Random Samples.

In December 1999, in anticipation of the new millenium, Editor Jules Rothstein called on readers to "think about the physical therapy profession and its place in the world.... reflect scholarly on our past and bring our own special knowledge, hopes, and fears into formulations about our future." He also invited Journal readers to send essays about the future of the profession. This month the Journal publishes another installment o f the series.

Cardiovascular/Cardiopulmonary Physical Therapy Sinks or Swims in the 21st Century: Addressing the Health Care Issues of Our Time

To the Editor:

Population and epidemiologic statistics indicate that the scope of cardiovascular/ cardiopulmonary physical therapy should be unprecedented in the 21st century, but this fact is belied by the low visibility of this area of practice. Leading causes of mortality and morbidity throughout the industrialized and nonindustrialized worlds are heart disease; hypertension and stroke; smoking-related lung conditions, including cancer and emphysema; and diabetes[1] Unless the physical therapy profession defines and develops this area commensurate with global health indicators, this essential area of physical therapy practice risks sinking into oblivion as others less qualified attempt to fill this void.

As noninvasive practitioners, physical therapists have an ethical responsibility to educate health care colleagues as well as the public about the power of and preference for noninvasive over invasive interventions whenever possible. Although it is easy to be overshadowed by the weekly, attention-grabbing media headlines proclaiming yet another miraculous, "hi-tech," invasive medical advance, exploiting noninvasive care always must be the first priority, consistent with a patient-centered rather than system-serving model of care. This commentary analyzes historical factors that have contributed to the relative invisibility of cardiovascular/cardiopulmonary physical therapy, the rationale for addressing this issue, and the strategies that must be aggressively promoted and implemented by the profession to reverse this trend and uphold our professional commitment to excellence in addressing contemporary global health problems.

Cardiovascular/cardiopulmonary physical therapy has evolved historically in a fragmented rather than systematic manner. Developed in the first half of the 20th century, its precursor, chest physical therapy (including postural drainage and percussion), was applied primarily to remove secretions from the airways. Space physiology and bed rest studies since the 1950s have provided the physiologic and scientific rationale for mobilization and exercise coupled with the upright position as primary interventions to maximize oxygen transport and reduce cardiovascular/cardiopulmonary risk. This body of literature was pivotal in defining "upright and moving" as the physiologic body position for humans. In 1959, in Physical Therapy Review (the precursor of Physical Therapy) Orlava was among the first to report a role for mobilization and extrapolation of exercise principles in the management of acute conditions. This pivotal contribution went largely unnoticed possibly because the meaning of the title was lost in the translation from Russian ("Therapeutic Physical Culture in the Complex Treatment of Pneumonia").

In the 1960s, cardiac rehabilitation was a significant turning point in which the physical therapist became an integral member of the cardiac rehabilitation team and began exercise testing and training of patients with cardiac conditions according to scientific principles. In the 1980s, the principles of cardiac rehabilitation were extended to patients with chronic lung conditions. As exercise science became recognized as a distinct discipline, it became clear that cardiac rehabilitation and pulmonary rehabilitation are not unique. Rather, they share common principles that can be modified and extrapolated to many other conditions treated by physical therapists, as well as from the chronic, stable patient to the acute patient.

The next major turning point was the concept of oxygen transport. Although described in the physiology literature over 100 years ago, oxygen transport has only appeared regularly in the clinical medicine literature since the 1970s.

When patients, particularly those who are critically ill, are managed in terms of oxygen delivery and consumption, survival rates improved significantly. In the 1980s, this concept was extended to cardiovascular/cardiopulmonary physical therapy and optimizing oxygen transport as a whole, and led to a paradigm shift away from a primary focus on airway clearance and secretion removal to circulatory-ventilatory-metabolic coupling. Oxygen transport explained the efficacy of the potent and direct effects of mobilization/exercise and body positioning and why these interventions should be exploited maximally even in patients who are acutely and critically ill to enhance oxygen transport centrally and peripherally and to minimize and potentially avoid the need for more risky, expensive, invasive procedures. Moreover, oxygen transport has explained the equivocal effect of conventional chest physical therapy despite having been practiced for almost a hundred years.

In the 21st century, noninvasive practitioners must work vigorously and even more closely with invasive practitioners to ensure that invasive interventions, where indicated, complement noninvasive interventions. The era of acute infectious disease has long given way to the era of chronic, progressive, degenerative conditions often confounded by lifestyle factors. In turn, this trend supports a shift away from a primary focus on interventionistic care to long-term support and management.

Given that the human body prefers not to be tampered with, attested to by the growth of iatrogenic medicine (the branch of medicine that specializes in side effects and untoward outcomes of invasive medical care), every attempt must be made by the physical therapist to promote and exploit noninvasive interventions as the first priority. Without question, patients should benefit from medical advances, and there are cases where invasive care often is the treatment of choice (eg, the emergency department). The clinical decision to treat invasively over noninvasively, however, must be made judiciously rather than by default with consideration of both short- and long-term benefit-risk and cost-benefit. In the present health care climate, these concepts shed new meaning on which profession, if any, is "allied" to which.

In 1998, the Cardiorespiratory Division of the Canadian Physiotherapy Association boldly established a contemporary definition of this area of practice, which reflects advances in the literature over the past 50 years. This definition is consistent with an expanded vision of cardiovascular/cardiopulmonary physical therapy required to meet the needs of people in the 21st century.[2]

Cardiorespiratory physical therapists are primary health care professionals who focus on maximizing functional capacity and physical independence by optimizing healthy active lifestyles and community-based living. Specifically, cardiorespiratory physical therapy involves a psychosocial and multi-system assessment to diagnose the status of oxygen transport and prescribe evidence-based interventions (eg, mobilization, exercise, body positioning, breathing control, and coughing maneuvers and airway clearance interventions). Education and patient-driven treatment planning are fundamental components of cardiorespiratory physical therapy.

This expanded definition provides a framework for cardiovascular/cardiopulmonary physical therapy that crosses other areas of practice such as orthopedics and neurology. As chemical exercise physiologists, physical therapists prescribe exercise like a drug, recognizing that it has indications, contraindications, and side effects depending on the patient. With respect to enhancing oxygen transport, mobilization/exercise can be selectively prescribed for its distinct acute effects, long-term effects, and preventive effects--both centrally and peripherally. These effects can avoid, postpone, or minimize the need for invasive interventions, inarguably outcomes of choice.

The definition also incorporates skills and expertise required by contemporary physical therapists because of trends such as practicing without referral and the aging of the population. Both of these trends are dramatically altering the scope of physical therapy practice and have necessitated that physical therapists, regardless of practice area, be competent to identify risk factors, specifically those that threaten oxygen transport, hence, life. Our first commitment is "to do no harm." The physical therapist must make a clinical judgment as to whether the patient should be treated in the conventional manner, what level of hemodynamic monitoring is indicated, whether the treatment should be modified and how, when a second opinion from another physical therapist in the cardiovascular/cardiopulmonary area is indicated, whether the patient should be referred back to the physician, whether more tests and information are needed before proceeding, or whether emergency services should be summoned.

Despite advances within cardiovascular/ cardiopulmonary physical therapy, the question arises as to why a profession that is uniquely qualified to specialize in the prescription of exercise as a means of countering pathology has inadequately asserted itself in preserving this unique position in the health care delivery system. Why is it that, with all the evidence supporting the role and benefits of cardiovascular/ cardiopulmonary physical therapy, the area has been significantly encroached upon by others with exercise physiology backgrounds over the past 30 years with little opposition by physical therapists? In the majority of industrialized countries, physical therapists are registered and licensed practitioners. Being licensed to practice ensures that the public is protected as much as possible and that the physical therapist, as a noninvasive practitioner, is competent to manage conditions by exploiting noninvasive interventions in the safest and most effective way possible. Despite this, this essential area of practice is in jeopardy.

To enhance its visibility, cardiovascular/ cardiopulmonary physical therapists need to be skilled in articulating their scope of practice and expounding the benefits and limitations of their care. Cardiovascular/cardiopulmonary physical therapy is holistic, is evidence-based, and has long-term benefits. In addition, compared with invasive interventions, it is low risk, has few side effects, and is cost-effective. Despite these attributes, physical therapists have had a history of being subservient to invasive medical care and biotechnology. With the exponential advances in biotechnology anticipated in the forthcoming century, the contemporary physical therapist requires advanced skills in initiating and endorsing health and wellness campaigns; participating in public health forums, health care policy making, health fairs, public health events, and health-related organizations; and being visible in the media as well as practicing in an evidence-based manner. Physical therapists must exploit existing technologies and develop new ones to assess, evaluate, and treat their patients more precisely and prescriptively. In parallel with these advancements and consistent with the trend toward chronic long-term conditions, physical therapists also must exploit the use and development of subjective outcome measures such as quality of life, given that impairment is not necessarily correlated with these outcomes.

To conclude, if one bases health care predictions on population and epidemiologic statistics, the cardiovascular/ cardiopulmonary area should be one of the most visible areas of physical therapy practice in health care. The profession must ensure that this area develops commensurate with global health care needs and that this is reflected in physical therapy academic curricula across areas of practice, and research. With the chronic erosion of health care resources, the profession must provide compelling and substantive arguments for appropriate coverage of the needs of patients with cardiovascular/cardiopulmonary conditions. All too often, patients with cardiovascular/cardiopulmonary conditions are treated with invasive measures only, and a relatively small proportion is referred to a physical therapist for noninvasive management solely or in combination with invasive management. This is untenable health care, unethical, and wasteful of health care resources. In part, the profession has failed to provide adequate continuing education to our health care colleagues who often hold outdated views of contemporary physical therapy.

The words of Nelson Mandela to his fellow South Africans in his inaugural address as president are particularly relevant to cardiovascular/cardiopulmonary physical therapists as they strategically plan for the 21st century and implement a contemporary vision of care:

   Our deepest fear is not that we are inadequate. Our deepest fear is that we
   are powerful beyond measure ... your playing small doesn't serve the world.
   There is nothing enlightened about shrinking so that other people won't
   feel insecure around you.... As we are liberated from our own fear, our
   presence automatically liberates others.

If physical therapy is to have an impact on global and regional health care and health care costs in the 21st century, given its unique, strategic position, this inevitably will be achieved through the cardiovascular/cardiopulmonary area of practice. Now is the profession's moment. We must rise to the many challenges before us. In the face of apparently overwhelming and daunting advances in invasive medical care, we must be secure in our knowledge and commitment to noninvasive practice and not lose sight of the fact that it has a rightful primary position in health care (ie, a first resort wherever possible). In terms of outcome, these high-profile advances are far from competing with the impact of effective health education regarding healthy living and lifestyle modification in conjunction with noninvasive interventions offered by cardiovascular/cardiopulmonary physical therapy in addressing health problems at a global level with respect to short- and long-term benefits, minimal risk, and cost-benefit. We must do a compelling job of selling our unparalleled, primary role as noninvasive practitioners in directly addressing the leading global health problems of our time.

Elizabeth Dean, PT, PhD
Professor
School of Rehabilitation Sciences
University of British Columbia
2211 Wesbrook Mall
Vancouver, British Columbia, Canada
V6T 2B5
([e-mail])

Donna Frownfelter, PT, CCS
Assistant Professor
Physical Therapy Program
University of Chicago Medical School
Chicago, Ill

Wai Pong Wong, PT
Principal Physiotherapist
Physiotherapy Department
Singapore General Hospital
Singapore

Kalthoum Al-Basarah, PT
Physiotherapy Department
Chest Diseases Hospital
Kuwait

Monika Fagevik-Olsen, PT, PhD
Research Physical Therapist
Department of Surgery
Sahlgrenska Universitetssjukhuse
Goteborg, Sweden

Rik Gosselink, PT, PhD
Professor
Department Respiratory Rehabilitation
University Hospitals Leuven
Faculty of Physical Education and Physiotherapy
Katholieke Universiteit Leuven
Leuven, Belgium

Zehra Habib, PT, PhD
Senior Lecturer, Departments of Pediatrics
 and Physical Therapy
Faculty of Health Sciences, Medical College
The Aga Khan University and Hospital
Karachi, Pakistan

Diana Hopkins-Rosseel, PT, DEC, MSc
Associate Professor
School of Rehabilitation Therapy
Queens University
Kingston, Ontario, Canada

Alice Jones, PT, PhD, FACP
Associate Professor
Department of Rehabilitation Sciences
Hong Kong Polytechnic University
Hong Kong
Special Administrative Region of the
 People's Republic of China

Constantina Lomi, PT, MSc
Physiotherapy Department
Onassis Cardiac Surgery Center
Athens, Greece

Jennifer A Pryor, PT, MBA, MSc
Research Fellow, Department of Physiotherapy
MSR Medical College
Royal Brompton and Harefield NHS Trust
London, United Kingdom

Savita Ravindra, PT, MSc
Professor
MSR Medical College
Rajiv Gandhi University of Health
 Sciences
Bangalore, India

Margot Skinner, PT, MPhEd
Lecturer
School of Physiotherapy
University of Otago
Dunedin, New Zealand

References

[1] World Health Organization. World Health Report 1999. Geneva, Switzerland. Available at: http://www.who.int/whr/1999.

[2] CPCRS and Cardiorespiratory Division: cardiorespiratory physical therapy current issues, future directions. Newsletter of the Canadian Physiotherapy Cardiorespiratory Society and Cardiorespiratory Division of the Canadian Physiotherapy Association. December 1998.