Barbara W. DeTurk
INTRODUCTION
As we move into the 21st century, much has been written about what the new millennium will bring. Forecasters have made detailed projections about world demographics and what the population will look like in terms of disease, activity levels, and health in the next quarter of a century. Dramatic changes are expected in the field of medicine that will impact the manner in which diseases are diagnosed and treated. There are large initiatives already in place in the United States, aimed at prevention and wellness, which project into the next decade. Information technology, an area where health care companies are beginning to invest heavily, will revolutionize how we communicate and utilize information.
This chapter will examine forecasts made for the next 20 years or so to create a picture of health care in the future and relate it to the practice of cardiopulmonary physical therapy. Many questions come to mind when one thinks so far into the future. What will the profile of a physical therapist look like in the year 2030? In what environments will therapy be practiced? How will physical therapists use new information technologies? There is no doubt that those just entering the field of cardiopulmonary physical therapy will witness a wide variety of change in the next 20 years. This chapter will attempt to prepare both the new and experienced therapist to meet the challenges of tomorrow’s health care environment.
GLOBAL DEMOGRAPHICS
Let us begin by looking at the world at large, to examine the changes anticipated in the growth of the population. Most demographers agree that the population of the world will continue to grow from its present 6.6 billion people to approximately 9.4 billion in 2050. The incredible fact is that 212,036 people are being added to the world’s population each day!1 United Nations forecasting predicts global population to peak at 11 billion in the year 2200. The total population in industrial countries is expected to decline, whereas 60% of the increases will take place in Asia, China, India, and Africa. Countries with the highest growth rate will feel the greatest impact on their public health system. Unfortunately, most of the world’s population growth is projected to occur in the most distressed regions, where destruction of land, lack of food, and water will have a major impact on the health of the inhabitants.2–5
Aging Demographics in the United States
Age composition of the United States will change dramatically as we move further into the 21st century. By the end of the 1990s, one in every four persons was aged 50 years or older. The United States Bureau of the Census projects a moderate increase in the elderly population until 2010, then a rapid increase for the next 20 years to 2030, and then a return to a moderate increase in the years 2030 to 2050.6 This is based on population momentum, more commonly referred to in the United States as the impact of the “baby boomers.” Baby Boomers are considered to be those born between 1946 and 1964, after the end of World War II. Seventy-eight million baby boomers will turn 65 in 2011; an influx that will exceed the number of providers who can care for them.7 This group will be responsible for the rapid rise in the elderly population between 2010 and 2030. The population will fall off again after 2030 because boomers have reproduced at a lower rate.6 The population of the oldest old (85 years and older) is expected to grow by 56% between 1995 and 2010. From 2030 to 2050 the population of 85 years and older is expected to increase to a whopping 116%, as the baby boomers reach 85 years. This means that a larger share of the elderly will be older than 85 years. (See Fig. 23-1.)
FIGURE 23-1 Number of older Americans. (Source: U.S. Census Bureau. http://www.agingstats.gov. Older American 2008.)
It makes sense then that the number of elderly in poor health are projected to increase sharply from 1990 to 2030. Heart disease and stroke deaths rise significantly after age 65 years, accounting for more than 40% of all deaths among persons aged 65 to 74 years, and almost 60% of those aged 85 years and older. The number of people in nursing homes is projected to double and possibly triple by the year 2030. Also projected to increase are the numbers of people with disabilities, with greater than 19% of the population expected to have activity of daily living limitations (ADLs) by 2020.6 (See Fig. 23-2.)
FIGURE 23-2 Functional limitations. (Source: Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey.)
Racial and gender composition of the elderly in the next 50 years will undergo significant change. Elderly women (85 years and older) will outnumber men by more than 4 million, or nearly 60%. Minority populations are projected to represent 25.4% of the elderly population in 2030. By 2050, the United States will be more of a multicultural society with Hispanic, African American, and Asian comprising the largest cultural groups (Fig. 23-3). As the racial ethnic ratios change, a greater proportion of our elderly will fall into a lower socioeconomic category, with fewer health benefits, access to health care, and less education on wellness and prevention.6
FIGURE 23-3 Racial and ethnic composition. (Source: U.S. Census Bureau, Population Estimates and Projections.)
The need for rehabilitative health care services in the United States should escalate dramatically by 2011. As the baby boomers reach age 65 years, they will tend to have more health-related problems, and a higher incidence of disabilities. There will be greater numbers of Hispanic, African American, and Asian elderly, with different cultures and beliefs that therapists must be sensitive to in their patient management. Therapists may increasingly practice cardiopulmonary physical therapy in nursing homes, assisted living facilities, and home care environments due to the anticipated growth in the elderly population. By 2011 there should be tremendous opportunity for physical therapists in general and cardiopulmonary therapists in particular. Let us see why…
Incidence/Trends for Cardiopulmonary Disease
Cardiopulmonary diseases are part of the broad classification of chronic diseases that impact health in the United States. Heart disease is the number one cause of death, with one of every two males and one of every three females aged 40 years and over at risk for developing the disease.8 We have already seen that the projected size of the elderly population in the United States will increase dramatically over the next two decades. There will also be an increased incidence of chronic disease associated with an aging America.
Today chronic diseases account for 70% of all deaths in the United States, and medical costs are more than 60% of the nation’s health care costs. Even though trends for coronary heart disease death rates have declined in the general population over the past 35 years, it will continue to be a major health problem due in part to the shear numbers of elderly who contract the disease.9 (See Fig. 23-4.)
FIGURE 23-4 Mortality. (Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.)
Lung disease is the number three killer in the United States, behind heart disease and cancer, and it is the leading cause of death in babies younger than 1 year. Lung disease costs the U.S. economy $154 billion annually, $95 billion in direct costs, and $59 billion in indirect costs.10 Chronic obstructive pulmonary diseases are ranked as the fourth leading cause of mortality.11,12 Asthma ranks highest in number of cases reported, as compared to bronchitis and emphysema. Although more adults have asthma, the incidence in children and adolescents has actually doubled in the time periods 1979–1980 to 1993–1995.8 Socioeconomic status, particularly poverty, appears to be an important contributing factor to asthma illness, disability, and death. In the United States, the rate of asthma cases for Asian, Hispanic and African Americans is only slightly higher than that for whites; yet, death, hospitalization, and emergency room visit rates for this group are more than twice those for whites.2 Although reasons for these differences are unclear, they likely result from multiple factors: high levels of exposure to environmental tobacco smoke, pollutants, and environmental allergens (eg, house dust mites, cockroach particles, cat and dog dander, and possibly rodent dander and mold); a lack of access to quality medical care; and a lack of financial resources and social support to manage the disease effectively on a long-term basis.11
Chronic diseases such as cardiopulmonary disorders will affect women, children, and minority populations disproportionately. Women comprise more than half of the people who die each year from cardiovascular disease, whereas death from asthma is more likely to occur among African Americans and Hispanics than among whites. As we move into the next decade, with trends indicating increased numbers of minorities and women in the population, we can project that chronic diseases will continue to be a major health and financial issue.11,12
MEDICAL CARE IN THE FUTURE
Wellness Revolution Merging of Eastern and Western Medicine
It has begun to happen. We are presently in a wellness revolution. What had been considered Eastern philosophy has begun to merge with concepts of Western medicine. Although scientists exclaim that there is little proof that Eastern techniques “work,” the American public has begun to embrace herbs, massage therapy, acupressure, acupuncture, and meditation as accepted forms of alternative medicine.13
In a recent article by The Journal of the American Medical Association, Dr. S. Straus, the Director of the National Center for Complementary and Alternative Medicine projected that by 2020 medicine will be integrative. Dr. Straus believes rigorous scientific studies of alternative therapeutic and preventive modalities will prove some interventions to be effective, and they will be incorporated into conventional medical practice. Those that are not found to be effective will be discarded. The effectiveness of herbal and nutritional supplements will also be further researched and clarified. By 2020 the terms alternative and complementary medicine will be replaced by integrative medicine.This new field will embrace the best of Western and Eastern medicine philosophies and offer the patient a more holistic approach.14
As the mainstream medical approach becomes integrative, physical therapy practice may evolve and become more holistic. What might a holistic physical therapist be like? We know that holistic health principles focus on the interrelationships among the body, the mind, and the spirit. In addition, how different body parts react to one another is seen as an important component of the healing process.15 Envision if you will, the therapist of the future routinely using a hands-on approach to not only unlocking muscle strain but also assisting in clearing mental and spiritual stressors as well. Some therapeutic techniques that are holistic in nature are already beginning to be integrated into physical therapy practice, such as acupressure, yoga, Feldenkrais, and t’ai chi chuan. Those who currently practice craniosacral therapy, for example, know that when the body begins to unwind, emotional feelings often accompany them as well. It is possible that therapists of the future will more frequently utilize their hands-on connection with the patient to improve functional status, while contributing to a more balanced spiritual state.13,16,17
Future Medical Advances
National Institute of Health Projections
The future of medical care will be characterized by dramatic change. Forecasters predict unprecedented medical innovations in the next few decades.
Dr. Claude Lenfant, NIH Director of The Heart, Lung, and Blood Institute, projects that coronary artery bypass operations will become mostly obsolete.14 He believes favorable trends in coronary risk factors should reduce the need for surgical intervention. Those who still require bypass surgery will benefit from replacement vessels that behave more like arteries than like veins. Dr. Lenfant predicts that arteries will be grown in advance of the procedure from the patient’s own cells. Dr. Anthony Fauci, NIH Director of the National Institute of Allergy and Infections, believes we will find new therapies and vaccines to fight chronic as well as infectious diseases. Chronic diseases such as cardiovascular disorders will be shown to have infectious etiologies and will be treatable with inexpensive antibiotics and vaccines.14
Advances in Pulmonary Care
Large organizations are stepping to the plate to conduct research leading to improved medical management of chronic disease. The American Lung Association has a network of 20 research centers currently conducting large clinical trials focused on the direct care of those with asthma. The most current clinical trial is a study of the connection between gastro esophageal reflux (GERD) and asthma. Other leading researchers are focused on genetic and molecular-level markers in relation to asthma, and bronchial thermoplasty.
Bronchial thermoplasty is now under clinical trial for consideration as a treatment for severe asthma. The theory is that asthma is caused by an overgrowth of smooth muscle tissue in the large airways. During asthma attack, the muscle contracts and narrows the passageway making breathing more difficult. In bronchial thermoplasty, heat is applied to the smooth muscle through a flexible tube during a bronchoscopy procedure. The heat causes the muscle to relax and keeps the airway open. Bronchial thermoplasty has been effective in reducing the number of asthma attacks, and reducing the use of rescue medication in patients with severe asthma.18
Of particular interest to physical therapists is the current research on the association of weight and asthma. In an analysis of seven studies those people who were considered overweight or obese had a 51% greater chance of having asthma than a person of normal weight. Physical therapists can have direct impact on this patient population through the use of weight reduction exercise programs, and referral for nutritional counseling.18
Innovations in modern medicine in the past had taken many years of research and clinical trials before treatments were introduced to the public. Now the development cycle has been greatly decreased because of the society’s demand for short-term payoff.19 In fact Cetron and Davies forecast that the first decade of the 21st century will be one of the most productive in the history of medicine.19 There will be hundreds of new treatments and diagnostic advances available to patients in the areas of gene therapy, stem cell transplants, and nanotechnology. These new treatments and devices will lead to rapid diagnosis, help predict disease, provide relief to patients with chronic respiratory ailments, repair damaged heart muscle, and treat hereditary diseases. For our purposes, we will examine those innovations that impact the field of cardiovascular and pulmonary physical therapy.
Advances in Cardiac Care
As an example of the fast-paced development cycle for clinical products, the progress in creation of ventricular assist devices (VAD) has been remarkable. Over the last few years VADs have been used experimentally as a bridge to transplantation, recovery therapy, and most recently as destination therapy. On April 22, 2008, the FDA gave approval for the use of the first compact heart assist device to support the weakened heart of a small-sized adult man or woman with heart failure awaiting heart transplant. Previous models were too large to be placed in the abdomen of the patient, and required the patient to be tethered to an external power source. The HeartMate II is a mere 3 in. in length and weighs approximately 1 lb, and can operate on two external batteries worn at the waist, allowing the patient to move freely for up to 3 hours. In a clinical study at 26 transplant centers, 57% of patients with the HeartMate II survived to receive heart transplantation. This result is comparable to those patients treated with currently approved assist devices of larger size. By the year 2020, who knows what the VAD will look like, perhaps technology will progress to the point where it will be completely internal.20
The Human Genome Project
The Human Genome Project, a publicly funded, international effort, has completed one of its primary goals: to map the human genome. This represents one of the most significant medical achievements in our time, and has far-reaching potential to improve health over the next decade! Begun in 1990, the project was originally slated to last 15 years, but because of rapid technological advances, some of its goals were completed ahead of schedule. The goals of the Human Genome Project were to identify all 30,000 genes in human DNA, determine the sequences of the 3 billion chemical bases that make up DNA, and store the information on databases.21
A mutation of a single gene has been known to cause as many as 4,000 rare diseases, such as cystic fibrosis, sickle cell anemia, and Tay-Sachs disease. The causes of heart disease, diabetes, hypertension, and hypercholesterolemia, from a genetic point of view, are considered more complex. These diseases are thought to be caused by multiple gene mutations, or be the result of a combination of environmental factors, such as diet and gene mutation. Gene alteration may also influence an individual’s ability to respond to viruses, bacteria, and toxins.21–23 Dr. Francis Collins, the Director of the National Human Genome Research Institute, likes to paraphrase Churchill when he says, “Sequencing the genome is not the end, or the beginning of the end, but simply the end of the beginning.”22 Unlocking the genetic code is the first step in understanding the nature of disease and may lead toward more effective treatments, possible cures, or ways to prevent thousands of diseases.23
Genetic Effect on Medicine
What do scientists project will be the effect of genetics on the practice of medicine by the year 2020? A complete list of the human genome will give rise to a vast number of new medications. Drell and Adamson predict the number of new drugs tested and released for consumer use will increase sixfold from 500 new drugs in 2,000 to 3,000 in 2020.24 Consumers of health care will have a record of their genome available during routine medical visits, and it will be used to predict which medications will most closely align with their body to minimize side effects and maximize treatment. Drugs will be prescribed more accurately for each patient based on information from their genome, and from knowledge of environmental factors that may also play a role in the disease process. Knowledge of specific gene abnormalities, which predispose a person to, for example, high cholesterol, will allow that person to make lifestyle changes prior to the development of active disease. By 2020 neonatal genetic testing will be routine and single gene related disorders will be readily treated.24
Gene Therapy
At present the Food and Drug Administration (FDA) in the United States has not approved any gene therapy product for sale. Gene therapy is still considered very experimental in nature; however, gene-related research and development continues to grow at a rapid pace.25
Gene therapy works by the insertion of a normal gene into the genome to replace an abnormal disease-causing gene. To get the gene into the body, a vector molecule is used, most commonly a virus. Viruses are used because of their capacity to encapsulate a molecule and then deliver it to a targeted cell. Different types of inactive viruses are used for their ability to deliver molecules to various areas of the body. One example is the adenovirus, the virus that causes the common cold. It has been used to deliver genetically repaired cells to cardiac muscle in gene therapy studies for patients with congestive heart failure.26
In 1990, 4-year-old Ashanti DeSilva was the first recipient of gene therapy with an infusion of white blood cells carrying synthetic DNA. Ashanti suffered from severe combined immunodeficiency disorder, or SCID, which left her without a functioning immune system. Doctor W. French Anderson, formerly of the U.S. National Institutes of Health, treated Ashanti with her own genetically altered cells. They were administered through her bloodstream and produced the missing enzyme, the lack of which had caused her disease. In subsequent months she received four more cell infusions. Since then she has required booster shots but has regained her health through the use of gene therapy, and medication.19
Use of Gene Therapy in Congestive Heart Failure
Prospects for the use of gene therapy in the treatment of congestive heart failure are very real indeed. Scientists have begun basic investigative studies on rodents and on isolated cardiomyocytes from failing human hearts. The interventions that were studied focused on enhancing sarcoplasmic calcium transport, which is decreased in patients with congestive heart failure. Disturbances in calcium metabolism have been shown to contribute significantly to the contractile dysfunction observed in heart failure. In these studies the subject was “infected” with sarcoplasmic reticulum Ca2+ ATPase (SERCA2a). In other words, the SERCA2a gene was carried by an adenovirus to targeted cells in the rodent or cardiomyocyte. The results showed that gene transfer of SERCA2a improved left ventricular function. Scientists are quick to point out that these are preliminary studies, and further experimentation is needed before this form of gene therapy is ready for use in humans.27–29
First Commercial Gene Therapy Product for Humans
In October 2003, China became the first country in the world to produce a commercial gene therapy product called Gendicine for use in the treatment of head and neck squamous cell carcinoma. In 2005, a second product called Oncorine was also approved for use of head and neck cancer in China. Gendicine is delivered by an adenovector virus. Eight weeks of injections of this gene therapy product are used in conjunction with radiation treatments. After 5 years of clinical trials with Gendicine on 26 patients, 64% of late stage tumors showed regression, and 32% of tumors demonstrated partial regression. So far the only side effect seems to be self-limited fever.30 Five-year survival rates show 17 of 26 patients surviving, 16 without reoccurrence of disease. In the control group of 26 patients, 14 have survived for 5 years and 10 remained cancer-free.
In the United States and other countries around the world, an experimental sample size of 26 patients is considered too small to reach a credible level of statistical significance. In addition, the combined therapies, genetic and radiation, make it difficult to discern how much gene therapy contributed to patient improvement.31
Stem Cell Research—The Body’s Self-Repair Kit
Human stem cell research, like gene therapy, is another important area in the medical field that holds great promise. Research in human developmental biology has led to the discovery of human stem cells (precursor cells that can give rise to multiple tissue types), including embryonic stem cells, embryonic germ cells, fetal stem cells, and adult stem cells. Embryonic (pluripotent) stem cells are harvested from 7-day-old embryos or aborted fetuses. These cells are used because they have the unlimited capacity to divide. In fact pluripotent stem cells can become any tissue in the body, including muscle, nerve, heart, and blood cells. Adult stem cells; however, appear to be restricted in what they can become. For example, adult stem cells in bone marrow give rise to blood cells, whereas those that are from muscle seem to create only new muscle cells. Pluripotent stem cells hold the most promise for treatment of disease but are controversial in nature due to their origin. In 2000, it was reported that scientists at the University of Wisconsin and Johns Hopkins University were able to isolate and successfully grow pluripotent human stem cells. The University of Wisconsin has been able to establish a stem cell bank so that new embryos are no longer needed, thus avoiding some of the controversy involved with this research.32,33
Scientists believe stem cells have the potential to cure disease, reverse the advance of chronic disorders, and heal injuries. These cells will be able to generate tissue for transplantation and replace damaged tissue such as myocardium. Stem cells also have the potential to assist in the way we currently develop new drugs. The drugs will be tested on stem cells first, then later on humans. Researchers project that patients with heart disease, Parkinson’s disease, severe combined immunodeficiency (SCID), diabetes, and spinal cord injuries will be some of the few that may be helped with this type of treatment.32,33
Scientists have begun to study the use of stem cells for patients with congestive heart failure. Preliminary work in mice and other animals has demonstrated that healthy heart muscle cells transplanted into the heart successfully repopulate cardiac tissue, without rejection from surrounding tissue. Use of stem cell transplants has the potential to overcome the problem of tissue incompatibility and the need to use immune-suppressing drugs currently used during cardiac transplantation. The challenge now is to develop heart muscle cells from human pluripotent stem cells and transport them into failing heart muscle in order to support cardiac function.34
Telomerase Activation—The Fountain of Youth?
Telomeres form the ends of human chromosomes, like the plastic caps on the end of a shoelace. The telomeres function to maintain chromosome stability, and require a minimum length. Telomeres shorten with each round of cell division, and this mechanism limits proliferation of human cells to a finite number of cell divisions. There is growing evidence indicating that telomere shortening also limits stem cell function, regeneration, and organ maintenance during ageing. Moreover, telomere shortening during aging and disease is associated with a 3.18-fold higher mortality rate from heart disease. Telomeres have emerged as crucial cellular elements in the aging process and in various diseases including cardiovascular and chronic obstructive pulmonary disease.35
Since 1995, scientists have been working on ways to activate telomerase, which functions to repair and lengthen the telomere. They have already accomplished this in both mice and humans. T.A. Sciences Center in New York Center, New York, now offers a telomerase-activating product called TA-65, as part of a 12-month protocol. TA-65 is produced by a company called Geron and is administered in tablet form like a supplement. In clinical trials 2 to 4 daily doses of 10-mg tablets of TA-41 (a precursor to TA-65) were given to men aged 60 to 85 years for 12 weeks in a double-blind study, and the condition of their immune system, eye sight, sexual function, and skin improved dramatically. As a result of these human trials, T.A. Sciences now offers a 1-year supply of TA-65 at the low price of $25,000.00! The fountain of youth may be here, but it comes with a hefty price tag!36
Nanotechnology: The Doctor That Floats in Your Bloodstream
Molecular nanotechnology is a field of research aimed at the manipulation of atoms and molecules into nanometer size (a nanometer is 1 billionth of a meter).37 All manufactured products are made from atoms manipulated in simple ways. “Nanoscience and nanoengineering—the ability to manipulate and move matter—are leading to unprecedented understanding of the fundamental building blocks of all physical things.”38 President Obama’s fiscal year 2010 budget requests $7 billion for the National Science Foundation, to support scientific research in the United States. It remains to be seen what portion of that scientific funding will go toward the National Nanotechnology Initiative.39 It is expected that nanotechnology will impact the way vaccines, medical-testing devices, computers, and even automobile tires are made.
An article in The New York Times relates a futurist episode where a person has an episode of chest pressure at lunch. Instead of rushing to the emergency room, the person injects themselves with minuscule cylinders called respirocytes packed with pressurized oxygen, designed to mimic the function of red blood cells. Aboard each respirocyte is a tiny computer that gives the command to deliver oxygen when the distressed cells are reached. Instead of collapsing, the person finishes lunch and goes for a checkup with their doctor.37 Ralph Merkle, a nanotechnology engineer, foresees a time when patients with cardiac and respiratory disorders will carry respirocytes like diabetics carry insulin. This technology may be 30 years in the future, but less fantastic medical applications may be only a few years away.40
The first medical applications of nanotechnology will probably be in the field of screening and diagnostic tools. The New York Times reports that a Palo Alto–based company called Quantum Dot Corporation is developing nanoscopic crystals to be used in basic genetic screening and detection of disease. These nanosensors will greatly enhance tools such as CAT scans, MRIs, and catheter tips that will allow physicians a better view of a patient’s anatomy. Within a decade we may see passive nanobots that can be inserted into the bloodstream to study internal organs. Beyond that, some predict that we will be able to create self-replicating nanobots, which will actually follow directions. They can be programmed to seek out viruses or cancer cells and destroy them before they have impact on the body.37
HEALTH CARE POLICY
Healthy People 2010
Did you know that the United States has an agenda for a health wellness and prevention program? Healthy People is a national program that sets the agenda for managing preventable threats to health and focuses public and private sector efforts in order to address those threats.8 The purpose of Healthy People is to improve health, not only of individuals but also of communities and the nation. It began in 1979 from the Surgeon General’s report entitled “Healthy People,” and has blossomed into the Healthy People Consortium. The consortium is a user alliance of 350 national membership organizations and 250 state health, mental health, substance abuse, and environmental agencies (with input from the American Physical Therapy Association [APTA]). Every 10 years new objectives and goals are determined for the health of the nation. These goals serve as a guide for developing a set of objectives, which focus on determinants of health. Three of the Healthy People goals pertain to cardiovascular and pulmonary physical therapy: heart disease and stroke, physical activity, and respiratory disease. Ultimately the success of the goals is measured by the health status of the target population.8
Healthy People 2020 Guidelines were due to be released in the fall of 2008, but due to a reevaluation of the goal-setting process, the publishing date has been pushed back. It was felt that the goals and objectives were too lengthy, and needed revision. A midcourse review was conducted in 2003 that evaluated the progress towards those goals. It is interesting to note that some physical activity goals set by Healthy People 2010 have been partially met, while others have fallen below previous health levels. For example, the objective for moderate activity in children between the ages of 9 and 12 moved away from its target. In 1999, 27% of children participated in moderate physical activity, but by 2003 that level had dropped to 25% instead of rising to the target of 35%.41
Using Healthy People Objectives
Healthy People materials are in the public domain and posted on their extensive Web site (http://www.healthpeople.gov) to encourage groups to integrate their objectives into health care programming. Cardiovascular and pulmonary therapists should review the objectives that pertain to their patient populations, and incorporate them into daily practice where appropriate (Box 23-1). For example, to apply Healthy People leading indicators to physical activity and obesity, therapists might conduct screenings of body mass or monitor heart rate and blood pressure before and after exercise. Therapists may find that they already inadvertently participate in Healthy People through data collection projects such as the Health Plan Employer Data and Information Set (HEDIS). Healthy People is an excellent example of a far-reaching public health policy that sets the standard for health care in the future. As health care practitioners, we should join in this national effort to prevent cardiovascular and pulmonary disorders and promote wellness of our communities.8,42
COMMUNICATION TECHNOLOGY OF THE FUTURE
Online Medical Records
There are now a number of online Web sites that provide storage for medical records. Google and General Electric to name just two, have started secure Web sites for online medical records.43 The online site allows patients to organize health information all in one place, gather medical records from doctors, hospitals, and pharmacies, and share that information securely with doctors and caregivers.43
The Obama Administration in its economic stimulus legislation entitled the American Recovery and Reinvestment Act of 2009, incorporated payment incentives to Medicare and Medicaid programs that utilize health IT (information technology). Health IT includes online medical records, computerized medical records, and telehealth to name a few types of technology. The Congressional Budget Office, which advises congress on the cost of legislation, expects that the increased utilization of health IT would reduce total spending on health care by decreasing inappropriate tests, paperwork, and medical errors.44
BOX 23-1
Healthy People 2010 Goals and Objectives Pertaining to Cardiovascular and Pulmonary Physical Therapy Practice
1. Heart Disease
Goal—Improve cardiovascular health and quality of life through the prevention, detection, and treatment of risk factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events.
Objectives (health determinants for cardiovascular disease)—coronary artery disease (CAD) deaths, knowledge of symptoms of heart attack and importance of dialing 911, artery-opening therapy, bystander response to cardiac arrest, out-of-hospital emergency care, and heart failure hospitalizations.
2. Respiratory Disease
Goal—Promote respiratory health through better prevention, detection, treatment, and education.
Objective—The health determinant objectives are deaths from asthma, hospitalizations for asthma, hospital emergency department visits for asthma, activity limitations, school or workdays lost, patient education, appropriate asthma care, and surveillance systems.
Example—An example of a specific goal for respiratory disease is to slow the rise in deaths from chronic obstructive pulmonary disease to achieve a rate of no more than 25/100,000 people.
3. Physical Activity
Goal—Improve health, fitness, and quality of life through daily physical activity.
Objective—The objectives monitor the degree of physical activity, muscular strength, flexibility, endurance, physical education requirements in schools, and television viewing.
Example—A more community-minded objective reads as—increase community availability and accessibility of physical activity and fitness facilities as follows: hiking, biking, and fitness trail miles: 1/10,000 people. Of the 13 physical activity and fitness objectives, only worksite fitness programs have met the year 2000 targets.
Physical therapists working in all types of environments now and in the future will benefit from online medical records. There are many instances in current practice when a therapist must evaluate a patient with little or no medical history other than what a client is able to relate. Therapists with online capabilities in their workplace will have a tremendous advantage if they are able to tap into the online medical record for information. Communication with other professionals working with the client may also improve, if their reports are included in the online medical record.
Communication Technology and Physical Therapy
Communication technology in the form of handheld computers is reaching out to the field of home care practice. Federal requirements now demand home care evaluation and discharge paperwork to be “locked and loaded,” as it is called, into a computer system within a short-time frame. Traditional paper-driven home care agencies are struggling to meet these strict time deadlines, as it is difficult to get paperwork data entered this quickly. Forward-thinking agencies are turning to handheld or laptop computer technology that allows staff to document care directly into a relatively small unit that is connected to a centralized server. There is no paper, and the documentation is available to the home care agency and payer source with little turnaround time.
In the future, handheld computerized documentation devices or laptops will probably become the norm in home care and in other practice environments. Technology may even advance to the point where all communication takes place via an all-in-one watch,37 a wristwatch-sized cell phone, with a keyboard and Internet access that will provide a direct link to the patient’s online medical record. For those who dread documentation, hang in there; future technology may solve your problems!
Telemedicine
Advances in telecommunication technology have now made it possible to link hospitals, medical centers, and patients in the home, for the purpose of providing support and clinical care at a distance. Telehealth has been defined as the use of electronic communication to provide and deliver health-related information and health care services. Those services include patient evaluation, education, medication reminders, and monitoring of interventions, performed by doctors, nurses, radiologists, physical therapists, and others. The benefit of telehealth is that it can be utilized over large distances, providing medical management to those who might not have access to care.45
East Carolina University School of Medicine (ECU), a leading center for telecommunications in the United States, began conducting telemedicine consultations in 1992. To date they have completed more than 3,000 consultations in 34 different specialties of medicine. ECU has integrated a hybrid network of telecommunication technology to link approximately 40 sites with 3 discrete channels of audio, video, and data. The ability to telecommunicate is dependent on the “lines” (ie, wires, cables, optical fibers, and microwaves) that connect 1 station to another.46–48
In the home care setting, there are various products available today that link the patient via a phone line to a centralized station that monitors the data transmitted. One such product called the AlereNet System is being used with congestive heart failure patients to help recognize the early signs of cardiac failure. Because daily monitoring by home care personnel is prohibitively expensive ($132/d), utilization of a telecommunication device allows for the necessary monitoring at a lower cost ($13/d).48
The AlereNet System is placed in the patient’s home and establishes an audio/visual link with the patient. The monitor asks the patient physician-specified questions about their symptoms, via an audible voice and visual display. The patient answers the questions by pressing yes or no keys and then uses a biometric measurement device to record their weight. The information obtained is then stored and forwarded to the home care agency or MD for interpretation. Health care practitioners can access the patient’s entire history of symptoms and weight, as well as their medical history and medications49 (Fig. 23-5).
FIGURE 23-5 The AlereNet System: an audiovisual device that links the home-bound patient directly to the health care provider. (Reprinted with permission from Alere Medical, Inc., Reno, Nevada.)
Another telehealthcare system called The Viterion 500 Telehealth Monitor uses store-and-forward technology to relay vital sign measurements and personalized questions or advice, as well as digital video technology and Web access. Depending on the specific needs of the patient, this telehealth device can be set up to monitor blood pressure, heart rate, breath sounds, heart sounds, ECG, weight, glucose levels, O2 saturation, and temperature. The video component allows a health care practitioner to have a two-way interaction with the patient, to answer patient questions and provide a supplement to in-home visits. Web access can link patients to specific disease management education programs that offer beginner through advanced information on topics related to the patient’s medical regime.
The Viterion 500 has been utilized in Veterans Administration Hospitals to assist in caring for patients with chronic disease. One such patient was the subject of an article in the Boston Globe on September 23, 2003. Richard Keirsead, a 72-year-old Air Force veteran, used to rush to the hospital at least 10 times a month for medical problems caused by diabetes, multiple sclerosis, and advanced heart disease. Since he started using a The Viterion 500, he has been able to manage his health at home through frequent monitoring of his vital signs. If there is a problem he can “meet” a nurse or physican at the Veterans Hospital via live video. Mr. Keirsead has only been hospitalized once since 2001 when he began using this telehealth device, a savings in travel time for him, and dollars for the VA Hospital.50
The American Physical Therapy Association’s stance on telehealth has evolved to now include the use of this technology in the practice of physical therapy. APTA guidelines have been revised to indicate that telehealth must adhere to basic assurances of quality and professional health care. Telehealth must be in accordance with the Guide to Physical Therapist Practice, and the laws of the jurisdiction in which the care is rendered. Services via telehealth must ensure that patient safety is comparable to the physical therapist being physically present.45
Physical therapists have just begun to interact with telehealth devices in the home care setting in the management of patients with chronic disease such as asthma, CHF, diabetes, and COPD. The therapist has improved capability to monitor patients through the use of ECG, and O2 saturation levels, as well as blood pressure, heart rate, and respiratory rate that are traditionally monitored. Therapists can utilize these units to relay vital signs taken pre- and postexercise, where they can be compared with previous readings. This allows closer patient monitoring during exercise and tighter control of medication regimes. In the future physical therapists may supplement home visits with the use of the video component of a telehealth device to monitor home exercises from the home care agency office. This might be particularly useful for patients located in remote areas, where travel time is an issue.
Kenneth Sparks, PhD of Cleveland State University, sees the use of telemedicine in outpatient cardiac rehabilitation. He studied 400 patients from five hospitals in Cleveland, Ohio, to determine if patients enrolled in cardiac rehabilitation would self-pay (because insurance does not yet pay for telemedicine) for rehabilitation services if they were more convenient. Apparently there were a number of patients who could not enter programs because of scheduling difficulties or distance. Eighty-four of 206 (40%) patients responding indicated that they would be willing to pay for more convenient cardiac rehabilitation services. From this study, Dr. Sparks developed a model for the use of telemedicine for monitoring patients with heart disease. He believes that a viable self-pay model can be established to bring cardiac monitoring to patients via telemedicine.51
PROFILE OF A PHYSICAL THERAPIST IN THE FUTURE
At the June 2000 annual APTA conference, the House of Delegates endorsed a vision statement describing the future of physical therapy and the characteristics of the physical therapist and physical therapy assistant. It so clearly defined the focus of strategic planning for the growth of the profession, the text is quoted directly:
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, function limitations, and disabilities related to movement, function, and health.
Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in clients’ health networks and will hold all privileges of autonomous practice. Physical therapists may be assisted by physical therapist assistants who are educated and licensed to provide physical therapist-directed and supervised components of interventions.
Guided by integrity, life-long learning, and a commitment of comprehensive and accessible health programs for all people, physical therapists and physical therapist assistants will render evidence-based service throughout the continuum of care and improve quality of life for society. They will provide culturally sensitive care distinguished by trust, respect, and an appreciation for individual differences. While fully availing themselves of new technologies, as well as basic and clinical research, physical therapists will continue to provide direct care. They will maintain active responsibility for the growth of the physical therapy profession and the health of the people it serves.52
Many Catherine Worthingham Fellows share the APTA’s vision of the future. Their thoughts have been recorded in a special section of PT Magazine titled Forecast 2000. When asked the question “What does the profession of physical therapy need to do to thrive in the new millennium?” one of the most common replies centered on evidence-based research. In the words of Beverly Schmoll, PT, PhD, FAPTA, “As we enter the new millennium, the profession of physical therapy must be grounded in clinical research, emphasize the behavioral sciences, and become ‘other’ oriented through effective advocacy for those whom we serve.”53 Other common themes included the idea that physical therapists must be seen as diagnosticians, that therapists must position themselves in the area of prevention and wellness, and that therapists must have direct access to the patients they serve. Arthur Nelson, PT, PhD, FAPTA, makes note of stem cell research and genetic manipulations that make it possible to rebuild components of the nervous system. He projects that physical therapists will be the clinicians who will design exercise programs to relearn movement!54
The Scientific Practitioner
Physical therapists of the future will be able to rely on a growing scientific base of knowledge for diagnosis and treatment of their patients. In the last 10 years, therapists have been challenged more and more frequently to justify the effectiveness of their treatment. Insurance companies have denied coverage of some traditionally used treatments because their efficacy had not been proven through clinical research. The physical therapy profession has been in a conundrum: They could not suspend certain physical therapy treatments until they could be scientifically supported, nor could they recommend continuing to practice without systematic inquiry and empirical justification. In response to this dilemma, in November 1999, APTA’s Board of Directors adopted a clinical research agenda that would provide scientific data to support clinical practice.55
The APTA’s Agenda for Clinical Research will project out at least 5 years, if not more. This group plans to rely on the resources of the Foundation for Physical Therapy to implement research, but will need additional funding sources to complete the proposed agenda. It is the goal of the Research Agenda to bring time-tested physical therapy practice into a full-blown science of physical therapy. Completion of the Research Agenda will modify physical therapy practice into evidence-based care. This will strengthen the profession’s standing with insurance providers, as well as with other practitioners in the community. The APTA projects that in the future physical therapists will be seen as scientific practitioners.55
PRACTICE SETTINGS OF THE FUTURE
Physical therapists have a long track record for effectively treating a “core” group of patients with functional limitations, disabilities, and changes in physical function and health status resulting from injury, disease, or other causes. Traditionally, therapists have practiced in setting locations that are often part of a continuum of care: from the acute hospital environment, to a postacute facility, to home care services, and finally to an outpatient clinic. Within the current health care revolution, these traditional settings will continue to demand the services of physical therapists; however, new avenues for practice may open up as well.
Today’s health care consumer has greater access to medical information and is more assertive about their care. In a sense the consumer is driving a health care revolution. They demand quality services, reasonable prices, and convenience. The health care consumer has learned that they must be their own advocates.56 As such, demand for convenient quality health care has created a new supply of treatment locations and options. Integrative outpatient centers have emerged to provide a variety of services in a convenient “one-stop shop” atmosphere. Corporations have opened their own employee fitness/wellness centers for the benefit of their staff and for lower health insurance premiums. Let us examine the opportunities that new practice environments present.
Longevity/Wellness Centers
Although the concept of a longevity or wellness center has just recently gained recognition, the Pritikin Longevity Center, one of many longevity centers in the United States, has treated patients for the past 25 years. They are particularly well known for their work with cardiac disorders.57 Wellness centers such as the Cardiovascular Wellness Center in Westbury, New York, utilize traditional noninvasive diagnostic tests (stress tests) along with careful analysis of blood chemistry, vitamin and mineral assay, body composition, and digestive analysis as part of their standard evaluation. A personalized program is recommended from the results of the comprehensive evaluation that incorporates proper nutrition, diet, exercise, and an integrated approach to medicine using essential drugs with natural therapies.58 Physical therapists can play a role in this setting by designing appropriate exercise programs and participating in wellness education.
Some longevity/wellness centers now offer a new nonsurgical therapy called enhanced external counterpulsation (EECP). This new treatment is indicated for patients with stable angina and utilizes a series of three compressive air cuffs wrapped around the legs to increase blood flow to the heart. A typical program calls for 30, 1-hour treatments over the span of 7 weeks. The increased blood flow to the heart causes the development of coronary artery collaterals that replace compromised vessels. Multicenter clinical research studies show EECP to reduce anginal pain, improve exercise treadmill time, and improve coronary blood flow as documented by thallium stress testing.59,60EECP has a promising future as a noninvasive treatment for patients with angina, perhaps administered in conjunction with an exercise program provided by a physical therapist.
The Henry Jackson Foundation for the Advancement of Military Medicine and Walter Reed Army Medical Center has developed an intensive lifestyle change program for military health care beneficiaries with coronary artery disease. In a study they conducted, 144 participants with a mean age of 61 participated in lifestyle changes for 1 year (lacto-ovo vegetarian diet, exercise, stress management, group support). Study participants were measured at baseline, 3 months, and 1 year with significant results. Fiber intake rose from 35% at baseline to 94% at 1 year, exercise levels greater than or equal to 150 min/wk increased from 31% to 79% at 1 year. Other parameters such as low-density lipoprotein levels, body mass index, and blood pressure also showed improvement. Study participants who were compliant with the program achieved improvement in at least three of the five heart health characteristics. The authors concluded that intensive lifestyle changes can promote improvement in health characteristics that, if maintained, may lead to reduced cardiovascular events.61
Health Clubs and Fitness Centers
Physical therapy practices have begun to emerge in health clubs and fitness centers. These clubs offer convenient locations for exercise during a lunch hour or after work, and do not evoke feelings associated with a medical office visit. Fitness programs are now being offered for those who are post-surgery, and for special populations such as seniors with cardiopulmonary disorders. Cardiac programs located in fitness centers can offer monitoring by telemetry, as well as blood pressure and heart rate response. Educational sessions on risk-factor management are also frequently available in these settings. As the patient improves, they require less monitoring, and can exercise in other parts of the facility.62,63
In the future, the health club or fitness center may be more frequently utilized as the site for primary prevention programs for families. In this setting the cardiovascular and pulmonary therapist would promote healthy exercise programs not only for adults but also for their children. Inactive lifestyles, an indicator that is currently tracked by Healthy People 2010, can put children at risk for cardiopulmonary disease later in life. Who would better serve the community than the physical therapist to establish movement and activity programs for people of all ages?64
Occupational Health
A number of physical therapists have identified the area of occupational health as a practice setting of great potential.65 They see this as an opportunity to provide on-site immediate care for disorders such as repetitive strain and acute injuries. Occupational health physical therapy can also play a role in employee asthma management, wellness and prevention education, preemployment screening, and on-site cardiac monitoring. As more studies document the effectiveness of moderate activity in the reduction of heart disease, the corporate world must be educated on the cost-effectiveness of programs like cardiac rehabilitation. Physical therapists may also play a larger role in primary prevention of cardiopulmonary disorders through promotion of employee wellness programs. Experience shows that penetration into the field of occupational health in corporations requires high-quality, comprehensive services that are marketed effectively. This relatively new practice environment offers exciting challenges for cardiopulmonary physical therapy!64,65
Integrative Outpatient Practice
Integrative outpatient practices that combine alternative and traditional medical practice techniques are beginning to emerge. These practices may employ many different types of practitioners such as physical therapists, acupuncturists, chiropractors, podiatrists, and massage therapists. The practices are designed to be one-stop shops where patients can get complete medical care under one roof. The additional benefit of alternative or integrative medicine in the form of acupuncture, chiropractic, or perhaps Chinese herbal medicine offers choice to consumers who are seeking out this form of therapy with increasing frequency. In this setting, physical therapists may find greater freedom to integrate nontraditional skills they have learned (shiatsu, craniosacral, Feldenkrais) to progress their patients to their highest level of function.56,58
Home Care Setting
As the population in the United States continues to age, we know that by 2030 all baby boomers will be 65 years or older representing a huge cohort of people seeking health care services. Ninety percent of adults older than 50 years have indicated they want to age at home rather going to a nursing home.66 We also know that when costs are compared, services provided in the home are considerably less expensive than a hospital ($5,765/d), or skilled nursing facility ($544/d) with homecare costing only $132/d.67 As health care costs rise with the volume of baby boomers seeking services, our health care system is already seeking the lowest cost environment to care for our elderly. Physical therapists will play an integral role in providing care in the home, by working for various types of home care agencies such as certified, hospice, and long-term agencies. Certified agencies are able to provide care for Medicare and Medicaid patients. Hospice agencies are the fastest growing segment of home care services, and physical therapists play an important role in family education. Long-term agencies are primarily focused on care of the patient with a chronic disease process like multiple sclerosis.
In the future another type of home care service will gain an important niche in communities around the United States. Naturally occurring retirement communities (NORC) have begun to spring up in areas where there is a concentrated group of people 60 and older. NORC provide supportive services to help older people stay in their own homes. At present there are approximately 80 NORC programs in 25 states, and they are part of a national trend to encourage aging in place. Typically NORC use the services of existing home care agencies, volunteers, and businesses to provide low-cost services. A University of California survey of 530,000 elderly on Medicaid found that Medicaid saved an average of $15,000 a year for each person served at home as opposed to a nursing home.66 Fall risk prevention is a key educational activity provided by many NORC, due to the high health care costs associated with falls in the elderly. Physical therapists will have an important role in this setting in evaluating the home environment for safety, instructing in fall prevention, and providing exercises to improve balance and strength.
Focused Factories
How many of you have eaten a McDonald’s hamburger in your life? Admit it; probably most of us have. By doing so you have eaten at one of the best known focused factories in the service industry. Focused factories are facilities that concentrate their efforts on one type of service for the purpose of improving the relationship between cost and output. They are common in the restaurant service sector but are an emerging breed in health care. In the case of McDonalds, they have perfected every operating procedure involved in the production of a fast, good-tasting meal.56
Health care–focused factories function in a similar way. Take, for example, Shouldice Hospital in Toronto, Canada, a hospital that performs only abdominal hernia operations. They are so good at what they do, and so successful in creating a social experience, that patients come back yearly to celebrate the repair of their hernias. Because care is focused on one surgery, each step in the process is carefully scrutinized until the best possible operating procedure is determined. The components of the Shouldice system not only create patient satisfaction but also result in lower cost and fewer surgical revisions than regular hospitals.56
St. Francis Hospital on Long Island, NY, is another example of a focused factory, in this instance in the field of cardiac care. Over the past 20 years St. Francis has performed more than 40,000 open-heart surgeries with excellent success rates. Studies demonstrate that patients benefit when hospitals and surgeons perform a high volume of procedures. In the case of St. Francis, the focus on cardiac care has allowed them to be leaders in the innovation of new techniques and procedures. They are now using robotically assisted surgery to repair heart valves on patients who qualify for this minimally invasive procedure. A patient who has undergone cardiac valve replacement using this technique may find themselves out to dinner within 1 week of the procedure, and 4 weeks later back to work full-time and working out at the gym! Dr. Alan Guerci, President and CEO of St. Francis, predicts by 2029 advances in medical technology and expertise will mean increased comfort, shorter stays and improved quality of life for patients. According to Michael Dowling, CEO of North Shore-LIJ Health System, most future health care will be delivered in outpatient settings, with hospitals serving as centers for wellness related activities.68
The financial community views focused factories as the next wave of transformation in health care. Venture capitalists have poured millions of dollars into focused factory services, especially those that target diabetes, asthma, and congestive heart failure. These venture capitalists observed that a small percentage of asthma patients (33%) accounted for 73% of the costs of treating the disease. They also found that a small portion (37%) of patient’s with chronic obstructive pulmonary disease caused 86% of the costs for one large employer. The venture capitalists concluded that a relatively small number of focused factories aimed at high-cost diseases could provide enormous health care benefits.56
Physical therapists may find that they will utilize their cardiovascular and pulmonary skills in focused factories that handle all aspects of care of one of the high-cost diagnoses, such as asthma or congestive heart failure. A limited choice of patients allows for more intense scrutiny of therapeutic procedures and techniques. Patients will benefit from specialized care, delivered by experts in their condition. If the success of the Shouldice system is replicated, the quality of care will be high, and the cost for management will be less. Due to the health care revolution currently in progress, physical therapists should anticipate changes to their practice environment. Therapists need to “think out of the box” and open their eyes to the needs of the health care consumer. By following those needs, the successful therapist will create new and exciting practice locations.
Demand for Physical Therapists in the Future
Historically, physical therapists have been in short supply. Therapists have enjoyed strong increases in salary, high job placement rates, and a choice of job opportunities. At the close of the 1990s the job opportunities for physical therapists began to diminish. This has been attributed to greater numbers of physical therapy graduates as education programs have increased over the past 10 years, the influence of managed care, and the health care cost controls implemented by the federal government. As a result, the APTA commissioned a study in 1997 on the supply of and demand for physical therapists for the years 1995, 2000, and 2005.65 The most recent data collected by this study was in November 2001.69
In order to make accurate forecasts, the study considered a wide variety of factors that would influence the outcome of both the supply and the demand for therapists. For instance, managed care penetration, increased competition from alternative providers such as chiropractors, athletic trainers, and occupational therapists were all taken into consideration. Forecasts were also estimated using a synthesis of information from a broad and comprehensive search of available survey databases, published and unpublished reports, and phone interviews with those knowledgeable in the field.
The initial projections of the Workforce Study have come to pass. We have moved from a shortage of physical therapists and through a period of increased unemployment in the late 1990s, and now are emerging with an improved job outlook for therapists.70 In fact The Bureau of Labor Statistics expects the employment of physical therapists to grow 27% from 2006 to 2016, much faster than the average occupation. Demand will be spurred by increasing numbers of patients with disabilities.71
As we approach the year 2011, when the baby boomers begin to reach 65, there will be a resurgence in demand for therapy services. As Jules Rothstein so aptly put it in the March 2000 issue of Physical Therapy, “Americans in the next two decades will go from being the baby boomer generation to being the largest geriatric population our nation has ever seen. Maintaining the status quo will not be enough when the boomers begin to devour health care resources like locusts devouring wheat.”72 Remember, cardiovascular and pulmonary disorders are in the top diagnostic categories for the elderly, and qualified therapists will be needed to utilize the most advanced means of treatment available.
SUMMARY
Step into the future, if you will, to the year 2030. We observe a physical therapist trained at the DPT level working in a facility that specializes in management of chronic cardiovascular and pulmonary disorders. Although most of the patients are 65 years and older, there is a fairly large contingency of children and adolescents with asthma. Women comprise 60% of the older population, and the ethnic composition of the clinic is multicultural, with high proportions of white, Hispanic, African American, and Asian clients. Coronary artery disease and chronic obstructive pulmonary disease are still major health problems for those seen in the facility, but they are being diagnosed and treated in different ways. Genetic testing is used routinely to determine who is predisposed to cardiopulmonary disorders. Nanotechnology has been incorporated into sophisticated diagnostic equipment to allow better visualization of internal human anatomy. New vaccines and gene therapy have been developed to ward off the onset of chronic disorders. Cardiac open-heart surgery, once performed routinely, is now done only rarely.
As a student entering the world of physical therapy today, it is essential to stay current with the changing face of American health care. Students should read from a broad spectrum of resources not only health-related journals but also current affairs, scientific research, and health policy. They should approach the workplace in a creative, imaginative way, perhaps pushing the field of physical therapy to places it has not been before. They should embrace technological advances that may allow one to practice without ever writing a note, or may allow monitoring of a patient in the next town, instead of in the next room. Students should use their knowledge of scientific research to expand the application of physical therapy practice into areas such as stem cell transplants and gene therapy. With a flexible, creative mind, the future practice of cardiopulmonary physical therapy will be rewarding indeed!
As a new therapist moving into the job market, be sensitive to consumer demands for convenient health care services, and consider employment in new environments. Recognize that health care costs will continue to be carefully controlled, and work with evidence-based treatments that will support the provision of physical therapy services. By “Catching the Age Wave,” forward-thinking physical therapists can ensure that our profession will lead in the provision of cardiovascular and pulmonary rehabilitative services in the future.72
REFERENCES
1.World Population Demographics. http://www.xist.org. Accessed December 30, 2009.
2.Mitchell JD. Before the next doubling. World Watch. January/February 1998:20-27.
3.Hollingsworth W. Population explosion: still expanding. USA Today. July 1998:28-29.
4.McRae H. The World in 2020. Boston: Harvard Business School Press; 1994.
5.Swanson S. Global population will peak at eleven billion, U.N. forecasting unit says. Chicago Tribune. February 1998:16.
6.Siegel J. Aging into 21st Century. Special Report for Administration on Aging HHS-100-95-001. http://www.aoa.dhhs.gov. Accessed September 22, 2003.
7.Boomers, 65, in Search of Medical care. Time Magazine. April 2008:19-22.
8.Healthy People 2010. http://www.health.gov. Accessed December 16, 2003.
9.Seeman T, Adler N. Older Americans: who will they be? Natl Forum. 1998;78:22-25.
10.American Lung Association. Data and statistics. http://www.lungusa.org. Accessed June 16, 2008.
11.Cardiovascular Statistics. http://www.lungusa.org. Posted March 2003.
12.National Center for Health Statistics. Data warehouse on trends in health and aging. http://www.cdc.gov/nchs. Accessed September 22, 2003.
13.Galantino M, Kane R. Evidence based complementary therapy interventions for the elderly. Gerinotes. 2001;8:10-13.
14.Goldsmith MF. 2020 Vision: NIH heads foresee the future. JAMA. 1999;282:2287.
15.New York College and FAIM Ed team-up for 10th health care symposium. Health Waves Newsletter. 2000;4:1.
16.Johnson J, Yu T. T’ai Chi for the elderly. Gerinotes. 2001;8:21-23.
17.Taylor M. Yoga for the elderly. Gerinotes. 2001;8:25-28.
18.American Lung Association Web site. What is new in asthma research? http://www.lungusa.org/site. Accessed June 16, 2008.
19.Cetron M, Davies O. Probable Tomorrows. How Science and Technology will Transform Our Lives in the Next Twenty Years. New York: St Martin’s Press; 1997.
20.FDA approves first compact heart assist device. http://www.fda.gov/bbs. Accessed June 16, 2008.
21.Human Genome Project. http://www.ornl.gov/hgmis. Accessed December 16, 2003.
22.Mestel R. Beyond the DNA map. Newsday. May 2000:C3.
23.Casey D. Genes, dreams, and reality. Judicature. 1999;183:3.
24.Drell D. Fast forward to 2020: what to expect in molecular medicine. http://www.ornl.gov/hgmis. Accessed May 5, 2008.
25.Human gene therapy. http://www.fda.gov/consumer/update. Accessed May 5, 2008.
26.Human genome project. http://www.ornl.gov/sci/rechresources/human genome. Accessed May 9, 2008.
27.del Monte F, Harding S, Schmidt U, et al. Restoration of contractile function in isolated cardiomyocytes from failing human hearts by gene transfer of SERCA2a. Circulation. 1999;100(23):2308-2311.
28.Miyamoto M, del Monte F, Schmidt U, et al. Adenoviral gene transfer of SERCA2a improves left-ventricular function in aortic-banded rats in transition to heart failure. Proc Natl Acad Sci U S A. 2000;97(2):793-798.
29.Hajjar R, del Monte F, Matsui T, et al. Prospects for gene therapy for heart failure. Circ Res. 2000;86(6):616-621.
30.China Approves First Gene Therapy. Nature Biotechnology 22, 3-4 (2004). http://www.nature.com/nbt. Accessed May 9, 2008.
31.China’s Gene Therapy Cancer Drugs. http://www.seekingalpha.com/article/58759. Accessed May 5, 2008.
32.U.S. Department of Health and Human Services. Stem Cell Research Fact Sheet. U.S. Department of Health and Human Services. http://www.hhs.gov. Accessed December 16, 2003.
33.Gorman C. Brave new cells. Time Magazine. May 2000:58-60.
34.National Institutes for Health. Stem Cell Information. http://stemcells.n.h.gov. Posted September 2002.
35.Jiang H, Ju Z. Telomere shortening and aging. Z Gerontol Geriatr. 2007;40:314-324.
36.Prenatt D. Ending Old Age Through Telomerase Activation. http://www.netesq.com. Accessed June 3, 2008.
37.Breslau K, Jones M, Webster D. A catalog of the near future. New York Times. June 11, 2000:80-102.
38.The White House Office of the Press Secretary. National Nanotechnology Initiative: leading to the next industrial revolution. http://www.whitehouse.gov. Accessed June 5, 2000.
39.National nanotechnology initiative. http://www.whitehouse.gov/omb/budget. Accessed March 8, 2009.
40.Merkle RC. Nanotechnology Web site. http://www.zyvex.com/nano. Accessed June 6, 2000.
41.Health People Web site. http://www.healthypeople.gov/data/midcourse. Accessed March 15, 2009.
42.Bainbridge D. Working for a healthier America. PT Magazine. October 2000:50-57.
43.Google health. On-line medical records. http://www.google.com/health. Accessed April 11,2009.
44.Schwartz R. Health IT Boosted in Economic Recovery. Remington Report. March/April 2009.
45.Telehealth holds to same standards as all PT care. http://apta.org/AM. Accessed May 9, 2008.
46.Telemedicine: statement of experience. http://www.telemed.med.ecu.edu. Accessed September 23, 2003.
47.Dansky K, Palmer L, Shea D, et al. Cost analysis of telehomecare. Telemed J E Health. 2001;II(3):225-232.
48.Kinsella A. Chronic disease management and telehealthcare. Telemedicine Information Exchange. March 23, 1999. http://tie.telemed.org/articles/article.asp?path=articles&article=diseaseManagement_ak_tie99.xml. Accessed January 1, 2010.
49.AlereNet System. http://www.alere.com. Accessed September 24, 2003.
50.Dember A. Keeping patients connected, technology helps VA reduce hospital visits. The Boston Globe. September 23, 2003:1.
51.Sparks K. Efficacy of telemedicine self-pay cardiac rehabilitation clinics. Lecture at American Association of Cardiovascular and Pulmonary Rehabilitation; September 23, 2000; Tampa, FL.
52.American Physical Therapy Association Vision Statement for the Future. http://www.apta.org/news. Accessed September 23, 2003.
53.Schmoll B, Wolf S, Sahrmann S, et al. Forecast 2000. PT Magazine. January 2000:38-42.
54.Nelson A, Harris S, et al. Forecast 2000. PT Magazine. September 2000:12-15.
55.Guccione AG, Goldstein M, Elliott S. Clinical research agenda for physical therapy. Phys Ther. 2000;80:499-513.
56.Herzlinger RE. Market Driven Health Care. New York: Harper-Collins; 1997.
57.Pritikin Longevity Center. http://www.pritikin.com. Accessed April 11, 2009.
58.Cardiovascular Wellness Center. http://www.vagnini.com. Accessed April 12, 2009.
59.Arora R, Nesto R, Chou T, et al. Results of the multicenter study of enhanced external counterpulsation (MUSTEECP): EECP reduces anginal episodes and exercise-induced myocardial ischemia. J Am Coll Cardiol. 1999;33(7):1833-1840.
60.Lawson W, Hui J, Zheng Z, et al. Improved exercise tolerance following enhanced external counterpulsation: cardiac or peripheral effect? Cardiology. 1996;87(4):271-275.
61.Marshall D, Walizer E, et al. Achievement of heart health characteristics through participation in an intensive lifestyle change program. J Cardiopulm Rehabil Prev. 2009;29:2.
62.Highlighted physical therapy practice settings. http://www.apta.org/career center. Accessed July 30, 2003.
63.Francis K. Fitness Watch. PT Magazine. October 1999:53-59.
64.Tepper S, Kovacek P, Morris D, et al. Challenges 2000. PT Magazine. January 2000:43-47.
65.Wicken A. The reliable resource. PT Magazine. June 1999:30-32.
66.Amon R. No place like home. Newsday. May 10, 2008.
67.National Association of Home Care Web site. http://www.nahc.org. Accessed April 11, 2009.
68.Hanc J. Hospitals of tomorrow on the drawing board today. Newsday. April 7, 2009.
69.Workforce study. Vector Research, Inc. 1997. http://www.apta.org/research. Accessed December 16, 2003.
70.APTA employment survery. http://www.apta.org/research/survey. Accessed July 25, 2003.
71.Bureau of Labor Statistics. Occupational Outlook Handbook 2008-09. http://www.bls.gov.oco. Accessed April 7, 2009.
72.Lewis C, McAndrew JM. Catch the age wave. Adv Phys Ther. 2000:45.