History of Physiotherapy in Croatia

The Balkan region, where Yugoslavia partly extended (Socialist Federal Republic from 1942 to 1992), comprised the republics at that time, which are now independent states: Slovenia, Croatia, Bosnia and Herzegovina, Serbia, Macedonia, Montenegro, and Kosovo.

In this territory, the Association of Physiotherapists and Occupational Therapists of Yugoslavia was established on 6 June 1956. The last assembly of the association took place in 1988 in Belgrade. After the secession of individual Yugoslav republics, the association ceased to exist (http://www.fizioterapija.rs/drustvo-fizioterapeuta-srbije-2/).

Physiotherapy in this region developed through the secondary education system and, during the sixties, through the higher education system. Simultaneously, associations were established in individual republics alongside educational institutions and programs. Thus, in Slovenia, education began in 1952, and the association was founded in 1952. In Croatia, the association was established in 1956. In Bosnia and Herzegovina, higher education for physiotherapists began in Sarajevo in the 1980s. In Serbia, the Society of Physiotherapists was founded in 1956, and education started in 1964 (Department for Therapists at the Higher Medical School in Belgrade). In the eighties, Montenegro initiated the study of physiotherapy. The Macedonian Society of Physiotherapists was established in 2017, and Kosovo in 2019 (www.wcpt.org).

Development of the Physiotherapy Profession and Education

In the territory of present-day Croatia, the tradition of using physical factors for the purpose of maintaining health and preventing diseases dates back several thousand years. Its origins are often associated with the application of hydrotherapeutic and balneotherapeutic techniques. Manual techniques were nurtured by “people from the community” who transmitted their knowledge and skills through family secrets. Numerous locations in our region bear witness to people’s belief in the “healing properties of mud” or “healing properties of water.” Even Emperor Diocletian, due to the medicinal properties of the springs in Split, had a summer palace built there. Throughout history, such folk beliefs and the application of manual techniques led to the establishment of health resorts and ultimately to scientific confirmation of their therapeutic effectiveness. The oldest health resorts in Croatia with centuries-old “good reputation” for their healing properties include Varaždinske Toplice (established in 1820), Splitske Toplice (built in 1821), and Krapinske Toplice (established in 1856) (1, 2, 3).

Development until 1999

The development of physiotherapy in Croatia followed historical events in other countries. Written materials from the early 20th century, often related to the care of those injured in World War I, reveal the beginnings of physiotherapy (1). These texts also track the development of medical and social rehabilitation and orthopaedics (2). The first physiotherapists were recruited from nursing, and knowledge and skills were acquired, as they are today, through practice (1).

The foundations of physiotherapy in Croatia were laid in 1908 when, upon returning from training in Germany and Austria to Zagreb, Prof. Dr. Božidar Špišić founded the first orthopaedic institute in Southeastern Europe (2), which was very modern for that time. It had an orthopedic clinic, a room for surgical-orthopaedic procedures and casting, X-ray facilities, two patient rooms, and a space for physical therapy and medical gymnastics (3). In 1914, Dr. Špišić established the “Orthopedic Institute for War Injuries” in Zagreb, and later in 1916, an Orthopaedic Hospital with a rehabilitation department. Through his professional work, Dr. Špišić dedicated significant attention to rehabilitation and physical therapy, not just prevention and surgical treatment. For this reason, he is considered the pioneer and promoter of physiotherapy in Croatia (14). The first Croatian professionally trained expert in the field of physiotherapy was his wife, Ema Špišić, whose professional activities were related to orthopaedics (3).

A significant event for the development of physiotherapy was the establishment of a public bath and the Institute for Hydrotherapy and Physical Therapy in Zagreb in 1928. The institute, led by Dr. Drago Čop at that time, still bears his name today. Ten years later, in 1938, within the present-day Sestre Milosrdnice Clinical Hospital, the Department for Physical Therapy and Rheumatism was founded, which later (in 1941) evolved into the first independent Department for Physical Therapy and Rheumatology. The department, later becoming a full-fledged unit, was led by the first Croatian specialist in physical medicine and rehabilitation, Prof. Dr. Jozo Budak. In 1942, Prof. Budak established the Chair for Physical Therapy and Balneology at the Faculty of Medicine in Zagreb, where he began teaching the subjects of physical therapy and balneology that same year (1, 2).

The first secondary school for physiotherapist technicians was established in 1947 within the Sestre Milosrdnice Hospital, under the name “School for Physical Medicine and Radiography.” This marked the beginning of formal education for physiotherapist technicians in Croatia, and the founding date of the school is considered to be August 1, 1947, when Prof. Dr. Jozo Budak became its director (1).

Association of Physiotherapists, Education, and Professional Terminology

The first professional organization of physiotherapists was founded on 25 November 1956, in Zagreb. It carried the name “Association of Physio and Occupational Therapists in Croatia” until 1998 when it changed its name to the Croatian Association of Physiotherapists (HUF). Maria-Luisa Betlheim (1904–1994), the co-founder and the first president of the association (from 1956 to 1964), was also the Chief Physiotherapist at the Orthopedic Clinic in Zagreb. She introduced music therapy and kinesiotherapy as fundamental techniques in physiotherapy (1, 2).

On 20 September 1963, the City Assembly of Zagreb established the School Center for Vocational Education of Health Technicians, which comprised three organizational units: the School for Health Technicians in Medvedgradska Street 55, the School for Physical Therapy and Rehabilitation within the “Dr. M. Stojanović” Hospital, and the School for Physical Therapy in Krapinske Toplice (1).

The first higher education in physiotherapy began in 1968 at the “Viša škola za medicinske sestre i tehničare,” founded in Zagreb two years earlier (1, 2). From 1984 to 1996, the school operated within the Faculty of Medicine at the University of Zagreb. In 1996, the school changed its name to the “Visoka zdravstvena škola,” and in 2005, it further changed to its present name, the “University of Applied Health Sciences,” which initiated the first higher education program for physiotherapists in 2007, lasting a total of 5 years (3+2). In other Croatian cities, education for physiotherapists began at universities in Rijeka (1986), Split (2001), and later in Osijek (2018).

In 1999, the Croatian Association of Physiotherapists (HUF) joined the World Confederation for Physical Therapy (now World Physiotherapy) (4, 5), marking the start of independence and development from a discipline to a profession. In 2008, the Croatian Parliament passed the Law on Physiotherapy, and in 2009, the Croatian Council of Physiotherapists was founded as the legal successor to the previous Croatian Association of Physiotherapists (HUF). With this, physiotherapy became a regulated profession, and as of 2023, it is recognised as a scientific branch within clinical medical sciences and the field of biomedicine.

At the beginning of the 21st century, with the change in the physiotherapy higher education program from two to three years, there was a shift in subject names, replacing “kinesiotherapy” with “physiotherapy,” and the term “medical gymnastics” was no longer used in educational programs. However, both “kinesiotherapy” and “medical gymnastics” still retain their terms in everyday clinical practice. The term “physical therapy” or “physiotherapy” is still in use in Croatia, although there is a gradual move towards standardisation according to the World Physiotherapy, expecting the adoption of a term that reflects the comprehensive and integrated nature of physiotherapy, which has been fundamental in prevention, treatment, and rehabilitation since the principles of Hippocrates. In Croatia, education for physiotherapists is conducted together in professional and university study programs and structures (180 ECTS or 300 ECTS).

 Social, Economic, and Political Influences

The history of physiotherapy education and practice in Croatia is closely tied to societal, economic, and political changes. In the early stages, the term “physical therapy” was used at the Department for Physical Therapy and Balneology (1942), where higher education in the field began, albeit not specifically for physiotherapists. The term “physical medicine” emerged with the opening of the first secondary school for physiotherapist technicians in 1947, named the “School for Physical Medicine and Radiography.” The term “physiotherapist technician” has significantly influenced perceptions of physiotherapists in both professional and societal contexts.

Since its establishment in 1956, the Croatian Association of Physiotherapists (HUF), with support from the World Physiotherapy, has played a crucial role in guiding and advocating for the development of physiotherapy in both the profession and education. From 1962 to 1968, the association evolved into an organisation that not only promoted professional activities but also advocated for working conditions, the enactment and encouragement of labor and protective clothing laws, physiotherapist categorisation, and a team-based approach to treatment and rehabilitation.

A pivotal moment in shaping the strategy for education and employment possibilities was the integration of the entire professional education system with economic organizations to meet workforce needs. In 1965, the Croatian Parliament adopted a resolution on building a system of vocational education, laying the foundation for the development of this educational system in subsequent years. This concept established the basis for further development of higher education, particularly in higher schools.

The social, economic, and political context significantly influenced the development of physiotherapy education and the profession. Between 1950 and 1980, Croatia experienced rapid economic growth, becoming one of the fastest-growing economies globally. However, the economic climate changed in the 80s, leading to macroeconomic disparities among the federal units of the former Yugoslavia.

After the dissolution of Yugoslavia and the death of the president in 1980, general unemployment became a significant economic and political problem. The demand for physiotherapy increased in the job market during the 1990s, but due to political and economic difficulties, physiotherapists faced challenges in finding employment, especially in state institutions. The economic crisis, changes in the political order, and the transition from socialism to capitalism shifted physiotherapy in the region toward market orientation.

In the late 1990s, the Croatian educational system began adapting to external standards, which already included 4 or 5 years of physiotherapy studies abroad. The relationship between supply and demand for physiotherapists started changing, and although the demand for physiotherapy procedures and professionals grew, the economic situation in Croatia hindered their fulfilment.

The 1990s and post-war period saw a demand for physiotherapy in the job market. Due to political and economic reasons, the private sector provided more employment opportunities for physiotherapists, primarily within medical practices or clinics and especially in primary health care. By the late 90s, the Croatian educational system started aligning with external standards that already included 4 or 5 years of physiotherapy studies. However, due to economic challenges in Croatia, cheaper secondary education for physiotherapists was maintained, despite the external standard of a three-year study without secondary education.

For the future development of physiotherapy as a professional medical occupation, international collaborations are essential to allow less developed countries to adopt knowledge and skills and align with global standards in physiotherapy practice. Additionally, raising the level of education for physiotherapists through educational system reforms, similar to those in Sweden and Croatia, is crucial. Croatia, as an example, quickly became a member of World Physiotherapy and facilitated its physiotherapists in adopting knowledge and skills through international collaborations.

Today, conflicts for dominance within medical professions continue, and unfortunately, in the eyes of the public, especially in Croatia, the perception that a physiotherapist is merely a masseur persists. Only through continuous elevation of standards in education and practice by all physiotherapy organisations worldwide, with World Physiotherapy as a guiding force, and the individual efforts of each physiotherapist, can this misconceived image be completely transformed.

References:

1. Jurinić A. Povijest fizioterapije u Hrvatskoj. FIZIOinfo. 2007; 8 (2): 7-15

2. Schuster S, Miklić A, Jurinić A. Istraživanje povijesnog razvoja strukovnog udruženja fizioterapeuta u Hrvatskoj. U:  Jurinić A, ur. Fizioterapija, znanost i umjetnost. 16.-19. listopada 2014.; Vukovar, Hrvatska. Zagreb: Hrvatski zbor fizioterapeuta; 2014. 21-27.

3. Jurinić A, Schuster S. Povijest fizioterapije u Hrvatskoj, razdoblje od 1908. do 1968. godine. U: Jurinić A, ur. Jučer, danas, sutra. 7.-10. lipnja 2012.; Varaždin, Hrvatska. Zagreb: Hrvatski zbor fizioterapeuta; 2012. 125-126.

4. Schuster S, Jurinić A. Povijest fizioterapije u Hrvatskoj u razdoblju od 1968. do 2005. U: Jurinić A, ur. Jučer, danas, sutra. 7.-10. lipnja 2012.; Varaždin, Hrvatska. Zagreb: Hrvatski zbor fizioterapeuta; 2012. 127-131.

5. Jurinić A, Vojvodić S. Povijesni koraci – HUF u WCPT-u. Fizioterapija. 1999; 3(2): 8-11