Principles of Physical Therapy

Edited by Japanese Physical Therapy Association

Principles of Physical Therapy

Japanese Physical Therapy Association

 Committee for Developing an Introduction to Physical
Therapy
Chairperson: Kazuo Kurosawa
Members: Akira Kimura, Yasuyuki Takakura, Tadahiro Murakami
Secretariat of the Committee: Takayoshi Saito, Keisuke Suzuki

 List of Authors
Kazuto Handa
Toshihiro Morinaga

Japanese Physical Therapy Association
Professor Emeritus, Kyoto University
Professor Emeritus, Shijonawate Gakuen University
Takashi Nakayama
School of Health Sciences, Tokyo University of Technology
Isao Nara
Professor Emeritus, Hiroshima University
Hiroyuki Fujisawa
Department of Rehabilitation, Faculty of Medical Science and Welfare,Tohoku Bunka Gakuen University
Michele Eisemann Shimizu
Professor Emeritus, Prefectural University of Hiroshima, University Medical
CenterHiroshi Momma
Department of Physical Therapy, Faculty of Health Sciences, Kyorin
University
Tetsuya Takahashi
Department of Physical Therapy, Faculty of Health Science, Juntendo
University
Yasuyoshi Asakawa
Department of Physical Therapy, Faculty of Health Sciences, Tokyo
Metropolitan University
Akira Kimura
Department of Physical Therapy, Faculty of Health Science, Gunma Paz
University
Shuhei Fujimoto
Shizuoka Graduate University of Public HealthYorimitsu Furukawa Department of Physical Therapy, Faculty of Health Sciences, Tokyo
Metropolitan University
Kazuhiro Harada
Department of Physical Therapy, School of Health Science and Social
Welfare, Kibi International University
Shuichi Obuchi
Digital Transformation for Aging Society Theme, Tokyo Metropolitan
Institute for Geriatrics and Gerontology
Nobuko Ohsaka
Elderly Care Room, Health Care Division, Daito City
Shigeto Yamazaki
Department of Rehabilitation, Mazda Hospital, Mazda Motor Corporation
Shinichi Daikuya
Hokuriku University
Ayako Yamamoto
Department of Physical Therapy, Faculty of Nursing and Rehabilitation,
Konan Women’s University
Tomoe Inoue
Department of Physical Therapy, School of Medicine, Nagoya University
Hisashi Mochizuki
Department of Physical Therapy, Faculty of Health Science Technology,
Bunkyo Gakuin University
Tetsuya Chiba
Department of Rehabilitation, Nissan Tamagawa Hospital
Kengo Takashima
Division of Physical Therapy, School of Rehabilitation, Faculty of Healthand Social Services, Kanagawa University of Human Services

Principles of Physical Therapy
Table of Contents
 Introductory Chapter
Introduction
1.

Current Status of Japanese Society and Future Challenges .................................... 2
1)

Society from a demographic point of view .................................................... 2

2)

Changes in disease structure .......................................................................... 4

3)

Issues of healthcare and nursing care............................................................. 5

4)

Ideal society Japan is trying to build in the 21st century ............................... 6

2.

New Area of Physical Therapy Required to Meet Social Demands ....................... 7

3.

Past, Present, and Future of Physical Therapists ..................................................... 8
Kazuto Handa, Kazuo Kurosawa, Akira Kimura, Yasuyuki Takakura,
Tadahiro Murakami, Takayoshi Saito, Keisuke Suzuki

 Chapter 1 History of Physical Therapy (recent times)
History and Definition of Physical Therapy (physical therapy for disease, physicaltherapy for functioning)
1.

History, Definition, and Roles of Physical Therapy in Representative Countries...................................................................................... Toshihiro Morinaga ....... 10
1)

History and definition of physical therapy in the US .................................. 10

2)

Changes in the roles of physical therapy in the US ..................................... 13

3)

History and definition of physical therapy in the UK .................................. 14

4)

Changes in the roles of physical therapy in the UK..................................... 16

5)

History and definition of physical therapy in Australia............................................................................. Takashi Nakayama ......... 16

6)
2.

Changes in the roles of physical therapy in Australia.................................. 19

History of Physical Therapy in Japan (law, definition, education, roles)............................................................... Isao Nara, Hiroyuki Fujisawa ................ 20
1)

Birth of a physical therapist in Japan ........................................................... 20

2)

Acts of physical therapists and their proposed revision............................... 20

3)

Necessity of radical revision of the Physical Therapists Act ....................... 21

4)Physical therapy education .......................................................................... 22

5)

Integration of knowledge and skills of physical therapy and definition of
education ...................................................................................................... 23

3.

6)

Issues of methodology of education ............................................................ 23

7)

Roles of physical therapy ............................................................................. 24

8)

In conclusion ................................................................................................ 25

An American’s Comparison of Physical Therapy for Japan and America............................................................................. Michele Eisemann Shimizu ..... 26
1)

The beginning of physical therapy schools in Japan ................................... 26

2)

Schools increased and changed .................................................................... 26

3)

Licensing for physical therapists ................................................................. 27

4)

Job hunting, etc. ........................................................................................... 27

5)

What is expected of students who try to be physical therapists and young
therapists in Japan ........................................................................................ 27

 Chapter 2 Background of Public Health and Physical
Therapy
Necessity of Public Health Studies in Physical Therapy..... Akira Kimura ................. 29
1.

WCPT’s Development of Physical Therapy ................ Toshihiro Morinaga ....... 31
1)

Physical therapist and health promotion ............. Akira Kimura ................. 31

2)

Prevention ........................................................... Hiroshi Momma ............. 33

3)

(1)

Trends of preventive physical therapy in Japan ................................. 33(2)

WCPT’s trends in preventive physical therapy .................................. 34(3)

Health Competency Standards ........................................................... 35(4)

Development of the Health Improvement Card ................................. 36(5)

Challenges of modern society for core health promotion .................. 36(6)

Health gap: Social Determinants of Health (SDH) ............................ 38(7)

Roles of physical therapists in correcting the health gap ................... 39

Treatment/intervention ........................................ Tetsuya Takahashi ......... 40(1)

Target and objective............................................................................ 40(2)

Clinical reasoning and treatment/intervention.................................... 40(3)

The actual physical therapy treatment/intervention ........................... 42(4)

Summary............................................................................................. 44

4)Re-habilitation/habilitation ................................. Takashi Nakayama ......... 45(1)

Differences between medical rehabilitation and rehabilitation
medicine ............................................................................................. 46(2)

Social background of the introduction of rehabilitation into healthcare............................................................................................................ 46

2(3)

Principles of rehabilitation ................................................................. 47(4)

Relationship between physical therapy and rehabilitation ................. 47

Public Health (studies) and Physical Therapy .............. Yasuyoshi Asakawa ....... 48
1)

Providing support to remove clients’ social barriers ................................... 48

2)

Improving participation restrictions and disabilities and policy
recommendations ......................................................................................... 49

3

Population-at-risk Approach/High-risk Strategy and Physical Therapy...................................................................................... Akira Kimura ................. 50

4.

1)

What is a population-at-risk approach? ....................................................... 51

2)

What is a high-risk strategy?........................................................................ 53

Physical Therapy from the Point of View of a Universal Language Called
Evidence ....................................................................... Shuhei Fujimoto ............. 55
1)

What is evidence? ........................................................................................ 55

2)

What is evidence-based physical therapy (EBPT)? ..................................... 56

3)

Information and health communication necessary to develop physicaltherapy utilizing evidence ............................................................................ 56

 Chapter 3 Paradigm Shift of Physical Therapy (New
Challenges of Physical Therapy - Physical
Therapy in the Fields of Prevention and
Health Promotion)
Development in the Fields of Prevention and Health Promotion.................................................................................................. Shinichi Daikuya........ 59
1.

Physical Therapy in the Area of Health Education........................................................ Yorimitsu Furukawa/ Kazuhiro Harada........ 61
1)

Knowledge, willingness and ability to obtain, evaluate and use healthinformation ................................................................................................... 61

2)

Prevention of diseases and health promotion in daily living ....................... 62

2.

3)

Maintenance and improvement of QOL throughout the lifespan ................ 63

4)

Holding a health education class by physical therapists .............................. 64

Physical Therapy in the Preventive Field ..................... Shuichi Obuchi............... 65
Current Status and Future Direction of Physical Therapy in the Preventive Field

3.

1)

Current status of physical therapy in the preventive field ........................... 65

2)

Specificity of physical therapy in the preventive field ................................ 66

3)

Techniques required for the preventive field ............................................... 67

4)Creating a society where people want to be healthy .................................... 68

Physical Therapy in the Administrative Field .............. Nobuko Ohsaka.............. 68
Current Status and Future Development of Physical Therapy in the Administrative
Field

4.

1)

What is the administrative field? ................................................................. 68

2)

Current status of physical therapy in the administrative field ..................... 69

3)

Operations related to physical therapy in the administrative field .............. 70

4)

Future development ..................................................................................... 71

Physical Therapy in the Industrial Field....................... Shigeto Yamazaki .......... 71
Current Status and Future Direction of Physical Therapy in the Industrial Field

5.

1)Current status of physical therapy in the industrial field ............................. 71

2)

Potential of physical therapy in the industrial field ..................................... 72

3)

Future direction of physical therapy in the industrial field .......................... 74

Physical Therapy in the Scholastic Field ..................... Shinichi Daikuya ............ 75
Current Status and Future Development of School Health, etc.

6.

1)What is school health? ................................................................................. 75

2)

Physical therapy for school health (methods and types) .............................. 76

3)

Future direction ............................................................................................ 78

Physical Therapy in the Field of Women’s Health............................................................... Ayako Yamamoto/Tomoe Inoue ........... 79
Current Status and Future Development of Physical Therapy in the Women’s
Field
1)

Physical therapy in the women’s field ......................................................... 79

2)

Current status of physical therapy in the women’s field in Japan ............... 80

3)

Current status of physical therapy in the women’s field in foreign countries...................................................................................................................... 81

4)

Future prospects of physical therapy in the women’s field ......................... 82

 MATERIAL
1.

2.

Physical Therapy and Ethics ........................................ Hisashi Mochizuki ......... 84
1)

Bioethics ...................................................................................................... 84

2)

Medical ethics .............................................................................................. 85

3)

Professional ethics ....................................................................................... 86

Physical Therapy Management (Safety Management/Risk Management Measures)...................................................................................... Tetsuya Chiba ................ 91

3.

1)

Medical safety .............................................................................................. 91

2)

Prevention of medical accidents .................................................................. 93

3)

Infection prevention measures ..................................................................... 94

4)

Personal information protection ................................................................... 95

5)Harassment measures ................................................................................... 96

International Statistical Classification of Diseases and Related Health Problems(ICD), International Classification of Impairments, Disabilities and Handicaps(ICIDH), and International Classification of Functioning, Disability and Health(ICF) ............................................................................. Kengo Takashima .......... 97
1)

International Statistical Classification of Diseases and Related Health
Problems (ICD) ............................................................................................ 97

2)

From the International Classification of Impairments, Disabilities andHandicaps (ICIDH) to the International Classification of Functioning,
Disability and Health (ICF) ......................................................................... 98

3)

Relationship with the Physical Therapists and Occupational Therapists Act.................................................................................................................... 100

AFTERWORD ............................................................. Kazuo Kurosawa .......... 103

Introductory Chapter
Introduction

Introductory
ChapterA “Principle” in this book title (Principles of Physical Therapy) means a “collection of basic theories”(Kojien, a Japanese dictionary). Over half a century has passed since physical therapists started
working in Japan, and physical therapy has gradually evolved as a science. On the other hand,
Japanese society is facing a big change. We need to fully understand historical backgrounds in order toprovide physical therapy services responding to the needs of the times. However, we must rememberthat physical therapy is based on the “principles” or “foundations” our predecessors have developed.
Without these “principles” or “foundations,” we cannot respond to changing times nor promote any
development.
From the planning stage, the main purpose of this book was to provide those who wish to study
physical therapy science with a textbook for beginners. Thus, this book is intended to help beginners
in physical therapy properly understand the “Principles of Physical Therapy” and establish afoundation to pass on their knowledge to the next generation of physical therapists.
Physical therapy was introduced to Japan in 1965 when the “Physical Therapists and Occupational
Therapists Act” (Law No. 137) was enacted; the objective of this Act is to contribute to the spread anddevelopment of medical habilitation and rehabilitation mainly introduced from Europe and America,
and this Act is characterized by its incorporation of patients with motor dysfunction because
therapeutic exercise is also included in the definition of physical therapy under this Act. Physicaltherapy was originally called electrophysical agents, utilizing resources such as physical energy innature, and it can also be said that the original physical therapy retained traces of ancient times,
including Hippocrates and the age of oriental medicine, when it was used as one of the treatment
options especially for “pain or peripheral nerve injury and circulation.” In those times, physicaltherapy was called aftertreatment or physics.
The Act enacted in 1965 was intended to extract challenges such as pathological conditions,
symptoms, and activities of daily living (ADL) on the basis of the assessment of physical therapy forspecific disorders or diseases, and treatment plans were prepared to deal with these challenges as
short- and long-term treatment goals. Electrophysical agents mainly used in physical therapy at the
beginning are still utilized today alone or in combination with other methods, and we should not makelight of them because they are conservative therapeutic approaches supporting modern medicine,including medicine and pharmacy, that has evolved since the 19th century and one of the therapeutic
approaches for the activation of natural healing.
Physical therapy is likely to be hidden behind rehabilitation, making it difficult to understand andrecognize the way it works, and it is one of the reasons why we planned to publish this book.
Rehabilitation originally means a comprehensive system incorporating techniques and social andoccupational measures to ensure that patients/clients can live alone as a human being regardless of
their disabilities, and it does not solely refer to functional recovery training for movement disorder aspart of medical rehabilitation (rehabilitation healthcare). Therefore, health professionals should
consciously use the right words (i.e., physical therapy, occupational therapy, speech-language-hearing
therapy) when providing individual treatment.
As disease structure changes, the scope of work of physical therapists also expands to include
independence support in acute, recovery, and living phases and improvement of living environment aswell as functioning approaches to physically handicapped children and people, and besides these
services, physical therapists must be engaged in activities in areas, including health promotion,

01
Introductory Chapter

prevention, health activities, and community rehabilitation management. Since the enactment of the
Physical Therapists Act, Japan has experienced great changes in healthcare systems due to the comingof a super-aging society and changes in disease structure, and there is a growing need to provide
healthcare and nursing care in familiar communities. We live in an age where the creation of
publications intended to increase awareness among beginners and members of the Japanese Physical
Therapy Association about the nature of physical therapists who respond to these changing times in atimely manner helps the people radically transform their image and understanding of physical therapy(therapists/science).

Introductory
Chapter

As mentioned above, physical therapists are primarily responsible for therapeutic exercise for physicalmotor dysfunction. In 2015, the American College of Sports Medicine published a thesis “Exercise as
Medicine,” summarizing the accumulated evidence of therapeutic exercise. The thesis deals with theaccumulated evidence of therapeutic exercise for 26 chronic diseases that physical therapists often
encounter, stating that exercise is an extremely effective method for reducing the risk of death andplays a big role in the “extension of healthy life expectancy.” The thesis, focusing on the future of
preventive physical therapy based on public health, suggests the importance of developing physicaltherapy from primary to secondary and to tertiary prevention. We also need to direct our attention to
the development of physical therapy based on public health as seen in foreign countries.
Based on the above, we decided to re-evaluate the future prospects of physical therapists on the basisof World Physiotherapy (name changed). To encourage teachers to incorporate the “Principles ofPhysical Therapy” in the class of Introduction to Physical Therapy, we put the basic idea of physicaltherapy in order, edited it as the “Principles of Physical Therapy,” organized information to summarize
development (paradigm shift) of physical therapists from a public health standpoint, including
community-based integrated care, disease prevention, health promotion, and school health, andincorporated the necessary information to prepare the textbook. We would like you to use it as asupplementary textbook in physical therapist training schools.
There are jobs that need to be done by physical therapists in different countries and different times.
What kind of age do we live in? What are the factors behind changes in social circumstances andsocial demands? What type of topic should we consider and how should we carry out our duties? Wehope that beginners and physical therapists will read this book and have the opportunity to share theirideas with us.

1.

Current Status of Japanese Society and Future Challenges

1)

Society from a demographic point of view

Japan has undergone economic development and how will its demographic structure change in the
future? How will Japan at the forefront of aging societies address its relationship with Asian countries?
These questions attract attention.
A population pyramid (Figure 1) visualizes the characteristics of demographic structure and isgenerally divided into five categories. The most primitive type of population pyramid is a pyramid
shape and as civilization advances, it will change to the shape of a temple bell, an urn, a star, or a
gourd. Japan had a pyramid-shaped age structure in the 1930s and a gourd-shaped structure in 1985,
and now, its population pyramid is “similar to a gourd,” indicating the “declining birthrate and aging”
population.
Figure 2 shows trends in aging population and projection for the future made public on the website ofCabinet Office. In a society with a decreasing population, the population continues to decrease because
deaths exceed births, and Japan is thought to have entered it in the latter half of the 2000s or after the
2010s.

02
Introductory Chapter As the birthrate declines and the population ages, the Japanese population pyramid (age structure) has changed
from a “Mt. Fuji” shape to the current shape of a “temple bell.” It will change to the shape of an “urn” due to acontinuing decline in the birthrate, and Japan will face an issue of decreased workforce in a high-mortality
society in the future.
Males

FemalesPopulation (10,000 people)

Source: 1920 to 2010, Estimated Population, Population Census of Japan; 2011 or later, "Population
Projections for Japan (projected in January 2012)"

Females

FemalesMales

Low fertility variant projection

Low fertility variant projection

Medium fertility variant projection

Medium fertility variant projection

High fertility variant projection

Population (10,000 people)

National Institute of Populationand Social Security Research

Population (10,000 people)

National Institute of Populationand Social Security Research

Source: 1920 to 2010, Estimated Population, Population Census of Japan; 2011 or later, "Population
Projections for Japan (projected in January 2012)"

Males

Females

Introductory
Chapter

Males

High fertility variant projection

National Institute of Populationand Social Security Research

National Institute of Populationand Social Security Research

Population (10,000 people)

Source: 1920 to 2010, Estimated Population, Population Census of Japan; 2011 or later, "Population
Projections for Japan (projected in January 2012)"

Source: 1920 to 2010, Estimated Population, Population Census of Japan; 2011 or later, "Population
Projections for Japan (projected in January 2012)"

Figure 1 Changes in Population Pyramids and Projection for the Future
Actual figures(10,000 people)

Projected figures
Total
population

Percentage of the elderly (theproportion of the population aged
65 and over) (projected in 2017)

Percentage of population aged
15 to 64 to support those aged
65 and over(Year)
75 years old
and over65-74 years

15-64 years

0-14 years

Unknown

Source: Rates of ageing in the bar graph and the solid line are based on data in “Population Census of Japan” (Ministry of Internal Affairs and Communications)for and before 2015, “Population Estimates (fixed value as of October 1, 2018)” (Ministry of Internal Affairs and Communications), for 2018, and“Population Projection for Japan: 2016-2065 (2017)” (National Institute of Population and Social Security Research) on the assumption that birth anddeath rates are ranked medium for and after 2020.
(Note 1) The population by age group after 2018 is based on the Statistical Bureau of the Ministry of Internal Affairs and Communications “Population census of
the census age and nationality uncertainty (reference table)” of 2015. Since it is calculated based on the population who were categorized as the “ageunknown”, age unknown does not exist. In calculating the rates of ageing from 1950 to 2015, the “age unknown” is excluded from the denominator.
(Note 2) 136 foreigners (55 males, 81 females) aged 70 and over in 1950 and 23,328 people (8,090 males, 15,238 females) aged 70 and over in 1955 in
Okinawa prefecture are excluded from the results by age groups.
(Note 3) Future Population Estimates projects future trends based on the demographic data obtained before a certain time. Deviation between the future
estimates and actual result is likely to occur due to structural changes and other reasons occurring after the standard time, and the Future Population
Estimates regularly reviews the estimation based on such results.

Figure 2 Trends in Ageing Population and Projection for the Future
Source: Chapter 1 Situation of the Ageing Population, Cabinet Office “Annual Report on the Ageing Society
FY2019” (Summary)

The Japanese population will decline to about 93 million (73% of the population in 2019) by 2060.
This phenomenon may have two big implications: First, the total working-age population decreases
and second, the proportion of the old-old increases. The total working-age population (15 to 65 years
old) started to decrease in the mid-1990s, declined to about 86 million in 2000, and is expected todecrease to about 69 million by 2030 and about 48 million by 2060. As the working-age population
03
Introductory Chapter

decreases, improvement of working environments and health and productivity management will be
issues in the future.
As for the elderly population (aged 65 and over), the proportion of the old-old will increase. The
elderly population was about 22 million in 2000 and will remain almost flat (about 36 to 38 million) inand after 2020. The rate of aging will increase on a long-term basis with decreasing population size. It
is inevitable that we will have an increased need for healthcare and continuing care.

2)

Changes in disease structure

Introductory
Chapter“Infections,” such as tuberculosis, were predominant in the disease structure of Japan after the war.
However, tuberculosis mortality sharply decreased in the 1950s and adult diseases (designed as agingrelated diseases after 1957), including hypertension, stroke, diabetes, and heart disease, tookprecedence over other illnesses in the Japanese disease structure. The name of the “adult diseases” waschanged to “lifestyle diseases” in and after 1996 (the Council of Public Health) and finding methods
for preventing lifestyle diseases is an important policy challenge. In particular, diseases such as cancer,
heart disease, and stroke account for about 60% of all deaths. We should improve our lifestyles toprevent diseases and extend a healthy lifespan (healthy life expectancy), which can be used as a future
guideline.
For health measures, measures to promote the health of the people of Japan (national healthimprovement measures) have been taken three times every 10 years. The third set of measures,“Health Japan 21,” is unique in that discussions were held to determine the measures required toprolong the period during which people can live a healthy life with good body function, or “healthy
life expectancy,” in a “super-aging society.” To extend the healthy life expectancy, numerical targets
are established by incorporating specific scientific evidence for target health management in “primaryprevention,” encouraging individuals to actively improve their lifestyles for prophylactic purposes.
Various measures have been implemented since 2000 and since 2008, Japanese people aged 40 andover have been obliged to receive a “metabolic syndrome-specific health checkup and healthguidance” that is provided on the basis of shared responsibilities among the national, local
governments, and insurers such as private businesses (as we say, “metabolic syndrome screening”). To
disseminate the advanced measures for prevention and health improvement taken by local
governments, companies, or insurers all over the country, “NIPPON KENKO KAIGI” was organizedon July 10, 2015, and specific numerical targets for 2020 were set. Verification in 2019 demonstrated
great improvement in eight targets in terms of the degree of attainment and the achievement of two
new targets.

04
Introductory Chapter

Cerebrovascular diseases

Heart diseases(excluding hypertensive heart diseases)

Senility
Cerebrovascular diseases
Pneumonia

Senility

Pneumonia

Introductory
ChapterMortality (per 100,000 people)

Malignant neoplasms<tumor>Unexpected accidents
SuicideLiver diseases
Tuberculosis

1947

'55

'65

'75

'85

'90

'95

2005

'15 '1Figure 3 Trends in Mortality (per 100,000 people) for Leading Causes of Death
Source: Ministry of Health, Labour and Welfare “Monthly Report Summary of Vital Statistics (annual total; roughfigures) (2018)”

Unlike the current process of an aging society where young people are becoming older slowly, elderly
people will get older and the proportion of the old-old will suddenly increase in 2030. Geriatricsyndromes often experienced by the old-old may interfere with returning home from acute hospitals
and medical establishments with facilities for chronic inpatients. This demonstrates the fact that
healthcare is inseparably related to nursing care. Geriatric syndromes refer to a series of symptoms
caused by a variety of factors often observed in the elderly, and they require treatment and nursing
care or care at the same time. Based on the characteristics of signs and symptoms, age, and otherfactors, geriatric syndromes are classified into three categories: [1] Acute disease/symptom; [2]Chronic disease/symptom; and [3] Disuse syndrome. Recent studies have shown that people with these“geriatric syndromes” such as debility, fall, and dementia, which are not illnesses, account for 40% of
those requiring nursing care. The disease structure of geriatric syndromes basically consists of thesame three categories in home care and health facilities for the elderly, and the frequency of geriatricsyndromes that the old-old often develop is high in younger elderly populations aged 70 years innursing care facilities. Early detection and intervention of geriatric syndromes through health checkups
may be useful in preventing these symptoms, and proper evaluation of elderly functioning on a timely
basis may also help figure out a good way to prevent diseases or conditions in elderly people that
require nursing care.

3)

Issues of healthcare and nursing care

Japan is the most aging society in the world. The “baby boomers” born during the first baby boom
(from 1947 to 1949) after the war will reach the age of the old-old, raising concerns about a sudden
increase in social security costs for healthcare and nursing care; this issue is referred to as the “2025problem,” and “community-based integrated care system” is one of the policies primarily aiming to
reduce increased social security costs. Thoughts (philosophy) on healthcare and nursing care were
presented in the final report of the “National Commission on Social Security,” with meetings held
between January and November 2008. Then, the “National Council on Social Security System
Reform” took over the thoughts on healthcare and nursing care in 2013, and various specific measures

05
Introductory Chapter

were implemented to establish the “community-based integrated care system” until 2025. The“National Council on Social Security System Reform” spent 60% of their time discussing integrated
provision of healthcare and nursing care (Figure 4). The purpose of these reforms starting in 2008 is tomake better healthcare accessible to patients/clients in an appropriate location irrespective of theirplace of residence.

4)

Ideal society Japan is trying to build in the 21st century

Introductory
Chapter

How will our aging society (society with a declining birthrate) change in the next 5 (2025), 15 (2035),
and 25 years (2045)? There are several factors that account for a post-aging society (i.e., demographic
trends, changes in disease structures, requests from the elderly due to aging, changes in circumstances
surrounding the elderly and people with participation restrictions, regional and community
development). Considering the above comprehensively, it is important for healthcare professionals
involved in health, healthcare, and welfare to take the lead in “realizing a community-based cohesivesociety” where the elderly, people with participation restrictions, and healthy individuals live together
for the creation of a society encouraging national participation that Japan is trying to build in the 21st
century. As urgent issues, we should again discuss and carefully consider what social contribution
physical therapists, healthcare staff members, should make and a plan of action in a post-aging society
by taking into consideration the realization of a community-based cohesive society.
Integrated implementation of public health programs with preventive health care for the elderly (image of
integrated implementation in municipalities)
Integrally implemented by municipalities[4] Identify elderly people who facevarious challenges and whose healthstatus is unknown because they stay Analysis of healthcare andnursing care data
at home all the time and refer them[2] Centralized control of information about elderly individuals
to healthcare services throughas healthcare and nursing careoutreach support and other services. [3] such
Coordination and analysis of community health issues
All-Japan Federation of National Health
Insurance Organization and National
Health Insurance Organization prepare
analysis manuals and provide training tomunicipal officers.

HealthHealthHealthinsurance
insurance Care needs
claims for checkups claims for assessment
nursing carehealthcare

Questionnaires forthe oldold

Public health programs

The elderly* Provide support
to all elderly
people who are
at risk of frailty[1] The municipality assigns the following healthprofessionals:• Public health nurses and other personnel in themunicipality in order to coordinate the entire project,
develop and coordinate plans, and perform analysis;and• Public health nurses, registered dietitians, dental
hygienists and other personnel in daily living areas inorder to provide individual support to the elderly andvisit places that they are going on a regular basis.
Costs paid by the association of public
services set up to cover several local
government areas(Insurance premiums plus a special grantfrom the national government)
Costs (business expenses foroutsourced projects) needed for:
 Assignment of health professionals forplanning, coordination, analysis, etc.
 Assignment of health professionals in
daily living area

Preventive health care and[5] Link National Health Insurance
other programswith public health programs in a
medical care system for elderly in
Improvement of
the latter stage of life
functioning
Prevention of
disease and its[9] Greatly expand facilities
aggravation
the elderly can visit on aregular basis in[6] Take measures [7] Health professionals
cooperation with private
focusing on
actively visit places
medical institutions, andfrailty, includingthat elderly people
utilize a point system associalare going on aan incentive to individuals[10]
Expandparticipation
regular basis
opportunities forresidents to take[11] If active support is provided to places that thethe initiative inelderly can visit on a regular basis from a healthtaking part incare point of view,
activities
Primary care
physicians, etc.
[8] Encourage the elderly to regularly visit facilities
and provide advice on the entire project• The elderly will be able to have a health consultation
with specialists in a place that they can visit on aregular basis or receive community-based support;• The elderly will be able to carry out attractive
activities to promote awareness of daily healthimprovement, including their bases such as a
shopping center; and• Frail people will be able to receive appropriate
healthcare services.

For integrated implementation in all municipalities by FY2024 (process table for a healthy life expectancy extension plan)
https://www.mhlw.go.jp/content/12401000/000551951.pdf(Source: Website of Division of the Health Services System for the Elderly, Health Insurance Bureau, Ministry of Health, Labour and Welfare)

Figure 4 Integrated Implementation of Public Health Programs with Preventive Health Care for the
Elderly

06
Introductory Chapter

2.

New Area of Physical Therapy Required to Meet Social
Demands

Introductory
Chapter

The Director of the Medical Professions Division, Health Policy Bureau, Ministry of Health, Labourand Welfare sent a notification of Use of the term ‘physical therapist’ to Directors of Prefectural
Medical Affairs Departments (Bureaus) on November 27, 2013, and the notification states that
“Physical therapists sometimes carry out duties that are not considered assistance with medical
treatment, such as giving guidance on fall prevention, for people without physical disabilities in abusiness promoting preventive health care for the elderly, and it is perfectly acceptable to use the term
‘physical therapist’ even when they perform duties other than physical therapy as stated above” andthat “Physical therapists carrying out duties that are not considered assistance with medical treatment
need no instructions from a doctor.” It can be interpreted as expectations for physical therapists who
would take an active part in not only preventive health care for the elderly but also in the preventive
field.
Duties that are not considered assistance with medical treatment fall under the category of preventive
physical therapy, potentially expanding the scope of physical therapy, and the time has come to collect
more evidence. According to a report from the Japanese Physical Therapy Association’s Special
Committee for International Verification (May 2013), the target population of physical therapy canalso be interpreted as “people who have body function and structure disorders” and “people may havesuch disorders” from a wider point of view and with International Classification of Functioning,
Disability and Health (ICF) in mind. The purpose of physical therapy is to “increase activities,
improve functioning, and promote health to support social participation,” and according to the report,
physical therapy options may also include “evaluation of functioning that restricts a patient’s/client’s
activities (impairments, activity limitations, and participation restrictions), provision of therapeutic
exercise, electrophysical agents, and orthotic therapy, practice of ADLs, and provision of guidance andimprovement of environmental factors as needed to maintain and improve ADLs.” The definition ofphysical therapy and physical therapist has been evaluated in specified regulations and in relation to
supply and demand of physical therapists, suggesting that physical therapists are expected to expand
their activities.
Public health aims to prevent disease in a community through organized social effort and prevent
diseases and maintain the health of local residents. The Chartered Society of Physiotherapy, a pioneerin public health studies, is undertaking four big projects: Treatment of bone and joint diseases,
management of nervous system and cardiorespiratory diseases, challenges to physical therapy, anddissemination and improvement of health education. We are entering an era in which lifestyles are
improved to prevent disease or body impairment and structure deformation or displacement rather thantreating disease after its onset, and physical therapists have also expanded their scope of activity froma public health point of view.
Preventive physical therapy is an academic discipline that studies body activities, including preventionof the onset and recurrence of diseases and geriatric syndromes to ensure that Japanese people can“participate in society” for a long time. Community-based physical therapy is an academic disciplinethat studies scientific and practical activities in the field of health and healthcare, primarily from thestandpoint of livelihood support, to ensure that the elderly and people with participation restrictions
and their families can continue to live in their familiar communities. Furthermore, the primaryobjective of industrial physical therapy relating to workers’ health measures is to prevent work-related
accidents and promote the health of workers.
Japan is improving community infrastructure with a view to realizing a community-based cohesivesociety. The role of physical therapists in disease treatment has developed in conjunction with the ideaof post-war habilitation and rehabilitation. Due to the accumulated data on disease prevention and07
Introductory Chapter

therapeutic effects, we have entered a new stage in which health also becomes a subject in the field ofhealth, healthcare, and welfare to encourage Japanese people to participate in society in the 21st
century. The dissemination and improvement of health education among Japanese people (healthliteracy) is one of the four big projects for public health, and it is also a future challenge to physicaltherapists specialized in exercise and physical activity. The future value of physical therapists will be
determined by whether they demonstrate evidence to ensure health literacy and aim in practice tomake their activities vital to Japanese people.

3.

Past, Present, and Future of Physical Therapists

Introductory
Chapter

Habilitation and rehabilitation healthcare were introduced as the third kind of healthcare. Since theenactment of the “Physical Therapists and Occupational Therapists Act” (Law No. 137) in 1965, bothterms have been used frequently. The director of the hospital for which the author (Handa) worked
around 1975 said, “You do not have to think about earnings at this department. You just try hard to
make patients/clients understand their conditions and rehabilitate them.” The author cannot forget thewords. At that time, the term “plateau” was often used and whether or not the patient/client hadreached a “plateau” was one of the subjects for discussion at the meeting. What was more important tous was holding a meeting with the patient/client and his/her family after he/she was found to havereached a “plateau.” During the meeting, the doctor declared that the patient/client was “not expected
to make any further recovery but his/her social abilities would improve greatly,” and the meeting often
turned into a shambles. Physical therapists changed their perspective from “Curing patients/clients” to“Encouraging patients/clients to live as people with participation restrictions.”
In 1971, the then Ministry of Health and Welfare declared that “it was necessary to strengthen
rehabilitation healthcare and nursing care in preparation for a future aging society.” After that,rehabilitation fees increased steadily because the Japanese government increased their medical fees asa matter of policy. As a result, many hospitals and clinics suddenly started to hire more physicaltherapists. Training institutions also increased rapidly to meet employment needs. Naturally, newly
established hospitals and clinics sought profitability and physical therapists at that time were in adilemma between “profitability” and “principles.” When the author met old acquainted physicaltherapists in a congress, we used to complain a lot about losing our principles. Somehow nocomplaints were heard. Looking back, I can see that it was still good to make a complaint.
The nursing-care insurance system introduced in 2000 is indispensable to the current aging society.
However, the introduction of this nursing-care insurance system greatly affects physical therapists.
Whenever the health insurance and nursing-care insurance are revised, “linking” of both types of
insurance has been strongly suggested to control the nation’s finances. The author suspects that
because of this “linkage,” physical therapists keep giving the same physical therapy aimlessly
although the medical insurance was changed to the nursing-care insurance. Physical therapists should
evaluate “users” properly and provide physical therapy according to the purpose.
Unlike in Europe and America, physical therapy is provided in parallel with occupational therapy fromthe acute phase for habilitation and rehabilitation healthcare in Japan. Every time the author (Handa)
receives training in hospitals in Western countries, he feels the difference. “Physical therapists become
occupational therapists.” “Occupational therapists become physical therapists.” It is quite natural for
health professionals to clarify this issue. If the origin of physical therapists lies in the law, physicaltherapy options are therapeutic exercise and electrophysical agents, and the purpose of physicaltherapy is to restore the abilities of basic activities. Physical therapists must scientifically verify themby themselves. As a matter of course, if physical therapists are also involved in “health improvement,”“prevention,” and other activities, their usefulness needs to be demonstrated scientifically. The aging

08
Introductory Chapter

society causing the increased demand for physical therapists will come to an end in the near future andwe need to consider the future of physical therapists now.
(Kazuto Handa, Kazuo Kurosawa, Akira Kimura, Yasuyuki Takakura, Tadahiro Murakami, Takayoshi
Saito, Keisuke Suzuki)

Introductory
Chapter

References
1)
Kojien, 7th edition, Iwanami Shuppan
2)
Changes in Population Pyramids and Projection for the Future
https://www.jeiu.or.jp/anshin/topic/images/2017/20171023-140948.pdf
3)Trends in Ageing Population and Projection for the Future
https://www8.cao.go.jp/kourei/whitepaper/w-2019/html/gaiyou/s1_1.html
4)
Japan Health Promotion & Fitness Foundation http://www.kenkounippon21.gr.jp/
5)
NIPPON KENKO KAIGI https://kenkokaigi.jp/about/index.html
6)
Toba K: Geriatric Syndromes and Comprehensive Geriatric Assessment. The Journal of theJapanese Society of Internal Medicine, 98(3): 101-106, 20097)
Kenjoh Y: Integrated Reform of Healthcare and Nursing Care and Finance. Keio University
Press, 2015
8)
B.K. Pedersen, B Saltin: Exercise as medicine - Evidence for prescribing exercise as therapy
in 26 different chronic diseases. Scandinavian Journal of Medicine and Science in Sports, 25
Suppl 3(Suppl 3):1-72, 2015
9)
Report from the Japanese Physical Therapy Association’s Special Committee for International
Verification: International Comparison of the Legal Position of Physical Therapists
http://www.japanpt.or.jp/upload/japanpt/obj/files/international/International_report_compariso
n2.pdf09
Introductory Chapter

Chapter 1
History of Physical Therapy (recent times)
History and Definition of Physical Therapy (physical therapy for disease,physical therapy for functioning) What you will learn in this chapter
You will learn the definition and roles of physical therapy, looking back on the history ofphysical therapy (therapist) in the US, UK, and Australia.

Chapter 1

When you study the definition, roles, and other aspects of physical therapy in Japan, it
is very important for you to learn the history of physical therapy in the overseas
countries that are role models for us and the history of a physical therapist’s work.
This will lead to knowing yourself, and you will learn the position of physical therapy(therapist) in your country. An American teacher of physical therapy who was involved in
education in Japan also gave us valuable feedback about expectations for students andyoung physical therapists.

1.

History, Definition, and Roles of Physical Therapy in Representative
Countries

1)

History and definition of physical therapy in the US

The American Physical Therapy Association (APTA) stipulates that entry-level (new graduate level)
physical therapists should have a Bachelor’s degree and complete a three-year specialized course. The
APTA gives the following vision statement for the physical therapy profession after 2020 when almost
all new graduates who have received education based on this new standard enter the workforce:
Physical therapy is provided by physical therapists who are doctors of physical therapy, recognized byconsumers and other healthcare professionals as practitioners of choice to whom consumers havedirect access for the diagnosis of impairments, activity limitations, participation restrictions, andenvironmental barriers related to people’s function, activity, and health. We will trace the historicalbackground to this vision and history of education.
We cannot explain the history of rehabilitation in the US without referring to war. Tracing backhistory, techniques in military medicine used to treat wounded soldiers during the First World War(1914 to 1918) may form a foundation for current physical therapy. In 1914, Reed College in Portland,
Oregon started to provide education for Reconstruction Aids, which may also correspond to current
physical therapist (PT). Women’s Physical Therapeutic Association, which may be an umbrella groupof the current APTA, was established by only 274 women in 1921. At that time, the term PT did not
become a household word. Mary McMillan was elected the first president. The Mary McMillan Award
that the APTA gives an excellent PT was named after Mary McMillan. In 1922, the first General
Assembly was held in New York, with an attendance of 63 Reconstruction Aids, and the name of the
Women’s Physical Therapeutic Association was changed to American Physiotherapy Association(APA). From then onward, men were also allowed to join the APA. At that time, a polio epidemic
spread in the US and the development of quantitative methods for evaluating the degree of polioinduced paralysis and therapeutics was an urgent issue. R. W. Lovett and his colleagues devised
muscle strength testing using gravity and resistance and W. Wright published a book on manual
10
Chapter 1 History of Physical Therapy (recent times)

From the beginning of its foundation, the APA focused on establishing standards for PT education andthe medical department in some universities/colleges started to provide courses for physical therapy. In
1930, the standardized curriculum was approved by the American Medical Association (AMA). The
initial curriculum included massage, therapeutic exercise, electropathy, and hydrotherapy, reflecting
treatment at that time, and other methods, such as muscle strengthening and deformity correction, wereadded later. The reason behind this is the polio pandemic, which may also be the reason that various
therapeutics were devised. The Social Security Act was enacted in 1935, and F. D. Roosevelt createdthe National Foundation for Infantile Paralysis in 1938 and expanded educational facilities andscholarship funds to respond to the shortage of trained professionals. In 1942, the US joined theSecond World War (1940 to 1944) and the expansion of social security coverage, including
systematization of military medicine and rehabilitation of wounded soldiers, became an urgent social
issue again. Then, rehabilitation medicine was considered the third type of medicine by H. Rusk,
known as the “father of rehabilitation medicine,” and his colleagues. Basic methods, including
therapeutic exercise, range of motion testing, and manual muscle strength testing constituting key
elements of physical therapy, were established especially between the 1930s and 1940s.
The APA established the House of Delegates in 1944, and M. L. Wagner was elected the firstpresident. The House of Delegates in 1947 decided to change the name of the APA to the American
Physical Therapy Association (APTA) and a journal was to be published as a monthly publication. By
the end of the 1940s, there were 31 training institutions and among them, 19 offered a bachelor’s
degree program and four provided a master’s degree program. The number of PTs sharply increased toover 8,000 between 1940 and 1950. Moreover, it increased to over 15,000 in 1960 and there were 52
training programs as well. In 1969, physical therapist assistants graduated from the first physicaltherapist assistant programs.
In 1976, the first Combined Sections Meeting (CSM; a national convention) was held in Washington
D.C., with an attendance of over 1,000 members from all over America (over 17,000 members in2018). In 1982, C. Worthingham was selected for the first fellowship program. It is now a great honor
for scientists to be selected as the Catherine Worthingham Fellow of the APTA. In 1979, the APTA
came up with a course of action to raise the level of PT education from bachelor to master, leading to asudden increase in master training programs across America, and bachelor and master training
programs coexisted in the 1990s.
In 2003, guidelines for physical therapist education were adopted at the 15th General Meeting of theWorld Confederation for Physical Therapy (WCPT). These Guidelines serve as a standard for physicaltherapist education in member nations of the WCPT. Based on these Guidelines, the APTA also
reviewed the education standards.

11
Chapter 1 History of Physical Therapy (recent times)

Chapter 1

muscle strength testing in 1928. The systematized version of this original method is the widely-used
Daniels’s manual muscle strength testing. This indicates the degree of freedom of physical activities
under the force of gravity and can be a very reasonable evaluation method of QOL for daily living andthe quantity and quality of support and assistance. The method of applying resistance corresponds to amuscle strengthening method and it may be deeply involved in the fundamentals of physical therapy.
This is why this approach is still widely used now. Likewise, Kendall, known for muscle strength
testing, and S. Brunnstrom, for evaluation of coordinated movement in spastic paralysis, played an
active part in roughly the same period.

1914-18
1914
1921
1922
1928
1930
1935
1938
1930-1940s
1944

Chapter 1

1947
1940s
1969
1976
1979
2003

Table 1 Abridged Chronology of Physical Therapy in the US
Techniques in military medicine used to treat wounded soldiers during the First WorldWar (physical therapy)
Start of education for Reconstruction Aids in Reed College (Portland, Oregon)
Formation of the Women’s Physical Therapeutic Association (umbrella group of the
APTA)
Holding of the first General Assembly (with an attendance of 63 Reconstruction Aids;
New York)
Name change to the American Physiotherapy Association (APA)
Publication of a book on manual muscle strength testing (W. Wright, et al.); a polio
epidemic in the US
Approval of the standardized curriculum of PT education by the American Medical
Association (AMA)
Enactment of the Social Security Act
National Foundation for Infantile Paralysis established by F. D. Roosevelt
Establishment of basic methods, including therapeutic exercise, range of motion
testing, and manual muscle strength testing
Establishment of the House of Delegates and election of M. L. Wagner as the firstpresident
Name change to the American Physical Therapy Association (APTA)
Training institutions increased to 31 (bachelor’s degree programs available in 19
institutions and master’s degree programs in four institutions)
Graduation from first PT assistant programs
The first Combined Sections Meeting (CSM; a national convention) in Washington
D.C.
The APTA announced their policy to raise the level of PT education from bachelor tomasterGuidelines for physical therapist education adopted at the 15th General Meeting of theWorld Confederation for Physical Therapy (WCPT)

Credits for the university/college curriculum in the US are recognized by a private accrediting agency.
Basically, this is not a government agency but it is to be recognized by the Federal Government (U.S.
Department of Education [USDE] and Council for Higher Education Accreditation [CHEA]). In
general, students who have graduated from an undergraduate course receive a bachelor’s degree, those
who have completed a master course receive a Master of Arts (MA) degree for the humanities course
and a Master of Science (MSc) degree for the science course, and those who have completed adoctoral program receive a doctorate in their chosen specialty, such as Doctor of Philosophy (Ph.D.).
At present, if you want to be a PT in the US, you should basically have a bachelor’s degree and mustcomplete a three-year course recognized by the Commission on Accreditation in Physical Therapy
Education (CAPTE). There are 256 courses available throughout the US. During these courses, you
should satisfy the education standards (entry level) specified by the WCPT and APTA. The curriculum
varies from course (university/college) to course, and education or research within the campus andclinical instruction account for about 80% and 20% (an average of 27.5 weeks) of the curriculum,
respectively. If you have completed the curriculum, you will obtain a Doctor of Physical Therapy(DPT). A person with any bachelor’s degree is eligible to enter this course and as the entrance
requirements, many universities/colleges stipulate that candidates should have completed prescribedcourses (mainly science courses such as biology and statistics) beforehand in bachelor’s programs.
Some universities/colleges require candidates to take GRE (Graduate Record Examination) or earn theminimum GPA (Grade Point Average) score. Furthermore, candidates may also need to work as avolunteer or watch PTs actually working in a hospital or clinic. The APTA declares that new students
will not be allowed to receive a Master of Physical Therapy (MPT) degree or a Master of Science inPhysical Therapy (MSPT) degree and that candidates who want to work as PTs must have a CAPTEaccredited degree and pass national and state examinations. The APTA has 68,968 members registered

12
Chapter 1 History of Physical Therapy (recent times)with the WCPT in 2019. PT has ranked high in a famous business magazine and is especially popularamong women.

2)

Changes in the roles of physical therapy in the US

To begin with, Japanese physical therapy (system) has been under the strong influence of the US.
Therefore, you can consider that basic roles of physical therapy do not differ greatly between Japanand the US. However, if you are actually involved in physical therapy, you will notice various
differences between the two countries.

Medicare is available for the elderly aged 65 and over and people with disabilities (such as disabled
people under the age of 65 who have diseases, including end-stage renal disease and amyotrophic
lateral sclerosis, or those who satisfy certain conditions). Nursing care is not covered by Medicare, andpeople covered by Medicare have to buy private nursing-care insurance; there is no public nursingcare insurance system like Japan. The rate of aging in the US was 14.1% in 2015 and 15.8% in 2020
and is expected to exceed 20% by 2040.
Medicaid is a medical assistance program that is available to low-income people, and there areconsiderable economic restrictions, such as income and assets, imposed on Medicaid candidates.
Insurance coverage for treatment depends on the type of contracted private insurance. Treatment ofserious diseases and rehabilitation are not covered by insurance, posing a big social problem. For thisreason, American insurance companies offer private nursing-care insurance and disease-specificinsurance (such as cancer insurance) systems. A survey in 2009 revealed that 93.4% of people aged 65
and over entered Medicare, and 59.0% of them bought private insurance at the same time. It is said
that informal care (provided by family members or volunteers) accounts for 90% or more of nursing
care of the elderly living in a community. This phenomenon may be unique to the US in which selfresponsibility is highly valued.
However, recently, the US government is adopting programs such as Program All-inclusive Care forElderly (PACE) that provide comprehensive support services in the community for individuals forwhom in home care is difficult, to keep them living at home even after the state certifies theiradmission to a nursing home for requiring nursing care, and respite care where care workers or
volunteers provide temporary care at night or on weekends.
Second, American physical therapists can provide medical care without a doctor’s prescription. Thus,
they can also start businesses. In Japan, no physical therapy is allowed to be provided without adoctor’s prescription under the Physical Therapists and Occupational Therapists Act. Althoughpermitted medical treatment varies more or less from state to state in the US, direct access to physicaltherapists is basically allowed without a doctor’s prescription across America (50 states and the Virgin
Islands of the United States). This was allowed first in some states in 1957 and later across America.
At present, 20 states allow unlimited direct access to physical therapy. There are some restrictions,such as treatment time or frequency, needle electromyogram, and spinal manipulation, in 27 states,
Washington D.C., and the Virgin Islands. Direct access to evaluation and fitness and wellness isallowed in the remaining three states, although a doctor’s prescription is required for some diseases.
As mentioned above, the US healthcare system basically relies heavily on private insurance.
Therefore, insurance companies managing insurance policies try to reduce healthcare costs from a
13
Chapter 1 History of Physical Therapy (recent times)

Chapter 1

First, no healthcare system (universal health insurance system) has been established as social
insurance in the US. Generally speaking, most workers take out private insurance and as part ofcompany’s welfare programs, a business owner often partially bears expenses to make a group of
workers buy insurance, whereas there are many uninsured people and many people cannot receive
adequate security depending on the type of insurance they take out. Medicare and Medicaid enacted in1965 are available as public medical insurance for the elderly.

managerial perspective. This is the reason that physical therapists are strongly encouraged to provide
therapy from a scientific point of view by creating a clinical path as a rational therapeutic strategy toshorten the duration of hospitalization, carrying out evidence-based physical therapy (EBPT), andclarifying outcomes.

3)

History and definition of physical therapy in the UK

The Chartered Society of Physiotherapy (CSP) defines physical therapy as helping restore themovement and function when someone is affected by injury, illness, or disability. Since the UK ismade up of four constituent parts, it does not have many standard documents on the history of physicaltherapy, and the CSP collects and organizes oral information in commemoration of the 70th
anniversary of the CSP.

Chapter 1

According to CSP’s records, the Society of Trained Masseuses created by four nurses in 1894 is theparent organization of the CSP. The purpose of the Society of Trained Masseuses was to establish
massage mainly used for relaxation as a medical technique, have the public recognize that massage
can be used as a medical intervention, and disseminate such ideas. In 1900, the legal and social statusof the Society of Trained Masseuses improved and became the Incorporated Society of Trained
Masseuses, achieving their original goals to some extent. In 1915, the first volume of the Society’s
journal “J. of the Incorporated Society of Trained Masseuses” was published. This journal became the
CSP journal “Physiotherapy” later.
Queen Mary became Patroness in 1916 and King George V Patron in 1920, and the Society’s namewas changed to the Chartered Society of Massage and Medical Gymnastics. As with the US, only
women were allowed to join the Society and men were permitted to take part in it from that year
onward.
Chartered Society means a society approved by the Royal Household and it corresponds to a
corporation in Japan.
In 1944, the Society adopted its present name, “The Chartered Society of Physiotherapy” in order torepresent the scope of its work, and also changed its journal name to “J. of the Chartered Society ofPhysiotherapy.” The title change took place in 1948 when it became Physiotherapy. In 1948, the UK
carried out major health care reforms to establish the National Health Service (NHS) and the British
were basically allowed to consult with physical therapists (called Physios in the UK) free of charge.
In 1949, the scope of a Physio’s activities expanded to include Domiciliary Physio, leading to anincreased demand for Physios (there were only 3,500 Physios at that time).
In 1951, the CSP started activities to establish the WCPT in cooperation with the APTA and the first(organization meeting) General Assembly was successfully held in London in 1953. In 1953, Queen
Elizabeth II became Patroness. In 1954, the number of Physios increased to 4,310.
In the 1950s, the polio pandemic also broke out in the UK and the application of physical therapy toother fields, such as respiratory therapy, and cooperation with other professions enhanced the namerecognition of Physios, making the public understand the meaning of their existence and need for theirservices.
In 1960, Professions Supplementary to Medicine Act established the Council for the Professions
Supplementary to Medicine (CPSM) to implement a system for Physios and other allied healthprofessions. In 1972, a Physio was elected Chair of Council for the first time. At that time, Physios
were mainly trained in vocational schools called Polytechnics and in 1976, Ulster College, Belfast
started the first undergraduate course in physical therapy in the UK.

14
Chapter 1 History of Physical Therapy (recent times)

1960
1972
1976
1977
1978
1981
1982
1987
1992
2001
2003
2004
2012
2013
2018
2019
2019

Table 2 Abridged Chronology of Physical Therapy in the UK
Establishment of the World Confederation for Physical Therapy (WCPT) (First General
Assembly)
The Professions Supplementary to Medicine Act established the Council for theProfessions Supplementary to Medicine (CPSM)
A Physio was elected Chair of Council for the first time
Ulster College, Belfast started an undergraduate course in physical therapy
The Department of Health established professional autonomy for Physios
Physios were legally allowed to treat patients under the NHS without prescription of a
medical doctor
North East London Polytechnic established an undergraduate course in physicaltherapy
Queen’s College in Glasgow established an undergraduate course in physical therapy
Abolition of an accreditation system for those who completed vocational schools
Physical therapy became an all graduate entry profession (three-year course in most
universities/colleges in the UK)
Established legal protection of the titles “Physiotherapy” or “Physical Therapy”
The CSP endorsed a professional doctorate for the first time (U. of Brighton)
Supplementary prescribing rights were extended to Physios by the Department of
HealthThe first step towards Independent Prescribing status was achieved
Physios were given the right to undertake full independent prescribing after suitabletraining (England)
Direct access to Physios was permitted for the management of musculoskeletal
disorders
Thirty of 51 British universities/colleges offering an undergraduate course provided amaster’s degree program
The CSP has 47,643 members (those registered with the WCPT) and about two-thirdsof Physios work at an NHS hospital

Chapter 1

1953

In 1977, the Department of Health established professional autonomy for Physios. The practice ofphysical therapy under the prescription of a medical doctor had been incorporated into the NHS, andPhysios were legally allowed to treat patients under the NHS without prescription of a medical doctor
in 1978. In 1979, a Physio gained a Ph.D. for the first time.
North East London Polytechnic and Queen’s College in Glasgow established an undergraduate coursein physical therapy in 1981 and 1982, respectively. In 1987, an accreditation system for those who hadcompleted various training courses (such as Polytechnic) was abolished and in 1992, physical therapy
became an all graduate entry profession (three-year course in most universities/colleges in the UK).
In 2001, the legal protection of the titles “Physiotherapy” or “Physical Therapy” was established bylegal amendment. In 2003, the CSP endorsed a professional doctorate for the first time (U. of
Brighton). In 2004, national healthcare services began under an agreement made with the NHS unions,and supplementary prescribing rights were extended to Physios by the Department of Health.
In 2012, the first step towards Independent Prescribing status was achieved and in England in 2013,
Physios were given the right to undertake full independent prescribing after suitable training. In 2018,
direct access to Physios was permitted for the management of musculoskeletal disorders. According to
CSP’s records in 2019, 30 of 51 British universities/colleges offering an undergraduate course (43 inEngland, three in Wales, four in Scotland, and one in Northern Ireland) provide a master’s degree
program. Most universities offer an M.Sc and a few universities provide an M.Phys. It seems that theU. of Brighton does not recruit students for their professional doctorate programs. The CSP has 47,643
members registered with the WCPT (World Physiotherapy from 2020) in 2019. About two-thirds ofPhysios work at an NHS hospital.

15
Chapter 1 History of Physical Therapy (recent times)

4)

Changes in the roles of physical therapy in the UK

As mentioned above, the National Health Service (NHS) institutionalized in 1948 provides
comprehensive healthcare, including preventive care and rehabilitation, free of charge as a general rulein the UK. The NHS financial resources are made up of taxes (80%), national insurance contributions(18%), and patients’ charges (1% or more). Test and surgical costs are free but patients bear partial
drugs costs.
The purpose of this system is to differentiate function between clinics and hospitals: Patients need tosee their general practitioner (GP) first, except in an emergency, and if they need advanced medicalcare, they can visit another hospital by GP referral.
The NHS had attracted attention as an excellent healthcare system; however, it had problems,
including a long waiting time for treatment, in the 1990s due to a lack of resources caused by medical
cost containment policies as well as advanced medicine. The NHS has strived to make anorganizational reform for problem-solving, reform the medical fee-for-service system, streamline
medical care, and improve services, although it still has many problems, such as a Physio’s work
environment and maintenance of the quality of services.
Chapter 1

In general, GPs often refer patients to Physios, and recently patients are allowed to see a Physio
directly without GP referral in more areas in the UK. If you want to find a Physio, you will be able tofind a private Physio near you using CSP’s Physio2u directory. Before selecting a Physio, you should
first ensure that the Physio is accredited by and registered with the Health and Care Professions
Council (HCPC). All Physios who can provide medical care under the NHS must be registered with
the HCPC. There is a consultation network of not only local Physios but also all private British
Physios.
Physical therapy provided during hospitalization is basically the same as that carried out by Japanesehospitals, and outpatients and home-visit rehabilitation are coordinated by GPs. GPs are also
responsible for health supervision or guidance not provided by Physios, for example, dietitian referralfor nutrition education. Physical therapy may be provided under personal health insurance and it varies
depending on the contract.
(Toshihiro Morinaga)

5)

History and definition of physical therapy in Australia(1) History of physical therapy
As with other nations with advanced physical therapy, the value of physical therapy as a profession inAustralia was enhanced during the First World War. Many doctors and ordinary people took a skepticalview of massage treatment but could not find any other good treatment during the early days of thewar. Since there was a growing need for physical rehabilitation after the war, the Australian Massage
Association (AMA) worked on a hot air bath, electrotherapy, and other treatment modalities. Active
exercise in a kinetotherapeutic bath was carried out instead of passive approaches around the end of
the war. Physical therapy and AMA became widely known by the end of 1918. Many practitioners andcitizens gradually became aware of the effects of massage, corrective exercise, and electrotherapy,
leading to the establishment of an educational system for physical therapists. After the Second World
War, there was a growing demand for physical therapists who could also manage patients with chronic
disease as next-generation of health professionals, and their efforts to respond to the expectations haveplayed a role in today’s development of physical therapy. Physical therapy in Australia owes its
development to many prominent figures.
Frederick T Hall, whose father is British and mother is Indian, made a great contribution to thedevelopment of the Australian AMA and Physical Therapy Association from the end of the 19th
century and before the First World War. He had a broad knowledge of specialties such as chemistry,

16
Chapter 1 History of Physical Therapy (recent times)pharmacy, and anatomy, and worked at healthcare service facilities in Melbourne. His knowledge of
massage and techniques brought him fame later, and even the Lord Mayor of London became his
customer. Many massage practitioners in those days treated patients without charge in charity hospitals
and performed massage in sports clubs. He started to teach medical students the importance ofphysical therapy in 1900, and a person who doubled as a practitioner and Dean of Dentistry at the
University of Melbourne recommended Hall as his/her successor. Hall became the most respectedmassage practitioner in Melbourne, implemented electrophysical agents, including electrotherapy,
exercise, manipulation, and other techniques, and devoted himself to the establishment anddevelopment of the AMA. In 1905, he planned to set up “Physical Therapy Association” and began a
project to establish an Australian joint association involving Melbourne, Sydney, and Adelaide the next
year. The joint association was recognized by the Commonwealth; Hall took office as a secretarygeneral and promptly held a monthly seminar in the above three cities. Then, he immediately createdan Australian curriculum, including anatomy, physiology, and pathology, updated it step-by-step, andobliged new members to take part in the educational programs; therefore, the association grew into a
professional organization that was far superior in level to its counterpart in the UK.
Chapter 1

In 1939, the AMA changed its name to Physiotherapy, which became the Australian Physiotherapy
Association (APA). In response to an increased need for treatment of wounded soldiers after the FirstWorld War and the polio epidemic, the standards of physical therapy were established by the Second
World War. With a growing demand for massage practitioners, many massage practitioners worked at
military hospitals during the Second World War and a new health profession was widely expected toemerge due to the polio epidemic and its treatment; we, physical therapists, responded to the
expectations.
In the early 1960s, a prominent figure emerged in the realm of manual therapy: Geoﬀrey D Maitland.
He played an active part worldwide as a pioneer in the establishment of manual assessment and atherapeutic system for patients with musculoskeletal disorders. He used his excellent skills to integratescientific knowledge, such as anatomy and pathology, into the clinical decision-making process andcontinued to perform international activities while teaching school in Australia. Meanwhile, he worked
hard to found Australian Manual Physical Therapy Association in 1966 and International Federation of
Orthopaedic Manipulative Therapy (current IFOMPT), a branch of the WCPT, in 1974. His great
achievements include helping Australia develop more theoretical and scientific manual physicaltherapy, coupled with the prosperity of clinical reasoning, and establish a world-leading position inthis area, greatly affecting many physical therapists.
After producing Maitland, Australia has turned out a great many leaders, including Gwendolen Jull,
Mark Jones, David Butler, Robert Elvey, Peter O’Sullivan, Paul Hodge, and Lorimer Moseley, andestablished itself as a nation with advanced physical therapy. Members of the AMA, consisting ofprofessionals who provide sophisticated clinical therapeutic techniques and have science-basedknowledge of these techniques, have built a reputation with an awareness of being a pillar of national
health and with a sense of responsibility, which has led to the establishment of Australia as a nation
with advanced physical therapy.
Next, let’s see how physical therapy in Australia has changed from an educational point of view. In
1906, School of Medicine, the University of Melbourne and the Royal Melbourne Hospital started thefirst two-year massage practitioner training course. The following year, Medical Electricity and
Gymnastics and the University of Sydney started a massage practitioner training course, and the year
after that, a Medical Gymnastics and Electricity-affiliated massage practitioner training course wasoffered in South Australia. After that, a three-year massage course was started in Melbourne in 1933and its curriculum focused on muscle re-education and clinical teaching to respond to the polio
epidemic at that time. In 1938, the University of Queensland solely offered a physical therapist
training course called “Diploma of Physico-therapy” for the first time, and started four-year
17
Chapter 1 History of Physical Therapy (recent times)

undergraduate education in 1950. Although other universities shifted their education to institutes oftechnology in the 1960s, the University of Queensland consistently provided education in a university
with the medical department and soon started a graduate course; Ms. Margaret Bullock was the firstAustralian physical therapist to obtain a Ph.D. in 1969.
What is noteworthy about the independent practice of physical therapists is that Australian physicaltherapists were the first in the world to be allowed to be first contact professionals under the changed
ethical principles in 1976. During the last three decades of the 20th century, the fields of study for
Ph.D. education expanded at several universities, and Australia successfully developed into a world
leader in physical therapy research.
In summary, as indicated by education in the medical department from the early days of physicaltherapist training and strict clinical teaching in royal and state hospitals, continuation of sophisticatedclinical techniques with a high level of scholarship helped Australia to secure a worldwide leadership
position in physical therapy. Table 3 shows the abridged chronology of physical therapy in Australia.

Chapter 1

1906
1907
1908
1918
1933
1938
1939
1940
1945
1950
1962
1969
1972
1976
1988
2006
2010
2018

Table 3 Abridged Chronology of Physical Therapy in Australia
Formation of the Australian Massage Association (AMA)The University of Melbourne and the Royal Melbourne Hospital-affiliated massage
Diploma course
A Medical Electricity and Gymnastics and the University of Sydney-affiliatedmassage Diploma course
A Medical Gymnastics and Electricity-affiliated massage practitioner training course
The effects of massage and subsequent physical therapy were demonstrated throughthe First World War
A three-year massage course started
A Physico-therapy Diploma course started (the University of Queensland)
The AMA was reorganized and changed to the Australian Physiotherapy Association(APA)
Physical therapy Diploma education was started in Melbourne
Physical therapy Diploma education was started by the University of Adelaide
The University of Queensland started four-year undergraduate education. Then, it
was provided in each state.
Queen Elizabeth II became Patroness (an official sponsor) of the APA
An Australian physical therapist gained a Ph.D. for the first time
A physical therapist was elected the APA’s president for the first time
Ethical principles were changed to make Australian physical therapists the first in theworld to be first contact professionals
The Physiotherapy Research Foundation was launched
Eighteen physical therapy entry-level programs in Australian universities
Children with disabilities gained access to Medicare funded physical therapy
The APA has over 26,000 members, 800 courses through career pathway framework(2) Definition of physical therapy
According to the Australian Standards for Physiotherapy, physical therapy is defined as follows:“Physical therapy includes prevention and diagnosis of movement disorder, and comprehensive
approaches for therapeutic management or function optimization in order to improve community
health and welfare from an individual or group perspective.” Physical therapists are also defined as“experts in the structure of the human body who cooperate with people of all ages in treating a wide
variety of health conditions, including sports injuries, musculoskeletal diseases, and chronic poor
health conditions, such as diabetes, obesity, osteoarthritis, and stroke. Physical therapists are involvedin the evaluation, diagnosis, planning, and management of patient care.”18
Chapter 1 History of Physical Therapy (recent times)

From the above, you can understand that Australian physical therapists, unlike those in Japan, arerecognized as total healthcare specialists responsible for prevention, evaluation, diagnosis, treatment
plans, and health supervision.

6)

Changes in the roles of physical therapy in Australia

As mentioned above, massage practitioners historically found their way into medicine and were also
engaged in care of athletes ahead of physical therapists, and musculoskeletal and sports physicaltherapy first became prosperous. Then, in addition to hydrotherapy, electrotherapy, and massage,
therapeutic exercise and manual therapy became mainstream physical therapy. Due to the polio
epidemic around 1940, development and sophistication of medical skills and technologies for spinal
cord and brain injuries caused by traffic accidents after the 1970s, and resulting lifetime extension, a
specialty in nervous system diseases, chronic diseases such as cardiovascular and respiratory diseases,
and internal disabilities was developed.

Chapter 1

Some of the earliest discussions on specialization arose out of a report on career structure undertaken
by a sub-committee of the Queensland branch of the APA in 1975. In 1979, a meeting was held
between representatives of the Australian College of Physiotherapists and the Federal Education
Committee of the APA. Based on surveys of the APA members, a proposal to organize the areas of
specialization and the process of clinical specialization in Australia was developed initially by aFederal Specialization Committee established in 1980. Subsequently, an Interim Committee forSpecialization was established in 1982, with representation from the College, the APA House ofDelegates, Schools of Physiotherapy, and APA National Special Groups, leading to the organization of
the world’s first specialization of physical therapy the next year. In 1990, the Interim Committee hadcompleted its task of developing the procedures for specialization and the responsibility for theprocess was handed over to the College. For specialists in Australia, there was one each incardiopulmonary physiotherapy, gerontological physiotherapy, and sports physiotherapy and six inmanipulative physiotherapy in 1996.
To be qualified as a specialist physical therapist, two-year practical experience as a physical therapist
in a professional area is required, and physical therapists who have taken a test and gained a certificate
of clinical specialization in physiotherapy are awarded a fellowship in a university or college andgiven the right to participate in educational and research activities. Applicants need to receive practicaltraining in areas such as cardiopulmonary medicine, men’s and women’s pelvic health, gerontology,
musculoskeletal system, neurology, occupational health, pediatrics, and sports. The APA encourages
physical therapists to obtain a qualification as a specialist physical therapist because it is advantageous
to them when finding a job in terms of salary and may help them take an active part both domesticallyand internationally.
There are also various types of practicing physical therapists in Australia: clinics with physicaltherapists alone still exist and there is certainly an increasing number of physical therapists who workwith an orthopedist or sports medicine specialist, in the Department of Neurology or pain clinic, orwith a dentist, podiatrist, speech therapist, psychotherapist, and trainer in the same clinic. From theabove, the clinical work that changes dynamically with the times is favorably connected with
university or college education, which is also the reason that Australia is a great power in physicaltherapy.
(Takashi Nakayama)

19
Chapter 1 History of Physical Therapy (recent times)

2.

History of Physical Therapy in Japan (law, definition, education,
roles)

1)

Birth of a physical therapist in Japan

Chapter 1

Half a century has passed since the birth of the profession of physical therapist, which came into beingin Japan in 1965 when the “Physical Therapists and Occupational Therapists Act” (Law No. 137) was
enacted. In 1966, the first state examination for physical and occupational therapists was conducted.
On July 17, 1966 (“Physical Therapy Day”; “Physical Therapy Week”), the Japanese Physical Therapy
Association (JPTA) was founded by 110 interested persons (15 university graduates) of 183 successful
candidates for the state examination. At the dawn of physical therapy introduction into the country,
persons providing services similar to medical treatment were permitted to take a state examination by“exceptional measures” if they had at least 5 years of work experience as healthcare workers inphysical therapy and participated in a training session for 300 hours. This measure was ended in 1974.
Since then, the JPTA has played an active part in contributing to the development of physical therapy
in Japan from various perspectives. The JPTA is now a big organization with over 130000 members,
the Japanese public has gradually recognized its own value in society and scholarship, and physicaltherapists have become one of the professions that play an important role in the health, healthcare, andwelfare of the people. I firmly believe that this is due to the cooperation and support of physicaltherapists who have been involved in the progress of physical therapy (studies) in Japan and the parties
concerned.
After graduating from the Health and Physical Education, Faculty of Education, Kagoshima
University in 1964, the author (Nara) taught at Hongo High School for one year and six months.
However, Japan lagged behind other nations in terms of physical therapy at that time and the author
went to America in 1967 to specialize in physical therapy at Loma Linda University (LLU). At thattime, Japanese universities/colleges required students to study general education subjects (common
education programs) for one year and six months after entrance, and they were not allowed to progressto specialist training unless they had studied the necessary subjects and earned credits. The LLU
permitted the author to use most of the credits in the general education subjects he earned at
Kagoshima University so that he could enter a specialist training program at the LLU. After graduatingfrom the LLU, the author was engaged in clinical practice for about one year and six months in Los
Angeles. The author was in the US for a total of 5 years and has been a member of the JPTA since his
return to Japan in 1971 when he was 29 years old.
The author has served on an executive board of the JPTA for a total of 30 years (16 years as a director
between 1973 and 1988 and 14 years as a president between 1989 and 2003). From then on, the author
has acted as an adviser for the JPTA until now. Based on his involvement in the JPTA, the author will
explain the topic chosen for this section in the “Principles of Physical Therapy” to be published by the
JPTA. The author hopes that this will be useful in building a better future for physical therapy.

2)

Acts of physical therapists and their proposed revision

As stated above, the act of physical therapists has also been considered a “sister bill” to that ofoccupational therapists, and except for some provisions, they are based on almost similar theories that
follow the basic principles very strictly. Before the enactment of this act, qualified persons involved inalternative medicine, such as a practitioner of acupuncture and moxibustion, a massage practitioner,
and a judo healing therapist, were engaged in physical therapy. Most of the patients/clients at that time
included wounded soldiers (the wounded) and patients with cerebral palsy, infantile paralysis, andrheumatoid arthritis, and physical therapy was provided by doctors at the Department of Orthopedics
and Department of Internal Physical Medicine. However, considering the development of
rehabilitation medicine in Europe and America, the Japanese government realized the necessity ofproviding formal education to train professions and made preparations for this purpose. In 1953, the20
Chapter 1 History of Physical Therapy (recent times)

3)

Necessity of radical revision of the Physical Therapists Act

The existing “Physical Therapists and Occupational Therapists Act” has a problem in that although
half a century has passed since its enactment, no radical revision has been made, except for specified
regulations (curricula) for both physical and occupational therapists. Japan’s political system is basedon the principle of the separation of the three powers (of judicature, legislation, and administration) for
ensuring the people’s lives in a democratic manner, and the political system itself is desirable.
However, in reality, a sense of sectionalism lacks the flexibility to develop a social system on the basisof the traditional Japanese culture, permitting Japanese people to avoid responsibility to execute areform and take their own side. In other words, they lack self-understanding to know for whom they
are doing their duties.
When it comes only to the Physical Therapists Act, physical therapy is defined in Article 2 as “Having
people with physical disabilities engage in therapeutic exercise or other exercise, and adding electricalstimulation, massages, heat, and other electrophysical modalities, mainly in order to restore abilities ofthe basic activities.” The definition that forms the core of professional education and duties remains
unchanged for half a century and no longer corresponds to the current reality of physical therapy, andit needs to be revised immediately. When a new law is enacted, it is impossible for the parties
concerned to be involved in the formulation of the law and it is natural that the law is discussed andestablished by a committee of government officials from the relevant ministries and agencies andexperts. Despite all of that, the author firmly believes that the Physical Therapists Act can be revised
radically in light of the philosophy and principle statements as professionals specified in the present
articles of association of the JPTA.
Speaking as the former president of the JPTA, the author (Nara) advocates using the following
definition of physical therapy as per the International Classification of Functioning, Disability and
Health (ICF) revised in 2001: “Physical therapy is defined as the treatment of people who have bodyfunction and structure disorders using exercise, therapeutic exercise, manual therapeutic approaches
and physical interventions, such as electricity and heat, to help them recover from their disorders,reverse damage, increase activities, improve functioning, promote health, including prevention, andsupport social participation.” According to the ICF, physical therapy is defined as interventions for
impairments in all patients/clients with disorders or illness and disease or conditions such as damage,
dysfunction, disorders, or structure displacement and deformation as needed to support activities andparticipation. The Japanese Association of Occupational Therapists has created its own definition,
which is not incorporated into the legal definition.
21
Chapter 1 History of Physical Therapy (recent times)

Chapter 1

Department of Health and Nursing was established in the Faculty of Medicine, the University ofTokyo, and there was a plan to add the Department of Physical and Occupational Therapy to the
Department of Health and Nursing; however, it was not realized due to poor understanding within theuniversity. More specifically, if a national university wishes to establish a new faculty or department, it
should submit a budgetary request to the Ministry of Education, Culture, Sports, Science andTechnology, which will determine the appropriateness of approving the request, and in this case, thebudgetary request was rejected by the University of Tokyo (so-called “the red gate of the University ofTokyo”). Then, the Japanese government established National Sanatorium Tokyo-affiliatedRehabilitation School that was under the jurisdiction of the former Ministry of Health and Welfare in
1963. If the Department of Physical Therapy had been established by national universities other thanthe University of Tokyo, we would not have had to take the long way around to create the Departmentof Physical Therapy in School of Allied Medical Sciences, Kanazawa University in 1979 and theDivision of Physical Therapy and Occupational Therapy Sciences, Program of Health Sciences,
School of Medicine, Hiroshima University in 1992. The author does not know whether it is destiny orfate, but we cannot change the course of history.

Chapter 1

Article 2-3 of the Physical Therapists Act stipulates that the practitioner of “physical therapy” is aperson that is in the business of performing physical therapy under the instruction of physicians with alicense granted by the Minister of Health, Labour and Welfare and with the name of a physicaltherapist.” In short, only the legal protection of the title “physical therapy” has been established forreasons such as the existence of persons providing services similar to medical treatment, and nooccupational licensing is granted. Treatment by practicing physical therapists in foreign countries,
especially North America and Australia, can be provided with a doctor’s referral or a prescription.
Despite some differences in physical therapist’s discretionary power among the states, the US adopts a“direct access” system where a client (the term “patient” is not used in the US) can visit a physicaltherapy clinic directly. This system is implemented to reduce the client’s healthcare costs and increasea therapist’s discretionary power due to advancement of physical therapy education. For these reforms,
APTA’s lobbying (private political activity of individuals or organizations with certain opinions thataims to influence government policies) has helped to increase their discretionary power. In the earlydays of physical therapy in the US, American physical therapy education and qualification systemwere supervised by the AMA, although Faculty and Department of Physical Therapy have beenauthorized by the APTA’s policies for over 20 years and there is a considerable disparity between the
US and Japanese systems.
For reforms in Japan, it is important for physical therapists to provide physical therapy by doctor’sreferral or under the prescription of a doctor instead of doctors who speak condescendingly whentreating medically unstable patients/clients during the acute and recovery phase. Although cooperation
with a director or family physician is important for living phase requiring a wide range of continuous
services, the time has come to approve the discretionary power of each profession.

4)

Physical therapy education

Article 2-2 of the “Specified Regulations for Physical Therapist and Occupational Therapist School orTraining Facilities” (MHW Ordinance No. 3) stipulates that the years required for completing a courseof study at physical therapist schools or training facilities are at least three years. The JPTA’s masterplan proposed in 1989 includes adoption of a four-year university/college curriculum. At present, fouryear universities/colleges and four-year vocational schools account for one-thirds and one-thirds of theJapanese educational facilities, respectively, and it may be acceptable to set the term of study at four
years or longer. The author is sure that the level of physical therapy (studies) in Japan will increase
remarkably if the term of study is six years or longer like some advanced nations and a one-year
Doctor in Physical Therapy (DPT) course is added. The term of study for a pharmacist became six
years or more in 2006 and some pharmacy students who have the intention to conduct research inpharmaceutical companies, etc. go on to graduate school after obtaining a bachelor’s degree.
A three-stage approach is used to provide clinical instruction (i.e., tour, evaluation, and comprehensive
practice) and because it is clinical training before qualification acquisition, this issue has also been
deliberated in the Diet as so-called unlicensed medical treatment. The authors propose that aside fromclinical assessment practice, only successful candidates who pass a state examination after graduation
should receive one-year training like resident programs at the Faculty of Medicine or Faculty of
Dentistry. During this period, they are also allowed to apply for medical fees and receive a certainsalary because they are qualified. With this training program, one year is added to the term of study,
which extends over four or five years at a minimum. In this connection, the author (Nara) did his
internship for five months after completing a two-year specialized course at the LLU from which hegraduated in 1969, and his term of study was virtually four and a half years. The facility in which theauthor did his internship paid his necessary expenses for the internship (travel, food, andaccommodation expenses and wages).

22
Chapter 1 History of Physical Therapy (recent times)

The specified regulations related to physical therapy education in Japan have not been revised for 20
years since their establishment in 1999. The number of credits set by the specified regulations fromFY2020 increased from 93 to 101, and some subjects were added with an increased number of clinicaltraining sessions. “Clinical clerkship,” where interns practice medicine under the supervision of aclinical educator, is recommended for clinical training. This might be a proper method, but it also
posed a problem because some students solely practiced medicine even under the guidance andsupervision of a clinical educator.

5)

Integration of knowledge and skills of physical therapy and definition of
education

As with other health professions, an oral test was conducted as part of a state examination for physicaltherapists; however, it was physically difficult to conduct the oral test due to an increased number oftest takers, and it was abolished for the state examination for physical therapists in the latter half of the
1970s. Although questions about patients are included instead of the oral test, the author has theimpression that teachers and students at training schools make light of the integration of knowledge
and skills of physical therapy.
Chapter 1

This is a serious issue if physical therapy education is regarded as practical knowledge from a future
point of view. For your reference, physical therapy associations in nations such as the UK and
Denmark are unions (amalgamated unions) and no qualifying examination is given to those who arepermitted to graduate from a training school with the condition that they should enter the association.
In other words, this may also mean that training schools are asked to assume responsibility for theirstudents in exchange for great discretionary power. In that sense, these associations offer a wide
variety of postgraduate training programs for those who enter the association and take theresponsibility for improving treatment skills as a professional group. The philosophy of education,philosophy, and methodology for curricula and knowledge varies among these associations and they
aim to train broad-minded, competent people. If Japan adopts this kind of system, it will also help toreduce the necessary expenses for conducting a state examination, and the author thinks it would begood for the Japanese government to delegate various authorities and responsibilities to training
facilities.
Education (“to bring out”) also has various definitions. It is defined as “activity to work on a personwith the help of others with intent to develop desirable attitudes and realize value” in Kojien, aJapanese dictionary, and the author thinks the expression “with the help of others” lacks self-educationand independence and it should be corrected to “by himself/herself and with others.” Educatio in Latinis the “action of bringing up,” and originally meant breeding of animals and raising of plants, but its
meaning has gradually changed to indicate bringing up of a child by a parent or training and education
by a teacher. With respect to the expression “activity to (snip) realize value,” it is also hard to define apurpose and value. In 1890, the Emperor Meiji preached the roots of morality and basic principles of
education as the Imperial Rescript on Education the year after the promulgation of the Meiji
Constitution. With human evolution and social conditions, thoughts, and social systems of the times inmind, the author feels that we have to walk a “thorny road” to democracy based on freedom andequality.

6)

Issues of methodology of education

In principle, an elementary school teacher is responsible for subjects, such as Japanese andmathematics. As the curriculum proceeds, academic subjects grow complex and it is natural that the
curriculum also branches into different discipline areas. All things considered, academic disciplines
are basically related to the “understanding and awareness of humans” irrespective of the subject.
Teachers focus on teaching their own specialty without concerning themselves with other subjects,
23
Chapter 1 History of Physical Therapy (recent times)whereas students are required to develop the ability to integrate specialized subjects anddeepen/increase the “understanding/awareness of humans” in a comprehensive manner (Figure 1). We
need to figure out a good way to promote cooperation among teachers so that students can learn in an
integrated manner.
Teaching/learning human body structure and function in
an integrated manner
Psychology, psychiatry
AnatomyPhysiology

Teaching/learningthese subjects
fragmentally is a big
issue!

Kinematics
Other

Improved power ofsynthesis in students
Teacher’scooperation needed!

Chapter 1
Figure 1 Teachers Finding a Solution to a Challenge in Studying Humans in a Comprehensive Manner

7)

Roles of physical therapy

The author has mentioned early physical therapy a little in previous sections. At that time, physicaltherapy was called “aftertreatment,” “internal physical medicine,” or “massage, acupuncture andmoxibustion therapy.” As mentioned above, most of the patients/clients at that time visited theDepartment of Orthopedics and Department of Internal Physical Medicine, and as described in thisbook, the scope of physical therapy has expanded to include various diseases as people are becoming
aware of its usefulness. The JPTA has 12 subcommittees and 10 divisions, which contain the “Mental
and Psychological Physical Therapy Division” as with subgroups of the World Confederation for
Physical Therapy (WCPT). However, unlike in Europe, a physical therapist’s direct intervention inpatients with psychiatric disorders is not legally acceptable in Japan, and this is an issue. This is also a
legal matter for discussion, and the author thinks that human mind and body should not be separated
dualistically; both science and the ICF are based on a monistic view of “body,” and we also need toprovide physical therapy for patients with psychiatric disorders mainly using therapeutic exercise.
Ichikawa states that Mi in Japanese (corresponding to body in English) is a word of purely Japaneseorigin and is the same as Shin (corresponding to heart in English), implying the necessity of reframing
physical therapy from a humanics point of view.
In Europe and America, veterinarians, animal health technicians, and physical therapists work together
to engage in animal physical therapy for companion animals (pets), racehorses, and other animals. In
Japan, physical therapists are also involved in animal physical therapy, but their numbers are small andan accreditation system is not yet available. The author (Nara) was asked to check on a young Indian
elephant (it had walked for one year after birth) in Kobe City Oji Zoo in 2011 because the elephant(weighing 600 kg) had chondrosis and fissured fracture of the extremities, had been bedridden forthree years, and was then four years old. For animal physical therapy, the author cut too much off of aJava sparrow’s nail (his pet), causing bleeding, and stopped the bleeding by using a stick of incense toburn the blood vessel. However, the author went to the zoo and checked the young elephant the day
after he received the request. The elephant apparently presented with extremity contracture and muscle
24
Chapter 1 History of Physical Therapy (recent times)

Chapter 1

weakness; the author developed a physical therapy program and asked the veterinarian and elephantkeepers in the zoo to implement it every day (Figure 2). The author also provided direct interventions
about twice a month and asked the keepers to measure the joint range of motion with a goniometer helent every week. Since it was difficult to use a muscle strength dynamometer, the muscle strength wasrecorded according to the manual muscle strength testing method. As one of the physical therapy
programs, the author used a proprioceptive neuromuscular facilitation (PNF) approach for the healthy
nose (Figure 3) and found that even if he could not communicate linguistically with the elephant, it
responded to resistance as animal nature and also showed postural reflex. Considering that the joint
range of motion and muscle strength of the young elephant gradually improved seven months after the
first consultation, the author planned to make a firm abdominal bandage and have the elephant get
down on all fours; however, unfortunately, the elephant died of intestinal volvulus as the author was
about to implement the plan. Empathy is usually considered undesirable, but the author had dreamed
that the elephant would walk again.

Figure 2 Bedridden Elephant with Contracture andMuscle Weakness

8)

Figure 3 PNF for the Young Elephant’s Nose

In conclusion

The author has described the “history of physical therapy in Japan (law, definition, education, roles)”despite limited space. In 1999, the JPTA held the 13th congress of the WCPT, with Nara acting as thechairman, and the Heisei Emperor presented an “Imperial Address” at the opening ceremony. In 2023,
Japan will again host the WCPT Congress. This is interpreted as a sign that the JPTA’s activities havebeen accepted both inside and outside Japan and it is very delightful. We wish to express ourappreciation to our predecessors and pray that the current JPTA’s members at an average age of 33
years will strive for their future.
Finally, body activities refer to the maintenance of life and living of life on the basis of the mechanismof micro and macro “movement.” Extending the “movement area” finally leads to participation and thewell-being and health of patients/clients. We consider that seen from such viewpoints, physical therapy
is nothing more or less than improved level of cure and care in patients/clients.
(Isao Nara, Hiroyuki Fujisawa)

25
Chapter 1 History of Physical Therapy (recent times)

3.

An American’s Comparison of Physical Therapy for Japan andAmerica

1)

The beginning of physical therapy schools in JapanThe first schools for training physical therapists began in the 1960s. There were just a few schools spreadaround the country, and they were vocational schools lasting for just three years. The teachers were all
foreigners who spoke only English and taught using prints in English for texts. Entrance into these schools
was not difficult, and most of the students came from different backgrounds who did not know anything
about rehabilitation before entering the schools. Hospital training for the students was not standardized.
At that time, American education was on a university level leading to a degree in physical therapy fora minimum of four years, and some programs on the Master’s level were two and a half years forpeople who had previously graduated from a university in another field.
Teaching students in Japan, whose main language was not English, and using English books for study
was not efficient. During class lectures and practice sessions the students tried to understand, but it
was very difficult. And many students did not study once they left the classroom.
Chapter 1

American students had to, and still have to, prepare for class beforehand and must actively participate
during class. After class, they must review what was taught. They have a great deal of homework to do
and must study quite a lot. The teachers do not review homework in class but teach on the next level.
Tests are given often, and the students must prepare to answer questions based not only on the class
lectures but on their homework as well. Students must also do research on their own for school credit.
If a student does not comply with the rules for studying, the student can be dismissed from school.
It was very surprising to find that the Japanese students usually did not prepare for their classwork anddid not study much after school. Tests were given only on the classwork given, and often students only
did the minimal amount of studying. Students did not seem to worry about not being able to graduate
from school because they did not usually get dismissed. It is still the same now.
Therefore, the level of education and level of professionalism is inadequate.

2)

Schools increased and changed

Gradually the number of schools in Japan increased as the graduates gained their licenses as physicaltherapists and became teachers. These teachers taught in Japanese, and professional books began to be
published in Japanese. Physical therapists working in hospitals increased, which improved the abilityof the students to learn patient treatment during their clinical affiliations. Therefore, the level of
education and hospital practice improved.
However, compared to the level of physical therapy students and therapists in America, the demandfor knowledge and practical abilities are not as high for the Japanese students. And students still do notprepare for classes nor do they study in advance.
In Japan, junior colleges were begun (1980s), and entrance examinations were introduced. The
educational level of the entering students increased, which helped improve the level of education.
However, the professional schools still continue as before. When universities that include
undergraduate, Master’s, and Ph.D. program were started (1990s), more discrepancies in educationand in the work place and salary increased.
The professional schools are monitored by the Japanese government’s Department of Health, but thecolleges are monitored by the government’s Department of Education. This is totally different in
America. In America, the original professional schools were removed when the four-year colleges
were started (1950s), and when the programs were elevated to the Master’s degree level (2002), all thecolleges changed to that level. Now, the programs have upgraded to a Ph.D. level (2020), and theMaster’s programs are no longer used. These programs are regulated by the American Physical
Therapy Association, not the government.

26
Chapter 1 History of Physical Therapy (recent times)

3)

Licensing for physical therapists

In both Japan and America, therapists must pass a difficult written examination to obtain a license. The
Japanese government conducts the examination, and this license can be used throughout Japan. But
each state conducts the examination and controls the licensing in America. Therefore, American
physical therapists must get a separate license for each state they work in.

The test in America is much longer than in Japan and has many more questions to answer. And thestudents must study and prepare for the examination on their own. The time in school is to gain more
knowledge and improve their abilities as therapists, not study for a test. Surprisingly, Japanese students
prepare for the test in school and get guidance from the faculty staff.

4)
(1)
(2)
(3)

(4)

Job hunting, etc.
American students look for jobs mostly on their own.
Japanese students receive job offers at school and often get help from the faculty. They get a lot
more help from the faculty and school during their school life than American students get.
After obtaining the license and graduating from school, Japanese therapists are required to work
under the prescription of a medical doctor. American therapists can work independently without
a doctor’s prescription and can own their own offices. After graduating with a Ph.D., theyreceive the title of “Doctor of Physical Therapy”.
The levels and methods of education for the two countries are different, but most therapists
equally upgrade their knowledge and therapeutic abilities once they begin their professional
duties in the workplace.

5)

What is expected of students who try to be physical therapists and young
therapists in Japan(1)

I want Japanese students to study more, including preparation for class.
American students have to prepare for class beforehand, actively participate in class discussions,and carefully review what was taught after class. Otherwise (if they do not comply with therules for studying), they can be dismissed from school. They are studying physical therapy in aharsh environment. Although Japanese and American students are from different countries, they
are the same students with the aim of becoming physical therapists.
As a health professional, please continue to study hard and think professionally at an earlystage. Medical technology is making steady advances. To respond to such advances, the level of
education is getting higher. You will start your career as a physical therapist in an era where anemphasis is put on what you can do rather than what you learned in training institutions.
Although the level and method of education differs between the two countries, I want you topursue specialization in your place of work and improve your knowledge and practical clinicalskills. I hope that you will continue lifelong learning as a physical therapist and play an active
part as a wonderful therapist.
Michele Eisemann Shimizu, RPT, MA, Ph.D.
Professor Emeritus, Prefectural University of Hiroshima

(2)

(3)

27
Chapter 1 History of Physical Therapy (recent times)

Chapter 1

The first Japanese licensing examinations included a practical test, because the people who took theexamination were not only graduating students but also people who were hospital-trained. This system
continued for a few years, after which written tests were given to only students graduating fromgovernment-monitored schools. In America, when the licensing of therapists changed to only students
graduating from schools, the hospital-trained people who treated patients were given “green cards”,
which allowed them to continue working as therapists till they reached retirement. In comparison, theJapanese system for testing the hospital-trained people seemed too harsh, and it restricted these people
from continuing to earn a living as before.

Chapter 1

References
1)
Matsumura S: The Japanese journal of physical therapy and occupational therapy. IgakuShoin, 19722)
Physical therapist professional entry level education: Guideline, WCPT,2011
3)
Morinaga T: The Japanese journal of physical therapy. 30-12, Igaku-Shoin, 1996
4)
American Physical Therapy Association, Home Page
5)
The Chartered Society of Physiotherapy, Home Page
6)
World Physiotherapy (WCPT), Home Page
7)
Japanese Physical Therapy Association, Home Page
8)
Australian Physiotherapy Association, Homepage
9)
Japanese Physical Therapy Association: A Thirty-Year History of Japanese Physical Therapy
Association. 1996
10) Japanese Physical Therapy Association: A Forty-Year History of Japanese Physical Therapy
Association. 2006
11) Japanese Physical Therapy Association: A Fifty-Year History of Japanese Physical Therapy
Association. 201712) Nara I: Questioning the Essence of Physical Therapy. Igaku-Shoin, 2000
13) Nara I: A Collection of Messages from Former President Isao Nara. Japanese Physical
Therapy Association, 2003
14) Nara I: Memoirs of Isao Nara, Half My Life Devoted to Physical Therapy in Japan. Bunkodo,
200615) Nara I: My Definition of Physical Therapy. The Japanese journal of physical therapy, 44:686,
201016) Nara I: What I Learned from Animal Physical Therapy; Experience Treating a Bedridden
Elephant Calf. The Japanese journal of physical therapy, 46:1042-1045, 201217) Nara I, Yagi N: Professional Revolution for the Future Physical Therapy. Journal of theJapanese Physical Therapy Association, 39:488-490, 2012
18) Fujisawa H: Reconsidering the Profession for Pursing and Taking Over a Physical Therapist’sClinical Techniques. Annual report of the Miyagi Physical Therapy Association, 31:17-25,
202019) Nara I, Togashi S, Senba H, Yamamoto T (written and edited): Physical Therapy for
Psychological and Psychiatric Disorders—Primary Approach— 201320) Nara I: Half-century History and Future of Physical Therapy in Japan; Chasing an Endless
Dream, Living in the Present, and Reading the Future. Journal of the Japanese Physical
Therapy Association, 42:112-125, 201421) Nara I: Integration and Balance of Knowledge and Skills in Physical Therapy from aStandpoint of Practical Physical Therapy Science. The Japanese journal of physical therapy,
48:270-273, 201422) Ichikawa H: The Body as a Spirit. Kodansha Gakujutsu Bunko, 1992
23) Fujisawa H: Basic Concepts of Physical Therapy. Hokuju Shuppan, 201624) Tsuda Y: Manuals for Clinical Clerkship. Department of Physical Therapy, Rehabilitation
Center, Kurashiki Heisei Hospital, Social medical corporation Zenjinkai 201625) Nara I, Hashimoto T, Asai H, Fujimura M (written and edited): Management in Physiotherapy
Practices. 201826) Nara I, Takahashi T, Uchiyama Y (written and edited): Physiotherapy Concept (7th edition).
Ishiyaku Publishers, 201927) Nara I, Takahashi T, Asai H, Moriyama H (written and edited): Movement as the basis forliving and rehabilitation from micro/macro perspectives. Igaku-Shoin, 2020

28
Chapter 1 History of Physical Therapy (recent times)

Chapter 2
Background of Public Health and Physical Therapy

 What you will learn in this chapter
In this chapter, you will learn about the roles of physical therapy (physical therapist) inpublic health.

Chapter 2

You will study physical therapist and health promotion, preventive physical therapy,
treatment/intervention, habilitation, and rehabilitation, under the World Physiotherapy
definition of physical therapy, from a global perspective. Considering the future
development of physical therapy in the preventive field, you are advised to think about thesocialization of physical therapy as professionals in exercise and physical activity. Publichealth aims at preventing disease, and preventing diseases and maintaining health at a
community level (including ensuring worker’s health). Health promotion is an evolving field
focusing on population health rather than a one-on-one therapeutic relationship. In
addition, you will learn physical therapy in conventional medical rehabilitation and the rolesof health professionals trying to realize a community-based cohesive society from theviewpoint of residents working to improve community infrastructure.

Necessity of Public Health Studies in Physical Therapy
Contribution to public health (studies) is one of the roles of physical therapy. Physical therapy has
played a major role in healthcare and rehabilitation in Japan to date. Public health is referred to as thescience of theory and practice targeting community health and population health issues. It is separated
from medical practice that focuses on individual health issues.
For strategies to address health issues, public health activities share the same foundations as healthcare
and medical science in terms of the fundamental understanding of syndromes and disabilities;
however, public health requires different approaches to identify the risk of health issues for threefactors (i.e., an epidemiology-based population, environment, and individual) and propose a solution
to the population, community, administration, and other bodies, although the practice of physicaltherapy is based on a doctor’s instructions and requests as a healthcare practitioner.
WCPT, in cooperation with the World Health Organization (WHO), has been committed to the missionof contributing to the health of individuals and populations since its birth. Likewise, academic andpractical activities contributing to public health are also necessary for physical therapy in Japan.
Japanese physical therapists have promoted rehabilitation with the primary objective of responding toindividual cases of diseases or disabilities. They have accumulated knowledge and techniques, aiming
mainly at establishing the framework for practical physical therapy with a focus on health issues(including etiology, pathology, and life tasks) for people with syndromes and disabilities. As ICFbased practice, these reflect the progress of physical therapy theory (studies) from a healthcare andmedical point of view.
You are encouraged to understand these backgrounds as well as the methodologies specific to publichealth studies, and broaden your field of expertise to include health maintenance and promotion.
On the other hand, we cannot afford to put off the optimal distribution of healthcare resources on thebasis of demographic changes in Japan from a standpoint of public health studies. It is predicted that29
Chapter 2 Background of Public Health and Physical Therapy

there will be increasing demands for practical physical therapy for people who may have diseases ordisabilities on a population basis. Since the enactment of the Community Health Act, communitybased and preventive physical therapy have established a legal basis, and besides individual physicaltherapy in conventional healthcare, they have solidified the foundation of public health, considering
the social challenges that are common to the environment and group to which the target population
belongs, and that cannot be overcome by the efforts of individuals in the target population.
Individual physical therapists will be asked to engage in public health activities instead of theirmember organizations (such as hospitals, facilities, local governments, Physical Therapy Association,and other academic societies). Then, we will be asked to learn how to deliver physical therapy services
and develop a way to offer better physical therapy services.
As an example of ideal physical therapy services with health promotion for “health improvement” inmind, it is important for us to create an environment in which we can involve ourselves with others,
connect with others, and support each other so that we can stay motivated and continuously address
the risks prevalent in a community. In modern society, the biggest challenge to health improvement is
the loss of relationship, and it is said that redevelopment of communication skills is necessary forrebuilding the relationship. Communication in the community, at work, and at home may help improvethe environment for health improvement. Physical therapists with contents of physical therapy also
have a role to play in actively enhancing the above-mentioned involvement in health improvement inpublic health. It is particularly important to support disabled people and provide a place where they
can receive support for health improvement.
Chapter 2

As described above, physical therapists need to pursue their studies to acquire knowledge of andexpertise in direct and indirect physical therapy and gain knowledge and expertise to meet social
demands for physical therapists in new services, such as community-based integrated care, prevention
activities for health problems, industrial hygiene not covered by a fee-for-service system, school
health, and the media industry, and they have to be prepared.
(Akira Kimura)

Public Health and Medicine
Distinctions Between Public Health and Medicine
Public HealthPrimary focus on populations
Public service ethics as an extension of personal interest
Emphasis on disease prevention and health promotion for
entire communities
A public health paradigm adopts an environment, humanbehavior and lifestyles, and a series of interventions
designed for treatment
Specializations organized, for example, by analyticalmethod (epidemiology, toxicology); setting and population(occupational health, global health); substantive healthproblem (environmental health, nutrition) beyond a
professional degree in public health
Biological sciences central, with a prime focus on major
threats to the health of populations; research moves
between laboratory and field
Population science and quantitative analysis constituting
the essential features of public healthSocial and public policy disciplines an integral part ofpublic health education

Medicine
Primary focus on individuals
Personal service ethics in the context of social responsibility
Emphasis on disease diagnosis, treatment, and care of theindividual patient
A healthcare paradigm gives primary importance tohealthcare
Specializations organized, for example, by organ system(cardiology, neurology); patient group (obstetrics,
pediatrics); etiology and pathophysiology (infectious
disease, oncology); technical skill (radiology, surgery)beyond a medical degree
Biological sciences central, stimulated by needs of patients;
research moves between laboratory and bedside
Numerical and computational science increasing remarkably
but occupying a relatively small portion
Social sciences generally an elective part of medical
education

Reference: Distinctions between public health and medicine (source: handouts supplied by Harvard
School of Public Health in 2019; translated by the author)

30
Chapter 2 Background of Public Health and Physical Therapy

1.

WCPT’s Development of Physical Therapy

In 1951, the UK and US took the initiative in discussing a basic plan for forming World Confederation
for Physical Therapy (WCPT) and in 1953, 11 countries participated in the first international academic
meeting and the second General Assembly in London. The WCPT’s HQ is located in London. The
WCPT is registered in England and Wales as its official organization name. The WCPT started to use
World Physiotherapy as its operating name in 2020.
At present, the WCPT consists of five regions (Africa, Asia Western Pacific, Europe, North America
Caribbean, and South America) and has independent subsidiary international organizations specialized
in 14 different areas ([1] Acupuncture; [2] Aquatic; [3] Cardio-respiratory; [4] Electrophysical; [5]HIV/AIDS, Oncology, Hospice and Palliative care; [6] Mental Health; [7] Musculoskeletal; [8]Neurology; [9] Occupational Health and Ergonomics; [10] Older People; [11] Paediatrics; [12] Pelvic
and Women’s Health; [13] Private Practice; and [14] Sports).

Chapter 2

Since the establishment of the Japanese Physical Therapy Association (1966), Japan had tried to join
the WCPT on the advice of American lecturers who were involved in PT education in Japan at thattime. However, Japan could not satisfy the conditions for membership due to the domestic affairs of
the time. People involved in physical therapy in Japan approached the then Ministry of Health andWelfare to establish international-standard physical therapist education and class systems with thesupport and advice of the WCPT. After that, the domestic affairs were settled and Japanese accession
to the WCPT was approved at the eighth General Assembly held in Montreal, Canada, in 1974. Japanwas elected as a member country of the executive committee in the WCPT in 1982 and the 13th
academic meeting was held in Yokohama in 1999. WCPT congress will be held again in Tokyo in
2023 (*postponed until 2025).
There are many developing countries in the world that have not established physical therapist
education and class systems. As Japan received advice from the WCPT at the dawn of physicaltherapy’s introduction to the country, these countries also need assistance from the WCPT acting as an
NGO with a close relationship to WHO.
The articles of association specify the purpose of establishing the WCPT. In summary, as aninternational umbrella organization consisting of physical therapy associations from 122 countries andregions all over the world (a total of 670,000 members), the WCPT aims to deepen friendships among
physical therapists from the member nations to promote academic exchange, ensuring high-quality
physical therapy services for all people who need physical therapy worldwide without being merely afriendly organization, and to encourage all WCPT member nations to provide education programs
specified by the WCPT to this end. To accomplish these goals, the WCPT needs to support thedevelopment of its member associations and strengthen their authority (function). Through these
efforts, the WCPT tries to contribute toward maintaining the state of being physically and mentally
healthy (wellness) for people around the world rather than being free from disease only, and send
physical therapy information useful in maintaining and promoting health and improving physicalstrength to the world.
To attain these goals, the WCPT will change the schedule of academic meetings and General
Assemblies that were held every four years until 2015 (every two years for academic meetings andevery four years for General Assemblies) to achieve closer international cooperation.
(Toshihiro Morinaga)

1)

Physical therapist and health promotion

Physical therapy’s contribution to health can be considered synonymous with the accomplishment of
the mission of the WCPT under the WHO’s definition of health. If health is basically defined as“maintaining the state of being physically and mentally healthy (wellness) for people around the world31
Chapter 2 Background of Public Health and Physical Therapyrather than simply being free from disease,” you could say that the mission of WCPT is to disseminate
information on physical therapy to the world that contributes to the maintenance and promotion ofhealth and improving physical strength. The mission of physical therapy is to engage populations,
including a wide variety of people in whom diseases or severe disorders need to be prevented, and thiscan be understood to correspond to the goals of public health.
Physical therapists involved in health promotion are to provide services to people with health issues,
including cultivated techniques in physical therapy (such as therapeutic exercise and provision of safe
electrophysical agents) and knowledge (not only direct techniques but also indirect and educational
techniques including telemedicine). Their legal base is the Constitution of Japan and Health Promotion
Act.
Paragraph 1, Article 25, of the Constitution of Japan stipulates that “All people shall have the right tomaintain the minimum standards of wholesome and cultured living,” and Paragraph 2 states that “Inall spheres of life, the State shall use its endeavors for the promotion and extension of social welfare
and security, and of public health.” Under this Article, all people shall have the right to live a healthy
life and this idea is the same as that of the WHO.
Article 2 of the Health Promotion Act stipulates that “The people must endeavor to deepen theirinterest in and understanding of the importance of healthy lifestyles, and to both be aware of the stateof their own health and improve their health throughout the course of their lives.” The efforts of thepeople are needed to maintain and promote health, and an emphasis is placed on the significance of“protecting our own health ourselves.”
Chapter 2

In contrast, the Health Promotion Act also emphasizes health promotion of the people in collaborationand cooperation with the State, local governments, related organizations, companies, and others, andthe promotion of lifestyle disease prevention.
It is important for physical therapists dealing with health promotion to consider its legal basis andthink academically (scientifically). Although physical therapists are apt to focus on the development ofspecific methods for performing therapy or providing exercise guidance to individuals with healthissues, they should achieve goals on the basis of not only exercise and physical activity in thepatients/clients and populations, but also the theoretical framework (scheme) for evaluating the healthissues faced by individuals by considering the use and utilization of objective data, with panoramic
information based on health theory in mind.
As a theory of the conditions for being healthy, Miyagi suggests that the three conditions constituting
health, subject, etiology, and environment, should be balanced (Figure 1).

32
Chapter 2 Background of Public Health and Physical Therapy

Etiology conditions

Subject (human) conditions

Pathological characteristics
of viruses, bacteria, etc.

Sex, age, race, heredity,
body constitution,
personality, immunity or
resistance, etc.

Conditions for the environment surrounding the subject
Physicalenvironment

Chemicalenvironment

Socialenvironment

Economic
environment

Bioticenvironment

Temperatureandultraviolet

Agriculturalchemicals,
exhaust gas,
etc.

Culture,religion, etc.

Income andoccupation

Pathogenic
microorganis
ms, vectors,
etc.

Figure 1 Conditions for Being Healthy (Mr. Shigeji Miyagi)

Environment
conditions

Etiology
conditions

Subject(human)conditions

Environment
conditions

Etiology
conditions

Subject(human)conditions

Environment
conditions

Chapter 2

Subject(human)Etiology
conditions conditions

Figure 2 Imbalance of Three Conditions for Being Healthy (Mr. Shigeji Miyagi)

An imbalance of the three conditions leads to the pathology of health promotion (pathologicalcondition) (Figure 2). It is thought that intervention by physical therapists to correct the abovementioned imbalance in the conditions of health could ensure that each condition functions well andmay improve the balance of these conditions and help physical therapists provide physical therapy
services to improve physical strength and prevent disease, etc. These measures, coupled with practical,
theoretical, and academic efforts for development, may contribute toward maintaining the state ofbeing physically and mentally healthy (wellness) for all people, and will play some of the roles ofphysical therapy in public health.
(Akira Kimura)

2)

Prevention(1) Trends of preventive physical therapy in Japan
In the Physical Therapists and Occupational Therapists Act, physical therapy is defined as “Having
people with physical disabilities engage in therapeutic exercise or other exercise, and adding electricalstimulation, massages, heat, and other electrophysical modalities, mainly in order to restore abilities ofthe basic activities.” As explicitly stated in this Act, physical therapy has been developed with a focus
on people with physical disabilities. However, more recent evidence shows that exercise is also
effective in preventing lifestyle diseases constituting risk factors for requiring nursing care and various
diseases, and physical therapy is now often discussed in terms of prevention. It is vitally important,especially for Japan as it enters a super-aging society, to prevent people from developing disease or
falling into a state requiring nursing care for the reduction of social security costs. Amid these changes
in the current situation, the Ministry of Health, Labour and Welfare issued a notification that “Physicaltherapists sometimes carry out duties that are not considered assistance with medical treatment, such
33
Chapter 2 Background of Public Health and Physical Therapy

as giving guidance on fall prevention, for people without physical disabilities in a business promoting
preventive health care for the elderly, and it is perfectly acceptable to use the term ‘physical therapist’even when they perform duties other than physical therapy as stated above” in 2013 (Figure 3). To be
more specific, the Act focuses on the care of “people with physical disabilities,” yet physical therapists
today are also largely expected to produce results through a preventive approach to respond to a superaging society. As described earlier, physical therapy and a physical therapist’s way of working in Japan
have gradually expanded their scope of application over more than half a century since the enactmentof the Physical Therapists and Occupational Therapists Act in 1965.
(2) WCPT’s trends in preventive physical therapy
Recently, the above-mentioned preventive involvement in people by physical therapists is rapidly
growing worldwide. On the website of the WCPT, you can find the statement that “Physical therapists
evaluate the physical, psychological, emotional, and social aspects of people and help maximize
Quality of Life (QOL). They are working in the fields of health promotion, prevention,
treatment/intervention, and rehabilitation.” Thus, physical therapy as medical rehabilitation fordisabled people is still an important task of a physical therapist, and physical therapists today are
required to take various approaches to maximize QOL; preventive involvement is also clearly
identified as one of the roles of physical therapists.
HPB-MPD Notification No. 1127-3
November 27, 2013
To: Directors of Prefectural Medical Affairs Departments (Bureaus)

Chapter 2

Director of the Medical Professions Division,
Health Policy Bureau, Ministry of Health,Labour and Welfare
Use of the term ‘physical therapist,’ etc. (notification)
The Team Medicine Promotion Council and Working Group for the
Evaluation of Measures to Promote Team Medicine established within the
Ministry of Health, Labour and Welfare have discussed the request for reviewof the scope of work by medical workers submitted by medical organizations
between June and October 2013.
As one of the requests for advisory opinions regarding the appropriateness ofusing the term ‘physical therapist’ and the necessity of receiving doctor's
instructions when physical therapists perform duties such as giving guidanceon fall prevention, for people without physical disabilities in a businesspromoting preventive health care for the elderly, the medical organizations
requested that “people who may have physical disabilities” should be includedin the target population of physical therapy because the interpretation of theappropriateness and necessity is confusing in the field (Attachment 1).
The 20th Team Medicine Promotion Council meeting was held on October
29, 2013, in connection with this request to decide on policies described in
Attachment 2 and based on these discussions, we decided to inform ourdecisions listed below with respect to the use of the term ‘physical therapist,’etc. We would like you to carefully read the following information and ensurethat you understand it, and make the information known to all parties andorganizations concerned in your jurisdiction.
Description
Physical therapists sometimes carry out duties that are not consideredassistance with medical treatment, such as giving guidance on fall prevention,
for people without physical disabilities in a business promoting preventive
health care for the elderly, and it is perfectly acceptable to use the term
‘physical therapist’ even when they perform duties other than physical therapy
as stated above.
Physical therapists carrying out duties that are not considered assistance withmedical treatment need no instructions from a doctor.

Figure 3 Notification from Director of the Medical Professions Division, Health Policy Bureau, Ministryof Health, Labour and Welfare (HPB-MPD Notification No. 1127-3)

34
Chapter 2 Background of Public Health and Physical Therapy

When a literature search was carried out with prevention and physiotherapy or physical therapy as the
keywords, some articles were found, including articles on prevention of deformities caused by polio
published around the 1920s. However, the recent concept of prevention in physical therapy has
become remarkably diverse, focusing not only on preventing the progression of disease-related
disabilities (or secondary prevention) but also on preventing the worsening of conditions unrelated to a
specific disease and maintaining a good condition (well-being), such as fall prevention, preventive
health care for the elderly, or postnatal physical therapy, as well as disease prevention by preventing
lifestyle diseases constituting risk factors for various diseases (or primary prevention).
In particular, the “Physical Therapy Summit on Global Health,” starting in 2007, is one of the WCPT’ssymbolic approaches to preventive physical therapy. The first Physical Therapy Summit on Global
Health was held under the theme of “Moving Physical Therapy Forward” as one of the programs ofWorld Physical Therapy 2007 held in Vancouver, Canada. This Summit revealed that physical therapist
is one of the major occupations related to health maintenance and that physical therapists who canprovide nonpharmacological interventions, such as health education and physical activity, play a majorrole in the prevention and management of non-communicable disease (NCD), representing a major
step in placing prevention of NCD as one of the WCPT’s efforts. When the second (Amsterdam) andthird (Singapore) Physical Therapy Summit on Global Health meetings were held concurrently withthe congress of World Physical Therapy that is organized every four years, Health Competency
Standards for NCD prevention and health promotion in physical therapy were established on the basisof these discussions.
Chapter 2(3) Health Competency Standards
The Health Competency Standards are composed of three principles and three recommendations:[Principles][1] Incorporate theoretical and practical foundations of health competencies into physical therapist
education and practice.
[2] Incorporate health-focused practice into physical therapist education and practice.
[3] Incorporate into physical therapist education and practice that health competencies need to beshared across health professionals.
[Recommendations][1] Health and lifestyle behavior examination/assessment tools should be core physical therapist
competencies.
[2] Health protection, health promotion, and NCD prevention interventions should be core physicaltherapist competencies.
[3] Behavior change theories and models should underpin core health promotion and NCD
prevention competencies in physical therapist practice.
As just described, the Health Competency Standards emphasize the importance of understanding not
only diseases and disabilities, but also core health and providing interprofessional interventions as aphysical therapist’s involvement in NCD prevention. The Recommendations also indicate that weshould think theoretically to learn how the patient’s/client’s behavior and lifestyle have changed, as
typically seen in the Transtheoretical Model (a behavior change stage model). If the patient/client is atleast in the “contemplation” or later stages for improvement of lifestyle, physical therapists should
encourage him/her to change their behavior using the “5A model:”Ask questions about the current lifestyle status;
Advise the patient/client on the necessity of improving their lifestyle;Assess the current lifestyle status and the stage of behavior change in which the patient/client is;
Assist the patient/client in improving their lifestyle by providing information and psychologicalsupport; andArrange the situation and provide support so that the patient/client can maintain a good lifestyle.
35
Chapter 2 Background of Public Health and Physical TherapyOn the other hand, “5R’s” intervention should be used if the patients/clients are still in the“precontemplation” stage:
Get the patient/client to understand why his/her health topic of interest is relevant to his/her lifestyle(Relevance);
Inform the patient/client of the risk of various diseases caused by lifestyle disease (Risk);
Inform the patient/client of the benefits brought about by improvement of lifestyle (Reward);
Identify barriers to the improvement of lifestyle and discuss measures (Roadblocks); andIncrease the patient’s/client’s interest by repeating motivational intervention (Repetition).
As described above, the establishment of the standard guidelines and recommendations for a physicaltherapist’s involvement in health promotion rather than response to diseases or disabilities helps the
WCPT promote a physical therapist’s efforts to improve health on the basis of competencies.
(4) Development of the Health Improvement Card
Development of the Health Improvement Card (HIC) is one of the accomplishments of the WCPT’s
efforts for health promotion and prevention. The Health Improvement Card is an evaluation tool foreasy visualization of the risk of NCD mainly developed by the WCPT as part of the efforts of theWorld Health Professions Alliance that the WCPT is also joined to.

Chapter 2

The HIC is developed for use by physical therapists as well as various health professionals. Needlessto say, a comprehensive, versatile team approach is important for NCD prevention among
patients/clients, especially for the improvement of lifestyles that constitute a risk factor for NCD.
Physical therapists play an important role in this comprehensive team approach and provide
nonpharmacological interventions through therapeutic exercise. The WHO adopts nine important
Voluntary Global Targets for health promotion in the Global Action Plan 2013-2020; physicaltherapists hold a key position and they are able to directly tackle these challenges. Among various
professionals, physical therapists may have the chance to show leadership in addressing healthpromotion for people around the world, including promotion of NCD prevention.
(5) Challenges of modern society for core health promotion
While a physical therapist’s involvement in fields such as disease prevention, characterized by NCD
prevention and preventive health care for the elderly, is rapidly growing worldwide, recent healthpromotion studies have revealed that social and environmental problems greatly affect the health ofpeople.

36
Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

Figure 4 Health Improvement Card (the former logo of the WCPT is provided at the bottom of thepage)

The WHO, established in 1948, defines health as follows:“Health is a state of complete physical, mental and social well-being and not merely the absence ofdisease or infirmity.”
As seen above, it is clearly stated that not only a physical aspect, such as diseases or disabilities, butalso mental and social aspects are important for health. When the WHO was established, the Second
World War was just over (1945) and in the aftermath of the Second World War, the world was forced
to fight various infections. In countries where the effects of the war and infections diminished as timeadvanced, the physical aspect of health improved and the mean lifetime was also greatly extended due
to improved social security policies, such as healthcare and welfare. Under these conditions,researchers gradually started to conduct a study focusing on the social aspect of health.

37
Chapter 2 Background of Public Health and Physical Therapy

Figure 5 Voluntary Global Targets in the WHO Action Plan 2013-2020

Chapter 2(6) Health gap: Social Determinants of Health (SDH)
The term ‘health gap’ is often used as a keyword for recent social issues of health. Since the WHO
Charter (1948) established that the possession of health is one of the fundamental rights of every
human being, surveys from around the world have reported a mean lifetime extension in many
countries. However, the UK Department of Health and Social Security released a report called“Inequality of Health” in 1980, revealing that the extension of the mean lifetime is affected by social
factors. Then, some studies on health and social factors demonstrated that health is affected by not
only physical factors such as diseases and disabilities, but also by social elements including
occupational social class and economic factors, such as poverty (Social Determinants of Health[SDH]). Under such circumstances, the WHO Commission on Social Determinants of Healthcompiled a report, Closing the gap in a generation (2008), and declared that the WHO has a moral
obligation to reduce the health gap.
The WHO and all countries of the world became aware of health gap issues, and after the WHO
approved a resolution at the General Assembly to take action on the health gap (2009), the “Rio
Political Declaration on Social Determinants of Health” was adopted during the World Conference on
Social Determinants of Health (2011) to promote health equity.
The number of SDH-related studies is also on the increase in Japan, reporting that manysocioeconomically low-class people (including low-income earners and a shorter period of education)
have not had a medical health checkup, are more liable to have depression, tend to stay at home, andhave experienced falls. As for the risk of frailty, studies have also reported that people who live alone,interact less with others, and have spent less time on education are liable to be frail. As with reports
from around the world, Japanese people are also gradually becoming aware of the health gap.
Health Japan 21 (the official name is the National Health Promotion Movement in the 21st Century) isthe backbone of Japanese health measures. Since 2013, measures, including review of the policies,
have been employed as Health Japan 21 (the second term). “Extension of healthy life expectancy” and38
Chapter 2 Background of Public Health and Physical Therapy

(7) Roles of physical therapists in correcting the health gap
What about health measures coming after Health Japan 21 (the second term) to be completed by 2022?
There are emerging best practices of the health promotion cycle achieved by taking measuresreflecting regional characteristics through community diagnosis. Although regional disparities areshrinking, it is a fact that health promotion does not go as smoothly as expected in some regions. As
preventive measures against these situations, a “primordial prevention” perspective has drawn
attention in recent years. From the standpoint of the relationship between public health and physicaltherapists, it can be said that the scope of a physical therapist’s work is expanding to cover physicaltherapy in hospitals, facilities, etc. (tertiary prevention), physical therapy for high-risk groups(secondary prevention), and health-related prevention enlightenment activities (primary prevention).
Primordial prevention goes beyond these approaches; however, unlike the high-risk approach and the
population approach, it is not targeted at humans, but rather is an environment-oriented approach (ortown planning). Primordial prevention is based on the idea that the effects of health-related SDHs areapparent and we need to build an environment and a community that will allow the community people
to get healthy. Considering that the environment and community are designed, it is not hard to imagine
that we need diverse perspectives, such as politics, resident autonomy, and companies. When it comesto building an easy environment in which to live or an environment that encourages you to go out or to
exercise, a physical therapist’s perspective may also be sufficiently useful.

Response to the SDH, including building an environment for health promotion[Primordial prevention]
Town planning
Environmental setting
Space for getting
healthy
Measures for healthsupportInterventions for improvement of lifestyles[Primary prevention]
Health promotion
Disease prevention
Injury prevention
Enlightenment
activities

Prevention of the aggravation of diseases,
injuries, and disabilities
Treatment and social[Secondary prevention] recovery support

Early detection
Appropriate healthcare [Tertiary prevention]
Functional recovery
Countermeasures forSocial recovery
complications
Rehabilitation

Figure 6 Prevention Stages and Desired Roles of Physical Therapists
Besides their fundamental duties of medical rehabilitation, more active roles, such as disease prevention, building
an environment for health promotion, and response to the SDH, are expected for physical therapists today.

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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2“reduction of the health gap” have been added to the basic direction of this Health Japan 21 (thesecond term). Each local government practices various approaches in line with basic policies forcomprehensive promotion of the health of the people of Japan (2012), and the local governments often
work with local medical institutions to hold events, such as a diabetes prevention class, walking class,and health promotion campaign. According to an interim report of Health Japan 21 (the second term)
published in 2018, an improvement has been seen in 32 of the 53 items (i.e., extension of healthy life
expectancy, a decrease in prefectural differences in healthy life expectancy, and an increase in thenumber of local governments undertaking health gap measures). In each region, region-specificproblems and characteristics are investigated beforehand (community diagnosis) using objective
indicators and by detailed observation, and region-specific measures are tried with the help of localorganizations, such as local government and medical institutions, and making use of community
networks (social capitals), which is producing good results.

Health measures advance over 10 or 20 years and as stated in the title of the WHO’s report on thehealth gap, we may have to work on them in a generation. Amid dynamic changes in social structurescharacterized by demographics, it is necessary for physical therapists to understand preventive
measures of the day and keep taking up new challenges to approach society in order to be an
occupational category that is always needed.
(Hiroshi Momma)

3)Treatment/intervention

Chapter 2(1) Target and objective
The term ‘physical therapy’ is derived from the combination of the Greek word ‘phandsis,’ whichmeans natural, and ‘therapehia’ meaning treatment. Etymologically speaking, physical therapy stands
for “treatment by nature” and in 1958, the WHO defined it as “the art and science of treatment throughtherapeutic exercise, heat, cold, light, water, massage and electricity.” In Japan, Article 2 (Definition)
in Chapter 1 of the “Physical Therapists and Occupational Therapists Act” (Law No. 137) stipulates
that “Under this Act, ‘physical therapy’ is defined as having people with physical disabilities engage intherapeutic exercise or other exercise, and adding electrical stimulation, massages, heat, and otherelectrophysical modalities, mainly in order to restore abilities of the basic activities,” and its similarity
to the WHO’s definition can be confirmed. Then, in 1999, World Physiotherapy released a new policy
statement about physical therapy, “Description of physical therapy,” and clearly indicates its objectives
and target by stating in the document that “Physical therapy is services provided by physical therapists
to individuals and populations to develop, maintain and restore maximum movement and functional
ability throughout the lifespan,” and that “The service is provided in circumstances where movement
and function are threatened by ageing, injury, pain, diseases, disorders, conditions and/or
environmental factors and with the understanding that functional movement is central to what it means
to be healthy.” At the same time, it is also stated that “Physical therapists are concerned withidentifying and maximising quality of life and movement potential within the spheres of promotion,
prevention, treatment/intervention and rehabilitation,” which contains health promotion, prevention,
treatment/intervention, and rehabilitation discussed in this chapter.
From the above, it can be said that physical therapy treatment/intervention is targeted at individuals
and populations with impairment of body systems essential for movement, various motor functions, orfunctioning due to damage and dysfunction of body structures and functions caused by disease. In
addition, physical therapy treatment/intervention is intended to maximize the residual function orcompensatory (alternative) function and develop, maintain, and restore functional abilities by making
full use of therapeutic exercise or electrophysical agents and with the understanding that movement
and function are threatened by ageing, injury, pain, diseases, disorders, conditions and/or
environmental factors, and by inducing remission and removing, overcoming, and accepting difficult
circumstances in some cases.
(2) Clinical reasoning and treatment/intervention
Keeping the function of each body part above a certain level and cooperation and interaction among
various functions of body systems are important for achieving functional movement and leading
independent daily living. Various functions inherent in the body include musculoskeletal function,neurological function, cognitive function, postural control function, coordination function, visceralfunction, and metabolic function. The “treatment/intervention” of physical therapy is provided forrecovery from and improvement/resolution of the above damage and dysfunction of body structuresand functions caused by disease (as described earlier, physical therapy also includes health promotion
and prevention for the management of damage and dysfunction of body structures and functions andrehabilitation if indicated). Therefore, understanding the damage and dysfunction of body structuresand functions based on medical information and pathophysiology is essential to proper

40
Chapter 2 Background of Public Health and Physical Therapy

treatment/intervention, and it is impossible to provide physical therapy treatment/intervention without
analyzing characteristic signs and symptoms (analysis of signs and symptoms).
Uchiyama (2006) defines semiology of dysfunctioning as “the investigation of the cause of an
impairment and adjustment of activities by incorporating observation of movement as a phenomenon
caused by changes in health status and environment into a criterion,” indicating a clinical thinking
process model of physical therapy. To maximize the performance of body systems essential for
movement and functional recovery, minimize incapacity, and achieve the maximum recovery ofresidual function, observation and analysis of movement should be based on functional limitation, thecauses and elements of underlying impairments should be identified, and the method of resolving
activity limitations or participation restrictions should be considered to practice physical therapy
treatment/intervention (Figure 7).

Movement(functional
limitation)observation andanalysis of
movement
Function(impairment)

Activity
Participation(activity limitation/participation restrictions)Pathophysiology

Pathologicalmovement

Anatomy and physiology, molecularbiology, genetic engineering, nutritional
science and pharmacology, etc.

Psychology, environment theory,
pedagogy, engineering, sociology
and welfare science, etc.

Socialinformation

Chapter 2

Medicalinformation

Figure 7 Bacic Framework for Semiology of Dysfunctioning
Yasushi Uchiyama: An Introduction to Semiology of Dysfunctioning. p.5, Bunkodo, 2006 (partially modified)Notably, to investigate the reason that movement cannot be made (movement dysfunction) with theunderstanding of disease characteristics rather than being in a hurry to provide treatment/intervention
and see results by examining what is needed for better movement (analysis of disabilities), thissemiology of dysfunctioning proposes carefully collecting medical information and trying tounderstand disease characteristics learned from interactions, such as surgery, medication, andtreatment, history of present illness, and past history, referring to anatomy and physiology, basic
disciplines for physical therapy science, and nutritional science and pharmacology, both of which werealso recently reflected in specified regulations, for the interpretation of pathophysiology, andidentifying “the reason that the movement cannot be made” (movement dysfunction) from the aspectof molecular biology and genetic engineering; the semiology of dysfunctioning also illustrates theinference process of functional prognosis.
Verification of the treatment/intervention details (i.e., examining “what is needed for bettermovement” [analysis of disabilities]) is also important for physical therapy treatment/intervention. To
maximize the performance of body systems essential for movement and functional recovery, minimize
incapacity, and achieve maximum recovery of residual function, we must not be negligent in carefullycollecting social information. For the development of positive thoughts about how to train eachfunction of the body parts, we have to draw up and implement a treatment/intervention program basedon realistic goals with social information, such as inherent ability to make a living, living environment(i.e., food, clothing, and shelter), family factors, and public service utilization, in mind. Furthermore,

41
Chapter 2 Background of Public Health and Physical Therapyeach patient’s/client’s psychological situation is essential information for maximum recovery ofresidual function and it can be used as a guide to infer practical adaptability.
Finally, we are to encourage interaction between the analysis of signs and symptoms and analysis of
disabilities, set goals after identifying issues, and plan and implement treatment/intervention (Figure
8).

1) Observation of movement
Movement(functional
limitation)[1] Severity of functional limitation[2] A proposal to use a hypothetico-deductive
method by observation
2) Analysis of signs and symptoms(understanding disease characteristics)

3) Analysis of disabilities(understanding disability characteristics)
Activity

Function(impairment)

Participation(activity limitation/participation restrictions)[5] Examine “what is needed for bettermovement”[6] Infer adaptability
i Activity levelii Motor learning and self-management
skillsiii Environment4) Integration and interpretation from thestandpoint of semiology of dysfunctioning[7] Intervention-oriented integration andinterpretationi Identify an issue
ii Set a goaliii Draw up and implement intervention[3] Investigate “the reason thatmovement cannot be made”[4] Infer functional prognosis
i Identify the factors
ii Interaction with medical treatment
iii Clinical course

Chapter 2

Figure 8 Clinical Thinking Process in Semiology of Dysfunctioning
Yasushi Uchiyama: An Introduction to Semiology of Dysfunctioning. p.6, Bunkodo, 2006 (partially modified)This clinical thinking process is also called clinical reasoning or clinical decision making. Clinicalreasoning is person-centered thinking or goal-oriented cognitive process; that is to say, therapists infer
pathology from patient’s/client’s complaints and symptoms, select an appropriate testing method on
the basis of a hypothesis, and decide on the most suitable intervention for the patient/client, andclinical reasoning involves this series of processes.
For the attainment of treatment/intervention goals of maximizing the performance of body systems
essential for movement and achieving the maximum recovery of residual function, we must emphasize
the importance of the following series of processes: Therapists make an accurate observation andevaluation and collect extensive and accurate information to get an overall picture of the patient/client,and on the basis of evidence-based achievable goals, they select and apply the optimal physicaltherapy treatment and intervention method/approach, evaluate the results on a regular basis, andmodify it to provide an optimal method according to the reevaluation results.
(3) The actual physical therapy treatment/intervention
Physical therapists use therapeutic exercise as one of the treatment options. The term ‘therapeutic’means “designed to help treat an illness” and it corresponds to physical therapy treatment/intervention.
The term ‘exercise’ means “to train your body or parts of your body or use your ability, etc.”
Therapeutic exercise, a key tool in physical therapy, can then be summarized as: Training your body orparts of your body for treatment purposes.
During physical therapy, therapeutic exercise is conducted for recovery from andimprovement/resolution of damage and dysfunction of body structures and functions caused bydisease, and it is based on various physical functions (including musculoskeletal function, neurological
42
Chapter 2 Background of Public Health and Physical Therapy

function, sensory and perceptual function, cognitive function, postural control function, coordination
function, visceral function, and metabolic function) and cooperation and interaction among various
functions of body systems.
[1] Muscle strengthening exercise and muscle endurance exercise
Muscle weakness is one of the characteristic signs and symptoms, such as activity limitations andmovement dysfunction, that are most commonly encountered by physical therapists. The cause of
muscle weakness is classified into one of the following categories: aging, myogenic, neurogenic,
neuromuscular junction, disuse, and other. Muscle strengthening exercises and muscle endurance
exercises must be conducted with the understanding of these causes of muscle weakness.

Muscle endurance exercise is intended to increase type IA or II fibers, which are red muscle fibers
with high oxidative capacity, and it is recommended to perform about 15 to 20 repetitions of theexercise at an intensity of ≤ 60% of the maximum muscle strength.
[2] Range of motion exercise
Limited range of motion, like muscle weakness, is also one of the characteristic signs and symptoms
that are most commonly encountered by physical therapists. It is caused by a wide range of conditions,such as dermatogenic contracture, connective tissue contracture, joint contracture, muscular
contracture, and neurogenic contracture.
Typical range of motion exercises include passive exercise, active-assistive exercise, active exercise,stretching, Hold and Relax, and Hold-Contact.
[3] Physical therapy for balance exercise and postural control function
Stable balance is indispensable for leading a daily life without falling, and postural control function isimportant. Decreased balance function is reported for all diseases, including but not limited toneurological diseases and musculoskeletal disorder, as well as for the elderly and long-term bedridden
patients/clients.
A specific treatment/intervention approach is when the base of support is first widened to keep a low
center of gravity, then the base of support is gradually reduced, and patients/clients are instructed topractice motor tasks so that they can control the center of gravity within the base of support and makeanticipatory postural adjustments; this treatment/intervention requires the originality and ingenuity ofphysical therapists.
[4] Coordinated movement
Reduction in smoothness and skillfulness of movement results in decreased work efficiency, affecting
independent living and quality of life. Motor coordination dysfunction includes dysmetria (hypometria
or hypermetria), dysdiadochokinesia, intention tremor, decomposition of movement, and ataxia.
During physical therapy, patients/clients are instructed to move at a constant speed, practice converting
the type of muscle contraction from concentric to isometric and from isometric to eccentric, and move43
Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

To carry out muscle strengthening exercises, the load based on the “overload principle,” duration ofmuscle contraction, number of repetitions and sets, exercise frequency per week, and duration oftreatment/intervention need to be determined. The load and number of repetitions are based on
DeLorme’s progressive resistance exercise theory. Muscle strength is dependent on the size of thecross-sectional area of muscle, although muscle strengthening effects specific to issues are observed
and an increase in muscle mass is noted without an increase in muscle mass at the beginning of themuscle strengthening exercise (an increase in muscle strength per unit of muscle cross-sectional area).
It is known that increased muscle strength is brought about by neurological adaptation due to anincrease in the type and total number of motor units recruited (recruitment), an increase in firing ratesof alpha-motor neurons (rate coding), and regulation of the timing of motor unit activation(synchronization).

slowly and then quickly, perform symmetric movement and switch to ipsilateral movement, alternating
movement, reciprocal movement, or diagonal reciprocal movement to ensure that they can perform
exercises under feedforward control.
[5] [Functional training programs and ADL practice
While muscle strengthening exercises, range of motion exercises, balance exercises, and coordinatedmovement are treatment/intervention for individual functions, physical therapy is given to accomplish
various practical activities of daily life, and physical therapy treatment/intervention should always
consider “practical daily life.”
A training program is based on three principles: the above-mentioned “overload principle,”“reversibility principle,” and “specificity principle.” To be more specific, if patients/clients want tolead a practical daily life, they practice repeatedly on the basis of specific simulation of the form or
patterns of the activities of daily living. Using the muscle strength, joint mobility, motor coordination,and balance ability needed for daily activities, patients/clients perform functional movements, such as
actually standing up and walking, to accomplish various activities. Patients/clients select assistive
devices such as a walking stick as needed to compensate for some impairments and attempt to get used
to a new environment where assistive devices are used; this practical approach is also important for theaccomplishment of various activities, and environment improvement, including selection of anassistive device, is also considered to be part of a functional training program.
[6] Physical therapy for visceral function
Physical therapy treatment/intervention is targeted at treating all patients/clients, including those withrespiratory or cardiovascular disease and decreased respiratory or cardiovascular function.
Chapter 2

Respiratory physical therapy is a physical therapy option used to prevent and treat respiratory failure
in respiratory management during the chronic and acute phase, including pulmonary physical therapy
for breathing exercise and induced sputum and therapeutic exercise and conditioning for independent
daily living. Therapeutic exercise (aerobic exercise and resistance training) based on medical
assessment and exercise prescriptions is a key element of cardiovascular physical therapy. Therapeutic
exercise will help improve cardiopulmonary endurance, generally leading to improvement of exercise
capacity.
Both respiratory rehabilitation and cardiac rehabilitation are long-term versatile and comprehensive
programs implemented through multidisciplinary cooperation with the purpose of improving thepatient’s physical, psychological, social, and occupational condition, preventing or reducing the
progression of underlying conditions, reducing recurrence, rehospitalization, and death, and realizing a
comfortable and active life; physical therapy is one of the most important treatment/interventions forthe accomplishment of various practical activities of daily life.
[7] Manual physical therapy
Manual physical therapy is a physical therapy treatment/intervention approach used to induce
remission of symptoms and signs, such as neurological symptoms due to dysfunction and chronic pain,by making full use of manual therapy techniques. It has a long history and a variety of systems havebeen developed and become established as schools of manual physical therapy. International
Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) is representative of theseschools and also recognized as a subgroup of the WCPT.
(4) Summary
As treatment/intervention intended to improve the quality of life, independent living, and workabilityof individuals suffering from motor dysfunction due to activity limitations, therapists first infer
pathology from their complaints and symptoms, identify “the reason that the movement cannot bemade” (movement dysfunction), and infer functional prognosis. Then, the therapists select anappropriate testing method on the basis of a hypothesis, set goals after identifying issues, and plan and
44
Chapter 2 Background of Public Health and Physical Therapy

implement treatment/intervention by examining “what is needed for better movement” (analysis of
disabilities).
The therapists should always have person-centered thinking and aim to improve the individual’s
independent living, as well as their workability and quality of life, without indulging intreatment/intervention that is not based on clinical reasoning or unscientific procedures or tools, which
is important for physical therapy treatment/intervention.
(Tetsuya Takahashi)

4)Re-habilitation/habilitation

In this section, we will dig a little deeper and also touch on “Homo Habilis.” The Homo Habilis is oneof our ancestors (Homo) and lived 2.4 million to 1.4 million years ago; it is nicknamed “handy man,”
having a slightly large skull, and is considered an intelligent species that made stone tools. If we trace
the history of the term that we described above, “rehabilitation” means “the act of empowering an
individual to have human abilities.” If you look up rehabilitation in the English dictionary, you willfind such entries as: 1. Functional recovery training of the sick and wounded; 2. Restoration, recovery;and 3. Restoration of rights or honor. If we focus on the events that are used as the etymology of theword rehabilitation, we can present an example well-known in later eras: Joan of Arc (the Maid ofOrleans) was excommunicated for heresy and tried and executed in the 15th century, although she wasrehabilitated by the pope 20 years later and sainted 500 years later. This example means that a person
who was deprived of human rights and dignity and alienated from society becomes socially acceptable
and is rehabilitated. From the above, “rehabilitation” refers to “all processes where people with someform of disability and the socially handicapped assert their own value in a positive manner and are
accepted and respected in society.” As of 2019, the WHO defines rehabilitation as “a set ofinterventions needed for individuals who experience or are likely to experience restrictions of dailyfunctioning owing to aging and the state of health, including chronic disease, disability, wounds, orinjuries.” It is also said that “rehabilitation is provided through professional rehabilitation programs or
it is considered an individual-oriented health strategy integrated with other health programs andservices, such as primary healthcare, mental healthcare, and an audiovisual program.”
We will look at the history of rehabilitation in the 20th century, especially in the US, from a legislation
point of view. The present rehabilitation policies are formed because of functional recovery, vocational
training, returning to work, and education programs provided to demobilized soldiers suffering fromwounds and the handicapped in Europe and the US after the First World War. Thus, “vocational
rehabilitation,” or rehabilitation support, was emphasized. In fact, the Soldier Rehabilitation Act of1918 and the Vocational Rehabilitation Act of 1920 were passed in the US. Prior to medical
rehabilitation, social and vocational rehabilitation first began to emerge in order to incorporate thehandicapped characterized by wounded soldiers into society. Then in the US, the Vocational
Rehabilitation Amendments of 1943 and 1954 that were adopted during the Second World War wereexpanded after the war to include services for a wide variety of handicapped people, such as thosewith mental disorders and mental developmental disorders and the blind, and a comprehensive
program was started. The name of the Vocational Rehabilitation Amendments remained unchanged
before and after the Second World War when Frank Krusen and Howard Rusk, globally distinguished
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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

Rehabilitation is composed of “re” and “habilitation” derived from ‘habilis’ in Latin. The term ‘habilis’
mean handy, apt, or fit; that is to say, rehabilitation means “the act of restoring to former ability” or“the act of restoring an individual to a satisfactory state.” Thus, “habilitation” applies to therapeutic
exercise, prosthetic-orthotic therapy, or training, education, care and education, and guidance using
welfare equipment for children with innate cerebral palsy and patients/clients with congenital limb
defects (though they do not always have disabilities) because they are not provided “again.” However,for the sake of convenience, we include all of these cases in the category of “rehabilitation.”clinicians, made strenuous efforts, but after the name change to the “Rehabilitation Act” in 1973, a
more comprehensive concept of rehabilitation became widespread. The enactment of this Act dealing
with handicapped people’s citizenship helped promote the movement of handicapped people toeliminate discrimination against people with severe disabilities, as well as “Independent Living”
Movement that longed for administration for disabled people, resulting in the establishment of the“Rehabilitation Act Amendments” in 1978.
Looking at these changes in legal provisions, we notice that the concept of rehabilitation has changed
with time because these Acts have evolved into multiple Acts covering education and social services,
including health and employment of children with disabilities, utilization of self-help devices or
welfare equipment and improved services, guaranteeing the rights of a broad range of disabled people,
such as those with mental illness and post-traumatic stress disorder.
(1) Differences between medical rehabilitation and rehabilitation medicine
Medical rehabilitation is often confused with rehabilitation medicine, but Sunahara and Ueda clearly
distinguish them. Showing that there is “medical rehabilitation,” “vocational rehabilitation,” “social
rehabilitation,” “educational rehabilitation,” and “psychological rehabilitation” within the large
framework of rehabilitation and that medical rehabilitation is one of the elements of rehabilitation,
Sunahara states that medical rehabilitation will be provided in each field of clinical medicine fordiseases and patients in all areas of healthcare. Medical rehabilitation corresponds to current
rehabilitation healthcare.

Chapter 2

On the other hand, Sunahara defines rehabilitation medicine (physical medicine and rehabilitation) as
a new academic discipline that emerged after the war as a part of clinical medicine, and it is the art oftreatment with a primary focus on motor dysfunction.
(2) Social background of the introduction of rehabilitation into healthcare
If you review the historical facts of rehabilitation introduced as healthcare activities, you will findrecords of rehabilitation, such as a picture of artificial legs painted on an ancient Greek pot,
therapeutic exercise or mechanical orthodontic therapy for the spine, hydrotherapy in China andEgypt, or soldiers wearing an artificial hand in the Middle Ages, and understand that it has a long
history. In this section, we will describe how rehabilitation was introduced into current healthcare andexplain its social background.
It is a well-known fact that wars of an era have helped advance rehabilitation. In the latter part of the
19th century, a desire to be independent as a nation, industrialize a country, and implement a policy forenhancing the wealth and military strength of a country grew in Europe, and it was strongly
recommended to do gymnastics or exercise to enhance the health of the people for building a strong
nation. In the Netherlands, physical medicine and orthopedics, athletics, and today’s manual therapy
were separated from each other at the end of the 19th century and individual associations were
established and evolved. On the other hand, impairment of workers and farmers wounded in war andpoor public health in cities caused problems for the US early in the 19th century. The strong desire ofthen politicians to solve social and economic problems, which were causing public dissatisfaction, andtheir leadership are thought to have helped establish rehabilitation medicine.
We should not forget the pioneers of rehabilitation either. Henry Kessler, Frank Krusen, Howard Rusk,
and other predecessors greatly contributed to the introduction of rehabilitation into healthcare at thattime. Kessler was engaged in the New Jersey Workers Compensation Program and accomplished thetask of responding to a request for rehabilitation medicine for the first time. This Program was madeinto a law of the United States by President Roosevelt, who also contracted polio and received
electrophysical agents and underwent therapeutic exercise. We should not miss this turning point as anopportunity to make society realize the importance of rehabilitation. At that time, emphasis was put on
experimentalism and empiricism, which are fundamental to existentialism philosophy, born first in the46
Chapter 2 Background of Public Health and Physical Therapy

(3) Principles of rehabilitation
Principles of rehabilitation are historically expressed in various ways. For example, some advocatethat rehabilitation be used to restore the right of the handicapped to live like human beings, or “total
restoration of human beings,” and in the words of a doctor from Mayo Clinic in the US, rehabilitation
is a “trinity consisting of human rights, social recovery, and rehabilitation techniques.” This is slightly
old information, but a report from Advisory Council on Welfare of the Physically Handicapped People
in 1957 says that “the principles of rehabilitation are based on the idea that a disabled person has the
dignity of personality as a person and his/her independence contributes to the development of theentire society.” As mentioned above, the principles of rehabilitation are mentioned in a variety of ways
and Sunahara offers the following opinion: “If rehabilitation refers to the process of giving disabled
people something to live for, it does not always mean that they have to be taxpayers, join social
activities, or work at home. We have to recognize the value of their existence.” We, reviewing thespectrum of rehabilitation, must remember that we have to thoroughly search for its fundamental
principles.
(4) Relationship between physical therapy and rehabilitation
When Physical Medicine and Rehabilitation was founded in the US, the American Occupational
Therapy Association and American Physical Therapy Association were launched in 1917 and 1920,
respectively. Because Kessler was an orthopedic surgeon and Krusen was a physician who sufferedfrom tuberculosis and fought against illness in a sanatorium, physical therapists were given an
important position as key rehabilitation professionals. After the First World War, hydrotherapy andphysical medicine were widely used in bathhouses from a sanitary standpoint, and physical andoccupational therapists were engaged in providing healthcare. Although both physical andoccupational therapists recognized their independence, they did not take on the support of thehandicapped as an interdisciplinary rehabilitation team. The American Academy of Orthopaedic
Surgeons and Massachusetts General Hospital were quick to provide massage therapy andhydrotherapy and perform exercise, and they were recommended as so-called programs for woundedsoldiers in reconstruction hospitals. After that, this kind of medical care and rehabilitation system wasadopted by military hospitals in the US, generating bureaucratic conflict among the federal agency,
doctors, and vocational rehabilitation specialists. Then, colonel Mock mentioned that physical therapy,
occupational therapy, and vocational training were indispensable to the best program offered byrehabilitation hospitals.
Interestingly, the American Physiotherapy Association (APA; a group of doctors), the predecessor of
the current Physical Medicine and Rehabilitation, was founded as an organization of physicians withan interest in treatment using electrophysical agents, and those who studied physical medicine orathletics and who were engaged in massage therapeutic exercise were also allowed to join the APA.
Most physical therapists were registered as members of the APA and electrophysical modalities, suchas ultraviolet rays, electrotherapy, and whirlpool baths, composed the main portion of physical therapy
at the beginning, gradually shifting to treatment approaches characterized by active exercise, and themethod of muscle strength assessment and training theories based on academic research were
established between 1930 and 1940. Then, the combination of rehabilitation medicine as a team

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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

US, as well as to science. Therefore, people of the day believed that professional training in social andphysical science was important and could change the problems faced by wounded workers andsoldiers, which constitutes one of the causes for rehabilitation being introduced into healthcare.
Furthermore, medical education of the time, which was not founded on science- and research-based
universities/colleges, was reformed and it became necessary to train high-quality doctors; the doctors
were also supported by society as healthcare leaders. If we may make a shrewd observation, we could
say that improvement of rehabilitation healthcare is also regarded as a national strategy to promote thesocial recovery of the handicapped, boost productivity, and turn them into taxpayers.

medicine, including physical therapy, occupational therapy, speech therapy, and social workers andphysical medicine resulted in the establishment of the specialty “Physical Medicine andRehabilitation,” unified rehabilitation medicine, in 1947. As explained above, physical therapy has
evolved in a very close relationship with rehabilitation in the US to date. We have learned that strong
cooperation between politics and science (medicine), interdisciplinary professionalism, and a strong
force of will for self-determination lie behind the development of nations with advanced physicaltherapy, such as the US and Australia (mentioned above).
(Takashi Nakayama)

2.

Public Health (studies) and Physical Therapy

About half a century has passed since the birth of the profession of physical therapist in Japan. There
are over 120,000 physical therapists working in Japan, and their function and scope of work have
expanded. From now on, physical therapists will need to make further contributions to the health andlives of the people as established professionals supported by a long history.

Chapter 2

It is useful to discuss measures for taking advantage of the specialty of a physical therapist for thehealth and lives of the people from a public health standpoint. The legal bases for the promotion of
public health are Paragraph 1, Article 25 of the Constitution of Japan stipulating that “All people shallhave the right to maintain the minimum standards of wholesome and cultured living” and Paragraph 2
stating that “In all spheres of life, the State shall use its endeavors for the promotion and extension ofsocial welfare and security, and of public health.” Physical therapists have also addressed important
issues of public health (studies) up to now, such as industrial accidents, lifestyle diseases, andcommunity-based integrated care systems. Physical therapists also have a history of contributing to
public health measures, such as measures for polio and the war wounded and sick, which helps toestablish them as professionals worldwide. We can also say that physical therapy (studies) has
improved its specialty with public health (studies) as a backdrop.
It will be necessary for physical therapists to have a sense of contribution to the majority of the people
and develop their function and scope of work from a public health standpoint, focusing on ensuring ahealthy and cultural life and integration with social welfare and security. Their specific roles are
explained as follows: 1) Providing support to remove clients’ social barriers; and 2) Improving
participation restrictions and disabilities and policy recommendations.

1)

Providing support to remove clients’ social barriers

To target the majority of the people as clients and improve their health and lives, we must clarify ourview of society as physical therapists (i.e., the way that we look at our society). This is based on theprinciples of rehabilitation. To be more specific, physical therapists are in a position to promote
diversity with the idea of social inclusion.
Diversity is the idea that society is made up of various people: Some have disabilities and others do
not in this society. If we look at society in this way, disabilities will be perceived as social barriers. For
example, the fact of “being unable to walk” is considered gait disturbance due to physical function at apersonal level from a medical and biological point of view. However, with social barriers in mind,“being unable to walk” itself is not a disability. People who “are unable to walk” develop disabilities
because society is based on the assumption that people “are able to walk.” If our society is based on
the assumption that people who “are unable to walk” and “able to walk” live together, disabilities seenin this light will disappear and society will evolve to ensure that various people can move freely andfreely participate in society.

48
Chapter 2 Background of Public Health and Physical TherapyPhysical therapists are professionals who learn deeply about the principles of rehabilitation andunderstand both the medical and social models. The medical models are useful in taking an approachto physical function at a personal level, while the social ones are helpful for targeting a wide variety ofpeople as clients and eliminating social barriers.
Needless to say, it is important for physical therapists to demonstrate their specialty expertise on thebasis of medical models in clinical settings and, taking advantage of their specialty, they also have an
important role in the recognition of various people as clients and the provision of support for removing
their social barriers. Physical therapists are expected to have a definite view of society and provide
public health approaches (measures) in a flexible fashion.

2)

Improving participation restrictions and disabilities and policy recommendations

Physical therapist involvement has expanded to include preventive health care for the communitydwelling elderly, prevention of lifestyle diseases in the middle-aged and elderly, caregiver support,childcare support, and other services. In recent years, physical therapists are also given more
opportunities to earn an obvious professional position in systems and measures, such as support forcommunity rehabilitation activities. Examples of such evidence include approval of the use of the term
physical therapist in providing guidance on fall prevention to the community-dwelling elderly in “Useof the term ‘physical therapist,’ etc. (notification) (HPB-MPD Notification No. 1127-3 from the
Ministry of Health, Labour and Welfare, dated November 27, 2013).”
As their function and scope of work expand, physical therapists are expected to provide knowledge
and techniques to help improve clients’ (individuals and groups) participation restrictions anddisabilities from a rehabilitation standpoint. For example, if people cannot walk a long distance so they
go out in a wheelchair, differences in levels and ditches in the road will become a barrier to movement.
On such occasions, physical therapists can provide therapeutic exercise to the client to help themacquire the ability to walk without the level differences and ditches being a barrier. If the client isunlikely to acquire the ability to walk from a medical point of view, physical therapists can also
instruct him/her to get over the differences in levels and ditches by improving their ability to operate awheelchair. Moreover, they can also propose improving the differences in levels and ditches using theknowledge and techniques of their residential environment. Clients’ expectations for the ability ofphysical therapists to make various proposals mentioned above lie behind the expansion of theirfunction and scope of work. Too many physical therapists work at a medical institution now and theymust make an effort to be closer to the people. Providing physical therapists more opportunities tomeet various clients, including children, adults, and elderly people, in locations such as schools,
workplaces, and local governments, leads to improved utilization of their function and scope of work.
The knowledge and techniques regarding “restoration of abilities of basic activities” is the core of thespecialty of physical therapy (studies) and as professionals, physical therapists are also expected tooffer a high degree of professionalism and have the ability to socially recommend their knowledge andtechniques. Specific systems and measures for reasonable accommodation for the handicapped areneeded to realize diversity. In addition, we also need to implement systems and measures for theextension of healthy life expectancy to respond to the aging population and new occupational safety

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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

In the “Physical Therapists and Occupational Therapists Act” (Law No. 137), a physical therapist is
defined as a professional who “mainly in order to restore abilities of the basic activities, for people
with physical disabilities engage in therapeutic exercise or other exercise.” The clients (people withphysical disabilities) and specialty (restore their abilities of basic activities) are obvious in this Act. We
have a great pool of knowledge and techniques accumulated over half a century under this category. It
is often useful to not only people with physical disabilities but also those who may develop physicaldisabilities and their supporters.

and health systems and measures with a decreasing worker population in mind. As professionals who
are able to make use of both medical and social models according to social demands, physicaltherapists must also make a contribution toward developing systems and measures for the
improvement of participation restrictions and disabilities among various people.
Physical therapists as professionals must acquire the ability to make various proposals to individual
clients and also develop the ability to widely inform the people of these proposals as various policy
recommendations.
(Yasuyoshi Asakawa)3.

Population-at-risk Approach/High-risk Strategy and Physical
Therapy

The basic disciplines of public health include basic/clinical medicine and social science, such associology, economics, and law. Furthermore, we need to perform epidemiological analysis to connect
medicine with sociology and develop methods for solving public health issues on the basis ofassessment of health issues in public health studies and public health practice. Medical and healthcare
evidence refers to findings demonstrated by this epidemiological analysis. This approach involves
observation of a group of individuals to determine the cause of disease, and the methodology is
critically different from a medical treatment approach based on the etiology and pathology of disease
in individuals, which falls under the same category of medicine.
Chapter 2

It is important to see these approaches from an epidemiological and statistical standpoint. Based on theabove, we need to understand the method specific to public health studies.
As a practical example of physical therapy in public health studies, physical therapists were
responsible for manual muscle strength testing as part of screening programs for physicallyhandicapped children during the polio crisis in North America in the 1940s and historically contributed
toward understanding the number of patients. This is an example of how physical therapists
contributed to public peace by devoting themselves to not only rehabilitation healthcare but also to
public health. Physical therapists will be encouraged more to join public health activities. Thus, weneed to learn the target and issues of public health and their countermeasures.
The relationship between today’s physical therapy and public health comes to the surface. During thenovel coronavirus infection pandemic in 2020, physical therapists became aware that they would needto incorporate public health into physical therapy because they also had an occupational risk ofinfection within and outside the scope of medical practice.
In the sphere of public health, there are two different measures for identifying risk factors (risk) fordamaging the health of the population and reducing the risk, or a combination of these methods may
be used. There may be various risks with which physical therapy effectively deals (i.e., obesity causedby physical inactivity etc., occupational low back pain due to misuse or excessive use, falls, being
bedridden, infections [including infection itself and secondary transmission], secondary disorders,etc.). The frequency needs to be reduced in the population exposed to (affected by) these risks.
For this reason, methods called population-at-risk approaches or high-risk strategies are used to reduce
infection risk for the population and labor risk in dangerous environments, and to promote health(Figure 9).
These methods have evolved on the basis of the science of epidemiology. Basically, epidemiology
defines three factors, “person,” “place,” and “time,” and understands the health status and healthcompromising events by investigating the “number (frequency) of people with symptomatic events” tohelp develop measures.
50
Chapter 2 Background of Public Health and Physical TherapyPhysical therapy in clinical medicine reduces risk in individuals with disabilities, while public healthreduces risk in patients/clients and people with disabilities (populations), and it differs from physicaltherapy in terms of population risk reduction. Accepting the assumption that the distribution of the
population at risk follows probabilistic rules gives us a glimpse of how the science is accommodated.
To practice physical therapy in public health, therapists need to acquire skills to perform physicaltherapy and provide a wide variety of health education programs, understand and put such theories
into practice, and verify the results with a view to affecting policies for helping the handicapped andpeople at risk of health problems to make up for any deficiencies that cannot be remedied byindividual efforts, or they should have the ability to report in order to make a proposal. Although theseapproaches have been believed to work independently until now, physical therapists are to be
responsible for them as indicated in the mission statement of the WCPT.
Next, we will explain these approaches below:

1)

What is a population-at-risk approach?

A population-at-risk approach is based on the idea that the overall risk is reduced by focusing on theentire population rather than targeting individuals. This approach is based on the assumption that there
are some risks to the majority of people not considered high-risk, which will be discussed later, andthat there are more people carrying potential risk in the background.
Population-at-risk approach

Risks, including
obesity,occupational lowback pain, fall,
bedridden,
infection, andsecondarydisorderRisks, including
obesity,occupational lowback pain, fall,
bedridden,
infection, andsecondarydisorderChapter 2

High-risk strategy

Low

High

Low

High

Figure 9 Population-at-risk Approach and High-risk Strategy in Public Health Studies (the figure of
Ross Wilkie revised by the author; dashed lines represent a theoretical distribution and solidlines represent the state after intervention)

The population-at-risk approach is used to shift the distribution of risk in the entire population to lower
levels and may be effective in reducing morbidity and mortality in the whole population. Among thesestatistical indicators, morbidity refers to the rate of disease in a population. Mortality, one of the same
statistical indicators, refers to the number of deaths due to a specific disease. It is important to observe
the morbidity and mortality indicating the number of people per population. A technique called age
adjustment is needed to eliminate the effects of aging, especially for comparing annual changes. In
other words, we need to make an evaluation after removing the effects of aging. We must understandepidemiological statistics to produce evidence for the intervention effect of physical therapy in publichealth.
Before age adjustment, we need to select an age distribution meeting a certain standard as the standard
population (model population). In Japan, the age distribution of the population pyramid in 1985 is set
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Chapter 2 Background of Public Health and Physical Therapy

as the standard population (model population) and used to calculate age-adjusted morbidity andmortality.
It is thought that even if the age distribution changes with time, age adjustment may be used to
calculate morbidity and mortality with the same age distribution as that for the model population.
Direct and indirect methods are available for age adjustment.
The formulas for the direct method are:Age-adjusted
morbidity=ΣAge-specificAge-specific standard
×morbidity
population
Total standard population=

ΣAge-specificmorbidity

Proportion of age groups
to the standard population

×Chapter 2

We also need to consider differences in age distribution when determining whether morbidity or
mortality by municipality is higher or lower than the whole country or that in Tokyo or Osaka.
However, when age-adjusted morbidity or mortality by municipality is calculated, it may be
impossible to make an age-adjustment calculation using the above direct method in some cases
because the population size is too small to calculate age-specific morbidity and mortality for five-year
age groups. In such cases, indirect age-adjustment calculations are often made. In this approach, agroup with a relatively large size, such as the whole country or Osaka, is selected as the standard
group, age-specific morbidity in the group is used as a standard to calculate the “expected number ofcases” in the comparator group (group by municipality), and its ratio to the actual “observed cases” isused to determine whether the result is larger or smaller compared with the standard group. As
explained above, the “expected number of cases” represents the number of cases who developed
disease in the age distribution in each municipality compared with the whole country (standard group)
and if it is identical to the “observed number of cases,” it means that the occurrence of the disease in
the municipality is similar to that in the whole country.
The formulas for the indirect method are:
Expected
morbidity= ΣAge-specificmorbidity in thestandard group

Standardized incidence ratio
=
(SIR)

×

Age-specificpopulation in thecomparator group

Observed number of cases
Expected number of cases

After these analyses are performed, health indicators are evaluated in the target group.
This method specifically focuses on the dissemination and enlightenment of information and isthought to provide a few effective examples. The North Karelia Project in Finland is one of the bestpractices for taking these essential approaches. The North Karelia Project was the world’s firstcommunity intervention project to reduce deaths from ischemic heart disease in the 1970s and it was
Finland’s national project. Measures focusing on lifestyle intervention related to ischemic heartdisease (i.e., smoking, diet, and physical activity) were taken. For example, measures involving local
residents and relevant local organizations were implemented to promote health education among theresidents concerned by leaders selected from among the residents, groups of homemakers, and othergroups that played a responsible role in this project, as well as by local media. For dietary changes, thefood industry cooperated to reduce salt content in food products and agricultural policies were shifted.
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Chapter 2 Background of Public Health and Physical Therapy

Specific examples include the development of fruit that can grow in cold climates, provision of legal
support to dairy farmers that helped shift to fruit production, and agricultural promotion policies for
producing vegetable oil instead of butter. In the fifth year of the North Karelia Project, National Public
Health Institute, Finland, continued implementing the project and took charge of disseminating it fromthe model district to other areas, greatly contributing to its success. Taking these measures over 30
years resulted in changes in the dietary habits of the residents, decreased smoking rates, decreases inblood pressure and serum cholesterol, and reduction in the age-adjusted mortality from ischemic heartdisease by 85% for 35 years. Improvement in the subjective health of the population and life
satisfaction were also reported.
A national movement of health promotion (population-at-risk approach) is ongoing in Japan. It is
intended to widely disseminate the concept of metabolic syndrome, basic ideas of lifestyle disease
prevention, and other information among the people and improve the environment to support anindividual’s effort to improve his/her lifestyle and change his/her behavior as a whole society.

In Japan, physical therapists have been involved in community-based integrated care, lifestyle disease
prevention, public health programs for health maintenance, and fall prevention in a business promoting
preventive health care for the elderly.
Since the integration of the public health programs with preventive health care for the elderly, physicaltherapists have acquired an improved legal status as a result of policy recommendations and they arerequested to play a more active role.

2)

What is a high-risk strategy?

A high-risk strategy is a method of identifying and targeting individuals who are at high risk of
disease. This strategy simply focuses on a small number of people with problems.
In epidemiology, we need to understand statistical indicators for susceptibility to a certain disease
before assessment of high-risk individuals.
Prevalence and incidence rates are used to indicate the rate of disease.
They are similar but different, and we must differentiate between them; it is important to know thedifference.
Prevalence refers to the proportion of individuals in a population who have a condition at a specificpoint in time (e.g., during a test) aside from the time that they had the condition. Given that patients ina certain population have a condition that is not curable or not fatal, the number of the patients in the
population would increase. Therefore, the prevalence of the condition will rise. On the contrary, if thecondition is curable or fatal, the number of patients will decrease due to cure or death. Thus, theprevalence may increase or decrease depending on the balance of patients and individuals who newly
develop the disease.
Incidence rate refers to the rate of newly diagnosed cases of a disease or illness in a population over a
specific period of time. Since it targets newly diagnosed patients, only individuals who may develop

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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

Various reports have been made on the effects of this approach. They include effective and poor results
and vary depending on the combination of target, environment, and disease (health issues), although
we should not be too quick to conclude that this approach is ineffective. The results will always be
updated after a long verification period and by collecting many samples. We need to gather
information from almost all patients/clients with this approach and note that participation rates become
problematic in community health settings. This is because a low participation rate causes unclear
distribution of all data. In this case, it is necessary to figure out some way to improve the participation
rate and review matters including accessibility.

the disease during a specific period of time are included in the population selected for investigating theincidence rate. Taking infectious disease as an example, it is known that once infected, an individual
will develop immunity to it and not be infected again, and those who have acquired immunity are
excluded from the population for the purpose of incidence rate calculation. Only the occurrence ofdisease is related to the incidence rate. The resulting decrease in the number of patients due to cure or
lethality is not taken into account.
Physical therapy may be provided to populations with a high incidence of occupational low back pain,
populations with a high chance of becoming bedridden, populations in which it is necessary to prevent
contagious diseases, and populations with a chance of developing secondary disorders. A polio
epidemic in North America in the latter half of the 1890s is cited as one of the practical examples ofphysical therapy in a population of contagious diseases.
An epidemiological approach was taken to deal with the polio epidemic because its cause was
unknown at that time. To be more specific, it was thought that if people contracted a particular
infection, it could be prevented by isolating (quarantining) asymptomatic children from symptomaticones. Medical devices were less developed at that time and the onset of sudden immobility of limbs,“inability to move limbs,” at an early phase of infection was detected as effective clinical findings; themethod of objectively investigating the “movement of limbs” was devised.
Doctors and physical therapists trained by this method formed a caravan across North America and left
the University of Vermont and because of this event, rehabilitation medicine and physical therapy
gained social recognition in North America. This is one of the examples of the high-risk strategy used
to practice physical therapy.
Chapter 2

As a testing method adopting the idea of using gravity and resistance as mentioned above, MMT
programs were devised by Wright and Lovert at the Department of Orthopaedic Surgery, Harvard
Medical School, in 1912. Then, the programs were revised by Daniels in 1946, and most Japanesephysical and occupational therapists evaluate muscle strength according to this testing method.
In other words, this activity is fieldwork itself, targeting local residents, and it shows that public healthactivities stem from North American physical therapy.
World Physiotherapy mentions the organizations listed below, with which physical therapists
cooperate in practicing physical therapy, as high-risk strategies for disaster. In Japan, physicaltherapists played a role in reducing health risks in the Great East Japan earthquake and an earthquake
disaster in Kyushu.
For disaster response, we should not think little of or incapacitate local responders, but we should
provide support to them. They are responsible for the first response and keep offering opinions evenafter an emergency has occurred. After a response team has left, we should cooperate with the local
responders (and improve their capabilities). We need to consider rehabilitation services at an earlystage of the post-disaster response.
For the reduction of health risk in a population, the objective of the population-at-risk approach is todecrease the overall average. By contrast, the objective of the high-risk strategy is to reduce thenumber of individuals (incidence) who fall within the tail of the distribution curve in a high-risk
population. Proper selection of statistical indicators used in epidemiological statistics according topurpose is needed for the verification of evidence.
Japanese physical therapy developed in the context of rehabilitation was actively involved in clinicalmedicine. Then the novel coronavirus infection pandemic occurred, and physical therapists from allover the world started to look for a way to make use of remote physical therapy as part of service
delivery, and to implement measures to provide a balanced combination of public health activities andmedicine in taking an approach to real and virtual “environments.” When risk reduction in a
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Chapter 2 Background of Public Health and Physical Therapy

population was needed at the time that physical therapy merely emphasized manual contact as atherapeutic technique, it is important for us to focus on incorporating muscle strength testing using
gravity and learning skills effective for groups, with individuality emphasized, as well as a method thatutilizes a health education viewpoint. To maintain the Japanese system for medical treatment coveredby health insurance, we also need to develop the ideas and evidence of physical therapy in which
initiatives not included in those systems evolve together with public health studies, and this is one of
the themes for physical therapists who will assume the responsibility of providing physical therapy.
(Akira Kimura)

4.

Physical Therapy from the Point of View of a Universal Language
Called Evidence

1)

What is evidence?

Comparison validity is a measure of comparison used to interpret effect or association. Let us supposethat Ms. A is going to receive X and Mr. B will receive Y. Given that Ms. A is a woman in her 40s withstroke and Mr. B is a man in his 80s with stroke, can you conclude that “treatment X is more effective
than Y” if Ms. A made a better recovery than Mr. B?
Of course, the answer is No. This is because the extent of recovery may be affected by age or sex insome cases. As mentioned above, comparison validity refers to the degree of “comparability.”
Comparison validity will be 100% if the same person receives intervention under the same conditions.
Since this is basically not feasible, assessment of the “degree” becomes important. The study design is
one of the conditions for comparison validity.

Meta-analysis/SRs
RCTs
Non-RCTs
Cohort Studies
Case Control Studies
Case Series/Case Reports
Expert Opinions

Figure 10 Evidence Pyramid

Evidence is universally accepted and distinguished from treatment that is believed blindly andprovided solely on the basis of experience. Understanding the importance and utilization of evidence
in physical therapy is gaining currency throughout the world.

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Chapter 2 Background of Public Health and Physical Therapy

Chapter 2

Evidence is the facts, signs, or objects that make you believe that something is true. In medicine, itcarries a strong sense of proven rationale (or proof). The term evidence is also used to explain to thepatients in front of us that not only theoretical backgrounds are important, but the proof obtained fromthe verification results of similar patients is also important. The level of evidence widely used in thewhole of medicine is specified by the study design (Figure 10). The study design refers to the “type of
methodology used to conduct research” such as randomized controlled trials and observational studies.
Evidence level is the hierarchy determined by comparison validity.

2)What is evidence-based physical therapy (EBPT)?

As the name suggests, EBPT stands for “evidence-based physical therapy.” It is originally derived
from evidence-based medicine (EBM). EBM is a concept proposed by Guyatt in 1991 and defined byHaynes et al. as the “integration of a healthcare professional’s clinical experience with a patient’s
preference and behavior and evidence.” Besides the above three elements, “a patient’s conditions andcircumstances” are incorporated as the fourth element of EBM (Figure 11), which would be one of themost commonly used definitions of EBM in today’s healthcare settings. By definition, clinical practiceguidelines are useful as information containing these four elements.
When it comes to EBPT derived from EBM, it is also important for us to consider not only evidence
but also other factors such as clinical experience and patient values. On the other hand, we need tonote that we should not emphasize clinical experience only instead of evidence, because EBPT comesfrom the term “evidence-based.”Patient’s
condition andcircumstances
Healthcare
professional’s
experience

Patient’s
intention

Evidence

Chapter 2

Figure 11 Evidence-based medicine

3)

Information and health communication necessary to develop physical therapy
utilizing evidence

Clinical knowledge is essentially needed to practice EBPT, and we also need to acquire techniques fordetermining what kind of physical therapy would be appropriate for patients through communication
skills using health information. When you hear the phrase “communication skills,” you may easily get
the impression that this corresponds to the “ability to speak well.” Communication in physical therapy
based on public health (informative communication, health communication) means the method ofhandling information and specifically the way of providing patients with information for consensus
development in physical therapy.
Hoffmann states that “evidence itself is oppression, and integrating shared decision making (SDM)with patient-centered communication skills leads to optimal patient care” (Figure 12). For informed
consent, translated as “explanation and consent (in Japanese),” much emphasis has been placed on
obtaining consent, and its intended purpose of providing education with a focus on “patientparticipation” has lost substance. Paternalism, informed decision, and shared decision models are
originally known as consensus development models. Although all of these models are applied indifferent clinical settings, the paternalism model, in any event, will certainly not be selected in areas ofrehabilitation or physical therapy involving high uncertainty (there are at least two treatment options).
While patients are expected to choose the “treatment selected by healthcare professionals” during
informed consent, neither the healthcare professionals nor the patients know the destination when
undertaking consensus development in the process of SDM, and there is a possibility that neither ofthem will reach a conclusion. You can imagine that in the context of rehabilitation, the latter approach
would be a more suitable technique of consensus development with evidence-based individuality inmind.
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Chapter 2 Background of Public Health and Physical Therapy

Figure 12 Schematic Drawing of Shared Decision Making

For the practice of EBPT, it is desirable to explore communication techniques useful for developing
consensus by considering not only evidence but also factors such as patient’s values and resources.

References1)
Dean E, Skinner M, et al.: Health Competency Standards in Physical Therapist Practice.
Physical Therapy, 99: 1242-1254, 2019. https://pubmed.ncbi.nlm.nih.gov/31189180/2)World Health Professions Alliance: https://www.whpa.org/sites/default/files/2018-12/ncd_
Health-Improvement-Card_web.pdf (Published 2014. Accessed Oct 14, 2020)
3)
WHO: Global Action Plan 2013-2020.
https://www.who.int/nmh/events/ncd_action_plan/en/#:~:text=The%20global%20action%20pl
an%20offers,attain%209%20voluntary%20global%20targets%2C (Published 2013. Accessed
Oct 14, 2020)
4)
WHO: Closing the gap in a generation. https://www.who.int/social_determinants/
thecommission/finalreport/en/ (Published 2008. Accessed Oct 14, 2020)
5)
WHO (translated by Masako Kihara and Masahiro Kihara): Basic epidemiology (2nd edition).
Sanko Publisher, 2008
6)
Kondo K: Japanese Public Health Approaches to the Health Inequalities—Achievements andFuture Challenges—. The Journal of Public Health Practice, 84(6): 368-374, 2020
7)
Ministry of Health, Labour and Welfare: The Report on the Interim Evaluation of Health Japan
21 (the second term)
https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/kenkou/kenkounippon21.html(Published 2018. Accessed Oct 14, 2020)8)
Kondo K: Health Inequality Society—Causes of Mental Illness and Health Problems—.
Igaku-Shoin, 2005
9)
Uchiyama Y: An Introduction to Semiology of Dysfunctioning. Bunkodo, 2006
10) Uchiyama Y: Clinical Reasoning, Clinical Competence Required for Physical Therapists. The
Japanese journal of physical therapy., 43(2): 93-98, 200911) Wolf SL: Clinical decision making in physical therapy. F A Davis Co, Philadelphia, 1985
12) WHO, Homepage13) Sunahara S: Rehabilitation. Iwanami Shoten, Publishers. 1993
14) Ueda S: Discussing Rehabilitation—Total Restoration of Human Rights of theHandicapped—. Series of Issues Surrounding the Handicapped, 1987
15) Verville R: War, Politics, and Philanthropy - The History of Rehabilitation Medicine.
University press of America, 200916) Nakamura R: An Introduction to Rehabilitation Medicine (3rd edition), Chapter 1 Changes in
Rehabilitation. 2008, pp.4-19.
17) Chino N: Modern Textbook of Rehabilitation Medicine (revised 3rd edition), Chapter 1
General Introduction of Rehabilitation. 2009, pp.1-16.
18) Japanese Physical Therapy Association: A Fifty-Year History of Japanese Physical Therapy
Association. 2017
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Chapter 2(Shuhei Fujimoto)

19)
20)
21)
22)
23)
24)
25)
26)
27)

Japanese Physical Therapy Association: The 50th anniversary website of Japanese Physical
Therapy Association. http://50th.japanpt.or.jp/
Website of Osaka International Cancer Institute. https://oici.jp/ocr/data/glossary_003.html
Tomabechi K (supervisor), Miyagi S (written and edited): Health Care Management Theory(revised). Kenpakusha, 2014.
Puska P, Vartiainen E, Laatikainen T, et al: The North Karelia Project: From North Karelia to
National Action. Helsinki, National Institute for Health and Welfare, 2009.
Ross Wilkie: Population thinking for physiotherapists: the importance of epidemiology. keele
University, The Queen’s Anniversary Prizes for Higher and Further Education, 2009.
Yasobant S, Mohanty S: Would Physiotherapists be Public Health Promoters?: Concern or
Opportunity for Indian Public Health System. https://www.researchgate.net/publication/
316033865, 2020.9.10
Guyatt GH: Evidence-based medicine. ACP J Club, 1991
Haynes RB, Devereaux PJ, Guyatt GH: Clinical expertise in the era of evidence-based
medicine and patient choice. Vox Sang, 2002
Hoffmann TC, Montori VM, Del Mar C: The connection between evidence-based medicine
and shared decision making. JAMA, 2014

Chapter 2
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Chapter 3
Paradigm Shift of Physical Therapy (New Challengesof Physical Therapy - Physical Therapy in the Fields
of Prevention and Health Promotion)

 What you will learn in this chapter
Let’s think about new challenges of physical therapy - You will learn about physicaltherapy in the fields of prevention and health promotion.
The International Classification of Functioning, Disability and Health (ICF) takes healthconditions into account. Physical therapists play a major role in the maintenance andimprovement of quality of life (QOL) throughout a lifespan. In other words, we are in an eraof contributing to society with good and universal services for health promotion, disease
prevention, treatment and rehabilitation, non-infectious diseases, aging and performance
decline through therapeutic exercise and health education based on evidence. You will
study how these challenges have been undertaken in workplaces in fields such asadministrative, academic, and industrial using activities by predecessors as examples.

According to intervention modes, physical therapy can be mainly classified into direct physicaltherapy and indirect physical therapy. Direct physical therapy is literally direct intervention inpatients/clients such as manual contact and verbal instructions. Indirect physical therapy is anapproach through advice, instructions, environment improvement, and education. From the viewpointof development in the fields of prevention and health promotion, direct physical therapy is primarily
intervention using the basic skills of physical therapists at healthcare and nursing care-related facilities
and businesses such as hospitals. Similarly, indirect physical therapy involves giving advice topatients/clients, their families and caregivers, and providing consulting to companies,
recommendations for building design, and consultation and instructions on elderly housing as
healthcare service providers. It can also be anticipated that physical therapists will be involved inestablishing a base of healthy living and creating a community as administrators, a planning anddevelopment department for companies, and community development committee members.
Physical therapists’ skills are also useful for health promotion strategies to improve wellness throughprevention. In intervention by physical therapists intended to promote health, there is direct physicaltherapy to assess physical strength and prescribe exercises, and give exercise instructions based on the
results, and indirect physical therapy to provide guidance on health education, raising awareness of
exercises, lifestyle improvement, and doing exercises. In the development of physical therapy in thefields of prevention and health promotion, not only implementation of exercises is required, but also
psychological intervention to build a lifestyle suitable for prevention and health promotion such as
habitually performing exercises. As for doing exercises and raising awareness about exercising, thenecessity of exercising for the health of all people is obvious, so physical therapists can instruct onsafe and effective exercises. In addition to safe and effective exercise guidance, in order to gain an
exercise effect, it is necessary to begin exercising (development of exercise intention) in the first place

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Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3

Development in the Fields of Prevention and Health Promotion

and then to continue (adherence). For starting and continuing exercises, it is necessary to understand“enjoyment” and “adherence.” Csikszentmihalyi has named a comprehensive sense where one iscompletely absorbed in what they are doing as “flow” and described that people who experience flow
do not seek accompanying rewards but the flow experience itself. In the relationship between thepatient’s/client’s skills and the level of difficulty of a task (level of challenge), when those with poor
skills challenge a difficult task, it results in an anxiety experience. In contrast, when those with highskills do an easy task, it leads to a boring experience. A flow experience emerges when the levels ofskills and task match (Figure 1). For enjoying exercises, a flow experience is important, so motor tasks
suitable for the patient’s/client’s exercise skills must be selected. It is often seen for continuing
exercises that physical therapists are involved in a situation of triggering health anxiety by using therisk of disease that “you may get sick if you do not exercise.” However, exercising is essentially an
enjoyable activity. In other words, for expanding physical therapy in the fields of prevention andhealth promotion with performing and instructing exercises as keywords, physical therapy is required
to have an ability to provide the patients/clients with exercise enjoyment.

Opportunity to challenge(Level of difficulty of task)

High

Anxietyexperience

Boringexperience

Low

Chapter 3

SkillsLow

High

Figure 1 Flow State Model

Adherence is a word signifying “a person sticking or feeling attachment to something.” Adherence
related to exercise is a concept of showing strong will to continue exercising. Improving exercise
adherence is an effective health promotion strategy. There are various reports on factors related to thecontinuation of exercising, showing relationships such as a human relations (social interaction), effects
of exercise, motor skills, self-efficacy, location of an exercise place, and temporal factors. In addition,
an element of “games” is also important for performing and continuing exercises. “Games” are freeand enjoyable activities without conflict of interest. Roger Caillois classified games into four main
items: Agon (competition), alea (chance), mimicry (mimesis), and ilinx (vertigo). These four items, theelements of games, are compared in Table 1.

60
Chapter 3 Paradigm Shift of Physical Therapy

Table 1 Caillois Classification of Games (Elements and Main Items)
Caillois
Role for achieving
Example activity
Classification the goal of the game
Football,bowling,
Agon
Competition
shogi,
marblesRoulette,
lottery
Alea
Chance(Elements ofgambling)
Roles,
Mimicry
Mimesisplays,
playing house
Riding roller coasters
Ilinx
Vertigo(Acceleratory
stimulation)

In the fields of prevention and health promotion, physical therapy can be expected to expand invarious areas such as health education, government, industrial hygiene, school health, and healthpromotion for women. For intervention in patients/clients in all of these areas, the elements of games
should be incorporated as well as paying attention to flow experience and adherence.

1.

Physical Therapy in the Area of Health Education1)

Knowledge, willingness and ability to obtain, evaluate and use healthinformation

Health is defined as follows: “Health is a state of complete physical, mental and social well-being andnot merely the absence of disease or infirmity (the Preamble to the Constitution of the World HealthOrganization).” All people have a right to have healthy lives. Health education is intended to maintainand promote health and is applicable to nations and people in communities. It is supported byhealthcare specialists with medical knowledge and implemented on the basis of a prevention modeland healthy life expectancy extension model suggested by the Ministry of Health, Labour and Welfare,academic research associations, and research organizations such as universities (e.g., prevention oflifestyle diseases, prevention of a state requiring nursing care, prevention of athletic injury, etc.).
First, the acquisition of health information starts with defining the population from which healthinformation is to be obtained, and the target population, such as the elderly, school children, working
class, women and sport athletes, is specified. Next, clinical outcomes (diseases, death, injuries, or
performance decline resulting from disease) are chosen. Finally, risk factors for the clinical outcomesare grasped. The risk factors include not only personal characteristics and lifestyles (psychological andbehavioral factors) but also social and environmental factors.
Effective procedures must be selected for giving health education. Examination of research data isnecessary for determining more effective procedures. The following viewpoints must be available aswell for understanding scientific evidence: Has the health of human population been quantitatively
measured? Has the extent or degree of exposure to risk factors been understood by quantitative
measurement? Has the relationship between the level of health and follow-up results been assessed?
And because the time to clinical outcome varies among individuals, has the length of time beenmeasured (monitoring)? It is important to evaluate risk factors in a prospective study, and missing
important factors and drawing conclusions on the relationship with the wrong design is problematic;hence, prior knowledge on study design is also essential.
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Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3(Shinichi Daikuya)According to a document issued by the Ministry of Health, Labour and Welfare, health education is to“support individuals, families, groups or local communities to gain necessary knowledge bythemselves, and be able to make necessary decisions and master faculty to proactively work on the
problems with which they are confronted when these parties solve health issues that they haveencountered.” In order to be able to make decisions and master faculty, intentional encouragement topromote behavior changes is necessary instead of education to pass on knowledge or giving
instructions (described later). In other words, physical therapists are required to gain support skills to
help the residents act to maintain health as a result of their voluntary and free choice.
The amount of medical knowledge has exponentially increased in the 2000s, and the number ofprocedures for obtaining data has been growing through databases and applications on the Internet.
Information in English-speaking countries can be instantly collected with the advancement of
automatic translation functions. A drastic augmentation in the amount of knowledge and knowledge
sharing is astonishing. Physical therapists should not only scrutinize resources that they havepossessed in the past, but also make an effort to provide the public with maximum value by
consciously and constantly noticing new information so that they can absorb it, leading to behavioral
changes.
Behavioral science therapy covering intervention techniques is a common health education model.
Based on the recognition of benefit and burden of modifying behavior and actual behavioral
experience, decision making is enhanced to make health-oriented behavior habits. In addition,
elevating self-eﬃcacy is important (described later), and the experience of achievement, verbal
explanation and feedback, and internal perception should be used to reflect them in the educational
process.

Chapter 3

Under Health Japan 21 and the Revised Health Promotion Act, physical therapists may have theresponsibility to clarify health education policies and explain the results of activities to healthinsurance premium payers and local society. In addition, physical therapists may have the role oftackling the issue of how to respond to the “right to be continuously healthy,” which common fromchildren to adults and the elderly in a super-aging society, as well as receiving criticism from third
parties and strong suggestions from society.

2)

Prevention of diseases and health promotion in daily living

What we can assume from preventing diseases in daily living is preventing lifestyle diseases. Lifestylediseases is a collective term for diseases that are closely associated with the continuation ofunfavorable lifestyle habits, i.e., poor diet, a lack of exercise, smoking, drinking and stress, affecting
body functions. This was previously referred to as adult diseases, but was changed to be called
lifestyle diseases because they may occur in non-adults as well.
Lifestyle diseases include cancer, cerebrovascular disease and heart disease, but diabetes mellitus,
hypertension, arteriosclerosis and dyslipidemia, which are considered to be risk factors for these
diseases, are also part of lifestyle diseases.
Now, let’s think about “habituation of behavior” for preventing these lifestyle diseases.
The first aspect is “habituation of exercise.” When hearing “habituation,” those who are not conscious
about exercise in regular life may put too much pressure on themselves and find it difficult.
“Habituation of exercise” does not mean to start a sport or go jogging, but to consciously act to move alittle bit more than now in daily living. To continue patiently every day is the first step. To “walk(walking)” is frequently done when moving in daily living. To walk even a short distance has been
known to consume one’s energy two to three times more than when sitting at rest. For example,
individuals should try to start with walking 10 minutes longer than now. In cities where public
transportation is developed, the distance between stations is short so it is recommended to get off the62
Chapter 3 Paradigm Shift of Physical Therapy

train or bus one station early and walk to the final destination. Office workers who often eat out atlunch are advised to go to a restaurant a little farther than that they usually go to. In addition, many
simple wearable physical activity trackers and pedometers have been distributed in recent years. If
specific numerical values can be checked with the use of such tools, desired values can be set, andpeople can more eagerly incorporate moderate exercise.
The next aspect is “smoking cessation.” Immediate smoking cessation leads to disease prevention.
Cigarettes contain many toxic substances and greatly adversely affect health. Decades ago, thesmoking rate was 70 to 80% for adult men but had largely decreased to 29% in a recent survey (2018).
Furthermore, with the total enforcement of the Health Promotion Act on April 1, 2020, indoor smoking
was, in principle, banned, resulting in more thorough prevention of undesirable passive smoking. Bytaking this as a good opportunity, individuals should be recommended to incorporate smoking
cessation behavior to lead to disease prevention and health promotion.
For “meals,” the balance between an appropriate amount of energy and nutrition is important. The
necessary amount of energy is determined based on age, body composition and the amount of activity.
The balance between intake and consumption of energy should be kept. A method to reduce only
certain nutrients or reversely increase them may be temporarily effective in some cases but it cannot be
concluded that it provides a good effect in the longer term. Drinking and between-meal eating are also
included in this energy and nutrition balance so attention should be paid to that.
The final aspects are “stress measures” and “rest.” It can be considered that no one is free of stress,
such as relationship stress at work and school, commuting stress, and family stress. Ways of copingwith stress vary such as exercise and travel, but it is important to find a way to release stress that issuitable for oneself. Sleep is expected to be effective for recovery from exhaustion by physical andmental relaxation. Regular sleep keeps the physical and mental balance, and this can be considered tolead to disease prevention and health promotion.

3)

Chapter 3

Physical therapists are mainly involved in the habituation of exercise. Not only this, but also having
overall lifestyle habits in place is crucial for disease prevention and health promotion. Hence, physicaltherapists should also be actively involved in it.

Maintenance and improvement of QOL throughout the lifespan

In order to improve QOL, in addition to being healthy, it is necessary to maintain opportunities for ties
to peers and social contribution. Aging while having a purpose in life and keeping vitality is essential
for society where postponing the retirement age is promoted due to a low birthrate and aging
population. Not only healthcare professionals but also the government and community resident
networks are needed for supporting QOL.
For maintaining and improving QOL throughout the lifespan, good and universal services are requiredfor health promotion, disease prevention, treatment and rehabilitation, non-infectious diseases, aging,and performance decline. Directly, this means health education based on pathological mechanisms,
and a public health science procedure (prevention model) is often employed. It is to regulate risk
factors that are related to health deterioration or that inhibit health maintenance. Physical therapists
cannot intervene in the characteristic of age but should attempt to eliminate changeable factors if they
induce a negative outcome (e.g., smoking) and add factors if they lead to health promotion (e.g.,
exercise habits). Support is given to groups, but the effect elevates by stratification or individualizationaccording to the level of behavior changes achieved. In the future, physical therapists should be awarethat a multimorbidity state will increase more, and the list of issues concerning the modes of
impairments and performance decline as well as participation restrictions will become complex.
In addition, it is anticipated that as backgrounds surrounding the elderly, difficulties with decision
making, an increase in people living alone (social isolation), solitary death, abuse by relatives, minor
63
Chapter 3 Paradigm Shift of Physical Therapycrimes attributable to economic poverty, shrinking social security costs, and changes in one’s view oflife and death (wanting to give up fighting against a disease) frequently occur, thus physical therapists’ability to solve social issues will also be tested. Local living used to rely on informal care mainly by
nearby relatives such as families, and social problems were properly managed by cooperation with andmutual aid by relatives and neighbors. Today, ties among residents have diluted, and informal care has
weakened. In local regions, the reality is that the population of younger generations at the productive
age is small, so knowledge about supporting residents who are likely to be left behind and dealing withdifferences in the degree of living hardships is required as well. A key to supporting QOL may becreating mechanisms of “self-help, mutual aid, mutual legal assistance, and public help” for eachregion.
The goal is to aim for a state in which individuals can have self-care and self-control. What should becontrived is that self-care and self-control are feasible, can be started today, can be expressed asconcrete numerical values, have countermeasures if they are difficult, are decided by residents, areshared with specialists, and can be self-monitored.
Physical therapists need to have the ability to enhance and maintain physical, mental, and social
viability necessary for the elderly and residents with performance decline to live a local life. Trying tosolve phenomena caused by various factors, which is not just the issue of chronic diseases such as
lifestyle diseases, may be a response to social demands.

4)

Holding a health education class by physical therapists

Chapter 3

As previously mentioned, it has been considered that health education is to support individuals,
families, groups or local communities to master faculty to proactively work on health problems withwhich they are confronted.” Health education is given as encouragement to promote healthmaintenance and has the aspects of prevention, early detection and early treatment, treatment, andrehabilitation. It is necessary that as a result of health education, the said parties make a habit ofhealthy living, are motivated to change their behavior, acquire the knowledge and skills necessary forthe behavior change, and actually change their behavior.
There are a variety of entities and scales of holding health education classes: They may be held by
local governments such as municipalities or as part of research by universities, research institutes orcompanies. The former is held by a community, such as a town or city, by persons in charge in the
town or city in consideration of the health management of the townspeople and citizens. The latter isheld to achieve the purposes of the sponsors (evaluation on the effect of intervention in the elderly
population, discovery of monitors for new products being developed, etc.) and can be structured toaccomplish the goals of the health education participants and beneficial for those who are participatingin the next class reflecting research results. In many cases, not only physical therapists but also
specialists such as physicians, nurses, health nurses, dietitians, and clinical psychotherapists are
involved in holding them. This may be because intervention using specialized knowledge is required
to achieve the aforementioned goal of health education.
“Behavior change,” the goal of the health education class, alters according to the situation thatpatients/clients are in (including environment, personal background and concept of values). There arepeople who understand it as knowledge but are in an environment where they cannot reflect it in actual
living or behavior, or do not intend to reflect it. Also, there are people whose living activities change(including changing in the wrong direction) without them realizing it and they do not understand the“behavior change” or have incorrectly perceived it. It is necessary to add that class participants(patients/clients) can voluntarily think, notice, and change their behavior. These changes, “behavior
change,” are expressed as five stages (precontemplation, contemplation, preparation, action, and64
Chapter 3 Paradigm Shift of Physical Therapymaintenance stages). Changes move from the precontemplation stage to the contemplation stage, andthen to the next stage: What perspective is necessary for maintaining the behavior change.
The concept of self-eﬃcacy is essential for encouraging a behavior change. Self-eﬃcacy refers to anindividual’s belief in his or her capacity to execute necessary behaviors and a degree of confidence,and is a factor involved in the behavior change that is the goal of health education. People with highself-efficacy can be said to be more easily able to sense a benefit from the behavior change. Methods
to increase this self-efficacy include (1) setting a simple topic/goal and gradually elevating it, (2)praising when the goal is attained, (3) presenting a role model, and (4) giving specific instructions.
Since physical therapists are specialists of perceiving human movements, they are often involved inhealth education classes from this viewpoint of movements. Physical therapists are expected toaccurately analyze the patients/clients’ movements and understand their current status and then advise
the patients/clients on their future motor behavior, and continuously aid them.
However, it does not mean that it is fine to only observe physical “movements.” As previously
mentioned, there are not only the movements themselves but also a variety of matters that must be
grasped: The psychological aspect of whether the patients/clients are willing (eager) to exercise;
whether the patients/clients have understood appropriate exercise methods and the favorable andadverse effects of exercising; whether the patients/clients are in an environment allowing them toexercise; and what support they have from their family and surrounding people. After understanding
these, physical therapists must prepare and provide the participants of a health education class with an
exercise program for a group and personalized exercise programs, induce a behavior change, and be
involved in maintaining the changed behavior.

2.

Physical Therapy in the Preventive Field
Current Status and Future Direction of Physical Therapy in thePreventive Field

1)

Current status of physical therapy in the preventive field

The first demographic transition refers to the transition from high to low fertility and mortality withthe modernization of society, whereas the second demographic transition is the transition from low
fertility and high mortality to an equilibrium population level. The demographic transition in Japanwas high fertility and mortality before the second world war to low fertility and mortality during
Japan’s economic boom, and then to low fertility and high mortality in 2008. This is associated withchanges in disease structure, so the demographic transition is also called an epidemiological transition.
Infection and perinatal disorders are issues in societies with high fertility and mortality, whereas noninfectious diseases such as lifestyle diseases are issues in societies with high fertility and low mortality
or with low fertility and mortality. Also, geriatric syndrome/frailty, which can hardly be referred to as
diseases but are declines in physical, mental and social function associated with aging, are issues forsociety with low fertility and high mortality. In addition, unlike diseases, no one can avoid death andaging (Wallace, 1992) so a manner of coping with them as things that should not be evaded but
accepted, which is different from that for diseases in the past, is needed. This is similar to accepting
disabilities. Under this circumstance, expectations are widely growing for the application of physicaltherapy, which specializes in the studies of function and impairment, to the people in the preventive
field.
In order to meet such expectations, physical therapy has to undergo a paradigm shift to incorporate
public health, preventive medicine, and knowledge on health promotion. For example, therapeutic
medicine focuses on the negative aspect of diseases and is given according to a disease avoidance65
Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3(Yorimitsu Furukawa/ Kazuhiro Harada)

model to detect and treat affected sites early, whereas preventive medicine and health promotion focus
on the positive side of health and are carried out with the salutogenesis model to increase behaviors
good for health as much as possible. The disease avoidance model that weighs importance on results islikely to change patients/clients’ behavior, but when the importance of the result, that is health, isfundamentally low, it is difficult to induce a behavior change.
Antonovsky (1979) has stated that for transition to the salutogenesis model, it is important to use thesense of coherence that individuals have acquired in their lives to properly cope with a variety ofstresses. Furthermore, Baltes (1990) has affirmed that instead of a negative concept such as stress,
derivative events should be perceived as a factor promoting development of humans, and thisdevelopment is unlikely to be affected by aging: so he stated the idea of life-span development. Withthe use of this salutogenesis model and the concept of life-span development for conventional physicaltherapy, instead of focusing only on the negative side of diseases or declining functions such as
lifestyle diseases and geriatric syndrome, physical therapy in the preventive field, which can positively
regard the current health condition as a result of adaptation by individuals, is needed.
With the aim of establishing such physical therapy in the preventive field, the Japanese Society ofPhysical Therapy for Prevention (JSPTP) was founded in 2016. The JSPTP has defined preventive
physical therapy science as “a study to research physical activity including the prevention of the onset
and recurrence of diseases, which may cause disabilities, and geriatric syndrome for the people to keep
participating until the end of time.” The areas of the study cover the elucidation of mechanisms, onset
prediction, development of preventive methods, development of devices, creation of social activity,and drawing up of systems. This concept includes the creation of a society in which individuals can
successfully acquire health.

Fertility
rate

Mortality
rate

Chapter 3
High fertility and mortality

High fertility and low mortality

Low fertility
and mortality

Year

Low fertility andhigh mortality

Vital statistics

Figure 2 Trends in Fertility and Mortality Rates in Japan

2)

Specificity of physical therapy in the preventive field

In preventive medicine, prevention is classified into prevention starting from the healthy state (primaryprevention), prevention starting after having risk (secondary prevention), and prevention ofprogression and recurrence starting after onset of disease (tertiary prevention) according to thepatients/clients. In this context, physical therapy equals tertiary prevention and has been playing amajor role in preventive medicine. In the preventive field, physical therapy is subject to primary andsecondary prevention as well. Hence, for physical therapy in the preventive field, the effect isvalidated when the knowledge of physical therapy accumulated for tertiary prevention is extrapolated
to primary and secondary prevention, and preventive intervention at new personal, social, and personal
x social levels on the basis of the salutogenesis model is studied and practiced. By the way, physicaltherapy is treatment, but the patients/clients of primary and secondary prevention are not those with
66
Chapter 3 Paradigm Shift of Physical Therapydiseases so this term is inappropriate. For this reason, instead of treatment, intervention is used forphysical therapy in the preventive field.
Physical therapy is therapeutic medicine, so evaluation of effects needs to be determined by arandomized controlled trial (RCT). This requires a premise that patients select a good therapy. In
physical therapy in the preventive field, however, the patients/clients do not always choose a goodintervention. The freedom of choice is greater compared with that for therapeutic medicine: The effectshown by an RCT does not mean the effect of the intervention. The product of the effect and theprobability of selecting the intervention should determine the effect of the intervention. Therefore,
even if confounding factors are less controlled compared with an RCT, study procedures, to which theeffect of selection can be added, such as a propensity score method, is used for physical therapy in thepreventive field.
Conventional physical therapy

Tertiary prevention(Prevention of progression andrecurrence in people with diseases)

Secondary prevention(Prevention of onset in people at risk)Primary prevention(Health promotion)• Tertiary prevention- Prevention of recurrent stroke- Prevention of exacerbation of COPD
- Prevention of recurrence of low back pain,
knee pain• Secondary prevention- Musculoskeletal disorder- Cerebrovascular diseases- Industrial injury- Geriatric syndrome• Primary prevention- Safe community- Health Japan 21 (the second term)- Age-friendly city

Furthermore, "Action Research” has been gaining attention in recent years (Haga 2020). A
characteristic of action research is that the patients/clients are also involved heavily in developing the
research design. Conventional studies clearly divide those who intervene and those who are intervened
upon. However, when intervention is at a social level, the patients/clients’ encouragement to society is
not ignorable. Thus, instead of ignoring it, adding the power of the patients/clients and anyone
surrounding such people makes the intervention more effective and durable. The scientific validationof this research is still technically difficult, but the integration of advanced technologies, such as
objective description of subjective activities by residents using artificial intelligence (AI), is also acharacteristic of physical therapy in the preventive field.

3)

Techniques required for the preventive field

In medicine, informed consent (IC) is considered to be critical. The actual circumstance is the processof a knowledgeable specialist explaining an appropriate treatment method to a patient to convince
him/her. This effectively functions when the effect of treatment is reliable but is unlikely to function
when there are two or more comorbid treatments or the effect is not definite but may be to someextent. In other words, when patients have broad choices that they can initiatively make, there arelarge limitations on IC. Shared decision making (SDM) is to replace IC because the super-aging
society and many comorbidities make the extrapolation of the effect of treatment to the young
generation difficult in a clinical study, and independent selection by patients is needed in recent years
for terminal care, etc. This is exactly the technique needed for the preventive field. Since healthbehavior is an act that people choose by themselves, the technique of SDM is particularly important.
For SDM, first, physical therapists must be aware that they are partners who select an intervention
with the patients, then it is necessary to present an appropriate number of options, provide evidence

67
Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3

Figure 3 Difference between Physical Therapy Science and Preventive Physical Therapy Science.
Examples of studies are presented on the right side.

used as criteria for selection, and make agreements on the reevaluation of the selected intervention.
Furthermore, regional SDM is required instead of personal SDM at a “community salon,” etc. held bya regional community. It has been called regional normative integration: Instead of communicating thecreation of a healthy living area downwardly from the government, it is necessary to develop atechnology to perform an analysis with a community and form consensus on the modality of thecommunity based on a fact-finding survey of living areas.

4)

Creating a society where people want to be healthy

For making people want to be healthy in a super-aging society, the society wishing them to be healthy
must expect the people to play new roles. The continuity theory in gerontological sociology holds that
individuals want to maintain activities as they did when they were young if the given conditions allow.
In contrast, the disengagement theory in social gerontology holds that the society exempts the elderly
from obligations, leading the elderly to actively disengage from their roles. Of course, excessive role
expectation damages motivation for health, but insufficient role expectation also impairs motivation
for health. In the modern world, role expectation from society rapidly decreases after retiring fromwork or child rearing due to a nuclear family style of living and the gap between a domicile andworkplace caused by highly developed economic structure. This is supported by the result of our mailsurvey in the urban elderly: While those with instrumental activities of daily living (IADL) disability
accounted for 5.8% of those with effective answers, 51.9% answered that they had communication
with a relative or friend less than once a week, showing that losing social interactions is more common
than a decline in physical or mental function. Maslow (1943) states that for maintaining the need for
self-actualization, the esteem-needs and need for social role must be satisfied. In the state that people
cannot feel their social roles due to a lack of social interactions, it is natural to lose interest in healthmaintenance, which is the basis of self-actualization.

Chapter 3

In other words, it is insufficient to attribute future health making only to individual effort, but a society
where people want to be healthy until the end of time needs to be built. In particular, the embodimentof living in which people can feel their roles after retiring from work and child rearing is an urgent
need. Fortunately, physical therapy has a proven record of community-based rehabilitation (CBR). By
reevaluating this CBR and changing the objective from the dissemination of rehabilitation to thecreation of a society where everyone wants to be healthy regardless of age or disabilities, thisembodiment can be realized.
(Shuichi Obuchi)

3.

Physical Therapy in the Administrative Field
Current Status and Future Development of Physical Therapy in the
Administrative Field

1)

What is the administrative field?

Administration is one of the elements of the so-called “separation of the three powers,” i.e.,“legislation,” “judicature,” and “administration,” and it is the governmental authority to govern.
“Administrative bodies” handling these are mainly divided into the government and local publicauthorities. The local public authorities include prefectures and municipalities as well as agencies
operated by these, such as public health institutes and welfare offices. Civil servants employed by thegovernment are called national government personnel, and those employed by local public authorities
such as prefectures and municipalities are referred to as local service personnel. Laws that are handled
by national government personnel and local service personnel differ, but all civil servants are in theposition set forth in Article 15, Paragraph 2 of the Constitution: “All public officials are servants of thewhole community and not of any group thereof.” The Local Public Service Act states that they have a
68
Chapter 3 Paradigm Shift of Physical Therapy

mission: “Local service personnel serves for public interest as servants of the whole community.”
Physical therapists employed by the administration are in charge of healthcare and welfare as havingsuch a mission. In recent years, the number of physical therapists employed through the mode ofoutsourcing of business, teaching remuneration, and fiscal year employees (former temporary workers)
as administrative services particularly from the municipalities has been increasing in addition toadministrative full-time employees. Administrative services widely include physical therapy atmunicipal hospitals, municipal nursing care facilities, and nursing facilities. Here, I describe physicaltherapy at administrative bodies such as prefectural governments, municipal offices, welfare offices,
health centers, and public health institutes, excluding therapeutic acts at medical, nursing care, andwelfare facilities.

2)

Current status of physical therapy in the administrative field

The characteristic of physical therapy in the administrative field is not physical therapy as atherapeutic act for individual patient/client but is mainly management operation. It is defined as “to aid
individuals or a whole community to be able to voluntarily work on health making and preventive
health care for the elderly, grasp local issues, draw up a plan for solutions (operations), assess results,
and develop social resources necessary for solving these issues regardless of the age of thepatients/clients and the presence or absence of disabilities” (“Role function of administrative physicaltherapists and occupational therapists” with modifications prepared in the “Study on effective businessdevelopment with involvement by administrative physical therapists and occupational therapists,” an
FY 2009 Community health comprehensive promotion project).
Physical therapy in the administrative field has five role functions as shown in Figure 4.

Directapproach

People needing
support[1] [3]
Relevant people,
organizations[2] [4]

Core people ororganizations

People needing
supportIndividual support

Chapter 3

Physical therapy in theadministrative field

IndirectapproachCommunity support[5] Establishment of a plan, operation management, etc.
Figure 4 Role Function of Physical Therapy in the Administrative Field The report of “a study on
effective business development with involvement by administrative physical therapists andoccupational therapists,” an FY 2009 Community health comprehensive promotion project,with modifications

Each function is as follows: (1) Individual support/direct approach: This is the implementation of
direct physical therapy (e.g., functioning/physical function assessment for preventive health care forthe elderly) involving “individuals” and a consultation activity, including approaches (fall prevention
class, low back pain improvement class, etc.) to involve “individuals” as the target and a “group” as ameans; (2) Individual support/indirect approach: This is an operation (e.g., advice on a plan at
individual community care meetings) to indirectly support “individuals” to aid the applicable“individual” supporters or teams instead of direct operations; (3) Community support/direct approach:
69
Chapter 3 Paradigm Shift of Physical Therapy

This is an operation to directly intervene in “organizations,” ‘groups,” etc. having common needs tosupport their community making (e.g., course on demand as support for launching a community
salon). This includes not only specific groups such as “XX Group” but also the creation of a wholecommunity or regional network; (4) Community support/indirect approach: This is an operation toindirectly support residents voluntarily develop community making through involvement in a “core”
group or person (e.g., the leader of preventive health care for the elderly, the president of a club for theelderly) of the region (e.g., course for an officers’ meeting such as a meeting of residents’ associationpresidents). This includes not only specific groups such as “XX Group” but also the creation of awhole community or regional network; and (5) Establishment of a plan, operation management, etc.:
This is a production-like operation to examine a community based on the involvement in theabovementioned four role functions and investigation, execute the project based on them, establish andevaluate plans at various levels involving the entire community, launch new projects, and manage
outsourcing.
For these five role functions, their operations exist on an equal footing as shown in Figure 5.

Specialized support for the wholecommunity(5) Establishment of a plan,
operation management(4) Community support/indirect
approach operation(3) Community support/direct
approach operation(2) Individual support/indirect
approach operation(1) Individual support/direct
approach operation

Specialized support for individuals

Chapter 3

Figure 5 Flow of the role functions of physical therapy in the administrative field The report of “a study
on effective business development with involvement by administrative physical therapists andoccupational therapists,” an FY 2009 Community health comprehensive promotion project,with modifications

3)

Operations related to physical therapy in the administrative field

There are a variety of operations related to physical therapy in the administrative field. The contents ofoperations vary according to the population size such as government-designated cities and core cities.
In recent years, the flow of transition from the prefectural governments to local governments has been
accelerated, and the larger the population size, the stronger the tendency to transfer administrative
affairs of the prefectural governments. Under the circumstances in which administrative personal andoperations are reduced, operations engaged by specialists such as physical therapists have been tended
to be outsourced from direct management by the administration to private sectors as entrusted
business.
The main operations of physical therapy in the administrative field can be classified into five areas.

(1)

Area concerning children (e.g., infant health examination project, home-visiting consultation
operation, technical support for other job types at related facilities, and planning nurturing and motherchild policies)(2) Operations concerning persons with disabilities (e.g., operation related to assistive device
distribution project, daily supply provision project, disability determination investigation operation,
physical disability certificate distribution project, job assistance operation, local service adjustmentrelated activity, and planning of welfare policies for persons with disabilities)(3) Area concerning the elderly (e.g., project for preventive health care for the elderly,
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Chapter 3 Paradigm Shift of Physical Therapy

comprehensive support project, operation for investigating the certification of care need, operation forthe committee for certification of need, planning of welfare policies for the elderly)(4) Area concerning health making (e.g., specific health guidance, operation for building awarenessof health making, and planning a health making policy)(5) Others, role to coordinate rehabilitation resources: Local rehabilitation coordinator (including
countermeasures against disaster), industrial area (e.g., work environment arrangement), building andcivil engineering area (e.g., making accessible buildings and roads), educational area (e.g., preventionof sports disorders and health checkup at school), etc.

4)

Future development

For future physical therapy in the administrative field, it is necessary to understand an entire
community from more diversified perspectives than ever, have the ability to plan projects suitable forthe actual conditions of communities, and to develop the projects: Management and coordinating
capacities. The basis is a capacity for gathering information. As well as analyzing quantitative data(which are numerical data for example, statistical data such as vital statistics, and questionnaire survey
results) and qualitative data (e.g., frank opinions of residents such as prior review, interview, social
gatherings as well as what the secretariat and responsible persons usually feel) to grasp the actual
conditions of communities, the ability to extract regional topics, and plan and execute measures forsolving the topics is necessary for physical therapy in the administrative field.
In the medical and nursing care fields, patients/clients receiving physical therapy by physicaltherapists may have some knowledge of physical therapy, but there are many residents who do noteven know the phrase “physical therapy” in operations related to physical therapy in the administrative
field. This is also the case for administrative staff. This point is specificity of physical therapy in theadministrative field. However, being able to be involved with many residents from the stage where
physical therapy as treatment has not yet been needed and to increase the recognition of physicaltherapy are also specificities of physical therapy in the administrative field. I expect that more physicaltherapists are engaged in physical therapy in the administrative field and thereby physical therapy isrecognized widely and properly by the people.
(Nobuko Ohsaka)

4.

Physical Therapy in the Industrial Field
Current Status and Future Direction of Physical Therapy in the
Industrial Field

1)

Current status of physical therapy in the industrial field(1) What is physical therapy in the industrial field?
Physical therapy in the industrial hygiene field is referred to as industrial physical therapy. Currently
in Japan, no definition of industrial physical therapy has been determined. The industrial hygiene field
is based on the Industrial Safety and Health Law. This Law is intended to promote the prevention of71
Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3

As for future development, projects for integrated implementation of public health programs withpreventive health care for the old-old, and a multi-layered support system development project topromote community making to realize a community cohesive society as a deepening of communitybased integrated care system may be developed in regions. A project for integrated implementation of
public health programs with preventive health care for the old-old, cooperation among three areas incharge of health insurance for the old-old, health making, and preventive health care for the elderly isneeded. The multi-layered support system development project is applicable to all generations from
infants to the elderly and requires cooperation among all of the aforementioned areas of physicaltherapy in the administrative field.

health problems and its maintenance with basic concepts to manage three areas: Health, working
environment, and work.
(2) Current status of industrial physical therapy
Physical therapists are extremely rare in an environment where they can give guidance on physicalactivity and daily life, including instructions on work environment improvement and management
systems to ameliorate health problems of workers while they are on duty at a hospital. The Industrial
Safety and Health Law stipulates that only one industrial doctor and one health supervisor shall be
designated at a workplace with  50 employees. Not only are physical therapists and other specialists
not specified to be appointed in the Law, but also physical therapists are not included among themembers composing of this field, while industrial doctors, dentists, nurses, health supervisors, laborand social security attorneys, and industrial health consultants are included.
(3) Industrial physical therapy in foreign countries
In the US, Australia, and Holland, which are industrially advanced countries, industrial physicaltherapy has been established. Exercise guidance for the prevention of industrial injury, ergonomic
assessment of work posture, and instructions to improve the motor function of older workers arecarried out, and their results are recognized by the people. The mode of industrial physical therapy is acontract between a physical therapist office in practice and a company in the majority of cases, butsome companies directly employ physical therapists (Figure 6).
Mode of industrial physical therapy in foreigncountries

Company including adoctorContents ofoperation

Contract

Company
Employs

Physical therapist
office in practicePhysical therapist

Chapter 3• Exercise guidance for the prevention ofindustrial injury• Ergonomic assessment of work posture• Instructions to improve the motor function ofolder workers

Figure 6 Mode of Industrial Physical Therapy in Foreign Countries(4)

Establishment of the Section of Physical Therapy in Occupational Health in theJapanese Physical Therapy Association
In the Japanese Physical Therapy Association (JPTA), the Japanese Society of Physical Therapy andits subordinate agencies consisting of 12 subcommittees and five sections were established in 2013.
The Section of Physical Therapy in Occupational Health was included as one of them.

2)

Potential of physical therapy in the industrial field(1) Contribution to health and productivity management and work-life balance support“Health and productivity management” are to strategically implement health management from theviewpoint of business management based on the concept that efforts in maintaining and promoting
employees’ health are investments to increase profits in the future. The expected effects of health andproductivity management may be improvement of the working environment, amelioration of thecompany image, and disease prevention measures, and active involvement in the health maintenanceand promotion of employees may be essential for the continuous development of companies in the
future. Health consultation, support for health screening, aid for cancer screening costs, reduction in
total work time, smoking measures, and harassment education are worked on mainly by industrial

72
Chapter 3 Paradigm Shift of Physical Therapydoctors and public health nurses. In the future, establishment of schemes to manage data on healthconditions and living habits and efforts in the visualization of health and productivity management
have to be initiated. “Work-life balance support” is one of the important efforts in Japan’s Plan for
Dynamic Engagement of All Citizens by the government; because the aging of workers and thenumber of people working while having diseases are anticipated to increase, the administration has
been asking companies for support. In recent years, it has been included in key words in the industrial
hygiene field. Physical therapists, who have a strong point in functional evaluation, are expected toactively participate in this field in terms of these two key phrases, “health and productivity
management” and “work-life balance support.”(2) Contribution to the primary preventive field
The “Physical Therapists and Occupational Therapists Act” (Law 137) established in 1965 limited thatphysical therapy would be applicable only to people with physical disabilities. After time passed, it is aknown fact that a revolutionary notification was issued by the Health Policy Bureau, Ministry of
Health, Labour and Welfare in November 2013 regarding the use of the name of physical therapists:“Physical therapists may perform operations in a scope not corresponding to assistance of medical caresuch as guidance on fall prevention to people without physical disabilities in the services of preventive
health care for the elderly. When performing such operations other than physical therapy, there is no
problem with using the name of physical therapists. In addition, when carrying out such operations ina scope not corresponding to assistance of medical care, no instruction of physicians is required.”
Today, the government’s policy and needs when implementing preventive physical therapy are
specified. Hence, physical therapists must aim to be recognized as specialists who can contribute tohealth management of not only people with disabilities but also those who are at risk of disabilities byaccumulating the intervention effects through involvement.

Chapter 3

Under the circumstances that almost no health supervisors with ergonomic knowledge have actually
been nurtured, the fact is that physical therapists, who have knowledge of body function andergonomics, are expected to acquire knowledge on safety and health, and exert the specialty andinitiative.
(3) Contribution to the society of older workers
The continued employment system set forth in Article 9 of the revised Law Concerning Stabilizationof Employment of Older Persons obliges employers to raise the retirement age and introduce systems
such as the introduction of the continued employment system. With the use of this system, physicaltherapists may well be able to contribute to ensuring maintenance of the labor population byevaluating the motor function of middle-aged and elderly persons who wish to work and giving
guidance to promote the employment of middle-aged and elderly persons (Figure 7). Merits gained
from employing the elderly are suggested to be not only merits for the elderly themselves but also a
reduction in medical costs as a result of continuing work. In addition, to inhibit the elderly who arecapable of working from working leads to an increase in burden of intergenerational support.

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Chapter 3 Paradigm Shift of Physical Therapy

Challenge and Prospects of Industrial Physical
Therapy in Japan
Contribution to society of older workers
Company
Want to use knowledge andexperience as keeping bodyfunction

Workers
The body is battered but want
to work.

Matching between physical characteristics of a reemployed person
and workplace(To adjust the workplace to the physical characteristics)
Physical therapists are involved to support the labor population in
Japan.

Figure 7 Contribution to the Society of Older Workers (Draft)3)

Future direction of physical therapy in the industrial field

Chapter 3

Regarding health and productivity management, companies’ care for their employees’ health will bevery important for company risk management, and ergonomic hygienic management may beconsidered to be effective from the standpoint of productivity enhancement. Furthermore, the handlingof companies with less than 50 employees may be reexamined. If physical therapy can be recognizedin this field, it can contribute to solving inherent social issues such as aging society, labor shortage,
and an increase in social insurance premium as well as to expanding the working area of the wholesociety. Then, why has industrial physical therapy still not become common? This is because (1) nobusiness model has been established; and (2) no intervention results have been accumulated (Table 2).
In other words, a platform for disseminating physical therapy in the industrial field in Japan needs tobe established. As for the direction of platform establishment, the World Wide Web (WEB) and digitaltechnologies must be actively used as means of facilitating recognition and spread. It may benecessary to build a system through which physical therapists can remotely give support. By adopting
a subscription-type business model, accumulation of data on intervention effects, a results feedback
function, questionnaire surveys, market analyses, and thinking about work style from a different angle
may be necessary. The use of the WEB and digital technologies has been found to be the optimal wayof raising awareness about physical therapy and disseminating its expertness, so establishing asystematic system to use and education on rules for its use are urgent needs. Since activities in theindustrial field require having the viewpoint of society as a whole, it is an area that current pre- andpost-graduation education cannot shoulder. The necessity of education in this field is expected to grow.

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Chapter 3 Paradigm Shift of Physical Therapy

•
•
•
•
•
•

•
•
•
•
•
•

Table 2 SWOT Analysis of Physical Therapy in the Industrial Field
Strength
Weakness
Expert skills• Overwhelming lack of results of the effects of(physical assessment, ability to analyze work
intervention in the field concerned (overwhelming
environment)
lack of studies and papers)
Thorough knowledge on disease treatment• Overwhelming lack of work experience in the field
Exercise guidance according to symptoms
concerned
Easily cooperating with other job types• Low recognition of physical therapists in the field
Validation of the effect of intervention using
concerned
statistics• No established intervention model/system
Distribution route through a network of connections • Time constraints of physical therapists, side businessfor the time being?
• Insufficient pre- and post-graduation education
Opportunity
ThreatArrival of society of older workers (introduction of • Poor company performance• Participation of other professions and job types
system to raise the retirement age)
• Repellence by existing professions
Increase in awareness of health and productivity
management (effort is companies’ mission.)
Increase in the needs of efforts in the reform ofworking practices
Increase in the needs of efforts in productivity
enhancement (limitation of hygienic management
only by staff physicians?)
Increase in telework due to the COVID-19
pandemic, a lack of communication among
employees, elevation in health injuries
Acute advancement of communication technology(5G, DX, etc.)(Shigeto Yamazaki)

5.

Physical Therapy in the Scholastic Field
Current Status and Future Development of School Health, etc.

1)

What is school health?

School health is literally “to protect (maintain) health” at school. Health services are activities tomaster culture and climate related to health promotion, health awareness, and disease prevention at asocial organization (e.g., groups by age and local community). In other words, school health is anactivity allowing mastering of culture and climate related to health promotion, etc. at school. Hence,
because school health is a health service (social work and cultural program) at school, which is a placeof educational business, it is desirable to develop it through deepening various discussions by
involving not only a single profession but also various other professions and people in general.
According to the School Health Safety Law, school health is intended to stipulate the mattersnecessary for health management at school to maintain and promote the health of its pupils and staff,
and to specify the matters necessary for safety management so that educational activities at school are
carried out in a safe environment ensuring the safety of pupils, thereby contributing to the smooth
implementation of school education and securing results. The methods include the following:

(1)
(2)
(3)

Establishment of a school health plan
Standards for school environmental health
School infirmary

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Chapter 3 Paradigm Shift of Physical Therapy

Chapter 3“What can we do to contribute to society?” – It is only by continuing to strategically challenge that we
can raise awareness about and entrench industrial physical therapy

(4)
(5)
(6)
(7)
(8)

Health consultation, etc.
Health guidance
Collaboration with local medical institutions, etc.
Health checkup
Prevention of infection

Of these, health guidance is stipulated in order to understand the mental and physical condition of
pupils on a daily basis, and when a health problem is identified, to give necessary instructions without
delay and advice to their guardians as needed. Health checkup is specified to prevent and treat diseaseor instruct treatment based on its results, and appropriate measures such as exercise and reducing work
shall be taken. In addition, health checkup includes health checkups of pupils and staff while attending
school. Article 14 of the School Health Safety Law stipulates that appropriate measures such as
intervention and exercise for disease prevention based on health checkup results should be taken.
Furthermore, the Enforcement Regulations of School Health Safety Law specify prevention andtreatment of disease and guidance after health checkups.
The potential for physical therapy to contribute to prevention and health promotion in the field of
school health includes a healthcare model for being involved in health consultation and guidance andaftercare for health checkup, and an education model to give health education and guidance and for
raising awareness. Physical therapists are specialists that eliminate problems extracted from physicaltherapy assessments in people with a decreased ability of basic activities or functioning due todiseases, trauma/disabilities, aging, etc., and those who are at risk of such, and seek tomaintain/improve and ameliorate body functions including motor function and the ability of basic
activities. At school, physical therapists are expected to actively participate in both the healthcare andeducation models for exercise guidance and prescription, and give movement guidance to not only
people with abnormalities with musculoskeletal disorder, respiratory or circulatory organs, or
metabolic function, cerebral paralysis, developmental disorder, etc. but also to healthy pupils andschool staff.
Chapter 3This paper addresses a wide range of activities for pupils and staff at school without dividing physicaltherapy in the scholastic field into regular classes and special needs education, from the viewpoints of
prevention and health promotion using the skills of physical therapists at school, in light of the purportof this chapter, i.e., physical therapy in the field of prevention and health promotion.

2)

Physical therapy for school health (methods and types)

There are two types of example cases where physical therapists work on health management at aschool site in collaboration with a school physician, health and physical education teacher, and nursing
teacher: They are involved with a sport department, or involved with the “school” without being
limited to the sport department. In the case of involvement with a sport department, a physicaltherapist is positioned between a coach and pupils and their guardians, and explains the healthcondition of the pupils to the coach, provides information helpful for improving the safety andcompetition power of the pupils, and actually gives guidance to the pupils. For the pupils and theirguardians, the main activity of the physical therapist is to reduce their fear of injury (Figure 8). In
contrast, in the case of broad involvement with a school, through collaborating with a school
physician, nursing teacher, and health and physical education teacher, the physical therapist may be
involved in the health management of pupils and school staff with the use of his/her specialized
knowledge such as physiology and kinesiology. Specifically, this is the implementation of healtheducation and exercise guidance based on the school physician’s instruction, advice for consultationfrom the nursing teacher, and health and physical education teacher, and cooperating in collaborative
activities (Figure 9).

76
Chapter 3 Paradigm Shift of Physical TherapyAt a school site, physical therapists are anticipated to be able to use their skills as follows:

Games? Training?
Necessity of medical
examination
Risks
Guidance/Consultation

PupilsGuardians

Prevention of trauma
Enhancement of physicalstrength/competition power
Sense of security

Appointment plan
Enhancement of competition
power
Sense of security

Coach

Want totake part in games
Fear of injury
Want to do training
Want to improve

Physicaltherapist

Physical therapists give advice on improvement of impairments, exercise
guidance, and instruction on actual training, etc. based on functional assessment.

Figure 8 Role of Physical Therapists in the School Sport Department
Nursing teacher
Health and physicaleducation teacher

School doctor

Healtheducation
Exerciseguidance

Consultation/Request

Physicaltherapist

Chapter 3

Inquiry
cooperation/ medical examination of
musculoskeletal system

Cooperation/Advice

PupilsSchool teachers

Instruction/Request

Figure 9 Role of Physical Therapists at School(1)

Actions and prevention of trauma and disabilities during classes such as physical education andclub activities
Direct actions for trauma and disabilities in learning activities, medical check and exercise
guidance for students, education contributing to the prevention of injury, and the like(2)

Improvement of lifestyles (obesity measures)
While taking account of the social environment surrounding students such as the popularizationof smartphones and gaming devices, involvement in reducing habits of not exercising by
making students, etc. realize the joy of exercising through exercise experience, etc.

(3)

Fitting of desks, chairs, and shoes
As a specialist of posture and movement, actions such as raising awareness about the adverse
77
Chapter 3 Paradigm Shift of Physical Therapyeffects (e.g., deterioration of posture, learning effects, and various musculoskeletal
malfunctions) of desks or chairs not fitting the physical size and the relationship ofmusculoskeletal abnormalities such as the foot region, e.g., slippers, gym shoes, the size ofshoes worn for exercising, the strength of cushioning properties, and way of wearing shoes(stepping on the heels, etc.)

Chapter 3(4)

Exercise prescription and health management for students with medical conditions (e.g.,
cardiovascular deformity and renal disease)
Guidance and advice on the appropriate amount and method of exercise after various
professionals have decided a safe and effective amount of activities for students with medical
conditions (e.g., physical education activities) in collaboration with a primary physician, school
physician, nursing teacher, health and physical education teacher, and others instead of a choice
between “doing” and “prohibiting” exercising(5)

Advice (risks and effects) on the selection, arrangement, etc. of playground equipment andexercise machines
Contribution to practicing (experiencing) safe and effective physical activities by selecting thetypes and sizes of various playground equipment and instruments used for exercising (physicalactivities) and thinking out their arrangement in the school(6)

Measures after medical examination of musculoskeletal system
Follow-up of students who were suggested to have abnormalities, and guidance, education, etc.
contributing to the prevention of musculoskeletal abnormalities based on the usual posture andmanner of exercise to pupils in whom no abnormalities were detected(7)

Health education
Education on items such as the body, posture, movement, and injury(8)

Individual and group lessons
Direct instruction on improvement and prevention of worsening to pupils with abnormal healthconditions, and guidance to groups such as classes and grades(9)

Mental health
It is a known fact that exercising has a good effect on mental health. Physical therapists may be
involved in mental health with exercise as a keyword.

(10) Health management and promotion (disease prevention) of school staff
Actions for musculoskeletal disorders such as low back pain, lifestyle diseases, mental health,
etc.

3)

Future direction

In collaboration/cooperation with stakeholders, namely the school physician, teachers (particularly thenursing teacher and health and physical education teacher), assistant principal, principal, and guardians(parents), activities contributing to the health promotion of pupils are required at school. In addition,
information sharing and cooperation with the board of education, prefectural governments, andmunicipalities are also important. In order for physical therapists to operate in the scholastic field, it is
crucial to encourage each stakeholder to understand the skills of the physical therapists and properly
act in close cooperation with various professionals. Physical therapists in the scholastic field can do
activities in the healthcare model and in the education model based on instructions of the school
physician and in cooperation with the school physician and nursing teacher.
As for a career plan and self-improvement into human resources who can actively participate in aschool setting, it is first essential that physical therapists learn about the “school.” Physical therapists
becoming involved in the scholastic field is not only for the purpose of transferring their workplacefrom a healthcare setting to a school; physical therapists must reinforce the perception that their
purpose is to create a climate and culture that aids in nurturing healthy children and leads to healthpromotion throughout life up to preventive health care for the elderly, which is the educational and78
Chapter 3 Paradigm Shift of Physical Therapysocial significance of school health. Schools are places of education, and professionals coming into
contact with children are required to have not only specialized knowledge and skills but also to berefined human beings with life experience. It is necessary to produce and nurture human resources
who can achieve such educational and social significance as well as enhance self-improvement andlife experience to realize it.
(Shinichi Daikuya)

6.

Physical Therapy in the Field of Women’s Health
Current Status and Future Development of Physical Therapy in the
Women’s Field

1)

Physical therapy in the women’s fieldPhysical therapy in the women’s field is applicable to a variety of women such as musculoskeletal
dysfunctions in perinatal women, pelvic floor dysfunctions in middle-aged women, sports disorders infemale athletes, osteoporosis in postmenopausal women, and lymphoedema in women who underwent
surgery for breast cancer or gynecological cancer, and it is needed throughout all stages of a woman’slife.
(1) Musculoskeletal dysfunction in perinatal women
A musculoskeletal dysfunction representative of perinatal women is low back/pelvic girdle pain. The
alignment of the spine and pelvis of women change due to pregnancy and childbirth, and child-rearing
activities after delivery increase the burden on the lumbodorsal muscles. Low back/pelvic girdle painis known to affect postnatal depression, and a leave of absence for active intervention of physicaltherapists is expected. When intervening for perinatal women, physical therapists must have athorough knowledge on the physiological changes in the body associated with pregnancy andchildbirth.
Chapter 3

In addition, women have had remarkable full participation in society in recent years; many women
return to work after childbirth. Good health condition is essential for women to work while raisingchildren after pregnancy and delivery. For this reason, aid from a preventive standpoint may benecessary. Not only support to improve decreased musculoskeletal function that occurred before andafter delivery is required, but also intervention that takes into account the psychological burden
anticipated when reintegrating into society.
(2) Pelvic floor dysfunctions in perinatal or middle-aged women
Pelvic floor dysfunctions such as urinary incontinence, pelvic organ prolapse, and sexual impairment
occur in not only middle-aged women but also young perinatal women, and they have been known tosignificantly affect the QOL of women. Numerous studies have reported that physical therapy forpelvic floor dysfunctions is useful for improving these symptoms, and it is considered to be one of thespecialized areas of physical therapists.
(3) Sports disorders in female athletes
In recent years, female athletes play remarkably active roles, and some of them are globally activefrom an early age. One of the reasons may be that training suitable for individuals is performed basedon scientific evidence. However, because female athletes are likely to face physical, mental, andenvironmental changes, actioning these changes is also an issue for continuing athletic sports. The
female athlete triad is known to comprise “functional hypothalamic amenorrhea,” “osteoporosis,” and“eating disorder (lack of available energy).” The onset of the female athlete triad may affect female
body development, so it is necessary to fully understand these symptoms and prevent their onset. For
the modality of support for female athletes, studies have been undertaken and comprehensive andstrategic efforts have been made. In order to aim for a high level of exercise performance from a

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Chapter 3 Paradigm Shift of Physical Therapy

young age, conditioning not only the musculoskeletal system but also the endocrine system isimportant. Because abnormalities in menstruation due to a decrease in body fat may occur in female
athletes, support for preventing abnormalities in menstruation associated with excessive exercise isnecessary.
(4) Osteoporosis in postmenopausal womenJapanese women were reported to have an average life expectancy of 87.45 years (Ministry of Health,Labour and Welfare) in 2019, and thus Japan is a super-aging society. The average age of menopause
in Japanese women is reported to be 49.47 years (Tamada, et al. 1995), so the duration of
postmenopausal life is nearly 40 years. In postmenopausal women, bone density acutely decreases due
to reduced estrogen secretion, frequently causing osteoporosis. In order to prevent osteoporosis
resulting from bone fractures and extend healthy life expectancy, it is necessary to monitor bone healthand make an effort to provide therapeutic exercise to maintain and improve bone density and fall
prevention. In addition, it is important to do an appropriate amount of exercise throughout life fromchildhood through to adulthood and the elderly years to maintain bone density. Physical therapists may
participate in the prevention and intervention of osteoporosis in all life stages.
(5)

Lymphoedema in women who underwent surgery for breast cancer or gynecologicalcancerLymphoedema occur in the arms and trunk (chest and back areas) in women who underwent breast
cancer surgery, particularly with axillary lymph nodes dissection, and in the lower body below theumbilical region in women who underwent gynecological cancer surgery with pelvic lymph nodes
dissection. The treatment of lymphoedema is referred to as “complex physical therapy” and includes[1] skin care, [2] manual lymphatic drainage, [3] compression therapy, and [4] therapeutic exercise
under compression. In recent years, it has been called “complex treatment” by adding [5] daily living
guidance to these.

2)

Current status of physical therapy in the women’s field in Japan

Chapter 3

Physical therapy in the field of women’s health is expanding from individual activities toorganizational activities. In 2016, the Section on Women’s and Men’s Health, Japanese Society ofPhysical Therapy was established. The number of members registered in this division has increased
and was 5,977 as of July 2020.
(1) Musculoskeletal dysfunction in perinatal womenFor cases such as low back/pelvic girdle pain, physical therapy can be provided as musculoskeletal
rehabilitation under health insurance treatment. In recent years, the number of physical therapists
engaged in rehabilitation in perinatal women in cooperation with obstetricians/gynecologists has been
growing.
(2) Pelvic floor dysfunctions in perinatal or middle-aged women
Health insurance treatment is not yet applicable to physical therapy for pelvic floor dysfunctions, andvery few medical institutions are actually providing rehabilitation as a healthcare service not coveredby insurance. In the FY 2016 revision of medical service fees, an “independent voiding guidance fee”
was newly established. Institutional criteria for calculation specify forming a voiding care teamcomposed of physicians, nurses, and physical therapists/occupational therapists to engage in care forpatients by various professionals. With this opportunity, in recent years, the number of physicaltherapists involved in rehabilitation for pelvic floor dysfunctions is gradually increasing.
(3) Sports disorders in female athletes
Physical therapy for sports disorders in female athletes has been practiced. However, there are few
physical therapists who are involved in guidance on posture during exercises and training instruction
for the prevention of diseases that frequently occur in women, such as anterior cruciate ligament
damage. Furthermore, measures to terminate the chain of the female athlete triad are necessary. To do
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Chapter 3 Paradigm Shift of Physical Therapy

so, self-care is needed to regulate the menstrual cycle, but there appears to be few physical therapists
who are proactively performing activities to prevent fatigue fractures associated with osteoporosis in
medical institutions. There is an opinion that support is needed for students who do strenuous exercise
during extracurricular activities at junior and senior high schools, so it is preferable to implement anapproach for women at the age of puberty in school education in the future.
(4) Osteoporosis in postmenopausal women
The Japanese Guideline for Prevention and Treatment of Osteoporosis 2015 Edition published in 2015
states that in a systematic review or meta-analysis of therapeutic exercise for osteoporosis, increasing
the bone density of postmenopausal women is rated Recommendation Grade A, recognizing thatintervention for postmenopausal osteoporosis is a critical item. Resistance and muscle strengthening
exercises, aquakinetics, balance exercises, impulsive motion, mixing motion, etc. have been reported
as therapeutic exercises for osteoporosis. In reality, however, it is difficult for general middle-aged andelderly persons to self-manage the implementation of therapeutic exercise, and it has been suggested
that guidance and management by physical therapists, etc. are essential. In recent years, opportunities
for physical therapists to play their roles are not just for secondary prevention at medical institutions,but have been expanding to primary prevention for local residents.
Lymphoedema in women who underwent surgery for breast cancer or gynecologicalcancer
The number of opportunities to give physical therapy has been growing for impairment after
mastectomy in breast cancer patients and after surgery in gynecological cancer patients. The
calculation of a “rehabilitation fee for cancer patients” established in 2010 was limited to, for example,
breast cancer patients “who were admitted to the hospital and will undergo or underwent mastectomy
with lymph node dissection during hospitalization and may develop movement disorder of theshoulder joints after surgery.” Nonetheless, in the FY 2020 revision of medical service fees, restricting
calculation according to cancer types, treatment methods, severity, etc. was eliminated. Furthermore, a“complex treatment fee for lymphoedema” was newly included in insurance coverage in 2016. In alymphoedema outpatient unit, which is recommended to be established mainly in cancer basehospitals, physical therapists have also been permitted to provide medical care that can be calculated
for the lymphoedema guidance fee and complex treatment fee for lymphoedema for cancer patients.
Hence, the number of opportunities for physical therapists to get involved with patients with breast
cancer and gynecological cancer may further increase.

3)

Current status of physical therapy in the women’s field in foreign countries

In Western countries, physical therapy in the women’s field has been recognized as an area ofexpertise and actively intervenes in treatment. One of the World Physiotherapy subgroups is theInternational Organization of Physical Therapists in Pelvic and Women’s Health (IOPTPWH). The
IOPTPWH specifies that its mission is to “improve health care internationally through facilitation andpromotion of best-practice of pelvic and women’s health physiotherapy.” After the IOPTPWH wasformally recognized as a subgroup at the World Physiotherapy Congress (Yokohama) in 1999, Japan
also became a new member in 2019, and it has become a subgroup in which 30 countries participate.
Forming close cooperation with the IOPTPWH member countries in the future may be a significant
driving force to bring physical therapy in the women’s field in Japan to a level equivalent to global
standards. The IOPTPWH was formally called the International Organization of Physical Therapists in
Women’s Health (IOPTWH), but because physical therapy is also applicable to pelvic floor
dysfunctions in men and children, the name has been changed to the International Organization of
Physical Therapists in Pelvic and Women’s Health (IOPTPWH) since 2019. Such an international
trend suggests the importance of developing physical therapy in not only the women’s field but also
the men’s field in the future.

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Chapter 3 Paradigm Shift of Physical Therapy

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(5)

4)

Future prospects of physical therapy in the women’s field

The Section on Women’s and Men’s Health conducted a survey among its registered members in
2019. The results revealed that the number of members who underwent training on physical therapy inthe women’s field was limited, and many responders wished to learn basic knowledge. Hence, a topic
for this field is to spread its knowledge to many physical therapists. To do so, it is necessary to provide
more study opportunities by holding training workshops, etc.
In addition, evidence reflecting the circumstances in Japan needs to be established in the future. Basicdata obtained so far are mainly from implementation in Western countries, so there may be differencesin physical constitution and social systems. Understanding the disease conditions in line with thecurrent status in Japan and searching symptom analyses, evaluation methods, and treatment methods
may lead to the provision of effective physical therapy.
In recent years, countermeasures for symptoms and diseases specific to women have been organized.
In contrast, diseases unique to men have not been sufficiently focused on. A disease specific to men is
prostate cancer, and therapeutic exercise is carried out for urinary incontinence after prostatectomy inWestern countries. Physical therapy for men’s health should be promoted to improve the maintenanceof men’s QOL.
Clinical settings are necessary for physical therapists with knowledge in this field to provide patients
who actually have problems with physical therapy. To secure the clinical settings, understanding
professionals in other fields is essential. At present, the independent voiding guidance fee and cancer
rehabilitation fee, etc., can be calculated for health insurance, but the scope is limited, and somephysical therapy is provided as a healthcare service that is not covered by insurance. In order toprovide physical therapy more widely in this field, it is desirable to expand the scope of fees calculable
for health insurance and get involved with patients as a member of a medical team.
(Ayako Yamamoto/Tomoe Inoue)
Chapter 3

References
1)
Japanese Physical Therapy Association: On-line Health in Smart and Super Cities—Fall
Prevention, Dementia Prevention, and Health Promotion by Physical Therapists—. Smart City
Institute Japan’s webinar materials, 2020, 9.11
2)
Csikszentmihalyi M: FLOW: the psychology of optimal experience,1st ed. Harper & Row,
NY, 1990, pp.71-93
3)
Dishman RK(Ed): Advances in exercise adherence. Human Kinetics, Champaign, IL, 1994
4)
Dishman RK(Ed): Exercise Adherence‒Its impact on public health‒. Human Kinetics,
Champaign, IL, 1988
5)
Bulls (Ed): Adherence issues in sport& exercise. John Wiley& Sons, England, 1999
6)
Roger C: Man, Play and Games (translated by Ikutaro Shimizu and Kazuo Kiriu). Iwanami
Shoten, Publishers. 1998, pp.15-55
7)
Website of Friends of WHO JAPAN; What is the World Health Organization (WHO) Charter?
https://japan-who. or.jp/about/who-what/charter/(quoted on November 2, 2020)8)
Miyasaka T, Kawata C, Yoshida T (written and edited): Current Health Science Supplement
Vol. 1, Health Education Theory. MEDICAL FRIEND Co., Ltd., 2007
9)Densen P: Challenges and opportunities facing medical education. Trans Am Clin Climatol
Assoc,122:48-58, 201110) Committee for Preparing Textbooks for Healthy Longevity Classrooms: Textbooks for Healthy
Longevity Classrooms (2nd edition). National Center for Geriatrics and Gerontology, 202011) Okado J, Hoshi T, Hasegawa A, Takabayashi K, Watanabe T, Fujiwara Y: Total Review ofSubjective Health and Its Supportive System. Comprehensive urban studies, 73, 2000
12) Antonovsky A: Health, stress and coping. Jossey-Bass, San Francisco, 1979
13) Baltes PB, Baltes MM: Successful aging. Perspectives from the behavioral science.
Cambridge University Press, New York, 1990.
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18)

19)
20)
21)
22)
23)
24)
25)
26)

Haga H (written and edited): Action Research Strategies. WORLD PLANNING, Tokyo, 2020
Maslow AH: A theory of human motivation. Psychological Review.50(4):370-396, 1943
Wallace RB: The epidemiologic study of the elderly. Oxford University Press, Oxford, 1992
Japanese Physical Therapy Association and Japanese Association of Occupational Therapists:“A report on the study of effective business development with involvement by administrative
physical therapists and occupational therapists,” an FY 2008 Community healthcomprehensive promotion project,” March 2009
Japanese Physical Therapy Association and Japanese Association of Occupational Therapists:“A report on the study of effective business development with involvement by administrative
physical therapists and occupational therapists,” an FY 2009 Community healthcomprehensive promotion project,” March 2010
Japanese Nursing Association: Consultation Project for Enhancing the Activities of Public
Health Nurses,” March 2011
Kumashiro M: Aging Management Useful in Hiring the Elderly—Approach from Industrial
Hygiene for the Realization of a Society in Which People Remain Active Throughout Their
Lives—. ROUDOCHOUSAKAI, Tokyo, 2011
Yamazaki S: Current Situation and Future Perspective for Physical Therapy in Occupational
Health. Journal of the Japanese Physical Therapy Association, 2017
Yamazaki S: Current Situation and Future Perspective for Physical Therapy in Occupational
Health. Japanese Journal of Occupational Medicine and Traumatology, 2018
Uchiyama Y, et al. (edited): Standard Physical Therapy Science, Specialty, Physical Therapy
Assessment. Igaku-Shoin, 2019Japanese Organization of Physical Therapists in Women’s Health (edited): Women’s HealthRehabilitation. MEDICAL VIEW CO., LTD., 2014
Uesugi M (supervisor), Yamamoto A, Araki T (edited): Women’s Health Therapeutic Exercise
for Physical Therapists. Ishiyaku Publishers, 2017
Suzuki S, Inoue T (edited): Practical Continence Rehabilitation Approaches for Rehabilitation
Staff. MEDICAL VIEW CO., LTD., 2018

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15)
16)
17)

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Chapter 3 Paradigm Shift of Physical Therapy

MATERIAL What you will learn in this chapter
This chapter addresses the knowledge and philosophy necessary for physical therapists todeepen your understanding; i.e., ethical issues (bioethics, medical ethics, and professional
ethics), physical therapy management (safety management and crisis management
measures) as well as the International Statistical Classification of Diseases and Related
Health Problems, the International Classification of Impairments, Disabilities andHandicaps, and the International Classification of Functioning, Disability and Health.

1.

Physical Therapy and Ethics

Ethics (life, medical, occupational and research), management (medical safety, prevention of medical
accidents, infection prevention measures, personal information protection, and Personal Identification
Law) as well as the International Classification of Impairments, Disabilities and Handicaps (ICIDH)
and International Classification of Functioning, Disability and Health (ICF) are important for
healthcare professionals to have knowledge in. This chapter therefore summarizes them as material.

1)

Bioethics

Ethics is social regulations and rules accumulated from “the right conduct of people or reversely thewrong conduct of people.” Ethics has almost the same meaning as morals. Ethics can also be the studyof logically systematizing rules and principles to classify correct and wrong actions and methodology.

MATERIAL

Among the subtopics of ethics, bioethics deals with issues concerning life and medicine. Bioethics can
be classified into medical ethics and research ethics. When applying it to physical therapists, medical
ethics is clinical ethics and professional ethics related to the clinical activities of physical therapists,and research ethics is ethics related to research activities by physical therapists (in other words,
physical therapy research ethics). Textbooks, etc. state that the four basic principles of bioethics areautonomy, beneficence, nonmaleficence, and justice. Their meanings are as follows: Autonomy is tohonor the patient’s right to make their own decision on treatment. Beneficence is the duty to act in thebest interests of the patient. Nonmaleficence is to do no harm to the patient (at least the benefit should
be greater than the harm). Justice is fairness and rightness in providing medical care.
Hippocrates said that “patients shall not be given the right to make decisions on anything at any time.”
This contains an idea that is criticized as paternalism in the contemporary ethical view. As in this case,the ethical view changes depending on the country, ethnic group, and historical context. Ethics is a
topic that many religions and philosophers have discussed since the period before Christ, e.g., what isgood and what is bad, how to distinguish between good and bad, but it has not been settled yet to thisday. With the advancement of scientific technology, the fact that humankind has acquired technologies
that significantly affect life and social living, such as organ transplantation, life-sustaining treatment,
and gene manipulation, has further complicated the bioethics discussion.
Half a century has passed since the birth of physical therapists in Japan in 1965. Many physicaltherapists have been nurtured, and the importance of the existence of physical therapists in medicalcare and society has been growing. Under such circumstances, physical therapists are required to behighly aware of clinical ethics and research ethics and to implement clinical and research activities

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based on them. The first step may be to think about specific problems in daily living and clinicalactivities from the viewpoint of bioethics.

2)

Medical ethics

Medical ethics and clinical ethics are almost synonymous; they were born as guidelines of behavior
that physicians should have, and have spread to healthcare-related professionals such as nurses,
physical therapists, and occupational therapists. The contents of activities and medical positioning inlaws vary according to the profession, and there are particularities of medical ethics for eachprofession. Nonetheless the rules and principles of medical ethics are shared, and this section looks atchanges in attitudes toward medical ethics based on the doctrines of Hippocrates, which are considered
to be the origin of medical ethics.
(1) The Hippocratic Oath
Hippocrates (around B.C. 460 to 370) is also referred to as the “Father of Medicine.” He developed
medicine from that which had been superstition and magic to empirical science based on theaccumulation of objective observation and clinical practice. Hippocrates wrote “the Hippocratic Oath”
for individuals who pursued medicine to make a pledge to God (Table 1). The Hippocratic Oathcontains the philosophy that forms the basis of modern medical ethics such as the purpose of medicine
to give health benefits, the protection of privacy, physicians’ devoted attitude, and fairness of
medicine. It has been passed down for a long time in Western Europe as a spiritual pillar for training
doctors.

The Nuremberg trials were held on inhumane Nazi human experimentation after the second world war.
Based on these, the World Medical Association adopted the “Ethical Principles for Medical Research
Involving Human Subjects (Declaration of Helsinki)” (1964). The Declaration of Helsinki strongly
states “adequate information provision and voluntary consent of subjects based on it” for participationin research, and this leads to the principle of medicine of performing medical practice based on
explanation and consent (informed consent) as the protection of the human rights of patients inmedicine. Implementation of medical care based on explanation and consent is also a principle ofmedical ethics that should be complied to in physical therapy as well.
Table 1 Main Contents of the Hippocratic Oath
•
•
•
•
•
•
•
•
•

I will reckon him who taught me this Art equally dear to me as my parents, to share my substance with him,
and relieve his necessities if required
I will look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shallwish to learn it, without fee or stipulation
I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by astipulation and oath according to the law of medicine, but to no others.
I will consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.
I will give no deadly medicine to anyone; and I will not give to a woman a pessary to produce abortion.
I will not cut persons laboring under the stone but will leave this to be done by men who are practitioners of
this work.
With purity and with holiness I will pass my life and practice my Art.
I will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females
or males, of freemen and slaves.
Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life ofmen, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept
secret.
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MATERIAL(2) Patient rights
The contents of the Hippocratic Oath are the basis of medical ethics and physicians should respectthem, but there is a paternalistic aspect of healthcare professionals compared to the modern viewpointof patient-centered medicine.

In addition to respecting patients/clients and research subjects and the necessity of obtaining informed
consent for voluntary participation in research by subjects, the Declaration of Helsinki mentions theprotection of privacy and personal information, approval of an ethical review committee when
conducting research, and medical research being reasonable.

3)

Professional ethics(1) Code of ethics
Matters concerning medical ethics with which physical therapists should comply when carrying out
clinical activities are the professional ethics for physical therapists. Regarding professional ethics forphysical therapists, the “Rules of Ethics” of the Japanese Physical Therapy Association serve a role inthe code of ethics (Table 2). Ethical codes are composed of five items of basic spirit and six items ofmatters to be observed. The basic spirit includes the basics of medical ethics such as equality,
autonomy, and beneficence. The matters to be observed address a sense of responsibility as physicaltherapists, the implementation of physical therapy based on explanation and consent, cooperation withvarious professions, the protection of personal information, unprofitability, and improper rewards.
(2) Clinical ethics
This section discusses clinical ethics for physical therapists using the “Guidelines for Professional
Ethics for Physical Therapists” by the Japanese Physical Therapy Association (Table 3). First, theGuidelines describe social ethics that the members shall not only improve their knowledge and skills
but also endeavor to constantly ameliorate a sense of ethics (morality) in the members’ clinicaloperations and daily living, and each member shall master and maintain suitable dignity. It should be
kept in mind that while physical therapists are healthcare professionals, they should comply with not
only clinical ethics but also social ethics.
Table 2 The Japanese Physical Therapy Association: Rules of Ethics
The Japanese Physical Therapy Association hereby establishes rules of ethics as standards for its members to
be aware of the mission and duties of physical therapists, always to order their lives and discipline themselves.

MATERIAL

Basic spirit
1. Physical therapists shall act toward each person in an equal manner regardless of nationality, race,
ethnicity, religion, culture, thoughts, creeds, family origin, social status, age, or sex.
2. Physical therapists shall provide society with their knowledge, skills and experience to the extent possible
for the people’s health, medical care and welfare.
3. Physical therapists shall constantly devote themselves to their studies as a professional and make efforts inthe development of physical therapy.
4. Physical therapists shall take responsibility and carry out operations in good faith and do their best.
5. Physical therapists shall make efforts in nurturing younger people.
Matters to be observed
1. Physical therapists shall give treatment and guidance based on the objectives of and responsibility for the operationsin the areas of health, medical care and welfare.
2. Physical therapists shall adequately explain the contents of treatment and instruction.
3. Physical therapists shall collaborate with other related professions in good faith and take their
responsibility, and maintain trust with all team members.
4. Physical therapists shall keep information learned through work secret.
5. Physical therapists shall not be involved in companies’ profit objective.
6. Physical therapists shall not request or collect rewards except for their specified just rewards.
(established on May 17, 1978)(partially revised on May 16, 1997)(partially revised on April 1, 2012)

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MATERIALTable 3 Guidelines for Professional Ethics for Physical Therapists
Preamble
Forty years have passed since the physical therapist qualification was born in Japan. Today, people routinely
use the word “rehabilitation” and accordingly, physical therapy, which is the act of physical therapists, hasbeen understood by the general population. In recent years, the background, i.e., aged society, is serving as afavorable condition for physical therapists and expectations and demands on them from society are
significantly growing. As if responding to this, many new physical therapists were born, and the number ofJapanese Physical Therapy Association members has been acutely increasing along with acceleration in the
reduction of their mean age. The activities of physical therapists are not only in the medical area but have
expanded into many fields, such as the welfare area. Under these circumstances, there is a growing number ofyoung physical therapists involved in operations in an environment where they can hardly receive advanced
guidance at their affiliated hospitals or facilities. In contrast, with the development of society, informatization
has rapidly advanced, and thus the people have very high levels of knowledge on medical care and welfare, i.e.,
diseases and disabilities. If the people have strong recognition of physical therapy through these phenomena, it
can be easily imagined that naturally, each physical therapist will be highly criticized.
In addition, considering Japan’s social situation of today, declined social morality has been argued at the backside of prioritizing economic efficiency in various fields including the medical field. Accidents and incidents,
which are likely to be attributable to inadequate or a lack of professional ethical perspective, have been brought
to the surface; it has even been said that the destruction of professional ethics has begun. During such a trend inwhich the number of young physical therapists has drastically elevated at once and social demands on
professional ethics have been growing, there is no doubt that we are in an era in which the character of physicaltherapists is being increasingly tested. Japanese Physical Therapy Association members shall not only improvetheir knowledge and skills but also endeavor to constantly ameliorate a sense of ethics (morality) in themembers’ operations and daily living, and each member shall master and maintain suitable dignity.

1.
1)
2)

3)
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2)
3)
4)

MATERIAL

Members need to discipline themselves and take responsibility for acting as physical therapists who areprofessionals engaged in medicine in not only their duties for medical care but also research and education for“improving personality and ethical and academic skills, making efforts in the spread and amelioration ofphysical therapy in Japan, and thereby contributing to the advancement of the people’s medical care, health andwelfare” (Article 3 of the Articles of Incorporation of the Japanese Physical Therapy Association). Then,
members shall act fairly toward patients and clients, make rational judgments while respecting their rights, andtake responsibility for carrying out the acts of physical therapy with the ethical codes of the Japanese Physical
Therapy Association as the basic spirit and the matters specified in these Guidelines for professional ethics as
the mode to be observed. The members should be fully aware that medical practice is a legitimate invasive act,
and physical therapists who get involved in medical practice shall not harm patients or clients and make efforts
to be able to provide them with profit while actively preventing and helping to eliminate harm. Furthermore,members have a responsibility to perform operations while respecting human rights so that the patients andclients can make autonomous decisions and behave.
Confidentiality
Pursuant to “Article 16 of the Physical Therapists and Occupational Therapists Act” and “Article 134 of
the Penal Code,” physical therapists shall not leak the secrets of patients and clients to a third party
without a justifiable reason.
The term secret refers to the secrets of patients and clients learned through the course of medical care or
consultation/guidance. Physical therapists shall recognize that matters, not limited to physical or mental
disabilities and disease conditions, are secrets as long as they are undisclosed to others and of benefit to
the patients or clients.
Physical therapists shall make efforts to prevent leakage of medical records, computer data, memos andconversations.
Personal Information Protection
Physical therapists shall prevent personal information and information of individuals from going publicfrom the viewpoint of privacy protection together with confidentiality obligation in a highly sophisticatedinformation society.
Physical therapists shall protect the personal information such as names, dates of birth, and addresses
related to patients and clients so that they are not leaked.
Physical therapists shall protect information related to individuals, i.e., patients and clients, such as
information on the disease condition, patient assessment, treatment program, therapeutic effects, andhealing status of patients or clients so that they are not leaked.
Physical therapists shall protect the personal information such as names and dates of birth related to87
MATERIALinstitution staff so that they are not leaked.
Physical therapists shall protect information related to individuals such as the physical features andpersonalities of institution staff so that they are not leaked.
3. Duty to Attend
1) Physical therapists have an obligation to accept the requests of patients and clients when they visit for
medical care or consultation/guidance to the extent that physical therapy is given under the direction of aphysician in accordance with Article 19 of the Medical Practitioners Act.
2) Physical therapists may request patients and clients for collaboration in medical care or
consultation/guidance.
4. Medical Care (Guidance) Contract
1) Medical care is also a contracted act and shall be a mutual participation type with the participation ofpatients and clients.
2) When medical care (guidance) for patients and clients is requested and physical therapists accept this, acontract on medical care (guidance) is established and deemed to be acknowledged.
3) Physical therapists shall execute medical care and consultation/guidance in accordance with the contract
on medical care (guidance).
5. Informed Consent (Explanation and Consent)
1) Physical therapists have an obligation to explain a situation to patients, clients and their families when
demanded by patients and clients or as necessary even if not demanded.
2) For explanation, physical therapists shall review policies for medical care and guidance, and the scope of
explanation in cooperation with physicians and team members (staff) in a coordinated manner.
3) Physical therapists shall approach their duties by requesting patients and clients to collaborate in mattersfor which physicians entrusted the physical therapists to make a judgement, and obtain consent from thepatients and clients.
4) Physical therapists have an obligation to give an explanation to the extent requested by patients and clients
who have an ability to make a judgement but should accept that they have the “right of not being
informed” as well.
6. Obligation to Accept Prescriptions
1) Physical therapists are medical care assistants, thus shall give medical care under the direction ofphysicians.
2) In medical practice, physical therapists shall give medical care to patients based on physicians’prescription.
3) Prescription is deemed as being made by its issuance by a physician and its acceptance.
4) Changes in the contents of medical care shall be also made with a prescription.
5) In the health/welfare fields, physical therapists shall give consultation and guidance to patients/clients
while keeping cooperation with team members (staff) including physicians and collaborating with them ina coordinated manner.
7. Obligation to Record and Retain Medical Charts
1) When medical care is given, physical therapists shall promptly record the date and contents of medicalcare in a medical chart or medical care assistance record.
2) Physical therapists shall enter the date and contents of medical care in a medical chart without
falsification.
3) Physical therapists shall retain medical charts or medical care assistance records for five years.
8. Disclosure of Medical Care Information
1) When the disclosure of medical care information is requested, it shall be disclosed through the head of an
institution or physician based on the judgement and instruction of the head of the institution and treating
physician.
9. Morals and Manners to Be Observed1) Physical therapists shall observe manners as members of society in accordance with public policy andcomply with morals of healthcare professionals, thereby making efforts in refining their dignity.
2) Physical therapists shall refrain from acts defaming the credibility of physical therapists.
3) Physical therapists shall be wary of receiving money and goods such as rewards that may cause
misunderstanding.
4) Physical therapists shall make sure to constantly check themselves to keep their own autonomy.
5) Physical therapists shall not obviously criticize or defame other physical therapists, etc.
6) Physical therapists shall not engage in merchandise sales for the purpose of their own profits.
7) Physical therapists shall not have personal interest with healthcare-related businesses.
8) Physical therapists shall not perform acts that may be subject to administrative punishment.
10. Procedures and Methods for Medical Care and Consultation/Guidance1) Physical therapists shall use procedures and methods that are based on scientific evidence.
5)

MATERIAL
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MATERIAL

4)
5)
6)
7)
11.
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12.
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13.
1)
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14.
1)
2)
3)
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Under all circumstances, physical therapists shall receive consent from patients.
When asking about the physical and mental condition of patients/clients, physical therapists shall pay
attention to wording.
When meeting patients/clients, physical therapists shall pay attention to not only language but also nonverbal expressions such as behavior and facial expression.
No harm or pain shall be given to patients, and when medical care causes pain, physical therapists shalladequately explain it to patients and receive their consent.
Physical therapists shall not cause patients/clients to have mental distress.
Medical care and guidance are intended to assess and treat patients/clients; physical therapists shall use
medically approved procedures and methods.
Safety Assurance
Physical therapists shall always be vigilant in caution for the prevention of medical accidents.
Physical therapists shall immediately report medical accidents if they occur to the primary physician andinstitution manager.
Prevention of Sexual Harassment
Physical therapists shall not sexually harass the other party, that is any sexual behavior that makes theother party feel uncomfortable, whether or not the persons who behaved such intended to do so.
Physical therapists shall not act in such a manner that can be mistakenly deemed as sexual harassment.
Prevention of Bullying in Academia
Physical therapists shall not harass staff or students of any relationship at educational institutions such as
schools, research, learning settings, extracurricular activities, and work by abusing power, whether or notharassment is intended.
Physical therapists shall not act in such a manner that can be mistakenly deemed as bullying in academia
Routine Refinement
Physical therapists shall continue mastering and improving knowledge, skills, and attitude throughout
their lives to have highly specialized knowledge, skills, and ethics suitable for a professional.
Physical therapists shall endeavor to constantly refine themselves to be able to select the best medical caremethod for patients.
Physical therapists shall continue to be studious and interested in training.
It is preferable to become specialized physical therapists in accordance with the lifelong learning systemof the Japanese Physical Therapy Association.
Research Morality
When conducting research, physical therapists shall comply with the “Declaration of Helsinki” and“Ethical Guidelines for Clinical Studies,” a notification of the Ministry of Health, Labour and Welfare.
When there are human subjects, physical therapists shall obtain the human subjects’ acceptance and statethat fact in a paper.
Physical therapists shall protect the human rights and rights of human subjects and be considerate so thatthe human subjects will not suffer any disadvantages.
When presenting research, physical therapists shall respect morals and be considerate of protecting thehuman subjects’ privacy, anonymity and confidentiality.
Good Teamwork
Physical therapists shall be mutually cooperative with other physical therapists and with all professionals
involved in medical care and consultation/guidance.
In a team, individual members shall respect each other and collaborate with each other.
Physical therapists shall promptly share learned information with their team and attempt to continue
treatment.
Nurturing of Younger People
Educating students who intend to become physical therapists and new physical therapists is an obligationof experienced physical therapists.
Experienced physical therapists shall be an example to students who intend to become physical therapists
and new physical therapists.

MATERIAL

2)
3)

March 1, 2006
(Revised on April 15, 2012) Ethics Committee, the Japanese Physical Therapy Association

In addition, the Guidelines specifically describe matters to be observed with respect to: [1]Confidentiality, [2] Personal Information Protection, [3] Duty to Attend, [4] Medical Care (Guidance)
Contract, [5] Informed Consent (Explanation and Consent), [6] Obligation to Accept Prescriptions, [7]89MATERIAL

Obligation to Record and Retain Medical Charts, [8] Disclosure of Medical Care Information, [9]Morals and Manners to Be Observed, [10] Procedures and Methods for Medical Care andConsultation/Guidance, [11] Safety Assurance, [12] Prevention of Sexual Harassment, [13] Prevention
of Bullying in Academia, [14] Routine Refinement, [15] Research Morality, [16] Good Teamwork, and[17] Nurturing of Younger People. There are many matters to be observed, but this can be proof thatthe work of physical therapists is important and requires responsibility.
(3) Physical therapy research ethics
Research has the processes of drawing up a research plan, collecting data according to the plan,
organizing and analyzing collected data, discussing and drawing conclusions based on analysis results,
and making reports/publications (Figure 1). In addition, through these processes, research has the
purpose of understanding the characteristics and laws of nature, humans, and society and enriching
human life by applying them. Researchers have the responsibility to properly carry out these processes
and present objective and logical conclusions. Responsible research acts require “honesty” to honestly
perform research as planned, “accuracy” to accurately inform obtained results without falsification,“effectiveness” to effectively use resources for research without waste, and “objectivity” to express
facts as is and eliminate bias.
However, if the processes of drawing up a research plan, collecting data according to the plan,
organizing and analyzing collected data, discussing and drawing conclusions based on analysis results,
and making reports/publications are not properly implemented, and misconduct such as datafabrication, falsification of results, or plagiarism of data from other research occurs, the credibility of
the research is lost, and can even lead to social loss. Physical therapy in research is also required tohave “honesty,” “accuracy,” “effectiveness,” and “objectivity.”
For medical research involving human subjects, the “Ethical Guidelines for Medical and HealthResearch Involving Human Subjects (Ministry of Education, Culture, Sports, Science andTechnology/Ministry of Health, Labour and Welfare)” were established in 2015 and used as thefoundation of ethical review on research involving human subjects including physical therapy. When
conducting research involving human subjects, a research plan must be drawn up in accordance withthese Guidelines. In research performed by physical therapists, the principles are to explain thebenefits and risks associated with the research to the human subjects in an easily understandable
manner and then obtain voluntary consent from the human subjects for participation in the research.
MATERIAL<Flow of Research>
Researchplan

Datacollection

Data
analysis

Discussion
andconclusions

Reporting/Publication

Research is the operation of properly implementing these processes to understand the characteristics
and laws of nature, humans, and society and enriching human life by applying them.

<Misconduct in Research>

Fabrication

Falsification

Plagiarism

If these processes are not properly implemented, and “misconduct in research” such as fabrication,
falsification, and plagiarism are made, the research is impossible, and can even lead to social loss.

Figure 1 Flow of Research and Misconduct in Research

90
MATERIALA statement on research ethics is strongly required when submitting a paper to scientific journals orpresenting it at academic conferences. For the “ Journal of the Japanese Physical Therapy Association”
the scientific journal of the Japanese Physical Therapy Association, its submission rules have specified
since 2017 that “prior to the research, it is essential to obtain approval of the ethics committee at theaffiliated research organization or affiliated institution or an organization equivalent to such, and thename of the ethics committee and the acknowledgment number (or date of acknowledgment) must be
provided;” thus, approval of an ethics committee has become an essential requirement for conducting
research. Ethics review is performed by an ethical review committee established in the organization
with which physical therapists affiliate, and the ethical review committee has also been formed in theJapanese Physical Therapy Association since 2017.

2.

Physical Therapy Management (Safety Management/Risk
Management Measures)

1)

Medical safety

Medical safety is referred to as “Patient Safety” in English. “Healthcare should be safe” but is notnecessarily so. Despite making an effort to safely perform medical practice as much as possible,
medical accidents occur. Until the 1990s, it was considered that “medical accidents are supposedly
impermissible things and can be prevented if individuals pay attention.” In Japan, an accident of
mixing up patients occurred at Yokohama City University Hospital and an accident of mistakenly
injecting a disinfectant occurred at Tokyo Metropolitan Hiroo Hospital in 1999: This year was referred
to as the first year of medical safety in Japan, and consciousness about medical safety was elevated. In
the same year in the US, the Committee on Quality of Healthcare in America stated that “every humanbeing makes mistakes,” and the attitude was changed to prevention by system. Currently in Japan,
instead of “paying attention” to human error such as “careless mistakes” and “omission,” which may
happen, the mainstream notion is “systematic measures (to work on accident prevention byorganizations and to avoid accidents through this scheme)” without depending on individual efforts
and credentials. Proper knowledge on medical and nursing care accidents is required to correctly grasp
these systematic measures. These accidents can be classified into “force majeure” and “negligence.”
Force majeure is any event for which no responsibility arises even if it could not be avoided despite
exercising caution and prevention. Negligence is an event that could have been avoided by paying
attention and for which legal responsibility may be held.
(1) Liabilities
Responsibilities are referred to as “three liabilities”: Civil, criminal, and administrative punishment.
Civil liability: For a “complaint,” etc., compensation for loss or damage is reviewed in settlement. The
contents are to question “whether the duty to care was violated” on the premise of the possibility of
avoidance as to “whether negligence was foreseeable.” For violation of the duty to care, the causal
relationship with “the medical standards in clinical medical practice at the time of giving medicalcare” is focused on. In addition, it is specified that “various factors, such as the characteristics of the
medical institution and the features of the regional healthcare environment where it is located, should
be taken into consideration.” The details are examined, and whether the accident was due to force
majeure or violation of the duty to care is reviewed from the viewpoint of medical standards at thetime that the medical care that caused the accident was given. In the past, there was a case of claiming
compensation for loss or damage because the contents of physical therapy were inappropriate. Hence,
it has been found to be essential to constantly study physical therapy that meets the medical standardsof an era. According to the Civil Code, violation of the duty to care is classified as follows:

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[1] Liability due to non-performance (Article 415 of the Civil Code)
Duty of due care of a prudent manager based on a medical care contract → Main
provider/establisher[2] Tort liability(a) Tort liability (Article 709 of the Civil Code)
Negligence (violation of the duty to care) by the person who performed the medical practice →Individual (clinical laboratory technician)(b) Liability of employers (Article 715 of the Civil Code)Violation of supervisor’s duty to care → Hospital, hospital president, laboratory director, etc.
(c) Liability of joint tortfeasors (Article 719 of the Civil Code)Violation of the duty to care in team medical care → All persons involved with intentional
negligence
Criminal liabilities (causing death or injury due to negligence in the pursuit of social activities): Deathoccurred, or a serious disability remained, the police was informed of such by a patient, family, or
medical institution and investigates, and prosecutors decide whether to file criminal charges or drop
the charges. A person who fails to exercise the due care required in the pursuit of social activities andthereby causes the death or injury of another person is punished by imprisonment or imprisonment
without work for not more than five years or a fine of not more than 1,000,000 yen. (Article 211,
Paragraph 1 of the Penal Code).
Administrative punishment: It often takes place when an individual is found guilty as a result of
criminal proceedings, and individual responsibility is taken. The punishments include the revocationof license, suspension of business, and reprimand. Serious warning is not an administrative
punishment but is “administrative guidance.”

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It is necessary to understand that there are cases where liabilities are imposed to individuals as
described above. Recently, in addition to physical therapy practice at the hospital, etc., physicaltherapists may operate business in an area without a physician’s instruction, such as preventive healthcare business for the elderly entrusted by municipalities. When engaging in such activities, physicaltherapists may encounter unexpected risks (being accused of an accident, harassment, etc.) so it isrecommended to purchase non-life insurance (liability insurance). In order for physical therapists tocontinue their activities, it is important to be conscious about protecting themselves by taking out nonlife insurance for unexpected risks.
(2) Legal grounds of medical safety
Article 6-10 of the Medical Care Act stipulates that “the administrator of a hospital, clinic, or birthing
center, pursuant to the provisions of an Order of the Ministry of Health, Labour and Welfare, shall takemeasures to ensure the safety of medical care in the relevant hospital, clinic, or birthing center such as
formulating guidelines to ensure the safety of medical care and providing training for employees.” Asfor specific measures, obligations to publish medical safety guidelines and a medical safety manual,form a medical safety committee, hold medical safety training for all employees, issue medical safety
news, and take measures to prevent medical accidents are specified.
We, physical therapists, are no exception. We must be sure to go through and understand the medical
safety guidelines, manuals, etc. at each institution. It is outrageous to make excuses such as “I don’tknow where the manual is” and “I don’t know the procedures for taking action in the event of a fallbecause I haven’t learned them from my senior colleagues.”

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MATERIALIn recent years, the active medical safety measures by physical therapists have been authorized at their
institutions, and the number of physical therapists playing the role of “medical safety manager” tomanage medical safety at the entire institution has been increasing.
(3) Actions in the event of an accident
As previously mentioned, physical therapists should verify the medical safety manual at their
institutions. It is important to take actions as specified in the manual. The physical therapists should
not consider that “no action or reporting is necessary for this degree of event” by their own judgment
but should consult their superior or senior colleague when in doubt.
As an example of a general action, this section describes the action to be taken in the case that apatient falls. First, a physical therapist should verify the state of consciousness and pain at the time of
the fall, and at the same time, ask for assistance by surrounding staff, transfer the patient to a safe bed,
etc., and examine his/her vital signs and injured sites. At that time, in order to grasp the course, it isimportant to request collaboration with surrounding staff so that the patient can remain there. The
patient’s condition may suddenly change while leaving the area for even a few minutes. If that
happens, the physical therapist cannot grasp the course and may not be able to take appropriate action.
The physical therapist should contact the primary physician and, as necessary, the emergency
outpatient unit and follow their subsequent instructions. In addition, it is an important task of the
responder to prepare an incident report as soon as possible after the onset of an event, analyze thecause, discuss recurrence preventive measures with his/her superior, and inform other staff of theevent.

Level
Level 1
Level 2
Level 3aLevel 3bLevel 4aLevel 4bLevel 5

Prevention of medical accidents

A medical accident is referred to as an “Adverse Event” in English. It is considered to be an event
contrary to “that expected” and translated into Japanese as a harmful event. This section introduces
three representative measures to prevent medical accidents.
(1) Incident report
When an incident (such as wrong medical practice that was identified before being implemented in apatient or wrong medical practice was performed but did not result in an adverse effect on the patient)or accident (wrong medical practice was carried out and resulted in an adverse effect on a patient)occurs, a physical therapist should submit an incident report to prevent medical accidents. Submission
is required even for near-miss events. This is not intended to pursue responsibility of individuals but toinvestigate the cause to lead to recurrence prevention.
(2) Heinrich’s Law
Heinrich’s Law is an empirical law of industrial injury suggested by William Heinrich, who was
working for a general insurance company in the US, based on data accumulated when investigating atleast 5,000 cases of industrial injuries. It states that for every accident that causes a major injury, there
are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. Based on thisresult, it is also referred to as the “1:29:300 rule” or “near-miss law.” For example, this law assumes
that if one case of bone fracture caused by fall occurred, there may be 29 cases of fall behind this bone93
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2)

Table 4 General Incident Levels
Details of injury
Severity of injury
No actual harm to the patient
No action taken or treatment given
Temporal reinforcement of observation, tests, etc.
Requiring a simple action and/or treatment
Administration of an analgesic, saturation, etc.
Requiring an intense action and/or treatment
Surgery, prolongation of hospitalization, etc.
Permanent disability or sequela
No significant impairment or cosmetic problem
Permanent disability or sequela
Significant impairment or cosmetic problem
Death
Except for the natural course of primary diseasefracture and 300 cases of stumbles, etc. behind them. For preventing a major accident, it is important
to avoid minor mistakes. It has been considered that measures should be taken based on information
on near misses. Consequently, a larger number of incidence reports is found to be better than a smaller
number. An annual number of cases five times higher than the number of beds is appropriate.

1 majorincident/accident
29 minor incidents/accidents
300 near misses
Figure 2 Heinrich’s Law(3) Swiss cheese model
The Swiss cheese model is a concept of safety management proposed by James Reason, a British
psychologist. The slices of cheese with holes in Figure 3 are regarded as barriers. This model
illustrates that one slice of cheese has many holes so an arrow can easily penetrate it, but if the slices
of cheese (barriers) are aligned with holes in different places, the arrow stops at the next slice (barrier)as shown in [1]. By aligning several slices, the possibility that the arrow can go through them isreduced as in [2]. However, if the arrow incidentally penetrates them as in [3], this allows an accident
to occur.
In other words, this model suggests that multi-layered measures can reduce the possibility of accidents
occurring. It may be time-consuming, but establishing multi-layered measures such as multiple
verifications leads to the prevention of accidents.
Accident
Barriers

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[2]
[1]

[3]

Figure 3 Swiss Cheese Model

3)

Infection prevention measures

The principles of infection prevention measures are: “Do not bring in pathogens;” “do not take out
pathogens;” and “do not spread pathogens.” Today, physical therapists’ awareness about infection
prevention has elevated due to the “COVID-19” pandemic, so many physical therapists are practicing
standard precautions. An infection prevention manual has been established for each institution.
Furthermore, many official websites such as the website of the Ministry of Health, Labour and Welfare
provide information on handwashing, cough etiquette, and personal protective equipment (PPE)
including masks and gloves.
Hand hygiene: Hand hygiene is the most basic and important measure. Prevention of pathogens
brought in via fingers is essential. Blood and body fluid can be washed with soap and running water,
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and alcohol is suitable for eradicating pathogens. There is a device called Hand Wash Checker toverify whether hand hygiene is properly implemented. There are many institutions where handhygiene is periodically checked, showing its importance.
PPE (Personal Protective Equipment): It includes masks, gloves, gowns, face shields, goggles, caps,
shoe covers, etc.
Mask: It has become commonplace to wear masks due to “COVID-19” and flu prophylaxis. If the nose
is not covered by a mask, the effect of wearing a mask is reduced; cases of improper wearing of maskscausing outbreak (collective occurrence of infection) are frequently seen in the news. Considerations
are also necessary, such as avoiding conversation while eating, during which masks are removed.
When having directly contact with patients with tuberculosis or individuals who are positive for“COVID-19,” N95 masks, which have good filter function and a better effect of preventing infection
than surgical masks, should be used.
Gloves: When touching blood, body fluid, or excrement or having contact with contaminated or
infected patients, physical therapists must wear gloves. They can prevent the possibility of transferring
bacteria to the hands when touching the patients and then spreading germs by touching other things or
people. It is important to be sure to change gloves after touching contaminants or infected materials.
Basically, physical therapists directly touch patients during intervention. Physical therapists should
accustom themselves to wearing gloves in settings such as treatment and care and master techniques toproperly remove them.
Goggles/Eye guards: Transmission to eyes is likely to occur during aspiration or contact with patientswith frequent coughing or highly contagious patients. There may be people who think that this mainly
concerns physicians and nurses and is not related to physical therapists, but physical therapists have
many opportunities to get involved in sputum aspiration and persons with infection and cough.
Physical therapists should keep in mind that cases resulting in death have been reported and takeaction.

Personal information protection

Article 16 of the Physical Therapists and Occupational Therapists Act stipulates that “physicaltherapists or occupational therapists shall not leak the secrets of individuals learned through their workto others, except for cases where there are justifiable reasons. The same provision shall apply after said
person ceases to be a physical therapist or occupational therapist,” and Article 21 strictly specifies that“any person who has violated the provisions of Article 16 shall be punished and liable to a fine notexceeding five hundred thousand yen.” The Japanese Physical Therapy Association also presents the“Guidelines for Professional Ethics for Physical Therapists” on its information disclosure site to callfor attention.
Personal information protection is officially referred to as the “Act on the Protection of Personal
Information.” With the rapid advancement of communication technologies, this Act was established toprevent leakage of information enabling identification of specific individuals such as the name, sex,
date of birth, individual physical information, assets, occupation, and title. This includes visual
information and sound information as well. For physical therapy, information on disease conditions,assessments, treatment programs, treatment effects, course, etc. has to be notified to parties outside thehospital due to transfer to another hospital and cooperation with nursing-care services. It is importantthat physical therapists are conscious about preventing leakage of personal information.
In recent years, we occasionally come across cases where social media users post information andphotographs identifying individuals without realizing that they are providing their personal
information when presenting their experience. Information that may be read by an unspecified numberof people should be posted with the greatest care.
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4)

In addition, information on patients or clients may be used for research, etc. Even when it is digitalized
and then collected, informed consent should also be carried out to obtain consent. Its retention should
be strictly controlled. It is preferable to retain information in paper form in a lockable place, andinformation in a computer in an independent environment in which no network is established. Personal
information is often leaked due to a loss of computers and USB, so they should be carried with due
care.

5)

Harassment measures(1) What is harassment?
Harassment is behavior that makes someone feel uncomfortable. It is annoying someone and signifies“abuse of human rights” in a broad sense. Sexual harassment, workplace harassment, pregnancy
discrimination, and bullying in academia (schools, research, learning settings, extracurricular
activities, and work) are common. What is important is not whether a person harassing someone (party
at fault) has such an intention, but whether the party at fault made the other party (harassed person)
feel unpleasant. For this reason, the party at fault often makes the excuse later that “I didn’t mean to dothat.” Physical therapists should always pay attention that their words and actions will not be
misleading.
(2) Legal rules for harassment
There is no precise definition of workplace harassment, but it is specified in the Act onComprehensively Advancing Labor Measures, and Stabilizing the Employment of Workers, andEnriching Workers’ Vocational Lives promulgated on June 5, 2019. In addition, sexual harassment is
stipulated in the Act on Equal Opportunity and Treatment between Men and Women in Employment.
Pregnancy discrimination is set forth in the “Child Care and Family Care Leave Act.”(3) Workplace harassment
Workplace harassment is behavior that causes mental or physical pain or deteriorates the work
environment of a person working in the same workplace beyond the appropriate scope of work (whena boss shows authority according to his/her job position and professional ability and supervises
operations and gives training/instructions) on the background of various superiorities such as
occupational position, relationship, specialized knowledge, and experience.

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The Act on Comprehensively Advancing Labor Measures, and Stabilizing the Employment ofWorkers, and Enriching Workers’ Vocational Lives (Article 30-2: Measures in Terms of Employment
Management) specifies that in order for an employer to preclude any behavior that is based on
behavior that constitutes bullying in the workplace exceeding the scope necessary and reasonable inthe course of business from damaging the work environment of the employer’s workers, the employer
shall provide consultation to those workers and take measures necessary in terms of employment
management, such as developing a necessary system for appropriately handling such behavior. Hence,
this Act is also referred to as the “workplace harassment prevention law.”(4) Sexual harassment
Article 11 of the Act on Equal Opportunity and Treatment between Men and Women in Employment
stipulates that “employers shall take necessary measures for employment management, such as
developing a necessary system for providing consultation to workers and appropriately handling thematters, so that the workers they employ do not suffer any disadvantageous working conditions on the
grounds of that worker’s response to sexual harassment in the workplace, nor suffer any damage to thework environment due to sexual harassment.” Article 11-2 specifies that “workers shall endeavor todeepen their interest and understanding of sexual harassment problems and pay necessary attention totheir behavior toward other workers, as well as cooperate with the measures referred to in Paragraph 1of the preceding article taken by their employers.” Thus, the provisions are stipulated for both
employers and workers.
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(5) Pregnancy discrimination
Article 25-2 of the Child Care and Family Care Leave Act specifies that “employers shall endeavor todeepen their interest and understanding of issues with childcare leave-related conduct and paynecessary attention to their conduct towards workers” and that “workers shall endeavor to deepen theirinterest and understanding of issues with childcare leave-related conduct, pay necessary attention toother workers, and cooperate with the measures to be taken by their employers referred to in Paragraph
1 of the preceding article.” Thus, the provisions are stipulated for both employers and workers as withthose for sexual harassment.
(Tetsuya Chiba)

3.

International Statistical Classification of Diseases and Related
Health Problems (ICD), International Classification of Impairments,
Disabilities and Handicaps (ICIDH), and International Classificationof Functioning, Disability and Health (ICF)

1)

International Statistical Classification of Diseases and Related Health Problems(ICD)

The formal name of the International Classification of Diseases (ICD) is the “International Statistical
Classification of Diseases and Related Health Problems.” It is a classification of the causes of deathand diseases specified according to globally unified standards developed by the World HealthOrganization (WHO). In Japan, the ICD has been adopted in official statistics (vital statistics, etc.) as“Statistical Classification of Diseases, Injuries and Causes of Death” which is statistical standards
based on the Statistics Act. The ICD has been commonly used as a medical classification for managing
medical charts at medical institutions. It has a long history: The first time that the ICD was introduced
in Japan was 1900 and it was established as “International Statistical Classification of Diseases,
Injuries and Causes of Death.” Then, it was revised about every decade by the WHO. Currently, theICD-10 (according to the 2013 version: Revision to the ICD-10 was made in 1990, but it was revised
according to the 2003 version and according to the 2013 version.) announced in 2013 is used in Japan.

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In other words, it is a statistical classification of diseases, injuries and causes of death and has beenused for vital statistics in Japan: The publication of statistics of causes of death, patient survey
conducted every 3 years, and Statistics of Medical Care Activities in Public Health Insurance
implemented every year, etc.
The classification of the ICD-10 (2013 version) contains the following 22 categories:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

A00-B99 Certain infectious and parasitic diseases
C00-D48 Neoplasms
D50-D89 Diseases of the blood and blood-forming organs and certain disorders involving theimmune mechanism
E00-E90 Endocrine, nutritional and metabolic diseases
F00-F99 Mental and behavioural disorders
G00-G99 Diseases of the nervous system
H00-H59 Diseases of the eye and adnexa
H60-H95 Diseases of the ear and mastoid process
I00-I99 Diseases of the circulatory system
J00-J99 Diseases of the respiratory system
K00-K93 Diseases of the digestive system
L00-L99 Diseases of the skin and subcutaneous tissueM00-M99 Diseases of the musculoskeletal system and connective tissueN00-N99 Diseases of the genitourinary system
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15.
16.
17.
18.
19.
20.
21.
22.

O00-O99 Pregnancy, childbirth and the puerperium
P00-P96
Certain conditions originating in the perinatal period
Q00-Q99 Congenital malformations, deformations and chromosomal abnormalities
R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhereclassified
S00-T98 Injury, poisoning and certain other consequences of external causes
V01-Y98 External causes of morbidity and mortality
Z00-Z99 Factors influencing health status and contact with health services
U00-U99 Codes for special purposes

For this ICD, the ICD-11, which was revised 30 years after the ICD-10, has been announced at 12:00(Geneva time) on June 18, 2018, by the WHO and approved by the member countries at the WHO
Assembly on May 28, 2019. In Japan, the ICD-11 is currently being reviewed by the ICD
Subcommittee/ICD Expert Committee, Ministry of Health, Labour and Welfare and is in a stage whereoperations to introduce it in the future have been undertaken.
This ICD-11, of which revision is currently being prepared, consists of 26 items, compared with 22
items in the ICD-10, and the following items were independently added: “Diseases of the immune
system,” “Sleep-wake disorders,” “Conditions related to sexual health,” and “Traditional Medicine
Conditions - Module I.” Particularly, “Gender identity disorders,” which were included in 5.F00-F99
Mental and behavioural disorders in the ICD-10, were changed to “gender incongruence” under the“Conditions related to sexual health.” In addition, “Gaming disorder” was added to the section
concerning disorders due to addictive behaviours; therefore, the ICD-11 enables classification taking
account of functioning.

2)

From the International Classification of Impairments, Disabilities and Handicaps(ICIDH) to the International Classification of Functioning, Disability and Health(ICF)

MATERIALThe International Classification of Impairments, Disabilities and Handicaps (ICIDH) was alsoannounced in 1980 by the WHO as a supplementary classification of the ICD. At that time, threewords, namely “impairment,” “disability,” and “handicap” were used because there is no single word
comprehensibly expressing these states in English. Thereafter, it became clear that their definitions
imply only the negative aspects of these words and have limitations. In other words, the ICIDH had astrong context of a disease-centered medical model: A disease, which is the cause, affects individuals’
pathological changes, manifesting as symptoms (dysfunction). This caused the users of the ICIDH tointerpret that a disease would result in social disadvantages, which is a straight-line relationship(Figure 4).
However, due to historical backgrounds such as a social model regarding declined abilities andhandicaps being environmental issues in some cases, the spread of normalized thinking, and the surge
of independent living (IL) campaign, the WHO revised the ICIDH. As a result, two drafts, namely the
ICIDH-2 Beta 1 Draft in 1997 and ICIDH-2 Beta 2 Draft in 1999, were announced as field trials. In
2001, the International Classification of Functioning, Disability and Health (ICF) was adopted at the
WHO Assembly as a revised version of the ICIDH. The Japanese version of the ICF was completed inJuly 2002.
The major characteristic of this International Classification of Functioning, Disability and Health(ICF) is that the perspective of “environmental factors” was added to its components: For thefunctioning and disabilities of individuals, there are “body function and structures” and “abilities andparticipation,” and the background factors affecting these are “environmental factors” and “personal
factors.” Consequently, these were added to the ICF. This has facilitated the concept that even if the98
MATERIAL

level of impairment is the same, if environments are arranged with accessibility and universal design,
the levels of “abilities” and “participation” improve.

Disease or disorder

Impairments

ExamplesExamples• Development of brain
infarction• Spinal cord injury, etc.

• Hemiplegia• Limb motion/ sensory
paralysis• Bladder/rectal
disorder, etc.

Disabilities

Handicaps

ExamplesExamples• Being unable to walk
• Requiring assistancefor dressing• Requiring bathing
assistance, etc.

• Being unable to go towork• Being unable to go
shopping, etc.

Figure 4 International Classification of Impairments, Disabilities and Handicaps (ICIDH)
ICIDH (International Classification of Impairments, Disabilities and Handicaps)
As shown in the examples in the lower boxes, with the ICIDH, the three dimensions arelikely to be interpreted in a one-way manner: Impairments caused by diseases lead todisabilities and handicaps.

The emergence of the ICF has enabled direct assessment of the restriction of abilities and participationin living regardless of the cause. For example, when there is the same level of impairment that limits
moving, if roads without steps and elevators in stations and facilities are arranged, the levels of“abilities” and “participation” can be more greatly improved compared with those in an environment
without this arrangement. In other words, the ICF intends to classify by combining elements from thecondition of functioning related to any health condition of an individual to the social systems andresources surrounding the individual, and express/describe them. Based on the concept that a disability
is an interaction, and the complex relationship between health conditions and their background factorsof environment and individuals, “environmental factors” and “personal factors” were added as
background factors. In addition, from the viewpoint that they interact with each other, all elements are
expressed with dual-directional arrows (Figure 5).

Body function andstructures

Environmental
factors

Abilities

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Health condition

Participation

Personal factors

Figure 5 International Classification of Functioning, Disability and Health (ICF)
ICF (International Classification of Functioning, Disability and Health)*It was established in 2001 as a revised version of the International Classification of
Impairments, Disabilities and Handicaps (ICIDH).
In response to a criticism that the ICIDH takes only the negative aspect of disabilities into
consideration, “environmental factors” were added from the standpoint of covering both
positive and negative sides of living as a whole. The terms were changed to “healthcondition,” “body function and structures,” and “abilities and participation.” As a result, allelements are expressed in a dual-directional manner.

The background of the ICIDH and ICD is a medical model based on “etiology.” Compared with them,
it would be difficult to understand the ICF unless the viewpoint of “living model” is present. The
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reason for the opinion that “the ICIDH is easier to understand than the ICF” even today may be that
the ICIDH is more suitable to the “mind-set” of the medical model than the ICF. In the concept of the
ICF, the relationship between “body function and structures” and “abilities” appears to include themind-set of this medical model.
As previously mentioned, the ICF is a classification supplementing the ICD, and the relationship is as
illustrated in Figure 6. In a category of the WHO international classifications, they have acomplementary relationship to divide their roles. The ICD is a classification of health conditions, i.e.,the causes of death and diseases. The ICF is a classification of functioning and disabilities related tothe health condition. Handling the two in a mutually complementary manner enables various
classifications, even country-by-country comparisons.

ICD“International Statistical Classification of Diseases and Related
Health Problems”* Classification of the causes of death and diseases, reason for
medical examination→ Conditions for health

ICF“International Classification of Functioning, Disability and Health”* Functioning, disability and health→ Functioning and disability related to conditions for health

Figure 6 ICF among the International Classifications by the WHO- Health and functioning classification for supplementing the disease classification -3)

Relationship with the Physical Therapists and Occupational Therapists Act

Our (physical therapists’) office organization is stipulated in the “Physical Therapists andOccupational Therapists Act” (Law 137) established in 1965.
In it, the definition of “physical therapy” is specified in Chapter 1, Article 2, Paragraph 1 as follows:

MATERIAL“Under this Act, ‘physical therapy’ is defined as having people with physical disabilities engage intherapeutic exercise or other exercise, and adding electrical stimulation, massages, heat, and otherelectrophysical modalities, mainly in order to restore abilities of the basic activities,” Similarly,“physical therapists” are stipulated in Article 2, Paragraph 3 as follows: “The term ‘physical therapist’in this Act refers to a person that is in the business of performing physical therapy under the
instruction of physicians with a license granted by the Minister of Health, Labour and Welfare andwith the name of a physical therapist.”
In other words, physical therapy “attempts to restore abilities of the basic activities” in “people withphysical disabilities.” A physical therapist is “a person that is in the business of performing physicaltherapy” “under the instruction of physicians” “with the name of a physical therapist.” Thus, it is socalled legal protection of the title.
In addition, Article 15, Paragraph 1 of this Act sets forth that “notwithstanding the provisions ofArticle 31, Paragraph 1 and Article 32 of the Act on Public Health Nurses, Midwives and Nurses (ActNo. 203 of 1948), a physical therapist or occupational therapist may engage in the business of physicaltherapy or occupational therapy as assistance for medical care.” This emphasizes that as long as it is an
instruction of a physician, the act of performing part of nursing work, which is the businessmonopolized by nurses, is legal. Similarly, Article 15, Paragraph 1-2 stipulates that “the provision of
Article 1 of the Act on Practitioners of Massage, Finger Pressure, Acupuncture and Moxacauterization,
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etc. (Act No. 217 of 1947) shall not apply to massage carried out as physical therapy by physicaltherapists at hospitals or clinics or upon specific instruction of physicians.” It is ensured that it is legal
to perform the work of various professions under instruction of physicians.
Consequently, there is a delicate relationship between the “Physical Therapists and Occupational
Therapists Act” (Act No. 137) and the ICF or ICD. Originally, it can be said that the primary work is“attempting to restore abilities of the basic activities” by performing physical therapy as treatment
under the instruction of physicians: The core of the work is to acquire the “abilities” particularly byapproaching the “body function and structures” in the ICF. However, the ability of basic activities isclosely involved in “abilities and participation,” and for environmental factors, which are backgroundfactors for “abilities and participation,” verification of the accommodation and adaptation of various
welfare equipment, wheelchairs, assistive devices, etc. and training for their use are essential. In otherwords, intervention in daily living activities, in which physicians, nurses, and public health nurses arealso involved, with physical therapy is necessary, and for this reason, clauses to specify not violating
the laws such as the Act on Public Health Nurses, Midwives and Nurses are included.
The healthy life expectancy extension and preventive health care business for the elderly in the lowbirth and super-aging society that Japan is facing have been dealt with by municipal comprehensive
projects, etc. separately from medical intervention; thus, the approach is not necessarily only forpeople with “physical disabilities.” Consequently, the Ministry of Health, Labour and Welfare issued a
Notification from the Director of the Medical Professions Division, Health Policy Bureau dated
November 27, 2013 (HPB-MPD Notification No. 1127-3). This notification specifies the use of theterm “physical therapists” as follow: “Physical therapists sometimes carry out duties that are notconsidered assistance with medical treatment, such as giving guidance on fall prevention, for people
without physical disabilities in a business promoting preventive health care for the elderly, and it isperfectly acceptable to use the term ‘physical therapist’ even when they perform duties other thanphysical therapy as stated above. Physical therapists carrying out duties that are not consideredassistance with medical treatment need no instructions from a doctor.”
It means that it is acceptable to use the term, “physical therapists” when giving advice on various
matters from the viewpoint of physical therapy to the elderly, etc., showing that the scope of activities
as physical therapists has been expanding.
(Kengo Takashima)
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References1)
Fushiki S, et al.: Bioethics and Medical Ethics (4th edition). Kinpodo, 2014
2)
Morioka Y: Medical Ethics and Law—Basic Knowledge—. Nankodo, 2004
3)
Miyasaka M: Methods of Healthcare Ethics, Principle, Narrative, and Protocol (3rd edition).
Igaku-Shoin, 2016
4)
Rules of Ethics of Japanese Physical Therapy Association
http://www.japanpt.or.jp/upload/japanpt/obj/files/about/0432.pdf
5)
Guidelines for Professional Ethics for Physical Therapists
http://www.japanpt.or.jp/upload/japanpt/obj/files/about/02-gyomu-03rinrigude2.pdf
6)Japan Society for the Promotion of Science Editing Committee “For the Sound Developmentof Science”: For the Sound Development of Science—The Attitude of a Conscientious
Scientist—. Maruzen Publishing, 20157)
Ethical Guidelines for Medical and Health Research Involving Human Subjects.
https://www.mhlw.go.jp/file/06-Seisakujouhou-10600000-Daijinkanboukouseikagaku
ka/0000166072.pdf

8)
9)

Mochizuki H: Research Ethics in the Field of Physical Therapy. Journal of the JapanesePhysical Therapy Association, 44:386-393, 2017
Uematsu M (supervisor): Physical Therapy and Management. Nankodo, Tokyo, 2018.5, pp.120
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MATERIAL

10)
11)
12)
13)
14)

15)
16)
17)

Guidelines for Professional Ethics for Physical Therapists
Iida S (edited): Medical Safety Management Textbook (2019, 4th edition). Japan Standards
Association, Tokyo, 2019, pp.31-68
Hosoda K: Introductory Textbook for Physical Therapy and Management (revised 3rd edition).
Nankodo, Tokyo
Director-General for Statistics and Information Policy and Policy Evaluation), Ministry of
Health, Labour and Welfare: ABC of ICD (FY 2019 version), Director-General for Statistics
and Information Policy and Policy Evaluation), February 22, 2019
World Health Organization (WHO), Society to Study the Welfare of the Handicapped (edited):
International Classification of Functioning, Disability and Health (ICF)—Revised Version of
the International Classification of Impairments, Disabilities and Handicaps—, Chuohoki
Publishing, August 15, 2002
Physical Therapists and Occupational Therapists Act (Law No. 137, dated June 29, 1965)
Additional Clause, Appendix 1 to the Physical Therapists and Occupational Therapists Act(Law No. 153, dated December 12, 2001)
Director of the Medical Professions Division, Health Policy Bureau, Ministry of Health,Labour and Welfare: Use of the term ‘physical therapist,’ etc. (notification), November 27,
2013 (HPB-MPD Notification No. 1127-3)

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MATERIALAFTERWORD
In every era, terms vividly expressing each of their backgrounds are created. The modern society inwhich we are living is suggested to be in a phase of major change by keywords such as the Convention
on the Rights of Persons with Disabilities, super-aging society, declining birthrate and aging
population, changes in disease structure, lifestyle diseases, community-based integrated care system,
healthy life expectancy, and integrated provision of healthcare and nursing care. In such an era, I am
glad that the Japanese Physical Therapy Association (JPTA) publishes a book titled “Principles ofPhysical Therapy” to consolidate the history and prospects of physical therapy (therapists/science),
and at the same time, I express my gratitude to each of the authors.
Our work has been established as a result of day-to-day accumulation of activities by our predecessors
and through social contribution by playing a specific role as professionals and getting involved in the
habilitation and rehabilitation areas for a long time. Half a century has already passed since thephysical therapists began activities during the pioneer days in Japan and acquired national
qualifications. In recent years, more than 120000 physical therapists are involved in various duties in
not only the medical area but also the healthcare, medical, and welfare areas.
The Committee for Developing an Introduction to Physical Therapy was established as a critical topic
of the JPTA. Then, after 12 meetings (August 2018 to December 2020) from the inauguration of theCommittee, this book was published. I would like to describe again the basic policy for editing the“Principles of Physical Therapy:” The existence and the contents of the work of physical therapy(therapists/science) can be included in the philosophy and methodology of habilitation andrehabilitation, and the original duties of physical therapy might have been not adequately understoodor even recognized by the people, including those who are involved in other healthcare, medical, andwelfare fields.
The reason for this is that we reflected that this situation was also partly attributable to our (physicaltherapists’) inadequate interpretation, and we reconsidered the modality of physical therapy soon after.
Then, from the viewpoint of reflecting the past results of the role served by physical therapists as partof the community-based integrated care system, such as health promotion including prevention,
independence support from the acute to living phases, reduction in fall risk, improvement of living
environment, and amelioration of the functioning of people with participation restrictions, we wereable to publish the JPTA-initiated “Principles of Physical Therapy.”
We are working in the midst of an acutely and drastically changing era including Covid-19. I hope that
this book is used as a reference and becomes a guidepost to our future.

AFTERWORD

I would like to use this opportunity to offer this book to our former presidents who led the JPTA:
Satoshi Matsumura (deceased) the second and fifth president, Takashi Nomoto (deceased), the thirdpresident, and Yataro Yago (deceased) the fourth president.

February 2021

Committee for Developing an
Introduction to Physical Therapy
Kazuo Kurosawa, Chairperson

103
AFTERWORD

Principles of Physical Therapy
February 1, 2021, Version 1
June 5, 2021, Version 2
Published by: Japanese Physical Therapy Association
7-11-10 Roppongi, Minato-ku Tokyo, 106-0032, Japan
TEL: (03) 5843-1747
Text design and DTP: Tokyo Press Co., Ltd.
This English version is developed as part of the 60th anniversary project.

Japanese Physical Therapy Association