institutions

and

health

care

facili-ties,and will be targetedforspecial reimbursement

privileges

by

health

insurance

carriers.

Fourth,

we, as a professionand the

APTA

as the

professionalorganization, will continue our

multi-pleefforts toenhance and

increase

the

PT

research

base ancl establish credibility as

health

_$cientists.

It

will

be

a

long

and

difficult

journey,

but

I

am

con-fidentwe will achieve that _goal.

Fifth,

I

anticipate the

full

professionalizationof

PT which will manifest inmany ways. Fewer and fewer therapSsts will be salaried employees of

insti-tutions

or corporations, and increasing numbers

will be obtaining

practice

privileges ina variety of settings similar to those ho$pital staff _privileges currently held'by physicians, pediatrists,

psycholo-gistsand others.

This

is

one of the most

important

NII-Electronic Library Service

Present

_Status

of PhysicalTherapy inthe

United

States

and Future

Directions

direction$of the APTA at _present and will contin-ue to

be,

Sixth,

we will continue inour attempts to

'

ence _publicpolicyat the

legislative

levels

and any

decision-making

thataffects

PT

education, _practice

or research.

We

have

learned

much about activity

in

the legislativearena in the _past two

dec-ades, and will continue to

increase

our

infiuential

effectiveness.

Seventh, we will continue to focus iricreasing

at-tentien

and effort on the

PT

personnel problem

in

the US, We must findways to be responsive to

so-cietal and marketplace demands for PT services

and do so in a qualitative and most-effective manner.

517

Summary

Again,Iapologize for having to limitthis

presen-tation

to

such a

brief

overview of the _present

status of PT inthe US, and itsmajor future

direc-tions.

In

the

69

years since

the

inception

of the

APTA,

we

have

made many achievements

in

ad-vancing the _professionand inadvancing the

pro-fessionalstatus and _prestigeof _physical therapists.

However,

we

have

also made major mistakes along

the way and we are most willing toassist you and

other internationalcolleagues inhelping you avoid similar pitfalls

in

your owR process of growth and

development.

Thank

you very much

for

this opportunity to

'

NII-Electronic Library Service 518 理 学 療 法学 　第

17

巻 第

6

号 第

25

回 日本理

学

療 法 士 学

会

特別講 演

1

ア メ リカの理学

療

法の現状と将

来

： 　 　　　 　　　 　　 　　　ジェ

ー

ン 　

S

．

マ シュ

ー

＊ は じ め に 　 本日， 講演の機 会を与え て くださっ た日本理学 療 法 士 協 会に心からお礼 申し上 げます。 特 別 講 演 者と して壇

一

ト に登っ て い る こと を大 変 光 栄に思い

，

皆 様の温かい歓迎 に感激 してお り ます

。

　 先 だっ て

，

宮 本 教 授か らは今 回はアメ リカの 理 学 療 法 の現状と将来の_方向ということで_話して くだ さい との こ とで したの で

，

そ れ を業務 教育

，

研 究の

3

っ の_分野に 分けて_話を進めて いき たい と思います。 とい うの は

，

こ の 3分 野 が 理 学 療 法 士の活動や計画を支え る大切な ポ イ ン トであるか らです。 時 間の関 係で詳 細にわ た ること は で き ま せ ん が， 各々の分野の主要な傾 向にっ いて簡潔に 述べたい と 思います

。

ア メ リカ の理学 療 法の現 状を お話 しす る前に

，

アメ リカ理 学 療 法 協 会の簡 単な歴 史を お話 し して_， そ の_後の_本論の きっ か け と さ せて いた だ き たい と思います

。

アメ リ力理

学

療 法 協 会の歴 史 　ア メ リカ にお け る理 学 療 法の正 式な始まりは第

一

次 世 界 大 戦 中

，

軍 医 総監室の

2

人の医師が我々 の当時の呼び 名で あ る

”

Reconstruction　Aids

”

を_{教 育 す}るプロ グラ ム を 作 製 し た こ とに 始 ま り ま す。

“

Reconstruction

Aids

” _は 主に戦場で負傷 した傷病軍人の_治療や介助を す るた めに訓 練さ れ ま した

。

　第

一

次世界大戦の_終結した

1921

年 からほどなく して

，

そ れ らの

“

Reconstruction

　 Aids

”

_{の 中の 何 人か が} ニ

ュー

ヨ

ー

ク で集 会を も ち

，

い わ ゆ る

“

American

Women

’

s　Therapeutic　Association

”

を設立 しま した

。

翌 年 名 称 変 更 し

，

“

American 　Physiotherapy　Associa

−

tion

”

とな り

，

そ の後 現 在の 名 称で あ る

”

American

Physical　Therapy 　

Association

”と なりました

。

　 最 初の 10年 間は

，

協 会と して は理 学 療 法 士 養 成 校の 最 低 基準の 改善に力 を 注ぎ

，

1928 年に 最 初の 基 準が発 表さ れ ま した_。 翌年に は

，

協 会教 育 委 員 会は

，

各々 の養 成 校がそれらの基 準に合い

，

受 け 入れ られて いる か どう か

，

現 場の視 察 を行い ま した。 こ こでそ の頃の理 学 療 法 士の地 位 を如実に語っ て い る私の先輩の意 見が 1927 年 ＊_{アメリ カ理 学 療法 協会 会 長} の

“

Physiotherapy　Review

”

に載っ ていますの で_，



引 用さ せて いた だ き ます。 「我々 は医師の処方箋 を忠 実に 実 行 す る という役 目の みの_存在で あり， そ れ は治療

，

処 方

，

また病気の治療に伴う如何な る試行的行為 も許され ませ ん

。

」ア メ リカの理 学 療法の現状と傾 向を お話しす ると きに この こと ば を 思い_出し て ください

。

い か に我々 の仕事が進歩した か お わ か りにな ると思いま す。

　1930

年代に入 る と

，

協 会は 1933年に 11の認定校を 発表し

，

ア メ リカ医 師会の協 力要請のた めに最 初の予 備 交渉を行い ま し た。 その成果は 1936年の 「理学 療 法士 養成校要 綱」の初 版 刊 行と して実を結び ま し た。 その当 時は_， 全て の養 成 校は

“

medical 　

director

”

であ る医 師 に牛 耳 られて お り

，

“

technical　

director

’

であ る理学療 法」1は その次の存 在で した。 1938年 まで には

， 14

の養 成校に 151名の学 生 が学び

，

9

〜

24ケ月にわ たる教 育 カ リキュ ラムが用意されて い ま したG1936 年の　「理学 療 法 士 養 成校要綱」には

2

っ の 基本的 入学 条件が明 記 さ れて いま し た。

1

）物理学及び生 物学 を 含 む

2

力年の期 間で 1学 期あ た り

60

時間授業

，

2） 入学 希望 者は体 育 学部又は看護学校を卒業していること。 　

1940

年まで には

，

理 学 療 法の 16公 認学 校が で き

，

毎 年約

135

人の_学生 が卒 業 していき ま した。 1941年

，

ア メ リカの_第二次世界大戦参 加と ともに

，

理 学 療 法 上の不 足が問 題にな り

，

新 しい養 成 校 を 開 設 するべ _く

，

_{協 会}は 再び軍医総監室 所属と なりま した_{。 最終}的に は 1948年 まで に 25の養成校が 開 設 さ れ

，

その内 17校は認 定のみ でな く

，

学 士号 を取 れるもの にな

っ

て い_ました。 そ して 1944年に協 会 本 部をニ ュ

ー

ヨ

ー

ク に設 置し

，

事務 局長 を お き まし た

．

1949年 に は協 会 誌で あ る

“

Physical Therapy 　Review

”

の毎 月刊行と なり1 本部の職員も

3

人と な りま した

。

そ の頃に は協 会 会 員は

4，

104

人

，

プエ ル ト リコ

，

ハ _{ワ イ}

，

コ ロ ン ビア地区を含む42 州に 55支 部を数え

，1940

年 代末に はすで に 理学 療法専門の

4

年 制 大 学を卒 業してい る開 業理 学 療法士のため に卒 後 教 育 あ るいは修士号取 得のための_教育機関が

20

施設 作られ ま した。 　1950年 代は

，

1936年の 「理 学 療 法士 養成 校 要綱 」の 見 直し と改善に努 力 しま した が

_，

ア メ リカ医 師会は よ く は受 け入れて は くれ ま せ んで し た。 け れ ど も努力の結果

，

そ れ らの_活動の_{承 認 過程}において も我々理学療法士の_言 い分が大き く以 前と は比べ もの にな ら ない_位大き く取り 入れ られ ま した。 　正

960

年 代は協 会に とっ て は最 もい ろい ろなこ とが N工 工

一

Eleotronio _Library

NII-Electronic Library Service ア メ リ カ の理学 療 法の現 状と将 来 519 あっ た 10 年間で した

。

連 邦 政 府は医 療 制 度に関する 主 要な健 康 保 険 法 を 成 立 しま し た。 そ れ に は

”

_Medicare”

とい う65歳 以 上の_市民へ _{の 医療 保 険や} ，

“

_Medicaid”

と 呼ば れる医 療 費を連 邦 政 府

・

州

・

地 区で 分 担 する低 所得 者を対象と する医療 保 険

，

さらに理 学 療 法 士 を含む 各種 の医療スタッ フ の教 育

・

研修の ための プロ グラムが含ま れて い ま した。 その法律に よって 理学療法士の需要は急 激に高ま り

，

協 会と して は技 術 担当者であ る

，

理学 療 法 助 手 （PTA ） 制 度を創設 し て対 応し ま し た。 理学 療法 助手は

2

年間の_{準学士 号}の取れる コ ミュ ニ テ ィ

・

カ レ ッ ジ で養成さ れ ま し た。 こ こ で言 及 して お きたい こと は

，

23

年間 経た今で もこ の理学 療 法 助 手およびそ の役割や 権利にっ い て_協会内で も論議の的で あ る ということです。 　

1960

年 代の末になりますと

，

再び 1936年の養成校要 綱の_改善に着手し

，

そ れ はのちの 1970年 代 半 ばに アメ リ カ理 学 療 法 協 会 総 会が実 現 したアメ リカ医 師会 とは独 立し た教育 認 定機 関の創 立へ の動きの端 緒と な り ま し た。 更に協 会 本 部が ワシ ン トン _に移っ てからの

1970

年代に は

，

協会は以前よ り も もっ と対 政 府 交 渉や議 会ロ ビ

ー

活 動に参 加す ること が多く なりま した。 　更に 1970年 代に は理学療法 研究基 金が創設さ れ

，

研 究

・

学術的 教育

・

その_他の_活動の_{助成を 通}して理学療法 士の専 門 性の確 立が進め ら れ ま し た。 1970 年代の間に 協 会は

，

組織と して も専門家集団と して も大きく成長 し まし た_。 そ の ころに は， 専門 的業務は

，

劇 的に変 容

，

拡 大 し

，

1979年に は理 学 療 法 士の _役割

，

機能

，

業務 　業 務環境の_変容に対応して理事会は後に_{大変 論}議を か も し だ すことになるある指針を打ち出し ま した。 その指針と は

1990

年ま で に 理学療法 士養成校を修士 号 取 得 以 上レ ベ ル に上 げる とい うことです （こ の ことにつ い て は教 育 の話の ところで も う少し詳 し く言 及 します ）

。

　私達が過去に経て きた道の りには さま ざ まなことが あ り

，

現 状にっ い て細 か くは言 及しません が

，

1990

年 現 在で は ア メ リカ理学療法協会の_会員は 理学療法士

，

理学 療 法 助 手

，

そ れ らを 目指 す学生 も含め約

5

万 人にな り ま し た。 1983年に は

，

バ

ー

ジニ ア州ア レ ク サ ン ドリア に 協会本部ビルを持ち

、

本 部の職 員 もllO人にな りま した

。

1990年の協 会 総 予 算は活 動の多 様 化の_中で約

1

，

500

万ド ル に達し ま し た

。

　今年協 会は69周 年を迎えるわ けですが

，

我々 の革 命 的 活 動のほ んの

一

部のみ しか お話しで き な かっ た よ うで す

。

これ か らの ア メ リ カ の 理学療法の現 況の_話の中で何 か補 充と な る こと があ ろ う かと思い ま す

。

理

学療

法

業

務の現

在

の

位

置 づけ 理 学療法 業務の現状や問題点は次の 5 項 目が_挙げら れ ます。 　1）理学 療 法サ

ー

ビ ス の需 要の増 加とそ の需 要と供 給 　 　 　の隔たりの拡 大 　 2）直接 診 療の立 法化

　 3） 臨 床 業務にお け る

“

referral

−for−

profit （紹介によ

　 　　り利 益 を 得ること）

”

に関す る 問 題の_協会と して 　 　 の_対応 　

4

） 政府関 連 活 動 　5）理学 療 法 専 門 分 野の資格 認 定 委 員 会を含 む

，

つね 　 　 に_変容を続 ける理 学 療 法の業 務

・

機 能

・

役 割 　

1

） 需 要 ／供 給 問 題 　ア メ リカ では理 学 療 法 士 不 足が周 知の ことでは あ り ま すが

，

「不 足」 とい うことが は っ き り証明 され ては い ま せん し

，

「不 足 」 とい うこと 自体が実際に起こっ てい る のか よ くわ か り ませ ん

。

しか し養 成 校か らの卒 業 生と 理 学療 法士 を必 要と す る現場の数との間に は明 らか な隔た りがあることは事 実です

。

どの_機関も新卒理学療法士を 欲しがっ ている わ けですが_， 特に病院に おい て は新卒の 理 学 療 法 士の応募の_少な さ も さ ること な が ら

，

現 職の理 学療法 士の_維持も難し く なっ て い るの です。 毎年

4．

000

〜 5

，

000_入の理学療法士 が卒 業 し

，

又 1

，

200〜

1

，

400

人 の 理 学 療 法 助手が 誕 生 しま す。 そ れで も供給が追いっ き ませ ん。 協会と して はこ の解決 策を必 死で模索する必 要 に迫 られ

，

クラスご との_学生 を増や すこと や教 師の供 給 を増や す た めの_財政 援助のた めに働き かけたり

，

また学 生の増 加のため に奨学金制度の確 立 な ど を続けて い ます。 更に臨 床 業 務から離 れて しまっ た理学療法 士に も う

一

度 業務に参 加して も ら うた めの特 別プ ロ _グラムを開設 し ま した。 これらプログ ラムは昨 年テ ネシ

ー

州ナッ シュ ビル で_行わ れた_年総会において開 設さ れ， 大変評判が良かっ たの で

，

これ か ら も続 けて い く予定です。 　 協 会が 理学 療 法 士 供 給を 「コ ン トロ

ー

ル」 して い ると 非難する外郭団 体 もある ようで す が

，

真 実 は

一

っ _です

。

例え ば 1980年か ら 1985年の 間に は学 校 数は20％， 1985年か ら 1988年の間に は 30％ 増 加し ま し た

。

同 時 にその学 校を卒 業 した理 学 療 法 士 数は前 者で

72

％

，

後 者で

70

％増 加 し ま し た。 実 際

，

認定 学 校 数とそ の卒 業 生 数はこ の ところ正 比例的に増 加しっ づ け て い ます。 協 会が行っ た病 院 勤 務理学 療 法 士や病 院を 退職 しいず れ か N工 工

一

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NII-Electronic Library Service

520

理学療法学　第

17

巻第

6

号 で開 業 して い る理 学療法 士の調 査に よ ると

，

業 務 環 境が 理 学 療 法 士の_補充

・

維 持に影 響を与え て い る ようです

。

更に 1978年から1987年の間の協会会 員 調査が その業 務 環 境の変 容 を如 実に表 して いま す。 1987 年の時 点で は

，

有効 回 答 理 学 療 法 士の 42％が病 院 勤 務 を選ん でいまし た が， 最近で は個人開業が人気がある よ う です

。

　 人 材の 需 要 ／供 給の ジレ ン マ は社 会 的 問 題で もあ りま すし

，

協 会に と

っ

て も要 注 意 事 項で す。 我々 は社 会の ニ

ー

_ズに応えるべ き道を創造 的かっ 画期的に_探して いか なければなりませ ん。 協 会と して は

，

理 学 療 法の役 割と 重 要 性の広 報 活 動のた めに約 50万 ド ル の予算を組ん で い ます。 しかし大 風 呂敷 を広 げるだけで実 力が伴 わなけ れ ば

，

か え っ て理学 療 法 士の専 門性は危 険にさ ら さ れ る ことになり ますが

。

　 2） 直 接 診 療の立 法 化 　 理 学 療 法 士の直 接 診 療が合 法 化さ れ ること が

，

専 門 職 と して の社会的信用の確 立につ _{な が る}ことは疑う余 地 も あ り ま せ ん。 アメ リ カ で は理学 療法士は個々 の州が 発行 す る免 許規則によっ て信任さ れて いま す_。 免 許に は理学 療 法士の_開業許可 資格 業務 内容， 業務規則等が明記さ れて いま す。 これ は職能団 体に よ る資 格 証 明書 発行方法 と は大き く異な り ま す。 第

一

の違いは

，

州の発行し た免 許 証や規 則， またその効力は州政府の権限で あ り， 職 能 団体ま た は連邦の_権力が及ぶ もの では あ り ま せ ん。 第二 の違い は州の_{開業許 可 証}は州の _法律や規 則か ら派生す る もの ですの で

，

_開業の法的基盤 を 証明するもの です。 職 能 団体の_発行す る 理学療法 士資格認定証 は そ れ だ けで は 開 業が法 的に認 め ら れるわ けで はあ りません

。

協 会は各 支部を通 して， 州の法 律 改 正に働 きか けていま す が

，

開 業に関 する各 州の持っ 権 限に は参 加 しえない とい うのが 現 状です。 　

1930

年代の_{初 期}に は特に_資格を満た して い な くて も 開 業が自 由に行え る状 態であ り ま した が

，

その後 すべ て の州の_資格規則は 「理 学 療 法士は_資格 必要条件を満た さ な くて は ならない」 とい う強制 的 意 味 を備え るよ うに な りま した。 また初 期には州の規 則によ りま す と理 学 療 法 士は有 資 格の医 師

，

外 科 医

，

歯 科 医の処 方 箋に従っ て の み治 療を す ること がで き る ということになっ てい ま し た が

，

その後 1960年 代になると紹介　（referral ） のみ で よい と な り ま し た。 しかし， 奇妙なことに は私は理学 療 法士に なっ てか らこ の 36年 間の_聞に詳 細にわ た る処方 箋や指示を受け取っ た覚え は ない ので す_。 「評 価し て治 療 して ください」という依 頼にすっ かり慣れて し まいま し た

。

　直 接 診 療へ _の活動_は ， 前述し た よ う に

1974

年に総 会 におい て協 会 自 身が医 師の紹 介な しの理学 療法評 価や治 療 をするとい うことにっ い て の概 念を調べ るべ きであ る と決 議 した ことがそのス タ

ー

トです

。

さ ま ざ まな努 力の 結 果

，

1979年に メ U

一

ラ ン ド州で最 初の_{直接 診療}が立 法 化され ま し た。 「直接 診療」の概念と は， 患者や依 頼 人が医者を通 ら ない で_直接理学療法サ

ー

ビス を受 けるこ と がで き る とい うことです。 　 1990年 現 在

，

直接診 療が 立法 化さ れて い る州は

25

州 に達し ま し た。 しか し その立法化状態は さ ま ざ まで

，

私 の所 属す るマ _{サ チ}

ュー

セ ッ ツ州のよ う に無制限 無 条 件が 許さ れて いる ところ か ら

，

卒後教育や実 習時間確保な ど の条 件 をっ けて いる州 も あ ります。 直接 診療に付 随す る 問 題と して は

，

_直接冶療に_訪れ た患者へ の_第三者 支払機 関 問 題や健 康 保 険料償 還など が あ り ま す。 後 者の 問 題は ノ

ー

ス キ ャロ _{ラ イ ナ}州の ようにすで に解 決 して いるとこ ろもありま す

。

そこで は州の_開業 法の中に理 学 療 法の分 野も含んでい るので

，

健 康 保 険 担 当官が州 司 法 長 官と協 力し て保険会社に理 学療法の直接診 療 分 も償 還 す るよう 指示し ています。 　上 記以外の問題 と して は

，

医 師からの治 療 指 示が あ っ た_方が_気楽に治療が_行え る と慰っ て い る理学療 法 士がい るとい うことです。 規則には医 師の指 示 を受 けて治 療 を し な くてはな らな いとは_明記さ れて い な い の に

，

残 念な ことです。 その ように医 師の指 示 を仰 ぎなが らの治 療 を 続け る理学療法 士がいるのは構いませ んが

，

医 師から独 立して も独 自に治 療が行え る と自負 してい る 理学療法士 の妨 げにな るの です

。

　直 接 診 療へ の動 きはますます活発になると思わ れ

，

こ れ が理 学 療 法 士の専 門 性の確 立 過 程におい て最 も困 難か つ重要な_点にな ると思います

。

　 3） 「紹介によ り_利益を得る」 環 境 　こ の問 題は 1980年 代の初めに医 師が理 学 療 法を行 う 場 　（Physician　

Owned

　

Physical

　Therapy 

Setting

，

POPTS ）を_持っ て い るとい うこと か ら起こ りま し た。 協 会と して はそ の状 況に_対立 する態 度を表し ま した_。 と い うの は

，

医 師 と共に理 学 療 法 を行 う と

，

患 者

，

理 学 療 法 士の利益

，

更に その専 門 性 が潜在 的に侵され や すいか らです。 その後ア メ リカの保 健 医療制度の変 革や

，

医 師 の_過剰な ど が

POPTS

の よ う な単純に解決で き ないよ う N工 工

一

Eleotronio _Library