ROLE AND CONTRIBUTIONS
OF PUBLIC HEALTH SERVICE THERAPIST OFFICERS
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.
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
DEVELOPMENT OF ROLES AND TRAINING OF THERAPISTS
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.
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
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.
MORE RECENT PROGRAM EXPANSION
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
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
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
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
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!