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People to People: Russia and Poland

Thirty PTs from the United States learned about the similarities and differences in physical therapy at home and abroad.

By Denise Wise, PT, PhD, with Kristin Wodzinski, PT

The titles and terms physical therapy and physiotherapy, and physical therapist (PT) and physiotherapist, are synonymous in the United States (HOD P06-03-18-15). Physical therapist assistants (PTAs) can perform physical therapy/physiotherapy only under the direction of a licensed physical therapist/physiotherapist (HOD P06-03-18-15). Imagine the confusion these definitions create when physical therapists from the United States venture abroad to visit physical therapists in other countries. In September 2005, 30 physical therapists from the United States did just that and discovered not only differences in term and title, but also similarities in the practice of physical therapy.

Organized by People to People Ambassadors Program and led by APTA President Ben Massey, PT, MA, and Darlene Sekarek, PT, PhD, 28 other physical therapists, one podiatrist, and 10 guests visited schools of physical therapy and health care facilities in St Petersburg, Russia, and Warsaw, Poland. We hope that ongoing communication will occur as we work toward furthering our profession worldwide.

Russia

St Petersburg Medical Academy of Postgraduate Studies

Professional visits in Russia included the St Petersburg Medical Academy of Postgraduate Studies (MAPS) and the St Petersburg Elizavetinsky Hospital. The MAPS, founded in 1885, is an educational, research, and medical facility with six colleges (surgical, internal medicine, pediatric, biomedical, public health, and dentistry), 78 departments, eight research departments and laboratories, and a 450-bed hospital. It serves not only as an educational facility for entry-level providers, but also as a site for continuing education. Every year, more than 30,000 specialists from around the world attend programs at the MAPS lasting from 20 days to 5 years.

Professional Delegates to Russia and Poland
Ben Massey, PT, MA, APTA President, leader
Darlene Sekerak, PT, PhD, co-leader
Juanita Accardo, PT, San Pedro, CA
Stephania Bell, PT, Redwood City, CA
Scott Delcomyn, PT, Gibraltar, MI
Carol Dionne, PT, PhD, Oklahoma City, OK
Marie Ellingson, PT, Portland, OR
Tom Fagan, PT, Santa Fe, MN
Mietka Franczyk, PT, PhD, Glenview, IL
Jennifer Gardner, PT, CWS, Swedesboro, NJ
Jane (Matthews) Gentry, PT, Steep Falls ME
Paula Glasser, PT, Pittsburgh, PA
Sherry Hayes, PT, PhD,
Palmetto Bay, FL
Dennis Houghton, PT, McAllen, TX
Martha Houghton, PT, McAllen, TX
Lois Huisman, PT, Rapid City, SD
Marleen Iannucci, PT, PhD, Warren, OH
Lynne Jones, PT, PhD, Rolling Hills, CA
Sandy Ladd, PT, Brattleboro, VT
Jacqueline Lovejoy, PT, DPT, Riverview, FL
Rhonda Meyer, PT, Delray Beach, FL
Raine Osborne, PT, Tampa, FL
Gail Pearce, PT, Bossier City, LA
Ed Pozarny, DPM, Arlington, VA
Lou Pozarny, PT, Buffalo, NY
Patricia Shields, PT, Seabrook, TX
Zubin Tantra, PT, Long Grove, IL
Corissa Todd, PT, Chicago, IL
Elena Wahbeh, PT, Mission Hills, KS
Denise Wise, PT, PhD, Duluth, MN
Kristin Wodzinski, PT, Traverse City, MI
At the MAPS, we toured the departments of neurology and physical therapy, which were fairly modern in design. Musculoskeletal impairments and dysfunctions were treated by what we would consider usual and customary interventions (such as manual therapy, massage, and electrical stimulation) and also with additional interventions such as cold laser and acupuncture. Treatment of the neuromuscular system consisted of familiar techniques, skills, and interventions. Documentation is performed electronically. Exercise, a large component of American physical therapy interventions, was not a component of Russian physical therapy plans of care.

The most significant difference was the training of physical therapists in Russia. Essentially, a physical therapist in Russia is a physician who then goes on to receive an additional 504 hours of physical therapy training. Physical therapist assistants in Russia are nurses who receive specialized training in physical therapy. Exercise instruction falls under the realm of curative exercise therapists who are specially trained physicians. In Russia, physical therapy is registered into the specialties of medicine.

St Petersburg Elizavetinsky Hospital

At Elizavetinsky Hospital, we received a tour of the entire facility. This 1,075 bed hospital-the largest in Russia-treats approximately 60,000 patients a year. The organization of the hospital is departmental, similar to the organization of health care facilities in the United States. The urgent care department sees the largest number of patients overall. The average length of stay for patients in the hospital is 6-8 days. Examples of typical stays were described for us: childbirth (labor and delivery), if uncomplicated, is 5 days. Uncomplicated myocardial infarction is 12 days to 3 weeks, followed by 3 weeks of phase II rehabilitation in what is called a sanatorium.

In all cases, the discharge goal is to get the person home and safely able to care for him or herself. In many instances, the family must care for the patient after discharge.

Medical and social services are separate in Russia, so there is no coordinated discharge planning as we know it. If a patient requires assistive or adaptive devices after discharge, the family must make arrangements to acquire the equipment. In instances where the family cannot do so, then the equivalent of social services become involved.

As we toured the hospital we were struck by some of the differences in the practice and delivery of physical therapy. One difference was in dermatology. Many American physical therapists are trained in wound care and the treatment of psoriasis using ultraviolet. Thus we were surprised to learn Russian physical therapists use interventions for cosmetic purposes. One such treatment involves the use of mud, which is warmed and then applied to a patient with electrodes implanted into the mud. The treatment is intended to restore skin to a more natural state and delay the effects of aging.

Health care in Russia is nationalized and is funded through taxes. However, patients who can pay extra or who are dignitaries are entitled to specialized services. For example, at Elizavetinsky Hospital we toured the VIP area, which included a therapeutic pool, juice bar, and sauna along with private treatment booths. Otherwise, patients are seen in a clinic or gym environment similar to clinics in the United States.

Regardless of the differences we observed, we were impressed with the care and compassion our Russian counterparts have for their patients. The Russia of old--long lines, gray or drab clothing, and unhappy people--is no more. St Petersburg is a vibrant, colorful city with beautiful, smiling people; it is considered the cultural capital of Russia. Looking at the old style architecture juxtaposed with the post-modern Stalin- and Khrushchev-style buildings (each is standardized to look the same) provided a glimpse into what it must have been like to go from the rule of czars to communist leaders to today's presidency. Russia transitioned to democracy in only the past 10-15 years.

But Russia also has come a long way in becoming westernized in style and delivery of services. Our interactions with our Russian hosts revealed their pride and love for their chosen profession. They are in the early phases of putting together a peer reviewed journal. Our hosts are interested in joining the World Confederation of Physical Therapy in order to share with and learn from other physical therapists around the world. They also desire to continue the dialogue we began and hope some day to come and visit clinics and educational programs in the United States.

Poland

Jozef Pilsudski Academy of Physical Education

Professional visits in Warsaw, Poland, began with the Jozef Pilsudski Academy of Physical Education. This is the largest university in Poland and educates teachers of physical education, coaches, and specialists in the field of physiotherapy, recreation, and tourism. The Academy also contributes to research in these fields and is a member of a number of international organizations of physical culture and sport. The Academy was established as a 2-year vocational school in 1929 following the initiative of the Marshal of Poland, Jozef Pilsudski, and in 1935 it received academic rights. It was rebuilt after the war and resumed activity in 1946.

At present, 6,000 students study there and at its sister institution, the External Faculty in Physical Education, in Biala, Poland. The Academy offers BA, MA, and PhD levels of education and a wide range of postgraduate and specialist courses. It is also a center of sports and runs activities in nine sports sections for 500 members, including many world and European champions, and Olympic medalists.

The education program for physiotherapists in Poland is 3 years. One is able to obtain the title of master physiotherapist after 2 additional years of training. A physical therapy technician (similar to a PTA) receives 2.5 years of training. The Academy is the institutional member of seven international organizations in the field of physical education, science on sport, recreation, tourism, and physiotherapy. There are 25,000 physiotherapists in Poland. The Society for Physical Therapy was developed in 1962; however, there are no regulations or standards, including licensure, for the profession of physiotherapy in Poland.

At the Academy we exchanged presentations with the Polish clinicians. Presentations by our delegates were: international organization of physical therapists in women's health by Patricia Shields, PT, BS, of the University of Texas Medical Branch-Galveston; use of computerized documentation and the electronic health record in education by Denise Wise, PT, PhD, of The College of St Scholastica in Duluth, Minnesota; and craniosacral therapy and private practice in the United States by Sandy Ladd, PT, president/CFO of Physical Therapy Services in Brattleboro, Vermont.

Our Polish counterparts also provided three presentations: physiotherapy in Poland by Maria Grodner, PT, and president of Poland's physical therapy association; security tests for the upper cervical spine in order using the Kaltenborn-Evjenth concept by Zenon Grzegorz Balik, PT, and faculty member at the Academy; and constraint induced movement, from theory to clinical practice, by Maciej Krawczyk. The similarities to the US in their association, compassion of physical therapists, scope of practice, and similar treatment approaches astounded many of us, and we were intrigued by their education and practice environments. Another similarity was funding of research. The Polish National Insurance provides grants for research in areas such as constraint- induced movement therapy.

Our hosts from this institution provided each of us a copy of Advances in Rehabilitation published by the Polish Rehabilitation Society. The articles in this peer-reviewed journal are similar to what we read in Physical Therapy.

Oncology Center Department of Rehabilitation at the Radium Institute

Our second professional visit in Warsaw was the Oncology Center Department of Rehabilitation at the Radium Institute. This oncology center was initiated in 1921 by Maria Sklodowska-Curie (Madame Curie) who emphasized the importance of incorporating clinical and research departments and their close and ongoing cooperation. The Institute, comprised of four buildings, was completed in 1932, and contained 120 beds, five X-ray machines, and 1 gram of radium donated by Marie Sklodowska-Curie. The Institute quickly became the leading center of its kind in Poland. During World War II, all scientific activities ceased but clinical work continued. The original institute was burned in 1944 and rebuilt, resuming activities in 1947.

In 1995 the Radium Institute was relocated and renamed the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology. It is now one of the largest and most modern oncological institutions in Europe. The clinical section is located in a 10-floor building with 700 beds, 10 operating theaters, an intensive care unit, several diagnostic departments, and an outpatient clinic. Each floor forms separate departments with surgical, radiotherapy, and chemotherapy wards. Each department provides the full range of combined treatment in a particular field.

The Center serves as a modern comprehensive oncological institute, conducting basic research, clinical trials, postgraduate and specialized training, providing the most up-to-date diagnostic and therapeutic facilities. The rehabilitation department is 20 years old and treats patients with a variety of different cancers affecting different locations on the body. The department is home to 34 clinicians, including physical therapists, speech therapists, psychologists, nurses, and social workers. The clinic, on average, sees 200 patients per day.

We received a thorough tour of the physical therapy department at the Memorial Cancer Center and Institute of Oncology. A primary focus of the tour was rehabilitation for patients with breast cancer, but patients with other cancers also were seen by the therapists in the department. The tour was arranged so that we were able to observe all stages of comprehensive rehabilitation that patients with cancer undergo.

A typical rehabilitation program begins with a visit to psychology where patients receive five visits with family support group for education and discussion about their concerns and relationship. Patients then receive a multitude of therapies, including relaxation (often consisting of modalities including pneumatic massage and electrical stimulation in gravity assisted positions) and exercise in group and individual settings specific to the cancer and treatment.

For example, a patient with lymphedema will receive different exercises from a patient undergoing chemotherapy or radiation. Patients further along in their rehabilitation receive exercises in the gym, while patients new to rehabilitation or in the acute and subacute phases of recovery engage in basic range of motion and gravity-eliminated exercises using pulleys and slings.

Other interventions include mobilizations, massage, and lymphatic drainage with bandages. To enhance lymph drainage, some patients also receive hydrotherapy. Typically, these patients will receive whirlpool in an appropriately sized unit with high powered jets and hydro-massage feature that produces a vibration through a rubber head. This rubber head is then directed to the affected limb to improve lymph drainage.

Mastectomy and breast reconstruction are free surgeries to Polish citizens. However, the time from diagnosis to surgery may be as long as eight weeks. Following surgery the expected hospital stay is one week with therapy beginning the day before and continuing two days after surgery. When the health care system in the United States was discussed and the length of stay for mastectomy was reported to our Polish counterparts, they were amazed that the stay was so brief. They questioned how we could address the medical, rehabilitation, and psychological needs of the patient with only overnight or two-night stays.

A prominent group in the breast cancer community of Poland is the Amazons. This group is composed of individuals who are at least 2 years post mastectomy and reconstruction. Their purpose is to provide counseling, support, and any other information and education that a patient may need following a cancer diagnosis. Annually, 10,000-12,000 women are diagnosed with cancer in Poland, but only one-third to one-half have a chance at full recovery. It is believed that more women could have full recovery and survival if proper screening and self examination were practiced. Awareness and availability remain large factors in the recovery of individuals with cancer.

Center of Education and Rehabilitation

The final clinic we toured in Poland was the Center of Education and Rehabilitation in Konstancin, a suburb located 17 kilometers from Warsaw. Although rehabilitation is a focus of the center, it also provides health, fitness, and wellness services. The wellness center houses an Olympic-sized swimming pool, a salt-iodine cave using salt from the Dead Sea, a cryotherapy chamber, various forms hydrotherapy, an aerobics room, and a gym and exercise room with a unique ceiling-suspended pulley system.

In addition to the recreation and biological regeneration portion of the wellness facility, the clinic also provides esthetic dermatology (reduction of wrinkles, scar removal, and so forth) and face and body cosmetics services. As impressed as we were with the recreation side, we were duly impressed with its rehabilitation side as well.

About People to People
People to People International (PTPI) was founded in 1956 by President Dwight D Eisenhower. The organization was privatized in 1961 and relocated to Kansas City, Missouri. Its purpose is to enhance international understanding and friendship through educational, cultural, and humanitarian activities involving the exchange of ideas and experiences directly among peoples of different countries and diverse cultures.

Today, as a not-for-profit 501(c)(3) organization, PTPI has a presence in 135 countries with more than 80,000 families and individuals actively participating in its programs. It offers both student and adult programs, including the International Visitor Program, Meeting the Americans, Missions in Understanding, and Professional Exchange Programs.

The visit of physical therapists to Russia and Poland was conducted in the Professional Exchange Programs' Ambassador Program. In this program, participants attend meetings, briefings, conferences, roundtable discussions, seminars, and symposia; visit facilities and institutions; and gather informally with counterpart professionals.

PTPI's chief executive officer is Mary Eisenhower, the granddaughter of Dwight Eisenhower. For more information, call 816/531-4701 or ptpi@ptpi.org.

Rehabilitation at the Center is provided by 30 doctors, 100 therapists (physiotherapists and kinesiotherapists, the equivalent of exercise physiologists), and eight nurses. The facility houses 240 beds, with a dozen single rooms available. Patients served by the Center include those with orthopedic conditions, rheumatic diseases, strokes, peripheral nerve injuries, and venous/arterial diseases. Each patient's program is highly individualized and is supervised by a physician or chosen therapist. Aside from the typical types of interventions we are familiar with, they also incorporate systemic cryotherapy. This modality involves whole body exposure to very low temperatures below 110û Celsius.

The procedure lasts 1-3 minutes, beginning with very short exposures. The patient enters the chamber wearing a swim suit, ear protection, shoes/socks, gloves, and a mask that covers the nose and mouth. After the 1-3 minutes in the chamber, the patient must exercise for 30 minutes. The systemic cryotherapy chamber is used to treat inflammation (arthritis) and edema, and induce muscle relaxation. The physician and therapists who described the chamber for their patients also claimed other benefits, including improved moods, improved sleep, and increased immunity against infections.

Take-Home Messages

On our final night in Poland--the last night of the trip--the delegates and their guests from the United States shared insights and take-home messages of our experiences. One significant impression was the rebuilding of both cities-St Petersburg and Warsaw-following World War II. St Petersburg was under attack but never occupied by the Nazis, but it sustained damage to more than 30% of its buildings and structures.

Warsaw did not fare as well; it was occupied by Nazis and in the end 87% of Warsaw was damaged or destroyed. The effort to rebuild both cities came at some cost, but today they are vibrant, energetic urban areas with strong pride and commitment to constant improvement. Based on this, delegates have a shared hope for the reconstruction of the cities and regions recently affected by Hurricane Katrina.

Another take-home message was how well English is spoken around the world. Presentations (using Microsoft PowerPoint) by both our Russian and Polish counterparts were composed in English and often delivered in English by the therapist. One Russian physical therapist used an interpreter only because she was embarrassed by what she considered to be her poor English-which was not poor at all. The best some of us could muster were short phrases in Russian or Polish; very few of us could hold a conversation in either of those languages.

The final take-home message addresses the differences and similarities of our profession the world over. Even though the education is different or the division of labor is different based on titles (physiotherapist, kinesiotherapist, etc), the dedication to our patients and profession, the desire for growth through research and publication, and the compassion for our patients and clients are the same. It is these things that make our profession unique worldwide.
__________________
Denise Wise, PT, PhD, and Kristin Wodzinski, PT, were two of the tour delegates.

 
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