The physical therapies of massage, exercise, heat/ice, electricity, light, etc., have existed for thousands of years across all civilisations, but it was not until the 20th century that physiotherapy emerged as a significant and unique profession.
In his latest article (available in Open Access) physiotherapy writer and researcher David Nicholls has explored historical and semi-fictional accounts of British sailors during the Napoleonic wars (1803-1815) to ask why there was so little organised physiotherapy before 1900.
In many ways, the 19th century was the century of the physical therapies, partly because they offered gentler and more conservative solutions to the many physical and mental health problems prevalent in society than were available through medicine and surgery. Consequently, many of the “modern” physical therapies had established a significant pedigree. But physiotherapy practice was largely confined to social elites, and those from working-class or poor populations rarely, if ever, experienced them.
To test this theory, Nicholls’s study focused on British sailors during the Napoleonic wars (1803–1815). He shows that healthcare on board naval fighting ships concentrated almost entirely on the prevention of disease, and the medical and surgical management of acute trauma. Despite sailors experiencing shocking levels of traumatic injury, significant benefits for them, the ship and the navy to undergo rehabilitation, and the available downtime to partake, none appear to have experienced any form of a physical therapy.
With the addition of research conducted on New Zealand settlers in the 19th century, the study supports Nicholl’s argument that prior to the 20th century, the physical therapies were luxuries available primarily to those with surplus time and money, and that widespread access to physiotherapy could only be realized with the advent of state-sponsored universal healthcare. He goes on to posit that any future decline of subsidised healthcare may have profound implications for marginal groups in society, as well as for the physiotherapy profession itself.
I took the opportunity to ask author Dave Nicholls some questions about the article and extended them into his two books The End of Physiotherapy and Physiotherapy Otherwise?
Using fiction to understand physiotherapy is highly unusual. What opportunities does it provide for researchers, and does it create fertile ground for further research into the profession, past and present?
Yes, fictional accounts aren’t used very often in healthcare research. But of course in subjects like comparative literature, history, philosophy, sociology, and many of the humanities they’re the norm. The difference is that in comparative literature the story, poem or play is the subject of the research, whereas in my case I used fiction as a source for data on sailors’ injuries. Factual accounts of the physical therapies in daily life before 1900 are surprisingly hard to come by. Is that because physical therapies weren’t performed, weren’t interesting to epidemiologists and researchers at the time, or couldn’t be accurately captured? Without the data it’s really hard to know. So secondary sources like newspaper articles and period stories can be incredibly useful. (Think of what we know about Victorian Christmases from Charles Dickens’ A Christmas Carol, living under Nazi occupation from Anne Frank’s diaries, or life in 1930s America from Harper Lee’s To Kill a Mockingbird). Of course, you have to be careful using fictional accounts because they can have varying degrees of verisimilitude, but in the case of Patrick O’Brian it’s less of a concern because he was an internationally acknowledged historical scholar who drew heavily on the factual record to write his stories, and he had a genius for capturing historical detail.
Fictional accounts need to be dramatic to maintain the readers interest. Likewise historical accounts can also be made more dramatic by the author for the same reason. Do you think the authors you studied may have overstated the injuries that were occurring on the naval vessels?
As with all text-based research you’re looking for triangulation. You don’t ‘read’ the stories in the same way as a casual reader; you’re looking for evidence from multiple angles. Of course, O’Brian’s fictional accounts only formed part of the data and there is a great deal of academic writing on sailors’ health and welfare during the Napoleonic Wars that was analysed, too. But I chose to supplement the factual record with O’Brian’s writings because he is particularly detailed on the mundane daily drudge of being a sailor, and the details of the medical/surgical work of treating injured sailors is extensive. Given how detailed his accounts were, it seems unlikely that the physical limitations and adaptations following an amputation, femoral fracture, or traumatic brain injury would have simply been glossed over, particularly when you consider how commonplace injuries were, and how vital the sailor’s fitness was in the effective running of a war ship. Taken together, the data does point to the fact that the physical therapies were not used. Which I think is extraordinary given the context.
Keeping up the drama also means skipping the mundane parts of life, like the slow progress of rehabilitation. Do you think physiotherapy may be missing from fictional and historical accounts because it is less ‘heroic’ and immediate than surgery or medicine?
Yes, absolutely. I’ve been researching the history of physiotherapy for years, and we don’t archive anything of the daily life of therapy and rehabilitation. In medicine and nursing, there are first-hand accounts of people’s everyday practice, diaries, letters, hand-written commentaries, summary statistics, photographs, all kinds of ephemera, but it’s incredibly hard to find these in physiotherapy. There’s no shortage of administrative material from registration authorities and professional bodies, and training schools are pretty good at retaining curricula and so on, but individual practitioners are terrible archivists. Perhaps we don’t think of our work as worthy of record? I don’t know, but that mundane everyday material is gold for a historian and sadly missing from the archives. Fictional accounts of people’s experience of the physical therapies are surprisingly common though, so at someone must find it interesting. O’Brian gives a good example of this. Documenting mundane things wasn’t a problem for O’Brian. In fact, it’s one of his great skills as an author. (Besides, you should read some of the mundane accounts of the public health measures taken by the Navy to prevent scurvy!) I wonder whether social media is going to make this better, because people are very happy these days to document the mundane challenges and opportunities of working life. It will certainly make it easier for historians in the future to understand what kinds of physiotherapy were going on and why.
WWI and the number of returned soldiers needing rehabilitation seems to have been the trigger for physiotherapy to grow, but the universalised health care you attribute as the cause did not begin in Britain with the NHS until after WWII. Which one was it, or was it just a slow gestation?
Probably both. There were probably a handful of key issues leading to the development and growth of organised physiotherapy: the desire to create a new professional middle class and the push for new professional roles for women; the growth of urban populations and the need to rationalize healthcare; the growing power and influence of the medical profession and its move away from physical therapies to germ theory; war and persistent disability caused by communicable diseases like TB and polio… But none of these on their own necessitate a physiotherapy profession. It’s worth remembering, for instance, that WWI wasn’t the first war in history. So, the role of war in forming physiotherapy is dubious because if war were really the trigger for the formation of the profession we’d have had a physiotherapy profession in 5000 BCE. So although physiotherapy had established its legitimacy by WWI, it wasn’t until healthcare began to be centralised and rationalised and made a central plank of the inter-war governments that physiotherapy truly consolidated its position. And this isn’t only a question of numbers, but of power and the profession’s ability to solidify its position as the recognised provider of orthodox rehabilitation and physical therapy services to the public.
Your premise of the importance of universal healthcare to the profession – past, present and future – is highly UK-centric. What would the global physiotherapy profession look like today without that UK 20th century experience?
I’m not sure I entirely agree with the first part of the question. UH has taken certain forms in the UK, as has social welfare more broadly, but UH wasn’t by any means isolated to the UK in the 20th century. Many of the colonial countries, as well as France, Japan, Sweden, Norway, and Germany also used UH to varying degrees. And don’t forget Franklin Roosevelt’s New Deal which revolutionised and massively centralized public services like healthcare in the 1930s. (Interestingly, Roosevelt was hugely influenced by the physical therapy treatment he received for polio at Warm Springs in the 1920s. This played a pivotal role in his thinking about the importance of healthcare for all Americans in the decades that followed). So, what we do know is that across these countries, UH played a pivotal role in shaping the health professionals, including – and perhaps especially – medicine, which initially was vehemently opposed to UH. The effect of UH on the health professionals internationally can’t be overstated: it created enormous, exclusive, government-sponsored monopolies over ways of thinking and practicing healthcare and was such a rich source of professional security and patronage that most organized health professionals wanted to be part of it. A lot of the data I draw on is from the UK and New Zealand, partly because there is a lot of interesting writing on these areas, but the findings are consistent with other countries too.
What makes you think state sponsored universal health care will roll back to levels akin to 18th and 19th century Europe? It sounds quite apocalyptic. But if it does occur, what makes you think physiotherapy will be lost over, lets say, low-value medical care? That is, now the benefits of physiotherapy are known and in some cases identified as superior in the scientific literature, will demand from the populace for them not continue?
Most high-income countries around the world have been looking to contain the spiraling costs of publicly funded healthcare since the mid-1970s. It’s part of a larger neoliberal project to reduce the size of government, reduce taxation, reduce central monopolies (in transport, power production, public service, education, healthcare, etc.), and give people more consumer choice. One of the challenges for central governments has been to do this without seeming to be punitive (the public always wants to pay less in taxation without losing services). In healthcare this has been done by trying to change the way people think about health. Governments have used health professionals like physiotherapists to encourage people to move from thinking about access to healthcare as a social safety net, to taking personal responsibility for their own care and wellbeing. We’ve encouraged people to think of themselves as ‘culpable in the face of known risk’, in the memorable words of Rose Galvin. It’s not apocalyptic because it’s not saying that there will be no healthcare at all in the future, only much less centrally governed healthcare. The challenge will be how to do this in a way that works for the many not the few because, at the moment, the only solution most countries have to publicly-funded healthcare is to leave it to private companies and non-governmental organisations to pick up the slack. So a lot of countries are slipping into a form of healthcare apartheid, where health is good for the white worried well but pretty bad for everyone else.
The question of the demise of physiotherapy is a complicated one. In fact it took me a whole book to work through it. But the basic argument in Physiotherapy Otherwise is that we are in a post-professional era now whether the physiotherapy profession likes it or not. The reasons for this are not really anything to do with current evidence; they’re sociological, political, economic, and cultural. And part of the profession’s problem is that it knows little of these things. So the book was written to try to give a readable introduction to the sociology of what’s happening in the hope that physios can get beyond the idea that all we need now are more well-conducted high-quality clinical trials.
What do you think is the best way forward for the physiotherapy profession, based on your studies of its evolution to date?
Toward the end of Physiotherapy Otherwise I look at four different ways physios are currently thinking about the future. Some are watching and waiting, some are arguing for what I call a modern heritage approach, some are calling for a renaissance in the profession, and others are trying to build a hybrid model of the profession. Each of these make a good case and have plenty of advocates, but each is also fundamentally flawed. My argument is that we’re actually asking the wrong question. If our goal is to preserve the physiotherapy profession at all costs, then we have completely misunderstood what’s happening in post-professional healthcare today and are likely to bring about the demise of the profession anyway. So, the question has to be how best to get the physical therapies into people’s hands so that they can become as skilled as we are. Like Jamie Oliver and his cookery books, we have to trust that the things we know and do will be valued by people in the future. And there’s no reason to doubt this because, after all, the physical therapies have been performed by people of all cultures since the dawn of humanity. The inevitable implication of this argument – and the one a lot of people have trouble with – is that we have to break out from the constraints of the profession. Physiotherapy was born from an act of colonization. We took what were common skills and said to people “you can’t have these… you can’t do these anymore unless you’re trained and licensed like us”. I believe that project is now coming to an end. But rather than waiting for it to die, we should now be giving everything away; returning physical therapies to the commons, with the added advantage of a century of learning, research and testing, technique and method. It could be our gift to humanity.
