Feature Celebrating A Milestone: 50 Years of PTAs Half a century ago, the first physical therapist assistants (PTAs) entered the workforce. Their roles, numbers, and participation within APTA have grown steadily. (This article is updated from an earlier story published in a 2004 issue of APTA's PT: Magazine of Physical Therapy that celebrated the 35th anniversary of the PTA.1) By Michele Wojciechowski | May 2019 In 1969, physical therapist assistants (PTAs) had cause for celebration. Fifteen students graduated from the first PTA programs at Miami Dade College in Florida and St Mary's Campus of the College of St Catherine in Minnesota. Just 2 years earlier, those programs had begun preparing students to fill an identified need in the physical therapy community—supporting the physical therapist (PT) in treating patients. The journey of PTAs in the 50 years since hasn't been completely smooth. But PTAs have become an important part of the profession, increasingly recognized for their role and contributions. That is reflected in PTA membership in APTA, which has grown from 52 in 1971 to more 9,000 today. To see how far the PTA has come, we've got to go back and see how it all began. The Need for PTAs David Emerick Sr, PTA, former president of the National Assembly of PTAs and past PTA Caucus chief delegate, notes that the concept of the PTA dates as far back as the 1940s. By the 1960s, however, a real need had emerged. There were too few PTs to fill the growing demand. Rather than watching other professions or organizations pick up the slack, PTs began exploring ways of acquiring assistance personnel. At the time, many PTs used aides, but what they realized they needed were assistants with education and training specific to physical therapy. In the early to mid-1960s, support staff already were being trained by pioneers such as Viola Robins, PT, at Rancho Los Amigos Hospital in California and Charles Dorando, PT, at St Joseph's Mercy Hospital in Michigan. But there were no official programs—yet. At the 1964 APTA House of Delegates (House), members of the California Chapter introduced a resolution to designate a committee to explore the use of nonprofessional personnel. Helen Blood, PT, EdD, FAPTA, who made the motion, remembers it well. "A group of us had done some research and realized that many of the tasks that people were doing did not require a lot of professional education," Blood says. After heated debate in the House, the motion passed, and Blood became chair of the Ad Hoc Committee to Study the Utilization and Training of Nonprofessional Assistants. Joining her on the committee were Dorando, Thelma Holmes, PT, Beth Phillips, PT, and Martha Wroe, PT, FAPTA. The committee looked at the feasibility of the PTA, Blood remembers, and considered the PTA's relationship to the PT, the tasks PTAs would perform, the training they should receive, who should be responsible for that training, and where the training should be conducted. "The whole issue was extremely controversial," she recalls. The committee discovered that between 1955 and 1965 about 80% of PTs had used nonprofessionals in this kind of role. Some even served as proxies for PTs when the latter went on vacation.2 Clearly, something had to change. In addition, there was debate as to whether the position should be called a physical therapist assistant or a physical therapy assistant. In 1967, the committee submitted a report to the House of Delegates with a policy statement—"Training and Utilization of the Physical Therapy Assistant"—that set policy on education, supervision, function, and regulation of the PTA. Years later, the name of the physical therapy assistant would be changed to physical therapist assistant to make it clear that the role of PTAs is to assist PTs. Also that year, Miami Dade and St Mary's began education programs for PTAs. In 1969, Barbara Bradford, PT, MPH, the first director of the St Petersburg program, presented a paper at APTA's Annual Conference in San Francisco. In it, she wrote, "We are educating technicians; we are not training physical therapy assistants. In other words, we are not just teaching skills, which is what training implies. We are attempting to afford students the opportunity, through planned learning experiences, to gain knowledge and understanding of basic principles and theories underlying the skills which are also necessary to their practice as technicians under the supervision of a registered physical therapist." Not everyone, though, was pleased. Some PTs were concerned that PTAs wanted to replace them. Before guidelines were in place, some PTs were unsure how to use PTAs. Patti Evans, PT, recalls an instance that occurred when she was APTA's assistant director of education. After a presentation, a PT stood up and asked, "Now that you've created the PTA, what is left for me to do?" Evans replied, "If that's what you think all of physical therapy is, then the profession is dead, and we should just stop agonizing about it now." Evans then walked out. "I was young," she laughs. "I'm a little more diplomatic these days." But her point was well-taken. In the 1970s, there still were gray areas with regard to the PTA's role and responsibilities. Today those areas are specifically defined, although state practice acts differ regarding use of PTAs. "I have certain rules and regulations I have to follow in Virginia," Emerick says, "that might be different from someone working in Arkansas." Joining the Club PTAs were granted temporary membership in APTA in 1970, and in 1973 permanent membership was brought to a vote in the House of Delegates. "I can still see that room where they voted," Evans says. "We were in Houston. Barb Bradford and her students were there, and they had lobbied the delegates all night long. They wanted to be a part of this club." The House passed the motion— by the margin of a single vote—and PTAs were admitted as affiliate members. Meanwhile, as more community and technical colleges began offering PTA programs, program directors formed the Physical Therapist Assistant Education Group to share information on everything from textbooks and clinical education to administrative issues and concerns. With a grant from the Kellogg Foundation, the group, led by Bradford, held its first meeting in St Petersburg, Florida. The group continued to meet every couple of years. Eventually, as both the group and its areas of interest grew, it began to meet at APTA conferences. Known today as the PTA Educators Special Interest Group (SIG) of the Academy of Physical Therapy Education, it continues to meet and share information. From Affiliates to Assemblies In 1983, Cheryl Carpenter-Davis, PTA, MEd, now the vice president of academic affairs at Cleveland University-Kansas City's College of Health Sciences, along with Virginia (Bunny) May, PT, DPT, and Tricia Garrison, PTA, led a group of PTAs in the quest for an organized voice. "We said that just as much as some of the APTA sections have special interests, we have special interests, too," Carpenter-Davis says. They formed the Affiliate SIG and began establishing regions and distributing newsletters. APTA's Board of Directors soon formed the Task Force on Organizational Structure, and Carpenter-Davis participated. In 1989, the House amended the association's bylaws and approved a new component—assemblies. The Affiliate Assembly was formed, with Carpenter-Davis as its initial president. It gave PTAs a formal voice for the first time. The Affiliate Assembly continued until 1998, when—after much analysis and discussion—the boards of the Affiliate Assembly and APTA arrived at the structure for the National Assembly (NA), a body solely for PTAs. According to Chris Junkins, PTA, who served as NA vice president and chief delegate at that time, it came about to further unify the voice of the PTA. Previously, PTAs could be members of APTA without being members of the Affiliate Assembly, as separate dues were required for membership in the latter. "We decided that the structure wasn't working as well as it could for all PTAs who were members," says Junkins, who's now co-owner of Dosher Physical Therapy in Easley, South Carolina. "They reformed the structure so that all PTAs who were members of APTA also automatically were members of the National Assembly." Junkins also says the NA offered PTAs a better venue for voicing issues that affected them but perhaps did not impact PTs. "We were definitely working for the profession as a whole," he explains. The NA, which continued until 2005, had 2 nonvoting delegates to the House of Delegates. Like section delegates, they could make and address motions and lobby delegates on specific issues. They could not vote on any motion. Within the NA was the Representative Body of the National Assembly (RBNA), where PTAs discussed issues related to motions coming before the House and decided which to support or oppose, based on how the motions would affect PTAs and the profession. They also could develop their own motions. RBNA annual meetings usually were held the Sunday prior to the APTA House of Delegates. This allowed PTAs to inform their delegates of the viewpoints or motions they wished to bring before the House. From an Assembly to a Caucus Although the NA and RBNA were great ideas at the time—and they did help PTAs—as the years passed, leadership determined that there was a better way to accomplish PTAs' goals. "We were a small version of the House of Delegates, but we would address only PTA issues," says Emerick, a PTA who works in home health care in Northern Virginia. "We would get together the weekend before the main House of Delegates met. With PTA representatives from every state, we would discuss issues, make motions, and try to take action." All NA decisions needed to go to the House of Delegates. "The whole idea of the NA and RBNA replicating the House for PTAs didn't work," says Emerick. "We were spending time and energy trying to make change and make a difference. When our motions went to the House, they could either be heard or not heard. And if they weren't heard, then all of our time was wasted." PTAs became frustrated with the time they had spent working on motions that went nowhere. Emerick says that the executive staff of the NA—he was NA president at the time—met with the APTA Board of Directors to determine what PTAs would need to make them more effective. "We came up with a different model in which we could discuss issues, but not in a formal setting like the NA, then move those results directly to leadership. APTA agreed," Emerick recalls. The outcome was the present-day PTA Caucus (Caucus), which succeeded the NA and RBNA in 2005. Its structure is as follows: PTAs elect representatives from each state to be Caucus representatives. They still meet on the Sunday before the House, but that meeting isn't as formal as it had been under the NA. "We decided that we would have discussions, and PTAs would bring ideas they wanted to talk about and motions they might want to send to the House," explains Junkins. The Caucus sends 5 delegates to the APTA House of Delegates—designating 1 of those 5 as chief delegate. "This structure is more of a caucus, because PTAs have a representative from every chapter," explains Lisa McLaughlin, executive director of the PTA Caucus and the Student Assembly. "If a chapter wants to have an alternate delegate, it can appoint one as well. Currently, there are 50 PTA Caucus reps and 11 alternate reps." While many PTAs anticipated that the new caucus was going to work better, that opinion wasn't unanimous. Emerick remembers that when the change was suggested, many PTAs were upset. "It was emotional for some within the National Assembly, because they thought they were losing everything they had." Emerick says. "For 2 years before the motion went to the House, we provided information and talked to PTAs to educate them so they could really understand it. Many PTAs were concerned that we were going to lose ground. But we actually gained ground because we had more PTAs involved in the House. We couldn't vote, but at least we could be present. We've gotten so much more accomplished without always needing a formal debate beforehand. "With the Caucus," Emerick continues, "we don't have a president or offices, so there's less emphasis on a person's prestige—but as a group, we're more effective. I think it was a great move." "The Caucus gives PTAs representation from every chapter in our nation," says David Harris, PTA, its current chief delegate. "The Caucus design not only gives a voice to PTAs, but it also gives us the ability to be more engaged and more actively involved within the profession." "With the Caucus, we are able to integrate better with APTA," says Amy Smith, PTA, the body's immediate past chief delegate. "Even though PTA delegates can't vote, they can make and move a motion, and speak for or against a motion. As a membership group, it's a great advantage to have this unified voice working for us." Getting the Full Vote One major achievement of the PTA Caucus was gaining a full vote for PTAs at the component level. "In 2012, some of the PTA Caucus leadership met with APTA leadership and began a discussion about the perceived disenfranchisement of PTAs, as well as the perceived lack of value that APTA brought to them," says Smith, who is regional director of operations for Restore Therapy in Birmingham, Alabama. "I've always understood and valued my APTA membership. But at the time, less than 7% of PTAs were members of the organization. We needed to look at that and begin to change it." The fact that at the time PTAs were afforded only a half vote within their chapters or sections was a known area of frustration. What resulted was the PTA Board Work Group. Comprising 3 PTA members, 3 APTA Board members, and 2 APTA staff members, it looked at the value of association membership to PTAs. "We discussed PTAs' concerns, and we brought motions to the 2015 House of Delegates to look at increasing the value of PTA membership." The House adopted a revision to the APTA bylaws to allow components to decide whether or not to give PTAs a full vote at that level. "Getting the full vote made PTAs across the nation feel valued," Smith says. "Moving forward, they felt they had a stronger voice." Today, 41 chapters and 9 sections grant PTAs the full vote, putting them on equal footing with their PT colleagues when voting on issues within their component. "The remaining chapters and sections are working on getting this through," says Harris, vice president of Integrations at Benchmark PT in Chattanooga, Tennessee. PTA Caucus Goals The PTA Caucus sets goals and works with member PTAs and the rest of APTA to achieve them. "The overall thrust is to establish an external focus for the Caucus that aligns with APTA's mission," says McLaughlin. "They are getting the ball rolling for PTAs to become more a part of the association, more inclusive, and more collaborative." The PTA Caucus has 3 strategic goals: PTA Caucus reps are informed and engaged leaders. The benefits of the PT-PTA team are understood and promoted. The PTA Caucus collaborates with APTA to enhance efforts to increase membership value for PTAs. "We want PTAs to become actively involved at the association, chapter, and district levels," Harris says. "We're also actively recruiting new members." McLaughlin adds that as part of the 50th Anniversary of the PTA, APTA has embarked on an initiative to exceed 10,000 PTA members. Evolving Education Although the academic degree required to be a PTA remains an associate's degree, over the years APTA has encouraged postgraduate proficiency development. The PTA Advanced Proficiency Pathways (APPs) program was established in 2016, replacing an earlier program called the PTA Recognition of Advanced Proficiency.3 APPs are educational guides that enable licensed PTAs to gain and be recognized for advanced proficiency knowledge and skills in selected areas of work. The program has 3 components: successful completion of core APTA courses common to all 7 areas of proficiency; successful completion of area-specific courses; and mentored clinical experiences with skills checks.4 Currently, the areas in which PTAs can study are acute care, cardiovascular and pulmonary, geriatric, oncology, orthopedics, pediatrics, and wound management. "It's a recognition of concentrated continuing education," says Kathy Giffin, PTA, chair of the PTA Educators SIG in the Academy of Physical Therapy Education. Regarding PTA education, Giffin says, "We have a degree that began 50 years ago, and it has not essentially changed in that entire time. What has changed, though, is the depth and breadth of what we cover, as well as the evidence-based practice that has developed. The knowledge base in general has expanded so much." Over the years, there have been many discussions of changing the education degree from associate to bachelor. Junkins says the concept has both pros and cons. "It would make the PTA more "professional" as far as payment for Medicare services is concerned," he says. "But most PTAs are educated in community colleges or technical schools. Those institutions don't offer bachelor's degrees, and it would hurt those programs. It also would increase the cost of becoming a PTA. You have to look at the whole picture." Giffin says PTAs need to learn more, because every 5 years the Federation of State Boards of Physical Therapy—which controls the licensure exam—conducts a practice analysis and adapts the exam to meet current practice. It sometimes adds new content, and that new material needs to be taught in the curriculum. A PTA program consists of either 3 or 4 semesters, the final semester being clinicals. "In my program, students are in technical classes for about 18 hours a week for 3 modules. To be successful, they must put in at least 2 hours of out-of-class time for each hour of in-class time. I'm fortunate because I have a program that doesn't limit my credit hours. But some programs do. Other states limit the credit hours and are expecting students to do much more on their own and to prepare," says Giffin, who is PTA program director at CBD College. "The discussion that's happening right now is not so much about a transition to a bachelor's degree," says Giffin. "It's about allowing programs to not be maxed out at a 105-week calendar, which is the limit now. If an associate's degree works for their student body, then keep it there. If it doesn't, don't eliminate the option of the program developing a bachelor's degree. Right now, many PTA educators just want to allow PTA programs to develop, and let the market decide." "We have to continue to look at PTA education," Smith says, "to ensure that the PTA has all the skills needed to be the only person who assists the physical therapist in providing physical therapy. We have to look at education as the medical field grows, as research increases, and as DPTs engage in direct access. We need to know what to add to PTA education so that they continue to be able to meet the needs of PTs, as well as the patients." Many PTAs have degrees outside of their PTA associate's degree. Matt Gratton, PTA, a former member of the PTA Student Assembly Board of Directors, is pursing one—he currently is a doctor of physical therapy (DPT) student. It's not, though, for the reason you might think. Gratton works as a PTA and cardiac telemetry team lead at Lutheran Hospital in Fort Wayne, Indiana, and as an adjunct instructor for the PTA program at the University of Saint Francis. To become a tenured professor at a PTA program, however, he needs a higher terminal degree. "I could get a master's degree in administration or education, but that's not going to serve my patients or my students as well," he says. "It doesn't do justice to the people I'm going to teach. If I want to teach student PTAs to be better PTAs, I need a higher level of education." As a member of APTA's PTA Early Career Team, Gratton helps the association look at the transition from PTA school to the clinic and what happens in those first few years. That's another reason he will earn a DPT but will not practice as a PT. He wants to learn as much as possible about the physical therapy field in order to best teach PTA students how to work with PTs. "PTs and PTAs need to continue to work together on growing the profession—that way the entire profession gets better," Gratton says. The Value of Advocacy All of the PTAs interviewed for this article stress the importance of advocacy and getting more involved in APTA. Doing so has brought about internal changes such as the Caucus and the full component vote, as well as external changes—such as a recent major policy change by TRICARE. The Department of Defense's (DoD) TRICARE program provides health care benefits for active duty service members, National Guard and reserve members, military retirees, and their families when services cannot be provided at a military treatment facility. In the past, TRICARE did not cover services performed by a PTA. APTA advocated for change, and in 2017 legislation was passed authorizing PTAs to be paid for services under TRICARE. "The fact that the DoD is adding PTAs to those recognized to treat TRICARE patients is huge," says Smith. "While it's still being finalized as to when this will take place, this is big." (Learn more about PTA reimbursement under TRICARE, and a timeline for implementation, at http://www.apta.org/TRICARE/.) Recent graduate Ky Pak, PTA, agrees. "Allowing us to be suitable providers for TRICARE patients is a big win for us. And it shows that advocacy is important. If you stand up for yourself and say that you're a qualified health care provider, things can get done," says Pak, a former PTA Student Assembly Board of Directors member. Now working as a PTA at Kort Physical Therapy in Lexington, Kentucky, Pak already has seen what being involved in APTA can do. "The PTA Caucus has done a great job of moving the PTA in a good direction," he says. PTA students, too, recognize the importance of being involved. "Advocacy is our way of furthering ourselves in our profession," says Molly Dalton, a student in her final semester in the PTA program at Somerset Community College in Kentucky. She was director of Student PTA Relations at APTA and is a former member of the Student Assembly Board of Directors. "It's important to have legislators on Capitol Hill—or even just within your state—understand that physical therapy is important," Dalton says. "We need to be included in all the facets that advocacy stands for. For example, I don't have a job unless I get paid, I don't get paid unless I have legislators supporting my field, and I don't have legislators doing that unless I have my chapter's support." "Just getting involved in your state and your PAC [political action committee] can make a big difference," Dalton adds. "I know that I can be highly influential as a PTA." Junkins remembers when PTAs weren't licensed everywhere. Advocacy helped change that. "We've got licensure in every jurisdiction for PTAs. We've come a long way," he says. "It's just been amazing to see the growth in my nearly 50 years of working as a PTA." "Advocacy helps not only with insurance payments, but also with improving the quality of the physical therapy profession and with getting the word out about us on a national and even global scale," says Harris. "It helps us let everyone know what physical therapy is and does, as well as that PTs and PTAs are a collaborative team." "Seeing the overwhelming support for teamwork, and the collaboration and value of the PTA as part of the physical therapy team—that has been great," Harris adds. "These are the things that will continue to build us as a profession and will prompt more PTAs to get involved. We've come a long way, but we have a lot more to do." Michele Wojciechowski is a freelance writer.