Evolution of Physiotherapy

The modern development of physiotherapy as a branch of professional health care began to take shape in the last few decades of the nineteenth century. Earlier physical treatments — in particular hydrotherapy, exercise, and massage — in Europe have their roots in antiquity and the baths and gymnasia of ancient Greece and Rome. In this sense physiotherapy drew upon varying themes of physical health stretching back into the mists of time, but the late-nineteenth-century advent of modern scientific medicine and related new skills had a particular impact. Lay practitioners of ancient skills such as bone setting, herbalism, and a range of physical therapies lost place to a medical profession fortified by accumulating scientific techniques of diagnosis and safer interventions. New ancillary occupations, such as radiography and laboratory science, were developing, thus expanding the division of labour beyond that of doctors and nurses, through a process of specialization that continues to the present day.

In changing circumstances the more traditional therapists faced a choice, either to continue as part of a broader world of physical culture and practice, or to seek a niche within an increasingly professionalized health care system. Their position was somewhat different, however, to the other emergent occupations associated with particular modern techniques of diagnosis and treatment. Traditional therapists had to find a place within modern medical practice without being a central part of the scientific transformation which was gathering particular force in the latter part of the nineteenth century. Their skills were manual, drug free, and external to the body. Moreover, they were linked to a physical regime of treatment and exercise which was part of the spa culture of the past rather than any clearly new professional domain. They were not, however, anti-scientific, and played a role in the nineteenth-century revival of a general interest in exercise.
Establishing respectability for physical treatments in the early years involved more than a proper ethical training for practitioners. Many doctors were critical of the therapeutic value of treatments offered by masseuses, and indeed of those medical practitioners working with them. Dr James Mennell, for example, a leading physical medicine specialist and far-sighted advocate of the mobilizing and gentle massage of patients soon after injury, recalled in later life the opposition of his colleagues. Massage and manipulation to assist healing remained for many doctors outside the pale of medical science, which for them centred on drug-based and surgical interventions. The other dimensions of early physiotherapy practice — heat, electrical, and water-based applications to aid muscle and joint movement — were equally thought to be reminiscent of charlatans and exhibitionist ‘healers’ who exploited both the desperately ill and the gullible well by useless practices and machinery. Mennell, closely associated for some three decades with physiotherapy in Britain, was approached as a young doctor by a delegation of his colleagues who asked him not to degrade his profession ‘by studying such a very doubtful branch of medical practice’.

The efforts of early physiotherapists to secure medical professional approval brought benefits to physiotherapy's development, but also substantial tensions which have been mainly resolved only from the 1970s onwards. These tensions related to autonomy in treatment procedures and the degree of medical professional supervision required. Over time, the debates on these issues were complicated by the therapeutic eclecticism and swings of fashion at the centre of physical treatment, ranging across massage, hydrotherapy, electrotherapy, exercise machines, ultrasound, and heat treatments in varying combinations and emphases. An early position was set out in 1917 by Dr J Mennell in his influential Massage, its Principles and Practice, and was based upon a clear model of professional subordination. Essentially, within this model the doctor was the thinker — diagnosing, prescribing, and monitoring — whilst the physiotherapist was the technician or assistant working to instruction. Physiotherapists were banned from seeing patients directly without medical referral and prescription. Internal debates over these requirements within physiotherapy, and between physiotherapy and medicine, routinely broke out throughout the first half of the twentieth century. Within the physiotherapy profession, private practitioners broadly chafed at medical restraints on their practice, whereas, at least up to World War II, hospital-based physiotherapists appeared less concerned about medical dominance.

The earlier period of medical professional monitoring and supervision was characteristic of the first half of this century, and has now passed away under changing historical circumstances. Across time, physical medicine as a speciality area of practice for physicians had become increasingly a very minor part of medical specialization. In practice the everyday medical supervision of physiotherapy treatments had become nominal prior to its formal end in a number of countries. Physiotherapists now see patients with a wide range of conditions, both independently and by medical referral, when illness, injury, or disability inhibit normal movement. Their techniques include exercise and movement therapy, hydrotherapy, massage, and manipulation, and more recent complementary therapies. Physiotherapy has become one of the specialist professions of health care rather than an ancillary or supplementary occupation. This change has to be placed in a broader context of inter-professional relationships in health, moving from hierarchical to more co-operative models of practice. Furthermore the development of all professions in healthcare has been influenced by international social changes.

In particular, the wider relationships between gender, status, authority, and work have been changing. At one point, for example, physiotherapists were mostly female, whilst doctors were mostly male. This gender composition and balance has been changing for some decades, alongside wider social challenges to male-oriented dominance within many occupations. Another major change of recent decades, of very notable significance for many health professions, including physiotherapy, has been the educational shift from apprenticeship in the workplace to education in the modern university. This development is likely to foster the growth of a particular scientific knowledge base for physiotherapy practice. Finally, physiotherapy, after a century of modern practice, is in ever greater demand, due to epidemiological and demographic changes. The relatively successful treatment of infectious diseases, and growing life expectancy, have highlighted the prevalence of chronic conditions. At the same time, social expectations of full function and mobility in later life have grown. Thus, in changed but continuing ways, the fundamental rationale for physiotherapy — of finding and applying means of retaining, restoring, and where possible expanding physical function and mobility — remains as relevant at the end as it was at the beginning of this century.