Public Health Service Therapists

Since the 1950's, Public Health Service Therapist Officers have played major roles in the development and research of rehabilitation techniques and devices to evaluate and treat a variety of clients in a multitude of settings. Many of their contributions have had far reaching ramifications in their respective professions, as they have set standards in provision and administration of care and furthered the cause of education and research. The strong support and interest of this group of therapists in the PHS demonstrated that these professionals could enhance the quality of health care beyond that in their clinics to that across the nation.

This abbreviated chronicle highlights events and important works of past and present PHS therapists. Their professional, chronological evolution demonstrates both their essential contributions to the management of health care, and the multifaceted responsibilities carried out on the local, state, and national levels.

The origins of the Public Health Service are to be found with sailors and with medical care. The first hospital fully dedicated to the care of merchant sailors opened in 1801 in Norfolk, Virginia.

With the casualties of World War II, medical officers were faced with the rehabilitation of thousands of servicemen and women. The PHS Act of 1944 authorized the commissioning of nurses, scientists, dieticians, physical therapists and sanitarians, and Physical Therapists were stationed in the 8 MERCHANT MARINE HOSPITALS during the onset of the polio epidemic of the late 1940's and 1950's. Although the Marine Hospitals were closed in 1981, several Therapist Officers retain positions in federally and university sponsored sites in Staten Island and San Francisco, and they offer a wide range of range of rehab services.

The historical development of the Occupational Therapy profession is reflected at ST. ELIZABETH'S HOSPITAL in Washington, D.C. First open to patients in 1855, St. Elizabeth's was the first Federal hospital devoted entirely to the mentally ill. More than 125 buildings have been constructed on the 320-acre site, and devoted Occupational Therapists (OT) have played a key role. OT's joined Saint Elizabeth's hospital as early as 1931. For the next 26 years, OT's developed and implemented programs to meet the needs of psychiatric patients. Art and craft activities were one of the earliest treatment tools, but disciplined study by the Therapists led to development and implementation of organized methods for habit and skill training for post-lobotomy patients. By 1956, the use of tranquilizers made possible a shift of emphasis to rehabilitation, and the needs of disabled psychiatric patients were recognized and addressed.

During the next 20 years, the OT's facilitated the development of certification of OT assistants and served as consultants to the World Health Organization for international psychiatric OT program development. In the late 1980's, after several agency shifts over its long history, St. E's became part of the DC Commission on Mental Health Services. The first Commissioned PHS OT was stationed there, and, with steady determination, visualized and filled the need for program development and officer recruitment. Today Therapists develop, implement and reassess new programs to promote successful transition from hospital to community living, and reduce recidivism rates. There remains unlimited opportunity for creative and innovative program development, as well as direct care and student training.

While OT was emerging as a Federally supported discipline at St. E's, Therapist officers were called to meet the expanding needs of the PHS. Several Physical Therapist Officers were placed in Headquarters in the early 1960's and in regional offices to provide consultation for the DIVISION OF CHRONIC DISEASE (DCD). The acknowledged value of therapies in primary and secondary prevention blossomed, leading to Master's in Public Health training for Therapist Officers who assumed responsibility for specialty programs. These Therapists had a national impact not only on patients with diverse diagnoses, but on Therapist training programs that were developed nationwide. Their programs incorporated the PHS public health focus, and provided standardization for university training of therapists. Cardiovascular health projects grew across America, including fitness, stroke prevention, and stroke rehabilitation. Standard operating procedures for Physical Therapy clinicians were developed at the USPHS hospital, Baltimore, Maryland. Therapists then developed the forerunner of the standard SOAP note format and musculoskeletal screening tools.

When, in 1965, the Medicare and Medicaid Acts were ratified, all of the above headquarters and regional Therapist Officers were involved in implementing the new programs. Their responsibilities included the following: establish and apply standards for personnel, facilities, and organizational structure; provide consultation to regional offices, local and state agencies, and providers of services; assume responsibility for major program components in the survey and certification processes; monitor fiscal aspects to prevent program abuse; and develop program policy and review at all levels.

Additionally, the PHS Physical Therapists collaborated with the Social Security Administration to set the standards and conditions under which independent practice therapists could bill. Since, no nationally mandated standards existed to measure programs in hospitals, nursing homes or home health agencies, PHS Officers developed these standards. The PHS then discovered that hundreds of Therapists had not graduated from approved curricula established for their professions. Despite intense debate, the basic standard of graduation from an approved school was retained, and the PHS Therapists developed and administered exams to test and license Therapists already in practice. In the ensuing years, other professions, such as laboratory and nursing followed suit.

Medicare and Medicaid were placed under the responsibility of the PHS during the reorganization of 1973. The HEALTH CARE FINANCING ADMINISTRATION (HCFA) started in 1978, and became the federal agency that administers Medicare, Medicaid, and Child Health Insurance Programs.

Therapists stationed with HCFA today continue to work with regulation of therapy services. Their roles include participation in the development, implementation, and/or ensuring compliance with regulatory requirements related to such topics as provider/supplier participation, and access or quality of care. They provide oversight both of State Medicaid beneficiary safeguards, and Medicare contracted insurance companies' billing and payment safeguards.

Overall, the scope of work is broad, incorporating skills such as health care planning, administration, quality assessment, project management, research and fiduciary responsibility. They have created electronic and hardcopy forms for Therapy certification, recertification, and additional medical documentation. As well, the Therapy Officers assist with revision of current Medicare salary equivalency guidelines for payment. They audit the Medicare insurance companies to ensure their reimbursement decisions for Therapy, and are leading the process involved with the all aspects of the new Prospective Payment System (PPS). They work hard to ensure that Medicare and Medicaid clients receive equitable and reliable rehabilitation services.

In 1959, the PHS first accepted research proposals from USPHS hospitals and officers. A Physical Therapist at the GILLIS W. LONG HANSEN'S DISEASE CENTER, in Carville, Louisiana studied the use of electromyography in Hansen's disease. The results showed that EMG was a reliable clinical tool that could provide knowledge of the status of select nerves and the progress of Hansen's disease at an earlier time then ever before possible. The EMG results were used to determine whether to perform nerve transplantation surgery. This contribution had broad and significant implications later for the physical therapy profession in developing the use of EMG for the evaluation of clients for accurate diagnosis of disease process.

Through the 1960's, Physical and Occupational Therapists at Carville directed their efforts to prevention and treatment of deformities and wounds associated with insensitivity of the limbs. Collaborative efforts with other health professionals, including those in medicine, rehabilitation research, vocational rehabilitation, orthotics-prosthetics and mechanical engineering resulted in new approaches, protocols, and recommendations that were shared locally, nationally, and internationally. Through their dedicated research and publications, they advanced clinical, practical solutions that have proven applicable and relevant for other types of clients with similar sensory conditions.

Examples of their past and present efforts include the first use of finger casts and splints to heal wounds on insensitive hands and arms, and collaboration to establish the armadillo as a research animal model for the study of Mycobacterium leprae in 1971. A new management philosophy evolved in the 1980's that focused on deformity prevention through education, adaptation, and splinting. Development of the hand volumeter for measuring edema occurred, as did standardization of objective assessment of wounds, with compilation of data related to type, size, location, and cause.

Therapist efforts at Carville led to development of programs nationally for teaching statistics and basic research technology to Physical Therapy students. Staff at Carville clearly identified the need to assess daily living activities, sanitation, and home environment as key factors in the management of insensate limbs, which expanded to international education and acclaim for therapists. The West Indies, Venezuela, India, West Africa, the Rykukyu Islands and others have benefited from the work of the Carville staff. Their work and recommendations have extrapolated to worldwide efforts to manage Diabetic insensitivity today. They are truly noteworthy for their impact on the health of the world!

Simultaneously, far sighted Physical Therapist, Occupational Therapist, Audiologist and Speech Pathologist Officers began serving the needs of the INDIAN HEALTH SERVICE (IHS). During the 1950's, IHS hospitals in Gallup, NM, Phoenix, AZ, and Anchorage, AK were overwhelmed with the care of patients with trauma and diseases such a polio, tuberculosis, and diabetes. Subsequently, a need developed for rehabilitation specialists to care for spinal cord injuries, arthritis, burns, and orthopedic injuries. These Officers were challenged to learn the culture of the various tribes and traveled long distances to meet the needs of patients in remote areas of reservations. Working through interpreters in isolated duty stations proved no obstacle to provision of superb therapy care for thousands of clients.

Dedicated Therapy Officers developed a comprehensive plan for the future needs of the IHS. Outcomes of this plan included the framework for practice without referral and the approval to practice as primary care providers. Work on the national level for practice without referral ensued, with success partly ascribed to the IHS movement. Collaboration of IHS therapists led to formation of an IHS therapy category and standards of professional practice for the Therapists were developed. Recognition of the valuable contributions of the early therapists led to tremendous growth in Therapy services to the Indian tribes across America. The Rehabilitation Branch formed in 1970, and by 1977 services expanded to include home care therapy.

The 1980's marked initiation of pediatric developmental therapy, and comprehensive management of spinal cord injury. Through the 1980's and 1990's, efforts to prevent injuries included the development of Athletic Injury Prevention Programs that had positive effects on individuals, encouraging them to accomplish educational as well as athletic and personal goals. IHS Therapists also established numerous statistical packages for tracking head injury, spinal cord injury, diabetic foot management, pediatrics and patient scheduling. Clinical Therapy Researchers investigated on the job injury, plantar fasciitis, diabetic foot problems, hand strength, head injury, and ergonomics. Strides to make adequate footwear available to all eligible patients have positively impacted DM outcomes. Recruitment and retention efforts staffed all federal therapy sites, and expansion into non-federally operated clinics is ongoing. Therapist consultants offer guidance to all tribes, notably ambulatory care clinics seeking to staff their programs with highly qualified therapy staff. Progress in billing enhancement has continued to make therapy not only effective, but profitable.

Interdisciplinary teams now address the overall health of IHS clientele, and therapists are diligent in providing education and monitoring quality of care across multi-faced care delivery systems. The current focus of Therapists is comprehensive rehabilitation, with all therapy disciplines involved in securing the best possible outcome for their clients. Therapist representation to the Surgeon General has continued over the years, positively impacting the health of the IHS, and other PHS clients. It is truly amazing how much has been accomplished in a brief span of history!

1954 marked the first year patients were referred to the NATIONAL INSTITUTES OF HEALTH (NIH) from other institutes such as Arthritis and Musculoskeleletal Disorders, Cancer, Mental Health, Allergies and Infectious Diseases, and Dental Research. The Rehabilitation Department was concerned "not only with the correction of deformity and the functional restoration of the patient, but with the prevention of deformity and disability". The initial emphasis was on direct treatment, including an emphasis on Mental Health Management and Initiation of Work Therapy Placement. However, the Physical and Occupational therapists moved quickly to assist with ongoing research, and conduct research of their own.

The 1970's saw OT adopt the Model of Human Occupation as the framework for clinical care and research, and Commissioned officers developed Physical Disabilities Evaluation and Treatment tools. OT developed a role in treatment of terminally ill patients, while PT expanded into clinical specialty practice in care of disorders of the foot and management of patients with oncologic disorders. The Therapists assumed responsibilities in clinical care, administration, research and education. With the advent of computers, the biomechanics laboratory was added, and therapists created the Rehabilitation Research Review (3RC) process to further define acceptability of research design and methodology. The leap into research was just getting started!

Expansion into validation of efficacy in Research Drug trials was a hallmark of the 1980's, and Therapists became principal investigators in therapy research. Standardized functional evaluations were developed and translated for international use, and in the same era, the Joint Protection and Energy Conservation workbook was developed and printed. As research advanced through Therapist Officer efforts, student internships evolved that included 50% clinical, 50% research with publication and presentation outcomes.

In the 1990's, the focus of NIH Therapists broadened. Collaboration intensified with Research Institutes in determining design and providing data collection and analysis associated with more than 20 protocols. Some accomplishments include data collection on childhood schizophrenia, the creation of a device to prevent accidental needle sticks to health care workers, international recognition for publications and presentations, the development of screening batteries for Bone Marrow Transplant and Chronic Fatigue Syndrome, the inception of Metabolic Exercise Testing, and the Daily Activity Questionnaire, used internationally for functional geriatric assessment. Top that off with clinical programs in pediatrics, oncologic and cardiopulmonary physical therapy, as well as treatment of arthritic foot disorders and lymphedema, and one gets the idea that every staff member is involved not only with collaborative research, but someone is actually treating patients! The student clinical /research internships continue today, with both national and international ramifications.

A Physical Therapist compiled the basic guide Physical Therapy Manual for Hospital Corpsmen, for the UNITED STATES COAST GUARD in 1964. Therapists were engaged to plan physical therapy departments, and design fitness facilities both for the USCG base on Governors Island in New York, and the USCG Headquarters Building in Washington, DC. The end products met the requirements for designs that permitted extensive use of the facility by large numbers of personnel at the same time.

Coast Guard Officers were happy to use the footwear redesigned for them by a PHS Physical Therapist in 1984. Later, in 1988, that same Therapist developed their new Physical Fitness Program for Rescue Swimmers. Therapists continue to work on Coast Guard Training Bases to facilitate safe, efficient physical training for new personnel, and rehabilitation from injury incurred during duty.

Established in 1970 and placed under the Center for Disease Control in 1973, THE NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH) is responsible for conducting research and making recommendations for the prevention of work-related illnesses and injuries. Therapists have played an important role in accomplishing the NIOSH mission in two primary areas: noise-induced hearing loss and musculoskeletal injuries.

Within two years of its founding, NIOSH issued its first criteria document recommending limitations on exposure to hazardous noise in the workplace and suggesting control and protective technologies to prevent hearing loss. Their recommendations were based on field studies or workers in multiple industries. Other important publications in this area have included guidelines for establishing hearing conservation programs, manuals for industrial noise control, and compendiums of hearing protection devices. PHS audiologists made significant contributions to these documents and the research behind them. These Therapists have also participated in health hazard evaluations, in which NIOSH personnel - at the request of a particular company or industry - evaluate and provide technical assistance to alleviating exposure to noise or other hazardous agents in the workplace.

Physical Therapists have been key players in NIOSH ergonomics research. Studies were conducted to develop a standardized set of tests and measures for use by clinicians in assessing musculoskeletal injuries to the low back. These efforts resulted in the publication of the "NIOSH Low Back Atlas". Additionally, PHS therapists developed basic guidelines for conducting electromyography and neural conduction studies in the occupational setting. These guidelines were also disseminated as NIOSH documents.

Therapists continue to make important contributions toward the CDC Mission. As new data have suggested other risks to hearing from occupational exposure to chemicals and heat, new studies have been undertaken to quantify the risk and develop appropriate guidelines for prevention. Work is in progress to better define ergonomic risks for specific occupations and tasks, and to evaluate various rehabilitation and return to work strategies. As the Public Health Service enters its third century, PHS therapists will continue to work toward the NIOSH vision of "safety and health at work for all people& through research and prevention".

In 1930, a law was signed that created the BUREAU OF PRISONS (BOP). The law also included provisions for the assignment of Public Health Service Officers to federal prisons to supervise and provide psychiatric, medical, and other scientific services. Over the years, the prison system grew, and the first Therapist joined the BOP in 1974, at the Medical Center for Federal Prisoners in Springfield, Missouri. After other Therapists joined the system in 1981, the BOP found that the USPHS Therapists and other USPHS Officers were a "bargain", in that they were able to provide cost-effective care to inmates. Through the later 1980's and 1990's, Therapy services expanded to 6 other Federal Medical Centers around the country.

In addition to "routine" rehabilitation services, Therapists are involved in many specialty areas, such as Back School, shoulder clinics, and NCV/EMG electrophysiologic evaluation for inmates. Therapists also provide wound care, and evaluation and management of insensate limbs, functional assessments, foot/ankle and specialized shoe clinics, and cardiac rehabilitation. Combined degrees in Physical Therapy and Social work at one facility led to development and management of programs on Anger and Depression management, Drug and Alcohol Abuse Treatment, Stress Management Self Esteem Building, Classical Music Appreciation, Progressive Muscle Relaxation, Process Therapy Group sessions, and Psychotherapy treatment.

The Director of Rehabilitation Service, a position established in 1997, is responsible for conferencing with and directing Therapists work towards establishing standardized evaluation forms and procedures for services provided by BOP Therapists. These hard working and skilled Therapists are also applying themselves diligently in the areas of quality improvement and statistical analysis of service operation. The inmates often receive more comprehensive care than they had prior to incarceration!

The FOOD AND DRUG ADMINISTRATION (FDA) is a team of dedicated professionals working to protect and promote the health of the American people. Conceived in 1938, the FDA was a relatively small operation until 1960, when it was reorganized, partly due to discovery of the teratogenic effects of thalidomide. Therapists joined the FDA as Regulatory Review Officers prior to 1981. With the scientific advancement of Physical Therapy, more officers have been added to achieve the FDA mission.

Therapist Regulatory Review Officer's manifold responsibility affects all aspects of the equipment utilized in provision of therapy services. They review scientific, technical and clinical data in premarket applications and assess the safety and effectiveness of the medical devices as intended for a specific medical use. They oversee regulations from the legal and medical perspective, and make recommendations to the FDA that consider not only the scientific and technical aspects of medical restorative devices, but incorporate the political, economic, and ethical dimensions of products as well.

The FDA's highly skilled Therapist Officers collaborate and cooperate with state and local governments; domestic, foreign and international agencies; industry; and academia to provide strategies for evaluation, and make decisions that set precedents for the resolution of subsequent cases within the restorative devices arena. They review proposed and ongoing clinical studies that involve important precedent-setting scientific issues. Their role in resolution of controversies and scientific issues effectively establishes FDA policy for handling subsequent review involving similar issues or products.

Because of the FDA's work, clinical Therapists have scientific guidelines and policies for review of restorative products, including standards of adequacy and methodology concerning the data required. The Therapists represent FDA as authoritative spokespeople at meetings with private industry, trade associations, and professional organizations. The breadth of the PHS Therapists' responsibility is staggering!

Specialization trends in the therapy fields continue, and PHS Therapists have successfully achieved recognition in the form of specialty pay for deserving Officers. Unarguably, the Therapy Category, made up of Occupational and Physical Therapists, Speech Pathologists, and Audiologists, has had a significant impact on the health of the American public in cross-cultural settings, and on around the world. They are a proud group of officers, second to none in their dedication to duty. They continue to strive for excellence, and if history is any indicator, they will achieve it!

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Last updated November 2007