When examining the history of the U.S. physical rehabilitation industry, it becomes evident that three core professions continue to shape and lead this market during the last century: physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP).
Each profession has its own distinct history and approach to achieving wellness, yet all share a common objective: to help people recover functionally from injury and disease. In today’s physical rehab environment, Medicare controls much of the industry’s processes. Medicare requires all hospitals, nursing homes, home health agencies, inpatient rehab facilities, and rehab agencies to provide PT, OT and SLP services. Such requirements speak volumes for these professions, so let’s explore the history of each.
As a profession in the U.S., PT developed its roots during the polio epidemic of 1916 and World War I. Around this time, the U.S. Army Medical Department created a special division to train medical personnel to learn “reconstruction” techniques. Physical therapists, many of them women, formed the first professional PT association in 1921.
The polio epidemic continued through the 1950s, and the demand for trained therapists continuously increased to meet the needs of soldiers returning from World War II, the Korean War, and the Vietnam War. By 1959, the American Physical Therapy Association had convinced 45 states to institute specific state regulations for physical therapists. The success of this initiative influenced the federal government to include outpatient therapy in the Medicare program in 1967 and 1968.
Since that time, the science, knowledge, and skill required to effectively restore functional loss following injury and/or disease – or to enhance people’s functional development through physical therapy – have evolved rapidly. Today, physical therapists work with patients to treat disorders of the central nervous system, cardiovascular/pulmonary system, and musculoskeletal system, providing services including the vast majority of all orthopedic surgeries and joint replacements.
OT also originated around the time of World War I, with a focus on the importance of returning wounded soldiers’ ability to work with their hands. Instead of focusing on purely physical etiologies (as physical therapists do), OT professionals suggested that a complex combination of social, economic, and biological factors cause dysfunction. Their training included principles and techniques gleaned from nursing, psychiatry, rehabilitation, orthopedics, self-help, and social work.
The profession established a national association in 1917. In 1920, OT specialists decided to officially name the profession “occupational therapy” to separate it from physical therapy.
The OT profession continued to grow in knowledge and skill as a result of World War II, the Korean War, and the Vietnam War, and it continued to gain the general public’s acceptance. During that time period, the core assumptions of OT were established. They remain in place to this day:
- OT has a positive effect on health and well-being.
- OT creates structure and organizes time.
- OT brings meaning to life, both culturally and personally.
- Occupational therapists understand people’s individual values for different occupations.
OT highlights the importance of satisfaction in one’s occupations, broadening the goal of recovery beyond the mere completion of tasks to include the holistic achievement of personal well-being.
Speech and Language Pathology
This skilled and highly specialized profession traces its origins to the mid-1920s, when people working in the field of speech disorders and speech correction created a national association. Their detailed history is categorized in the following periods of professional growth and influence:
- Formative years (1900 - 1945)
- Processing period (1945 - 1965)
- Linguistic era (1965 - 1975)
- Pragmatic revolution (1975 - 2000)
In the early 1900s, the profession focused on the classification of speech disorders, specifically regarding standardizing terminology and treatment protocols. Much of the information originated from the review of European literature on speech disorders at the time.
Through the decades, the profession steadily developed its collective breadth and depth of skill and knowledge as the science of SLP grew. Inspired authors and thought leaders altered the evolution with new approaches and techniques.
Through the 1960s and 1970s, the emergence of the study of linguistics broadened the scope and capacity of the profession exponentially. Originally, speech and language pathologists were more commonly associated with their work with children; however, they soon expanded their reach to include working with adult populations in nursing homes and hospitals. Pathologists started treating adults with central nervous system disorders, neck and throat conditions, as well as speech and swallowing disorders.
The SLP profession remains strong and growing, ubiquitous in all therapy settings, and it is working collaboratively with PT and OT to meet today’s industry challenges.
Since the 1990s, the PT, OT, and SLP services have been significantly affected by the changes in the U.S. healthcare system with regard to managed care, the Balanced Budget Act of 1997, the Medicare Prospective Payment System (PPS) and Medicare caps on therapy services and functional limitation reporting.
Fortunately, all regulations, including specific reimbursement structures established by the Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), Medicaid, and all third-party payers, treat PT, OT, and SLP exactly the same. This means that all of the documentation requirements, treatment intervention billing procedures, and chart audit criteria are identical for each discipline.
The clinical content and the specific functional/physical focus of the clinical reports are what separate these professions with regard to regulations and reimbursement.
About the Author
Gerry Stone is a physical therapist and the founder/chief clinical officer of The Rehab Documentation Company, Inc., makers of ReDoc Software. He served on the Neuro-Muscular panel of American Physical Therapy Association to help to write The Guide to Physical Therapist Practice, Volume 1, (1995-1997). He has extensive knowledge of the CMS and TJC regulations and billing structures pertaining to rehab settings.
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