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The purpose of this article is to describe the social and political events that have had a major influence on the shaping of physical therapy education since the beginning of the profession. This theme was developed by looking at the early history of the development of the field in the United States followed by an examination of the effects of World War I and the Great Depression on development of the education of the physical therapist. Following this, there is an exploration of the effects of World War II and the postwar period on the further development of the education of the physical therapist related to the social and political changes occurring in the nation. During the 1960s, there was a great deal of change in the nation’s political, cultural, and social values, and these changes were explored in relationship to the physical therapy profession’s educational changes. From the 1970s to the 1990s, rapid changes were taking place in terms of accreditation and education of the physical therapist, and these changes are discussed. During this time, increased legislative activity leading to direct access occurred, and the initiative to develop a postbaccalaureate degree as the primary method for education for the physical therapist began. The postbaccalaureate degree discussion finally led to the development of the Doctor of Physical Therapy (DPT) degree being adopted as a goal for the profession. In the late 1990s and at the beginning of the 21st century, changes took place in physical therapist practice requiring the profession to deal for the first time with a potential surplus of physical therapists. Also discussed is the concept of strategic adaptation and the successes and failures of the adaptations that the profession has made. Finally, there is a discussion of the transition to the DPT degree and the continuing changes that are occurring in the field of physical therapy.

Social and political events have had a major influence on higher education institutions and activities during the time period that physical therapy emerged and developed as a health care profession. Many have made the observation that survival of institutions and professions is related to how well change is managed. In general, higher education has continuously changed over the past 100 years as universities and colleges in this country have adapted to the needs of a society requiring more access to higher education as well as accommodating the needs of emerging professions and occupations. Progress in these areas often seems to be made both grudgingly and slowly, but viewed over the long run, the changes are remarkable and impressive.

Lawrence1 has suggested that in medicine and other health care professions, the most important roles have traditionally been practice, research, and teaching. The teaching role referred to here is the role of preparation of those who want to enter the professions represented by health care. The Flexner report on medical education of 1914 caused a revolution in medical education that has influenced thinking in all health care professions.2 The Flexner report set the general framework for health care professions education and stressed the importance of the education of the health care professional and the importance of a relationship between professional education and universities.

It is a daunting task to explain the political and social issues that have shaped physical therapy education. I am not a political scientist nor a historian, and certainly not a sociologist. I am a physical therapist with significant experience in both the clinical practice and higher education aspects of physical therapy; therefore, the perspective presented will basically be one that is, in many ways, personal and anecdotal.

EARLY HISTORY OF THE FIELD

We begin with the historical perspective. The role of the physical therapist as a practitioner began to grow in this country out of the posture and scoliosis clinics established by physicians at the turn of the 19th to the 20th century.3,4 These physicians sought assistance from women with backgrounds in physical education to assist them. During this time, poliomyelitis epidemics occurred, and orthopedic surgeons, primarily in the New England area, expressed a need for help in caring for patients with poliomyelitis after the acute stage of their illness. This need was met primarily by employing women who were physical educators who provided prograins of exercise and what we would now call rehabilitation. During this period, hospital departments in Boston and Philadelphia were established for the management of orthopedic problems in addition to poliomyelitis.4

WORLD WAR I TO THE GREAT DEPRESSION

Although physical therapy was being recognized as an important service, a great deal of growth did not occur until World War I. The war was a key factor in the development of the profession.1-6 During WWI, the Army took on the role of educating women as reconstruction aides. Physicians were the primary force in recognizing that soldiers and other military personnel with front-line and battlefield injuries would need a great deal of assistance in reaching their full potential as their wounds and injuries healed. Reconstruction aides trained by the Army at Walter Reed Hospital and also at Reed College in Oregon among others formed the backbone of what was to become the profession of physical therapy. Reed College was among the first institutions to offer education to women who desired this training and who were not prepared directly by the Army.

This article describes the developmental processes underlying the implementation of the Doctor of Physical Therapy (DPT) program at Creighton University. Creighton University established the first professional (entry-level) UPT program in physical therapy. An explanatory case study was used to frame the analysis of specific decisions and key events. A case study database was created using documentation, archival records, interviews with key decision makers, and authors’ experiences as participant observers. Critical factors in the development of this program included institutional and school leadership, institutional commitment and capacity, contributions of key educational leaders in physical therapy, a strong institutional mission consistent with work of health care professions, and a strong faculty belief system focused on the key role of clinical doctoral education for preparation of a professional physical therapist.

In 1985, Geneva Johnson, PT, PhD, FAPTA, in the 20th Mary McMillan Lecture, advocated for the development of the clinical or professional doctorate for the first professional degree for physical therapists: “Changes in education are key to full professional status…. I expect us to develop the professional doctorate in physical therapy as a standard for entry-level education within the next five years.”1(pp1693-1694) During this time, physical therapy education was in the midst of transition from the baccalaureate degree level to the master’s degree level. The Education Division of the American Physical Therapy Association (APTA) did not initiate widespread discussion on doctoral education until the late 1980s. The 1989 Report on Doctoral Education clarified distinctions between PhD programs, designed to prepare scholars, and professional or clinical doctoral (DPT) programs, designed to prepare students for entry into the profession. The report also included recommendations for continued discussion within the physical therapy community on doctoral education.2 In 1993, Creighton University initiated the first professional (entry-level) physical therapist program that would lead to the Doctor of Physical Therapy (DPT) degree upon completion.

This article is an explanatory case study focused on analysis of the critical factors and influences that led to the planning and implementation of the DPT program at Creighton University.

CASE STUDY METHOD

Case study methodology can be used to illuminate a decision or set of decisions surrounding a specific process or program.3 In this instance, the case is focused on the development and implementation of the DPT program at Creighton University. The explanatory case will focus on why decisions were made and how decisions were implemented leading to the realization of the initial DPT program.

Data Sources

Data sources for the case study database included: (1) documentation that included letters, memoranda, agendas, meeting minutes, written reports, and administrative documents such as progress reports and proposals; (2) archival records that included organizational and institutional records; (3) selected interviews with key decision makers in the process; and (4) participant observation of authors who were all involved at various times in program development and implementation.

Case Study Creation

Three core principles were followed in the creation of the case study. First was the use of multiple sources of evidence, second was the creation of a case study database, and third was the maintenance of a chain of evidence. A chain of evidence means that one goes beyond single sources of data and looks for connections and patterns of evidence across the data sources.3 Review of the case for verification of assertions and interpretations was done by selected key stakeholders and decision makers.

Case Descriptive Framework

One analytic strategy for case study creation is development of a descriptive framework for organizing the case. While the stated purpose of this article is descriptive and explanatory, it also provides a historical view of the development of the first professional DPT program. Therefore, the framework will be centered on a chronology of decisions and actions across time (Tables 1 and 2).3

INITIAL BEGINNINGS: FROM IDEA TO FEASIBILITY

In the fall of 1986, Father Michael G Morrison, SJ, president of Creighton University, in conjunction with Richard L O’Brien, MD, vice president for Health Sciences, requested that the School of Pharmacy and Allied Health Professions consider the establishment of a physical therapist education program. Creighton University initiated an occupational therapist program in 1985. The university was interested in investigating the possibility of initiating other health care professions programs. A related factor in the president’s interest in physical therapy came from a personal contact-his sister was a physical therapy faculty member at Marquette University. She suggested that if he was interested in starting health care professions programs, he should consider physical therapy.

Background and Purpose. Professional (entry-level) education in physical therapy, as an enterprise distinct from, yet central to, the profession of physical therapy as a whole, has reached a level of maturity at which there is value in reviewing its development. The authors identify major elements of importance in professional education, including the nature and institutional setting of professional education programs, curriculum content and design, and characteristics of students and faculty. Major events and developments are highlighted for each major element. Methods and Materials. Information has been drawn from published materials dating from the 1910s through the end of the 20th century and from archival records maintained by individual professional education programs and professional organizations in or related to physical therapy. This information has been augmented by the authors’ personal experience of professional education during the years from the 1940s through the end of the century. Summary of the Literature. Comprehensive reviews of professional education in physical therapy have been conducted at various points in time. Detailed analyses of different aspects of physical therapy education have been published throughout the 20th century. Comprehensive, but nonscholarly, histories of the profession of physical therapy, including discussions of events pertaining to professional education, also have been published, most recently in the mid 1990s. Conclusion. The article provides an overview of the history of professional education in physical therapy.

A thorough discussion of professional (entry-level) education in any field needs to address a variety of related topics, including curriculum content and format, institutional setting and program resources, faculty and student characteristics, and program standardization and accreditation. Fortunately, a number of these specific concerns are addressed in other articles in this special issue. This article, while not attempting to do complete justice to the remaining topics, will highlight the major issues and developments that occurred during the 20th century in regard to curriculum content and design, faculty and student characteristics, and institutional setting of professional education in physical therapy.

Put yourself in the position of responding to the hypothetical requests for information that are interspersed throughout this article. What might you emphasize in response to each one? How might your response have varied in each circumstance?

Lucy C_

Boston, Mass

Dear Cousin Lucy, February 21, 1918

I was so excited to hear that you have decided to apply to be one of these new Reconstmction Aides. It sounds so thrilling! I have been thinking that maybe I could do that, too, if I could get into a training program this summer, rather than going to normal school as I had planned. Could you tell me more about it? Where would I have to go to get training, and what would it be like?

I’m sorry you were not able to be home for Christmas . . .

Your loving cousin, Beth

The Cedars, Park City, Iowa

If Beth was considering attending normal school in the fall, she almost certainly would have been much too young to become a Reconstruction Aide, the lower age limit for applicants being 25 years.2 Her cousin Lucy, if she was entering training in the Boston area, had open to her a choice of three programs that had been identified by the Office of the Surgeon General of the Army, the American School of Physical Education, the Boston School of Physical Education, and the Posse Normal School of Gymnastics.3 Another East Coast school also was identified by this time, the New Haven Normal School of Gymnastics. Later, in 1918, a new training program was instituted at Walter Reed General Hospital under the auspices of the Medical Department of the Army. If Beth had been of an age to consider entering a Reconstruction Aide program, she would have found one nearer to hand at the Normal School of Physical Education in Battle Creek, Mich. Or she could, as did many individuals from all over the country, have attended the program at Reed College in Portland, Ore.4 If Lucy had already received training considered appropriate for a Reconstruction Aide, she might eventually have refined her knowledge and skills under the direction of Janet Boyd Merrill at the advanced training program established jointly by Harvard University and the Boston Children’s Hospital in 1918.

Both the Reconstruction Aide training programs authorized in January 1918 by the Office of the Surgeon General of the ArmyS and acceptable physical education programs were expected to have provided the potential Reconstruction Aide with knowledge and skills in the areas of massage and corrective exercise, with emphasis on the application of these interventions to pathological conditions. The programs identified as of January 1918, were-with the probable exception of the one at Battle Creek-situated within institutions with established, relatively standard physical education certificate or degree-awarding programs. Even though the Reconstruction Aide training programs in these institutions were much shorter in length-rarely lasting longer than 3 months-than the full preparation for physical education, they did incorporate such basic course work as anatomy (structural and functional), pedagogy, and various sports as well as the medically oriented courses in pathology,6 massage, and corrective exercise.7 Clinical application was closely integrated with didactic work, with students typically spending part of the day in supervised clinical practice and the remainder in class.

The authors review the recognition of physical therapy education programs from 1928 to the present and describe the chronological activities that led to the accreditation process as we know it today. The history, current practice, and the broader national accreditation environment in which the Commission on Accreditation in Physical Therapy Education (CAPTE) must operate are explained. The evolution of the standards used in making accreditation decisions in physical therapist professional education is described along with the changes in the arenas of education and practice that have influenced the accreditation process. Possible and probable changes for the future are proposed.

In 2003, the year after the Commission on Accreditation in Physical Therapy Education (CAPTE) celebrated its 25th year of national recognition as an accrediting agency, a 1977 quote from Rosemary Scully, PT, EdD, which predated CAPTE’s initial recognition, is still quite applicable to the profession:

Physical Therapy has an ancient history, a proud past, an exciting present, and a challenging future. Education for physical therapy practice has been built on a strong foundation and with resourcefulness and wisdom it should be able to meet the demands of the present and the challenges of the future.1(p159)

This article will explore the history of accreditation in physical therapy and the evolution of the standards used in making accreditation decisions in physical therapist professional education. It will describe the changes in the arenas of education and practice that have influenced the accreditation process and the national environmental influences with which each nationally recognized accreditation agency must deal. The work of CAPTE also includes the activities of accreditation related to physical therapist assistant education programs. However, this article will not compare the evolution of the criteria related to those programs nor the changes within the practices of physical therapists that have clearly led to changes in the work done by physical therapist assistants.

HISTORY-THE EARLY YEARS

Education programs for the preparation of physical therapists have been recognized in some manner since 1928. The American Physical Therapy Association (APTA) first published a list of approved programs in the June 1928 issue of The Physiotherapy Review and continued to publish such a list through 1933. Little is known about the process used to approve programs, but the standards by which they were measured are well documented in the Minimum Standard for Schools of Physical Therapy.2

In 1933, because APTA lucked the financial and human resources needed to manage the accreditation effort, APTA requested and received agreement from the American Medical Association’s Council on Medical Education and Hospitals (AMA/CME) to become involved in accreditation and recognition of programs in physical therapy.3 During 1934 and 1935, no additional programs were granted approval, nor was approval withdrawn by either organization.

The AMA/CME inspected and approved13 programs in physical therapy using as its standards for approval the Essentials of an Acceptable School for Physical Therapy Technicians.4 An annual list of approved programs was published in the Journal of the American Medical Association beginning August 29, 1936. From 1936 to 1956, the AMA was solely responsible for accreditation activities, though AMA staff did submit a report on each program to the APTA Executive Committee prior the AMA/CME action.5 The Essentials of an Acceptable School of Physical Therapy6 was developed and adopted in December 1949 in collaboration and cooperation with the Council on Physical Medicine and Rehabilitation, APTA, and the AMA Council on Medical Education and Hospitals.

COLLABORATION AND CHANGE Although documented evidence is difficult to find, it is rumored that in the mid 1950s the AMA approached APTA and requested that its members become involved in a collaborative accreditation effort. The APIA’S former director of education, Patti Evans, recalls Sarah Rogers’ vivid recollections of the complaints, conditions, and conversations that led to the request that physical therapists join in that collaboration (Patricia Evans; personal communication; September 16, 2003). One might surmise that by this time APTA’s members were well prepared to assume roles of responsibility in the survey visits and decision-making processes and were more plentiful in numbers than during the 20 years prior when a similar request was made by APTA to the AMA.

From 1957 to 1963, AMA and APTA shared an informal arrangement, and from 1964 to 1976, a formal collaborative arrangement existed for accreditation of only physical therapist education programs using the December 1955 revision of the Essentials of an Acceptable School of Physical Theraphy.7

In 1967, while the collaborative effort with the AMA was operating for the accreditation of physical therapist education programs, the APTA House of Delegates (House) authorized the education of physical therapist assistants at APTA’s Annual Conference by adopting a policy statement regarding the training and utilization of physical therapist assistants.5 At th time, the AMA/CME was not interested in accrediting these programs, so APTA developed standards for education programs for the physical therapist assistant and established approval procedures. The first Standards for Physical Theraphist Assistant Education were adopted by the APTA Board of Directors (Board) in June 1972 and were published in the September 1972 issue of Physical Theraphy.8 After discussion with representatives from the National Commission on Accreditation, the US Office of Education (USOE), and the American Association of Community and Junior Colleges, the APTA Board adopted the Statement of Interpretations and implemented the Interim Approval Program for Education Programs for the Physical Therapist Assistant.5 The first interim approval decisions were granted by APTA in 1971 with effective dates that retroactively included graduates of the first class from each approved program. The first published list of APTA interim approved programs for the physical mcrapist assistant appeared in Physical Theraphy in 1972.9

The emphasis of this special issue is on the history of physical therapist education; one manuscript, however, specifically illustrates the history of physical therapist assistant education. All of the authors describe the early days of physical therapy in the United States and the external and internal influences that make physical therapist practice and education what it is today.

As you read this issue, you will be impressed by the way societal and political factors, along with the continual evolution of disease, have affected physical therapist practice. Over the years, the manner in which physical therapy professionals dress, talk, and relate to patients has changed markedly. Surges or resurgences of certain diseases have impacted the profession, as has the political arena, from payment structures to the domination by physicians of our profession in the early days.

The key elements of our profession include practice, teaching, and research. The transformations in physical therapy education and practice were very difficult to capture in short manuscripts. The authors have provided you with a tour of critical past events.

Physical therapy practice has evolved from being prescriptive, with physicians telling physical therapists exactly what to do, to physical therapists practicing independently. The proposed national Medicare regulations for payment for direct-access services substantiates how far this profession has come; this issue is discussed by Marilyn Moffat, PT, PhD, CSCS, FAPTA, in “The History of Physical Therapy Practice in the United States” and by John L Echternach, PT, RdD, HCS, FAITA, in his article “The Political and Social Issues That Have Shaped Physical Therapy Education over the Decades.”

Education has also changed from being prescriptive to evidence-based over the last 80 years, as illustrated by Elizabeth H Littell, PT, PhD, and Geneva Richard Johnson, PT, PhD, FAPTA, in their article “Professional Entry Education in Physical Therapy during the 20th Century.” At one time, when a teacher entered the room all of the students had to stand up in deference to the instructor. Those days are long gone! Students now expect excellence and challenge their instructors, which would not have been accepted in the early days of physical therapy education.

Clinical instruction has also changed with the evolution of the profession. With entry-level doctoral education, identifying and developing superb clinical instructors (CIs) is a challenge. Issues such as finding talented CIs to mentor students continue to be a concern, as does the number of clinical placement sites. Jan Gwyer, PT, PhD, and colleagues, in “The History of Clinical Education in Physical Therapy in the United States,” describe critical issues that have shaped clinical education.

The evolution of the Doctorate in Physical Therapy (DPT) has recently been a catalyst for change in the profession. Schools across the county have followed the Creighton University faculty in offering a DPT degree. The Creighton University faculty’s decision to train doctorally prepared clinicians was controversial, widely discussed, and criticized. They believed in their goal and persevered. Sidney J Stohs, PhD, FASAHP, FACN, CNS, FATS, and colleagues explain the steps in the evolution of the first physical therapist doctoral program in their paper, “Initiating Clinical Doctoral Education in Physical Therapy: The case of Creighton University.”

Societal issues have affected the recruitment and retention of minority groups.

In “The Historical Significance of Minority-Serving Institutions in Physical Therapy Education,” E Anne Reicherter, PT, MEd, OCS, and colleagues illustrate the trials, tribulations, and successes that the profession of physical therapy has achieved as a result of efforts to promote diversity.

How we judge ourselves as a profession is well depicted by the work of Virginia M Neiland, PT, MS, and Mary Jane Harris, PT, MS, in “History of Accreditation in Physical Therapy.” They describe the changing standards of physical therapy education by cataloguing the history of accreditation for more than half a century.

Elizabeth Domholdt, PT, EdD, FAPTA, and colleagues further demonstrate in “Journal of Physical Therapy Education: Birth to 16 Years” how physical therapy educators learn from each other in their scholarly study of the contents of the Journal of Physical Therapy Education. They have provided us with an exhaustive study of contributions to the journal over the last 16 years.

Finally, in “Physical Therapist Assistant Education Over the Decades,” Cheryl A Carpenter-Davis, PTA, MEd, discusses the development and changes in physical therapist assistant education and practice. She attempts to provide insight into the evolution of the physical therapist assistant’s role and provides thoughts about the future.

Recognition of key physical therapist and physical therapist assistant leaders was attempted where possible. As with all attempts to recognize leaders in any profession, oversights may have occurred. Realizing this, it was still deemed important to try to recognize some of the talented people who have paved the way for future physical therapists. Historical research never tells the entire history.

Mrs JC, a 55-year-old woman, arrives for her annual gynecologic exam. Besides wanting to update her Pap smear and mammogram, she would like to discuss estrogen replacement. She reached menopause at age 52 and began taking estrogen for hot flashes and night sweats. Her cholesterol levels have been elevated since menopause. She read that estrogen can lower cholesterol levels and therefore may possibly reduce her risk for heart disease.

She did very well with estrogen. Her hot flashes and night sweats disappeared and she felt great. However, after hearing news reports about the danger of estrogen, she discontinued the hormone pills a few months ago. She is now feeling poorly with hot flashes, night sweats, vaginal dryness, and occasional stress incontinence. She has many questions and concerns and eagerly seeks your advice about what to do.

Medical history

* Borderline hypertension

* Hyperlipidemia

* Obesity: body-mass index of 32

Family history

* Mother, age 75, has hyperlipidemia, hypertension, myocardial infarction (MI) at age 60, and osteoporosis

* Father, died at age 55 of MI; had hypertension and diabetes

* Her grandparents also had history of stroke and heart disease, but she doesn’t know all the details about their health. She believes her maternal grandmother broke her hip when she was elderly.

Social history

* Married, 2 children, works as an attorney with the local government. Her job is fairly demanding

* Does not smoke, occasional alcohol consumption

* Does not exercise on a regular basis

Review of systems

Negative except for hot flashes, night sweats, vaginal dryness, and occasional stress incontinence.

Physical examination

* Alert female in no distress. Blood pressure, 145/90 mm Hg; weight, 165 lbs; pulse, 82; respiration, 18; temperature, 98.1[degrees]F

* HEENT exam, normal

* Neck, heart, lung, abdomen, breast, and pelvic exams are all normal except for mild atrophic changes of the vaginal and genital tracts.

You perform the gynecologic exam and order a mammogram. Mrs JC has not been seen for 2 years. Her lipid profile done 2 years ago was elevated, but Mrs JC did not repeat the tests as requested. You explain that you would like to further define her risk factors and would like to order a few tests. Making a well-informed decision on hormone replacement therapy (HRT) is complex and requires more information and adequate time for a full discussion. You would like to see her after her laboratory tests and will reserve time to address her concerns and questions.

Laboratory tests

Complete blood count, normal

Cholesterol, 250 mg/dL (LDL, 130 mg/dL; HDL, 45 mg/dL)

Triglyceride, 220 mg/dL

Electrolytes, blood urea nitrogen/creatine

(BUN/Cr) ratio, normal; glucose, 85 mg/dL

Mrs JC has many symptoms of menopause:

* Vasomotor instability

* Urogenital symptoms She also has risk factors:

* Cardiac: hypertension, hyperlipidemia, obesity

* Osteoporosis: family history, sedentary lifestyle

Before addressing Mrs JC’s specific concerns, you review the findings of the Women’s Health Initiative (WHI) study, (1,2) which probably prompted her concerns. You also have been asked to lead an upcoming geriatric grand round presentation on HRT, and you further prepare for both encounters by meeting with colleagues Dr Richard Pees, a gynecologist, and Dr Deborah Erickson, a urologist, to discuss practical applications of the WHI findings.

* Findings of the WHI

WHI, sponsored by the National Institute of Health, comprised 2 multicentered clinical trials to determine if conjugated equine estrogen (CEE) given alone for women who had a hysterectomy or in combination with progestin (MPA, medroxyprogesterone acetate) would reduce the risk of cardiovascular events. The study also assessed the long-term risks and benefits of postmenopausal hormone therapy in other chronic disease prevention.

Exclusion criteria for the study included competing risks with survival <3 years, prior breast cancer, low hematocrit or platelets, severe menopausal symptoms, alcoholism, mental illness, and dementia. In this study, 27,000 women aged 50 to 79 years (mean age, 63) were randomized to take hormone or placebo.

The combined CEE/MPA (Prempro) trial, with 16,000 women enrolled, was discontinued at 5.2 years, on July 2002. The unopposed CEE (Premarin) trial, with 11,000 women, was discontinued at 6.8 years, on February 2004. The study was stopped earlier than planned (2005) because of increased adverse events in the group taking hormone.

TABLE 1 summarizes the absolute risks–number of events per 10,000 as compared with the control group–for both arms of the study. In the CEE/MPA arm, there were more cases per 10,000 of coronary heart disease (+7), breast cancer (+8), stroke (+8), and venous thromboembolic disease (VTE) including deep vein thrombosis/pulmonary embolism (DVT/PE) (+18). However, there were fewer cases per 10,000 of colorectal cancer (-6) and hip fracture (-5).

Recently published data-’ on the unopposed estrogen arm showed an increase in stroke (+12) and VTE (+7). No significant increase was noted for coronary heart disease (CHD) (-5) or breast cancer (-7).

Background and Purpose. The inaugural issue of the Journal of Physical Therapy Education was published in 1987 by the Education Section of the American Physical Therapy Association. The purpose of this article is to describe the evolution of the Journal and its contents across its first 16 years of publication. Sample. The 353 indexable items found in the 37 issues of the Journal published between 1987 and 2002 were reviewed. Methods. Each article was reviewed by one of two authors to determine the article topic and type of contribution. If applicable, the type of academic program, type of research, and research sample were also determined. Trends across four 4-year phases were also studied. Results. The journal has reflected the contributions of 34 different board members and 243 primary authors affiliated with 155 institutions. Teaching/learning methods, clinical education, and curriculum were the three most frequently addressed topics. Research articles were the most common (63%) type of article published. Physical therapist preparation programs were the most common (88%) type of academic program addressed within articles. Quantitative descriptive research was the most common (36%) type of research represented and program students (46%) were the most frequent research sample. Important trends across time included an increase in research articles and a decrease in method/model articles; an increase in articles about graduate physical therapist preparation programs and a decrease in those about baccalaureate programs; and a more even distribution of research methods, with a decrease in quantitative descriptive research and an increase in qualitative descriptive work and in articles in which differences between study groups were analyzed. Discussion and Conclusion. The trends in article types and research methods reflect a maturation of the scholarship of physical therapy education across the 16years in which the Journal of Physical Therapy Education has been published.

Journals are a time-tested und revered form of learning. They are gifts of knowledge and experience from the past on which to improve the present and prepare for the future. The challenge before us, then, is to develop a climate of scholarship that will allow the journal not merely to endure, hut to flourish.1(p3)

These 1987 words of Samuel B Feitelberg, then president of the American Physical Therapy Association’s (APTA) Section for Education (now known as the Education Section), marked the publication of the first issue of the Journal of Physical Therapy Education. Leaders of the Education Section had for years been convinced that such a journal was needed-but the Section lacked the financial resources to make such an undertaking possible (Samuel B Feitelberg, personal communication). Feitelberg’s vigorous, personalized, fundraising efforts succeeded in raising the capital needed to launch the journal: More than 100 individual members of APTA and a few physical therapy practices contributed to this effort.2 Initially published in 1987 as a single-issue volume of 44 pages, the most recent full volume (2002) of the Journal consisted of three issues with a total of 227 pages. Initially accessible only to Education Section members, today the contents of the Journal are retrievable to a worldwide audience through the Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic database.3 Viewed along these three dimensions alone-publication frequency, issue size, and electronic retrievability of journal contents-the Journal of Physical Therapy Education can be said to be flourishing at the age of 16 years. However, a more complete assessment of the contributions of the Journal to the climate of scholarship in, and to the body of knowledge of, physical therapy education has never been published.

Analyzing the journals within a profession is an established method of tracking trends in the development of the body of knowledge of physical therapy.4-16 Collectively, these 13 studies demonstrate a high level of interest in using the literature of physical therapy to understand the development of the profession and its body of knowledge. Although these articles provide a great deal of insight into the development of the body of knowledge in physical therapy in general,4-12 as well as in focused areas such as ethics,13 pediatrics,14 knee and back dysfunction,15,16 and use of electrical stimulation,15,16 we could find no published studies analyzing the body of literature in physical therapy education.

PURPOSE

The purposes of this study, therefore, were: (1) to describe the nature of the Journal of Physical Therapy Education across its first 16 years of publication, (2) to identify influential individuals who contributed to the production of the Journal and influential individuals and institutions that have contributed to the content of the Journal across the years, (3) to characterize the content and methods used within articles published in the Journal, and (4) to analyze content and method trends across time.

The number of persons in the United States who were diagnosed with Alzheimer’s disease in the year 2000 was 4.5 million. The prevalence of Alzheimer’s disease increases with age, affecting 1 percent of patients 60 years of age, but rising to 30 percent of those 85 years of age. Cummings reviewed the management of this commonly encountered cause of dementia.

Alzheimer’s disease is marked by a steady decline in cognitive function, accompanied by mood and behavior disturbances, especially as the disease progresses. Motor or sensory abnormalities, gait disturbances, and seizures typically do not occur, although these may appear in the later stages. Increasing evidence indicates that the accumulation of neurotoxic beta-amyloid peptide plays a central role in this debilitating disorder. The neurofibrillary tangles, inflammation, and oxidation effects that received attention early in the investigations of Alzheimer’s disease appear to be secondary effects precipitated by deposition of this peptide.

The author notes that the initial work-up of a patient with suspected dementia should include screening measures for causes other than Alzheimer’s disease. Thyroid function testing, vitamin 812 level, complete blood count, and a comprehensive metabolic panel (i.e., serum electrolytes, renal function, hepatic function) typically are included in the laboratory screen. The review author recommends a screening brain imaging study (computed tomography or magnetic resonance imaging) during the work-up as well.

Treatment of Alzheimer’s disease has proved to be difficult. Options available to date have produced modest benefits in slowing the decline in cognitive function. Results of drug therapy trials typically have shown improvements of 2.5 to 3.5 points on a 70-point scale of cognitive function. This represents about a six-month reversal in the usual 7-point decrease in function that occurs annually in persons with Alzheimer’s disease. Therapies specifically targeted to beta-amyloid peptide are under investigation, but none has been produced yet. Antioxidants, principally vitamin E, have not been shown to improve cognitive function in patients with Alzheimer’s disease, but can delay progression to some clinical milestones (e.g., placement in a nursing home). Higher dosages of vitamin E supplementation (i.e., 2,000 IU daily) are advocated by some for patients with Alzheimer’s disease. Although brain inflammation is evident in Alzheimer’s disease, prospective trials of steroidal and nonsteroidal anti-inflammatory drugs have failed to show benefit. Hormone therapy in women with dementia initially was thought to be beneficial, but this was not borne out in prospective trials.

The mainstay of drug therapy for patients with Alzheimer’s disease is cholinesterase inhibitors (see accompanying table) for patients with mild to moderate dysfunction. Tacrine is used rarely because of hepatoxicity. The other three agents (i.e., donepezil, galantamine, and rivastigmine) appear to be largely equivalent in efficacy. The nausea, vomiting, diarrhea, and other side effects that accompany these agents may be ameliorated by a slow titration of dosing and giving the medications with meals. The review author suggests waiting up to four weeks between dose escalations to decrease the adverse effects.

Memantine is a newer medication for the treatment of Alzheimer’s disease that works by antagonizing the N-methyl-D-aspartate receptor. The U.S. Food and Drug Administration has approved memantine for treatment of moderate to severe Alzheimer’s disease, and it may be used in combination with a cholinesterase inhibitor. The cognitive benefits seen with this agent have been modest as well. To date, no serious adverse effects from memantine are apparent.

Management of depression, agitation, and other neuropsychiatric symptoms often becomes necessary as Alzheimer’s disease progresses, and the review article covers this area as well. Use of antidepressants and other psychotropic medications tends to follow usual guidelines, with the exception that tricyclic antidepressants usually are avoided, owing to their anticholinergic properties.

The author notes that caregivers of patients with Alzheimer’s disease tend to report more physical and mental health problems than their peers. Referral of caregivers to community assistance organizations that deal with Alzheimer’s disease may help decrease their burden.

What is Aquatic Physical Therapy? Aquatic Physical Therapy is a type of rehabilitation that uses water exercise to achieve physical therapy goals. It allows patients previously limited in attempts at land-based therapy to improve their strength, range of motion and general movement patterns so they may eventually return to more functional activities on land. Aquatic Physical Therapy sessions are led by a licensed Physical Therapist (PT) or Physical Therapist Assistant (PTA), under the direction of the PT People of all ages can benefit from exercising in the water with the correct guidance and program targeted to their individual needs.

The water is an ideal medium for exercise since its properties offer several benefits. There is no other method of exercising available that creates a zero impact environment that is found with aquatic exercise. The natural buoyancy experienced in a pool supports the body and decreases the effects of gravity, leading to a reduction in compressive forces and stress on the joints. This phenomenon allows for easier, safer, and more comfortable movement while in the water.

The amount of support offered for weight-bearing joints can vary depending on the depth one is submerged while exercising. Joint stress can be reduced by as much as 50% when exercising in chest deep water, for example. Therefore, one way to increase the intensity of an exercise is to simply have a patient perform the same exercise in shallower water. Conversely, if the exercise is too difficult to perform, the patient can be moved into slightly deeper water to decrease the intensity.

The position of the patient and direction of the movement can also alter the amount of assistance or resistance provided by the water. Movements directed toward the water’s surface are considered to be buoyancy-assisted exercises because the movement is being “helped along” by the buoyant properties of the water. Movements directed toward the bottom of the pool are known as buoyancy-resisted exercises because the movement is opposing the buoyant nature of the water. Finally, movements performed parallel to the bottom of the pool are considered to be buoyancy-supported activities because they are neither assisted nor resisted by buoyancy, but rather supported during the movement.

As the participants become more conditioned and stronger, aquatic exercise equipment, such as kickboards, aquatic dumbbells, ankle/wrist weights, and webbed gloves or shoes, can be introduced for more advanced strengthening techniques. This gear is used to provide greater resistance during movements. The therapist can a& create perturbations in the water to challenge all of the trunk stabilizing muscles to work to keep the patient balanced when exercising.

What are the Benefits of Aquatic Therapy?

A wide variety of people can benefit from aquatic therapy. It can be used to decrease muscle spasm and promote relaxation for those with neurological conditions, such as CVA (stroke), Brain Injury, Spinal Cord Injury, or Cerebral Palsy. Decreasing pain for those with arthritic joints, healing fractures, and chronic pain conditions, such as Fibromyalgia, is another advantage to aquatic therapy. As previously mentioned, the water decreases joint compressive forces allowing greater ease of joint mobility and range of motion for many types of patients, including prenatal mothers, patients with post-surgical total hip or knee replacements, and those with orthopedic injuries. Aquatic Therapy is also a great way to improve muscular strength and endurance and cardiovascular conditioning at any level, from athletes to those with industrial or traumatic injuries. When exercising in the water all of the body’s muscles become engaged in the activities, producing increased circulation, coordination and balance.

How Do I Get Started?

Just as in land-based Physical Therapy, every patient is initially evaluated on land. If it is determined that aquatic therapy is the most suitable rehabilitation option for that patient, a referral from a physician is required before beginning the program. All aquatic exercise programs are matched to the needs of each patient, with the goal of progressing to land-based exercise, if possible. During treatment sessions, patients are educated as to benefits of each exercise, proper techniques, and ways to advance exercises. This will ensure that patients will continue to benefit from their program when resuming exercise independently after discharge. At St. Lawrence Rehabilitation Center, aquatic exercise instruction is provided by a licensed Physical Therapist and class is conducted twice a week at the YMCA in Hamilton, NJ. The moral support received from fellow patients combined with gains made in strength, mobility, endurance, balance and coordination will translate into an overall improvement in one’s confidence and quality of life.

It is imperative to incorporate current research evidence into all aspects of physical therapy, including clinical practice, education, and administration. A major difficulty in performing this task is efficiently searching and selecting relevant research articles from the current literature. Research evidence is one factor used in evidence-based decision making along with clinical expertise and patient preferences.1 The components of evidence-based decision making are illustrated in Figure 1 . Systematic review articles and other forms of preappraised evidence are extremely helpful in efficiently gathering research information.2,3 Systematic reviews “…synthesize the results of multiple primary investigations by using strategies that limit bias and random error. These strategies include a comprehensive search of all potentially relevant articles and the use of explicit, reproducible criteria in the selection of articles for review.”2 The purpose of this article is to provide an overview of methods for efficiently searching for systematic reviews and other types of preappraised evidence.

Regardless of the specific scenario, evidence-based decision making involves several steps. The first step is to identify a gap in current knowledge. The next steps are to formulate a clinical question and search for the best evidence. Then the acquired evidence must be evaluated individually and as a whole. The final step in evidencebased decision making is to apply the evidence to patient care.2,3 The steps in evidence-based decision making are illustrated in Figure 2. There are several techniques and unique databases that facilitate searching for systematic reviews and other types of preappraised evidence.

IDENTIFY GAP IN CURRENT KNOWLEDGE

Identifying gaps in current knowledge can originate from different sources and have different applications. Recognizing need for information can come from several sources including professional practice, professional trends, existing published research, and existing theory.6 In addition, identifying gaps in current knowledge may apply to one of 3 areas of patient management, diagnosis, treatment, or prognosis. Consider this example, “Is physical therapy beneficial for patients with pulmonary disease?” The source of this gap in knowledge is professional practice and it applies to patient treatment or intervention.

FORMULATE A CLINICAL QUESTION

A clinical question must contain 4 components to be answerable. These components are patient population (P), intervention or exposure (I), comparison (C), and outcome (O).1 The components of a clinical question are illustrated in Figure 3. The previously posed question needs to be refined in order to contain and narrow all the needed components of a good clinical question. First, patient population must be defined and narrowed, for example, ‘patients with cystic fibrosis! Next, an intervention must be defined and narrowed, for example, ‘exercise training! A comparison group must be included in the clinical question, which could be either a different intervention group or a no treatment/control group. Lastly, an outcome must be defined and narrowed, for example, ‘exercise tolerance.’ Once a clinical question has been refined a literature search can be undertaken.

SEARCH FOR BEST EVIDENCE

Databases

General databases that include both primary and preappraised literature citations can be used to gather best evidence. PubMed and Ovid are examples of database search tools that include both primary and preappraised citations. PubMed is a search tool that contains several databases including MEDLINE. MEDLINE contains over 11 million records from over 4,000 journals dating back to 1966. MEDLINE is a very inclusive database that contains original trials and preappraised articles and is considered one of the best sources of recent evidence. The primary disadvantage of using MEDLINE to obtain evidence is that it does contain a large number of citations and therefore many limits and strategies are needed to refine a search. Using primary literature can be time consuming to individually appraise quality of research studies and draw conclusions across multiple studies. There are several search strategies that can be used to locate systematic reviews and other preappraised sources of information in MEDLINE. The United States Library of Medicine provides free access to PubMed at www.ncbi.nlm.nih.gov/pubmed. or http://www.ncbi.nlm.gov/entrez.7 Ovid is another database provider for a collection of health and medical subject databases. It includes MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), HealthStar, and Evidence Based Medicine (EBM) reviews. CINAHL contains over 7,000 records from more than 1,200 medical and health-related journals, including the Cardiopulmonary Physical Therapy journal.6 Ovid has similar advantages and disadvantages as PubMed, with the additional feature that it allows simultaneous searching of up to 5 databases. Many of the citations found in Ovid also have full-text access. Ovid is provided by subscription at gateway2.