PHYSIOTHERAPY

Origins of physiotherapy

The origins of modern physiotherapy, or physical therapy as it tends to be called in the United States, cannot be traced to a single individual. Instead, its roots are to be found in the contributions of various people working in fields such as professional medicine, nursing, massage, gymnastics, electrotherapy and hydrotherapy (Barclay, 1994; Huijbregts, 2010; Pettman, 2007). Among them the name of Per Henrik Ling, who was instrumental in founding the Royal Central Gymnastics Institute in Stockholm in 1813, is noteworthy because of the influence he and followers such as Henrik Kellgren had on the development of both exercise and manual therapy. The name of the German physician Lorenz Gleich is also important, as his mid-nineteenth century writings included the term “physiotherapie” (Gleich, 1851, pp. 29-30).

In Britain the beginnings of organized physiotherapy can be traced to the last years of the nineteenth century. Concerns of links between massage and prostitution, which came to a head in 1894, acted as the incentive for a group of masseuses to become organized. The British Medical Journal wrote of “massage shops” that were “little more than houses of accommodation” (British Medical Journal, 1894). It raised concern for the wellbeing of the women involved, but counselled that official registration of masseuses “would mean neither more nor less than a recognition of prostitution”. Even so, Rosalind Paget, Lucy Robinson, Elizabeth Manley and Margaret Palmer were committed to forming a society of masseuses with the aim of making massage more respectable (Barclay, 1994, p. 23). Their efforts led to the formation of the Society of Trained Masseuses, which was incorporated in 1900. In 1920 the Incorporated Society of Trained Masseuses was amalgamated with the Institute of Massage and Remedial Gymnastics and under a Royal Charter became the Chartered Society of Massage and Medical Gymnastics. In 1944 that organization became the Chartered Society of Physiotherapy.

Medical authority

“The responsibility for the treatment of a patient rests entirely on the medical man. The only responsibility of the masseur is to see that orders are carried out implicitly, and, if dissatisfied with the progress made as the result of the faithful performance of these orders, to report accordingly.” (Mennell, 1917, p. 107)

From the beginning the Society of Trained Masseuses accepted to a greater or lesser extent a subordinate position with respect to the medical profession, thereby enabling acceptance of their work within the context of orthodoxy. In Britain, the history of those who would come to be known as physiotherapists was therefore linked to medicine and subject to interplay with medicine. One of the consequences of this was that physiotherapy developed in a climate where science was valued at the expense of more abstract notions. The belief that the successful practitioner required “some mysterious gift” (Romer, 1915, p. xi), an idea which had been a part of bone-setting, was less apparent in physiotherapy.

Through the course of the twentieth century, the medical profession came increasingly to depend upon an array of ancillary workers. From nurses and midwives, to radiographers and laboratory technicians, a multidisciplinary culture developed, a culture which was cemented following the formation of the National Health Service in 1948. Physiotherapy developed as part of this culture. Physiotherapists came to support the physical rehabilitation of patients with a variety of conditions, including cardio-thoracic, neurological and obstetric complaints, post-surgically and otherwise. Musculoskeletal care, including the management of sports injuries, became a key component of physiotherapy.

Manipulative physiotherapy

In the early part of the twentieth century manual therapies were influenced by British medical texts on manipulation included Romer’s Modern Bonesetting for the Medical Profession (1915) and Fisher’s Manipulative Surgery (1925), a book which came to be published in five editions between 1925 and 1948. Among other medical proponents of joint manipulation were Robert Jones and Morton Smart, but perhaps of more significance to the development of manipulative physiotherapy were Edgar Cyriax and James Mennell. Edgar Cyriax studied at the Royal Central Gymnastics Institute in Sweden, married the daughter of Henrik Kellgren, and made Kellgren’s approach to manual therapy the subject of his medical doctorate (Cyriax, 1903). James Mennell taught manipulation at St. Thomas’ Hospital in London and participated in the evolution of physiotherapy both within the teaching hospital and more widely through his involvement with the Chartered Society of Massage and Medical Gymnastics (British Medical Journal, 1957). From 1938 Edgar Cyriax’s son, James, continued Mennell’s work at St. Thomas’. He wrote (Schiötz and Cyriax, 1975, p. 69):

“During my time at St. Thomas’s Hospital, our medical and physiotherapy students were brought up to regard manipulation as an integral part of everyday medical treatment, called for in a few common conditions and to be performed without further ado when required.”

It was James Cyriax’s belief that the practice of manipulation called for more “time and paraphernalia” than most medical doctors could afford and that it was therefore important to train physiotherapists to undertake the work. He was an advocate of high velocity manipulative techniques and thought it a pity that guidance produced by the Chartered Society of Physiotherapy in 1973 expected that undergraduate students not apply movements to a point where they could not be controlled or prevented by the patient (Schiötz and Cyriax, 1975, p. 184). High velocity thrust techniques came to be predominantly the stuff of postgraduate rather than undergraduate study, the subject of special interest rather than of routine practice in physiotherapy, thereby providing market opportunity for chiropractors and osteopaths.

Between 1963 and 1992, when it became a part of the British Institute of Musculoskeletal Medicine, the British Association of Manipulative Medicine promoted the post-graduate training of medical doctors in manipulation. Similarly, the Manipulation Association of Chartered Physiotherapists, which became the Musculoskeletal Association of Chartered Physiotherapists in 2011, advocated the use of manipulation by physiotherapists.

Professional autonomy

The Professions Supplementary to Medicine Act of 1960 provided statutory regulation for physiotherapists in Britain (UK Parliament, 1960). Its title implied that physiotherapists, and those others included under the legislation such as chiropodists, dietitians and occupational therapists, were ‘additional’ to medicine. The Act provided legal recognition, but it did so in a context of medical hegemony. As part of his PhD study examining aspects of professionalization in physiotherapy, a study which was completed in 1978, John Mercer reflected on issues of place, autonomy and gender in physiotherapy. In conclusion he wrote (Mercer, 1978, p. 308):

“In clinical work, it was found that senior doctors were generally willing to understand, make use of and give greater autonomy to experienced physiotherapists. The therapists on the whole recognised this, accepted it and worked on it. It was the junior doctors who could prove difficult to the therapist who wanted to exercise her expertise within those professional limits possible for her. For this reason most therapists saw it as part of their clinical task to teach or socialise the junior doctor into the ways of physiotherapy. Sometimes this meant pointing out that physiotherapists would do less for a patient than the houseman hoped, more often it meant tactfully conveying to a registrar that the therapist could do more for the patient than he knew or understood. But always the therapist has to be tactful. She is supplementary to medicine. Normally she has to treat after a doctor has made a diagnosis. Many doctors gave a diagnosis and expected and even encouraged the physiotherapist to assess and treat according to her expertise. Sometimes the physio did not want this responsibility. Sometimes the doctor made sure she never had it.”

Even so, Mercer recognized that the situation was changing. Year by year, in clinical settings, in management and in training, physiotherapists were becoming more autonomous. Having previously worked under the direction of medical doctors, they were accorded increased professional responsibility. They were to become practitioners to whom medical doctors could refer, rather than delegate. That is to say, they became personally accountable for the care they provided and responsible for their own clinical decision making in a way not previously seen.

References

Barclay J. (1994). In Good Hands: The History of the Chartered Society of Physiotherapy 1894-1994. Butterworth-Heinemann Ltd., Oxford.

British Medical Journal (1894). Immoral “massage” establishments. British Medical Journal 2 (1750), 88.

British Medical Journal (1957). Obituary. J.B. Mennell, M.D. British Medical Journal 1 (5018), 589.

Cyriax E.F. (1903). The Elements of Kellgren’s Manual Treatment. John Bale, Sons and Danielsson, Ltd., London.

Fisher A.G.T. (1925). Manipulative Surgery. H.K. Lewis and Co., London.

Gleich L. (1851). Das Grundwesen der Naturheilkunde den Schiefen Ansichten des Kongresses Deutscher Wasserärzte in Dresden Gegenüber. In German. Georg Franz, München.

Huijbregts P.A. (2010). Orthopaedic manual physical therapy – history, development and future opportunities. Journal of Physical Therapy 1 (1), 11-24.

Mennell J.B. (1917). Massage. Its Principles and Practice. J. and A. Churchill, London.

Mercer J. (1978). Aspects of Professionalisation in Physiotherapy, With Some Reference to Other Remedialists. PhD thesis. University of London.

Pettman E. (2007). A history of manipulative therapy. Journal of Manual and Manipulative Therapy 15 (3), 165-174.

Romer F. (1915). Modern Bonesetting for the Medical Profession. William Heinemann, London.

Schiötz E.H. and Cyriax J. (1975). Manipulation. Past and Present. William Heinemann Medical Books Ltd., London.

UK Parliament (1960). Professions Supplementary to Medicine Act. 1960, Chapter 66, Elizabeth 2.

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