The role of the Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences.

[Benson CJ, Schreck RC, Underwood FB, Greathouse DG. The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences. Phys Ther. 1995; 75.-380-386.]

Key Words: Neuromusculoskeletal, Orthopedics, Pharmacologic medication, Physical therapy.

As the US Army prepares to enter the 21st century, Army physical therapists will be trained and ready to support Army efforts during regional contingencies, peacekeeping missions, humanitarian missions, nation assistance, and natural disasters. The mission of Army physical therapists is to provide physical therapy evaluation and treatment to correct or prevent physical impairments resulting from injury, disease, or preexisting problems. Furthermore, Army physical therapists perform primary care for patients with neuromusculoskeletal (NMS) conditions.[1-5]

In 1972, following the end of the military draft, the Army Medical Department was faced with vast numbers of patients with NMS complaints and a shortage of orthopedic surgeons to evaluate and treat these patients. These conditions created long delays in primary care. The use of physical therapists as nonphysician health care providers to evaluate and treat patients with NMS complaints was one solution to this problem.[1,2,5] The Army regulations that document the Army physical therapist nonphysician care provider roles are Army Regulations 40-48[3] and 40-68.[6] Since its implementation in the early 1970s, we believe the use of physical therapists as primary NMS evaluators has been a resounding success with high acceptance by patients and practitioners, especially orthopedic surgeons.[1,5]

In the context of their expanded roles as nonphysician health care providers and primary evaluators for patients with NMS conditions, Army physical therapists may be allowed to prescribe certain pharmacologic agents.[3,6] These privileges are granted when necessitated by specific clinical situations. Most typically this applies to settings with a scarcity of orthopedists and large populations of active-duty soldiers who have sprains, strains, joint dysfunctions, and overuse syndromes. The purpose of this article is to report the experience of the US Army physical therapists who are granted limited privileges to prescribe certain pharmacologic medications in their professional practice. Much of the data on the experience has appeared in US Army publications and reports and has yet to appear in the peer-reviewed literature. Out of necessity, we will rely heavily on the sources of information cited in the article.

All uniformed services of the United States have mechanisms to allow physical therapists to prescribe medications. The US Air Force,[7] US Navy,[8] and US Public Health Service (Captain Mike Huylebroeck, Chief Physical Therapy Officer, US Public Health Service; personal communication) vary in the proportion of central control versus control at the local treatment facilities. In all cases, however, the privilege to prescribe exists exclusively as part of these services' respective NMS screening programs. Although the original regulations[3,6-8] were written with oral medications in mind, revisions are currently in process to include agents used in iontophoresis and phonophoresis.

Expanded privileges, such as referring patients to radiology for appropriate radiographic evaluations and ordering some analgesic and nonsteroidal anti-inflammatory medications, are mandatory if physical therapists are to safely perform NMS evaluations. Army Regulation 40-483 is the specific regulation that outlines the procedures for Army physical therapists to become privileged as nonphysician health care providers and serve in their role of evaluating and treating patients with NMS conditions. Greathouse et al[5] recently described the past, present, and future professional roles of Army physical therapists, especially as they serve as nonphysician health care providers in the evaluation and treatment of patients with NMS conditions.

Army Regulations 40-48[3] and 40-68[6] address the use of physical therapists as physician extenders. Additionally, the Physical Therapy Consultant, Office of The Surgeon General, issued guidelines for NMS evaluation, which provide guidance to commanders of medical treatment facilities and chiefs of physical therapy when granting clinical privileges to physical therapists performing NMS evaluations independently.[9]

These guidelines state that an Army physical therapist must (1) be a graduate from an accredited physical therapy program; (2) hold a current, unrestricted license to practice physical therapy; (3) have completed an Army training program in NMS evaluation and treatment; (4) have completed a minimum of 6 months of work with an assigned physical therapist preceptor who has clinical privileges to perform NMS evaluations; and (5) participated in a peer review of the NMS evaluation program involving both physical therapist and physician supervisor. Upon recommendation of the physical therapist preceptor, the chief physical therapist at the facility will recommend in writing to the Hospital Credentials Committee that the physical therapist be granted clinical privileges to work independently as an NMS evaluator.[9] At each Army facility at which physical therapists are privileged to serve as nonphysician health care providers for the evaluation and treatment of patients with NMS dysfunctions, their performance is monitored as a part of the total continuous quality improvement (CQI) process.[3,5,6] With regard to the privilege of Army physical therapists to prescribe certain pharmacologic agents, Army Regulation 40-48 states

Physical therapists who are credentialed

may write prescriptions for selected

medication. These medications must

have been: 1) Approved by the Pharmacy

and Therapeutic Committee; 2)

Reviewed by the credentials committee;

and 3) Approved by the medical treatment

facility commander.[3]

Army physical therapists credentialed to order certain pharmacologic agents will first be credentialed as nonphysician health care providers for the evaluation and treatment of patients with NMS dysfunctions. These physical therapists will have completed instruction with a pharmacist and the physician supervisor, specifically discussing the pharmacological implications in medical conditions evaluated and treated by physical therapists. Interaction by the physical therapists with the pharmacy service, which includes continuing education experiences and CQI programs, and monitoring by the Pharmacy and Therapeutic Committee are required in facilities in which physical therapists prescribe medications.[3,6,9] The commander of the facility is the final approval authority to grant clinical privileges. This decision, with input by the chief of physical therapy, chief of pharmacy, physician supervisor of the NMS program, and the Pharmacy and Therapeutic Committee, is based on the specific need of physical therapists serving as nonphysician health care providers to more expeditiously and efficiently perform their primary NMS mission.

Historical Perspective

In 1975, James and Stuart, two Army physicians, described the use of Army physical therapists as primary evaluators of patients with low back pain.[10] At that time, physical therapists were not yet prescribing any pharmacological agents. James and Stuart reported more expeditious treatment for patients with NMS disorders when the patients were primarily evaluated in physical therapy clinics than in outpatient or other specialty clinics. The outcome, according to those authors, was appropriate, effective, and produced high-quality care. Of 995 new patients with low back pain, 50 were randomly interviewed. Of these patients evaluated and treated by physical therapists, only 3 felt they should have been given medication in addition to physical therapy interventions.

During the mid-1970s, the number of Army physical therapists serving as primary NMS evaluators increased, and their role as nonphysician health care providers became more defined.5 Concomitant with this increase in the scope of Army physical therapy practice, the physician and physical therapy leaders of the Army Medical Department identified the need for qualified Army physical therapists to be allowed to order certain pharmacologic medications. Thus, in some facilities, physical therapists were allowed to order certain analgesic, muscle relaxant, and nonsteroidal anti-inflammatory medications.[1,5]

By 1984, just 10 years after the study by James and Stuart, Franklin, an Army physical therapist, surveyed all Army physical therapy clinics to determine the extent of Army physical therapists serving as nonphysician health care providers in evaluating and treating patients with NMS dysfunction.[11] Franklin found that in more than 75% of all Army medical centers and in slightly fewer than 50% of the remaining Army facilities, physical therapists were writing prescriptions for selected medications.[11] Franklin determined that Army physical therapists at the large medical centers ordered more pharmacologic agents than did those at the medium-sized medical treatment facilities and small outpatient health clinics. Questionnaire responses by 382 Army physicians revealed a majority supported the following components of physical therapy practice: ordering roentgenograms, writing orthopedic software prescriptions, issuing temporary duty restrictions, and placing duty personnel on bed rest for up to 72 hours. Only 68 physicians (18%), however, supported physical therapists writing prescriptions for medications. When Franklin surveyed 150 Army physical therapists serving as physician extenders and performing as primary evaluators of patients with NMS dysfunction, 97 (65%) supported being allowed to prescribe from a limited formulary. For each item (statement) in the questionnaire, the values assigned were as follows: strongly agree, agree, disagree, strongly disagree. These data were recorded by Franklin into low, medium, and high, approximating the percentage table averages on the individual items. Orthopedists, internists, neurologists, general practitioners, and pediatricians gave medium to high support to physical therapists performing independent NMS practice; however, more than half of the physiatirists and neurosurgeons gave low support. Franklin did not specifically address physician support of physical therapists credentialed to order pharmacologic agents.

Hamilton, an Army pharmacist, surveyed Army facilities in 1987 to determine prescriptive activities among physical therapists (B Hamilton, Army Medical Department Center and School, Fort Sam Houston, Texas, February 1987; unpublished study). He found that Army physical therapists were allowed to prescribe medications in 23 of the 35 facilities that responded. Prescribed medications varied by location. In addition to topical agents used in wound and bum care, Hamilton identified the main categories of medications ordered by physical therapists to be analgesics, muscle relaxants, and nonsteroidal anti-inflammatories. The medications ordered by Army physical therapists are listed in Table 1. At some facilities, nonsteroidal anti-inflammatories and muscle relaxants were limited to a 10-day supply per patient. Physical therapists stationed in locations requiring increased self-sufficiency, such as Korea or Panama, were allowed to order more types of medication. Hamilton reported that Army physical therapists at the medium-sized facilities and small outpatient health clinics ordered more pharmacologic agents than did therapists at the large medical centers. Thus, by 1987, usage as related to the size of the medical facilities had reversed. This reversal could have been expected. The rationale for the reversal is that the majority of Army posts with large troop populations, which produce an increased number of patients with NMS dysfunction as a result of training and sports injuries, are staffed by medium-sized and smaller facilities, therefore requiring more physical therapists functioning as NMS evaluators.

[TABULAR DATA 1 OMITTED]

1994 Survey of Army Physical Therapy Clinics

In 1994, the Consultant in Physical Therapy, Office of The Surgeon General, surveyed all Army physical therapy clinics to determine the number of physical therapists serving as primary NMS screeners who were prescribing pharmacologic agents. Thirty-four Army physical therapy clinics responded to the survey. Physical therapists at 25 of the facilities are currently credentialed to prescribe medications. Of the 134 Army physical therapists practicing as nonphysician health care providers and allowed to perform primary NMS evaluations, 85 therapists were routinely writing prescriptions.

The medication list varies by treatment facility and is approved by the Pharmacy and Therapeutic Committee of each facility. The medications most commonly prescribed by Army physical therapists continue to be analgesics, muscle relaxants, and nonsteroidal anti-inflammatories. The complete list of medications currently being ordered by Army physical therapists is shown in Table 2. There was no change in the categories of medications from 1987 to 1994, and only Robaxin was added to the limited formulary in 1994. The number of prescriptions written by each therapist also varies according to the size and type of treatment facility. The trend for physical therapists ordering pharmacologic agents continued to be higher at the medium- and small-sized facilities than at the medical centers. The average number of prescriptions written per month per physical therapist was 45 (range=1-120). The majority of physical therapy practitioners have restrictions placed on their prescription-writing privileges. These restrictions are at the discretion of the local Pharmacy and Therapeutic Committee with approval of the facility commander. Examples of restrictions include limiting muscle relaxants to a 7-day supply, limiting the number of refills, and prohibiting prescriptions for patients under age 17 years and over age 65 years.

[TABULAR DATA 2 OMITTED]

The survey demonstrates that prescription-writing privileging of Army physical therapists continues to follow Army regulations and guidelines for health care extenders.[3] Privileges at each facility are reviewed and renewed on an annual basis. The survey indicated that the most common training required for the credentialing process is physical therapy in-service programs taught by pharmacists and physicians. Emphasis is on indications and contraindications of pharmacologic agents. Many clinics reported a probationary period during which prescriptions are reviewed and countersigned by another therapist or by a physician. Furthermore, the results from this survey confirmed the existing requirement that all medical facilities at which medications are prescribed by Army physical therapists have a medical supervisor and peer-review process in place.

Educational Opportunities Preparing Army Physical Therapists to Be Credentialed to Prescribe Medications

Entry-Level Didactic 

The didactic education in pharmacology presented to the entry-level students in the US Army-Baylor University Graduate Program in Physical Therapy has been designed to prepare these students for general physical therapy practice as well as to function as nonphysician health care providers for the primary evaluation and treatment of patients with NMS dysfunctions. The majority of Army physical therapists are graduates of this program. The bulk of the material related to pharmacology is integrated within other courses. There is only a single 3-hour lecture, entitled "Pharmacology for Physical Therapists," and it is taught by a pharmacist. The focus of this lecture is on Army regulations dealing with credentialing of physical therapists to prescribe medications, as well as the indications, contraindications, and adverse effects of the drugs authorized for prescription by physical therapists.

General information related to metabolic pathways involved in inflammation and the effects of anti-inflammatory drugs are presented as a part of the first-semester Physical Agents course, as well as during lectures on wound healing. This material is taught by physical therapists.

Information about mechanisms of drug actions, including pharmacodynamics, toxic effects, and principles of therapeutic drugs, are presented over a two-semester period as part of the courses Physiology I and II. Currently, this material is taught by a physical therapist. The emphasis is on principles rather than specifics (eg, receptor sensitivity, distribution, and regulation; second-messenger pathways; and dose-response relationships).

Specific drugs that may be encountered during clinical practice are presented throughout the program. For example, drugs that are used to treat patients with cardiovascular or respiratory dysfunction are presented in the second semester as part of the Cardiopulmonary Rehabilitation course. This material is taught by a physical therapist. Drugs used in the management of neurological dysfunction are discussed in the third-semester Neurosciences course, generally by a neurologist.

Entry-Level Clinical

There is no formal opportunity for education regarding pharmacology during the 6 months of clinical work in the US Army-Baylor University professional program. Nearly all students, however, have at least one 6-week affiliation in a clinic where physical therapists are credentialed to prescribe medications. Therefore, the opportunity to learn how to prescribe certain medications appropriately does exist.

Postprofessional Short Courses

Each year, a 10-day continuing education course, Evaluation and Treatment of Neuromusculoskeletal Disorders, is presented at Fort Sam Houston, Texas. This course is designed to assist in the preparation of physical therapists to practice as physician extenders and to perform primary evaluations of patients with dysfunction of the musculoskeletal system, to include the peripheral nervous system. in this course, a pharmacist presents 3 to 5 hours of material related to pharmacologic agents authorized for prescription by Army physical therapists. The lecture focuses on mechanisms of action of the medications, adverse reactions, and possible harmful drug interactions.

Graduate Education

US Army physical therapists who are selected for graduate education at the master's or doctoral level have opportunities to pursue formal education in pharmacology by incorporating pharmacology courses in their programs of study. There are no opportunities for Army physical therapists to obtain a degree in pharmacology, but pharmacology course work is appropriate for those enrolled in a physiology curriculum.

Literature Sources

Textbooks and references used in the US Army-Baylor University entry-level curriculum dealing with pharmacology are similar to those used in other curricula.[12-15] Journals that provide more current information in this area include Pharmacology and Therapeutics, Pharmacology, Pharmacological Reviews, Pharmacological Research, and Pharmaceutical Research.

Discussion

The issue of physical therapists writing prescriptions has caused controversy in the medical community. Clarity on this issue can be gained by asking the question: What approach to the prescription of medications best allows physical therapists to use their skills? From the perspective of NMS screening programs, we believe physical therapists' greatest strengths are in treating conditions that do not respond to chemical approaches. For example, therapists routinely see large numbers of patients with mechanical shoulder dysfunction. Treatment interventions involve strengthening scapulothoracic muscles, stretching the lateral (external) rotators and posterior cuff, restoring inferior glide, and providing the stretch-shortening training needed for neuromuscular control. Pharmacological contributions to care are minimal.

There are patients, however, with such acute conditions that any movement causes lingering pain. Because these patients are in a stage that permits only minimal manual intervention, anti-inflammatory medication may be invaluable to maximize benefits from physical therapy. Optimum initial visit outcome for these patients would be evaluation and treatment that includes appropriate medication. In a hectic outpatient clinic, properly trained therapists are often in an excellent position to prescribe these medications, and an additional advantage is to increase efficiency. It is more efficient for a physical therapist to write prescriptions for medication than for the therapist or the patient to search for a physician and obtain a prescription for medication.

In our opinion, two common observations of Army physical therapists ordering pharmacologic medications are rendered. First, as individuals, Army physical therapists write fewer prescriptions as their clinical experience increases. The tendency over time is to reserve anti-inflammatories for those patients whose conditions are in an irritable stage, and rely on the traditional ice and rest for common inflammations. Most patients do not need anti-inflammatory medication, particularly if their problem involves abnormal stress on normal structures. Second, as members of the health care team, physical therapists need to know about medications whether they prescribe them or not. The knowledge of drug interactions and the impact of pharmacologic intervention on patient conditions, especially as it affects physical therapy intervention, is of the utmost importance to the physical therapy practitioner. Additionally, patients do not routinely know how long it takes for their medication to reach therapeutic levels, that spotty compliance will dilute effectiveness, or that their gastrointestinal complaints might be related. Patient education in this area is a contribution that physical therapists can routinely make.

We contend that the use of physical therapists as nonphysician health care providers in the US Army has been an overwhelming success. There is no record of any legal action being brought against Army physical therapists or the government of the United States as a result of physical therapists serving in the physician-extender role, including those Army physical therapists credentialed to order pharmacologic agents.[5] This is remarkable evidence, considering the literally millions of NMS evaluations and treatments performed by Army physical therapists. The privilege for Army physical therapists to order pharmacologic medications was developed, implemented, and monitored to meet the needs of an expanded scope of practice, The pharmacologic agents available to Army physical therapists are chosen to meet the needs of the physician extender, dispensed with a specific purpose (analgesic, muscle relaxant, anti-inflammatory) and ordered for specific periods of time.

The successful utilization of Army physical therapists as nonphysician health care providers for the evaluation and treatment of patients with NMS disorders, and who have additional privileges to prescribe pharmacologic medication, depends on four factors. First, Army physical therapists undergo specific training in NMS evaluation and a rigorous credentialing process to serve as primary NMS evaluators. Second, there is total support of physical therapists functioning as NMS evaluators by the Army Medical Department health care team. The specific support of the medical staff and physician supervisors at the local facilities includes the immediate and direct access to physician specialists, when the need arises. Third, there is a monthly CQI process at each facility, which reviews the entire program of physical therapists serving as nonphysician health care providers. The CQI process includes peer and physician review of physical therapy records. Fourth, the Army Medical Department has specific guidelines, policies, and regulations that are standard throughout the command. These guidelines, policies, and regulations are key to the successful implementation of the Army's nonphysician health care provider program.

The question arises: Should physical therapists be privileged to prescribe pharmacologic agents? In our opinion, not unless the above critical factors are acknowledged, implemented, and monitored. This would require changes in physical therapy academic standards, licensure acts, and widespread acceptance by the medical community.

Conclusion

All US uniformed services have found it beneficial to grant limited prescription credentials to physical therapists serving as nonphysician health care providers in the evaluation and treatment of patients with NMS dysfunction. This article described the regulations, credentialing process, and continuous quality improvement programs developed to meet this expanded clinical privilege.

In the Army experience, patterns of pharmacologic medication usage by physical therapists have changed depending on specific clinical situations. The three categories of medications ordered by Army physical therapists are analgesics, muscle relaxants, and nonsteroidal anti-inflammatories. As individuals, Army physical therapists tended to order pharmacological agents less frequently as experience increases, reserving anti-inflammatories for only the irritable stage of pathology. What approach to medications best allows us to use our skills? Answers no doubt vary depending on work settings. One certainty drawn from the Army physical therapy experience is that regardless of whether physical therapists order pharmacological agents or not, they must understand the pharmacological interactions of the medications their patients are using and the effect on physical therapy interventions.

Acknowledgments

We thank Colonel james Wilson, Pharmacy Consultant to The Surgeon General, Colonel Wade Daigle, Occupational Therapy Consultant to The Surgeon General, and Captain Laurie Sweet, Army Medical Specialist Corps, Office of The Surgeon General, for their assistance in preparing this manuscript.

References

[1] Greathouse DG, Sweeney JK, Hartwick AM. Physical therapy in a wartime environment. In: Belandres PV, Dillingham TR, eds. Rehabilitation of the War Casualty: Textbook of Military Medicine. Washington, DC: Office of The Surgeon General, US Department of the Army. In press. [2] Hartwick AM. Army Medical Specialist Corps 45th Anniversary Commemorative Monograph. Washington, DC: US Army Center of Military History; 1993. [3] Nonphysician Health Care Providers (Army Regulation 40-48, Ch. 4-2b, Prescription Writing). Washington, DC: US Department of the Army; 1992. [4] DEPMEDS Policies/Guidelines and Treatment Briefs, Washington, DC: Defense Medical Standardization Board, US Department of the Army; 1992. [5] Greathouse DG. Schreck RC, Benson CJ. The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys Ther. 1994:.19:261-266. [6] Quality Assurance Administration (Army Regulation 40-68). Washington, DC: US Department of the Army; 1992. [7] Air Force Instructions 46-102, #34. Washington, DC: US Department of the Air Force; 1994. [8] Bureau of Medicine Instruction 63.20.66a Credentials Review and Privileging Program). Washington, DC: US Department of the Navy; 1991. [9] Guidelines for Physical Therapists Serving as Neuromusculoskeletal Evaluators. Rev ed. Washington, DC: Office of The Surgeon General, US Department of the Army.: 1994. [10] James JJ, Stuart RB. Expanded role of the physical therapist: screening musculoskeletal disorders. Phys Ther. 1975;55:121-132. [11] Franklin RJ. The Physical Therapy Profession and the Expanded Role of Practice Independent of Physician Referral as Viewed by Army Physicians and Physical Therapists. Tacoma, Wash: Pacific Lutheran University; 1984. Master's thesis in public administration, [12] Gilman AG, Rall TV, Nies AS, Taylor P, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. New York, NY: Pergamon Press; 1990. [13] Melmon KL, Morrelli HF, Hoffman BB, Nierenberg DW, eds. Velmon and Morrelli's Clinical Pharmacology: Basic Principles in Therapeutics. 3rd ed. New York, NY: McGraw-Hill Inc; 1992. [14] Ciccone CD. Pharmacology in Rehabilitation, Philadelphia, Pa: FA Davis Co; 1990. [15] Malone T, ed. Physical and Occupational Therapy: Drug Implications for Practice. Philadelphia, Pa: JB Lippincott Co:. 1989.

CJ Benson, LTC, SP, USA, PT, is Chief, Physical Therapy, Tripler Army Medical Center, Honolulu, HI 96859-5000.

RC Schreck, COL, SP, USA, PT, is Chief, Physical Therapist Section, Headquarters, US Department of the Army, Office of The Surgeon General, 5109 Leesburg Pike, Falls Church, VA 22041.

FB Underwood, LTC, SP, USA, Phd, PT, is Assistant Professor, Graduate Program in Physical Therapy, US Army Medical Department Center and School, US Army-Baylor University, Fort Sam Houston, TX 78234-6100.

DG Greathouse, COL, SP, USA, Phd, PT, is Chief, Army Medical Specialist Corps, Headquarters, US Department of the Army, Office of The Surgeon General, 5109 Leesburg Pike, Falls Church, VA 22041 (USA). Address all correspondence to Colonel Greathouse.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the Department of Defense.