Evolution of rehabilitation
We can only understand the present we consider the past. Why does rehabilitation as a medical speciality not include rehabilitation for people who abuse drugs? Why does rehabilitation have such a low priority and few resources in the UK? How did the term physical become attached to rehabilitation? What explains the significant increase in research over the last 30 years? We will understand many otherwise inexplicable aspects of rehabilitation and rehabilitation services better when we know the history. I give a brief overview of the evolution of rehabilitation its history here. War played an essential role in this history.
Table of Contents
Evolution - the beginning
The Roman army probably ran the first rehabilitation services to return wounded soldiers to work. They were called a valetudinarium, with the same Latin root as convalescence. Interestingly, the name valetudinarium implied convalescence, a word and concept that links to rehabilitation – see here. Most large armies likely developed services to help wounded soldiers to return to fighting.
The primary component of rehabilitation for soldiers 2000 years ago would have been exercise and practice, with a degree of psychological support and encouragement. It is also interesting that three of the four main pillars of rehabilitation were probably already used 2000 years ago.
After the Roman era, there was little change for centuries. The hospices and hospitals that developed in the Middle Ages were primarily places of refuge, albeit including shelter for disabled and sick people.
Then, in the mid-nineteenth century, a more active approach to recovery after illness started during the nineteenth century, especially in its latter half. Physical therapy, such as exercise, gymnastics, and massage, developed in mainland Europe including Germany, the Netherlands and Sweden. Among other titles used for the activities were medical gymnastics and physical medicine. Physicians were actively involved and indeed attempted to gain complete control over it. (here)
At the same time, convalescence also became a recognised part of healthcare in Victorian England.
“In Victorian England, an ideal for many recovering patients was, at least in this respect, precisely the opposite: not to return home, but to spend a few weeks or months in an institution specifically designed for the needs of convalescents. These convalescent homes, as they were often called, began to appear in the middle of the nineteenth century, but became an increasingly popular destination for patients in the following decades. By the end of the century, more than three hundred convalescent homes had been established, each serving anywhere from dozens to hundreds of patients each year.”Anders, 2014 (here)
Thus, at the end of the nineteenth century, there was no real focus on rehabilitation to help people recover from a specific disability. The Roman emphasis on returning people to work after injury was lost, probably with the end of the Roman Empire.
Evolution - early specialisation
Interest in the active treatment of disability remained limited until the First World War. The sheer number of people injured and left permanently disabled stimulated the development of services to return as many men as possible to the workforce. These services were, by and large, focused on people injured whilst fighting. The government developed services for people with amputations and other musculoskeletal injuries; they started the Artificial Limb and Appliance Service. (see here). Exercise, occupation and electrical treatments featured among the treatments offered. (see here)
Although services gave most attention to working-age people with traumatic injuries, some doctors recognised the presence of psychological trauma during war, for example, at the specialist unit at Craiglockhart War Hospital in Edinburgh. (here) Unfortunately, despite its success in treating people such as Siegfried Sassoon and Wilfred Owen, it was closed after 28 months.
In the mid-1930s, attention moved to people with spinal cord injuries. The second world war not only precipitated the use of the word rehabilitation, but it also saw a significant expansion in rehabilitation for people with spinal cord injury, with the government founding specialist hospitals – they still exist. The management of and rehabilitation after burns also received more attention.
Spinal cord injury rehabilitation. An overlooked rehabilitation success
Between 1935 and 1955, spinal cord injury rehabilitation revolutionised people’s lives with spinal cord injury. In 1936, the first spinal cord injury unit was established in the US in Boston by Donald Munro. (here) He realised that attention should move from the injury to resolving the secondary problems and started rehabilitation on that basis.
Nonetheless, an army surgeon speaking to another doctor in 1944 said, “‘Allen,’ he said to me, ‘I am sorry to have to inflict this on you, but we have been ordered to open a spinal unit at Leatherhead Hospital and I want you to take charge of it. Of course, as you know, they are hopeless cases—most of them die, but you must do your best for them.’“
However, in the same year, Ludwig Guttmann was given responsibility for a spinal injury unit at Stoke Mandeville. He also recognised the need for a systematic, holistic problem-solving process and developed a world-famous centre there. (here)
The approach taken by Munro, Guttmann and many others changed the prognosis. In 1935, a patient would expect a short life, probably in residential care culminating in early death from infection, often from skin pressure ulcers, septicaemia and urinary tract infection. By 1955, a patient could expect a much longer, nearly normal life expectancy and a return to the community and social life. By 1975, employment was also a reasonable expectation.
If a specific treatment had led to such a transformation, a Nobel prize would have been awarded. There was no real recognition that rehabilitation was responsible for the scale of the transformation. Even in 1980, when I started to research, most doctors believed that rehabilitation was ineffective and a waste of money.
Then, in the 1950s, the polio epidemic left many people with long-term focal weakness, which again precipitated the development of services. Shortly after, many children born after their mothers took thalidomide developed phocomelia and needed rehabilitation services. Children with cerebral palsy were also a focus of rehabilitation in the 1950s, with the main driving force being surgeons who operated to reduce contractures and other musculoskeletal abnormalities.
Thus, by the middle of the twentieth century, rehabilitation had developed with a strong emphasis on the physical aspects of rehabilitation: equipment, technology, exercise and operations. The compelling part of rehabilitation, a systematic, almost obsessive attention to detail covering all aspects of a person, which was the basis of effective rehabilitation for spinal cord injury, had not yet reached professional or public consciousness.
Development of rehabilitation as a medical speciality
No one used the word rehabilitation for a healthcare activity before 1940. Still, recognition that the rehabilitation process was an area of specialisation started in the 1920s. Eventually, it became an officially recognised speciality in the United States in 1947. Nearly 40 years later, in 1984, doctors formed a specialist rehabilitation society in the UK, and, in 1996, the General Medical Council recognised rehabilitation as a specialist area of medical practice.
The current American Congress of Rehabilitation Medicine started in 1923 as the American College of Radiology and Physiotherapy, a professional association of physicians who used physical agents to diagnose and treat illness and disability. The college dropped Radiology in 1925 when they also changed physiotherapy to physical medicine. In 1933, the American Congress of Physical Therapy assimilated the American Physical Therapy Association.
Then in 1939, the first speciality society was formed, the Society of Physical Therapy Physicians. This society became the American Academy of Physical Medicine and Rehabilitation in 1956. Towards the end of the Second World War, the US government recognised the importance of rehabilitation. Eventually, on 27th February 1947, the American Board of Physical Medicine became incorporated, officially recognising rehabilitation as a separate medical speciality in the US.
In the United Kingdom, Marjorie Warren was the first rehabilitation physician, and she cared for the elderly. (here) This branch of rehabilitation’s focus on older patients led to the speciality of geriatrics. Nevertheless, rehabilitation expertise is still a significant proportion of the expertise of a geriatrician. (here)
The British Association of Physical Medicine, founded in 1943, was the first specialist society for rehabilitation formed in the UK. (here) The founding members had developed their practice and ideas following the First World War. The Association was “founded as the professional body to promote and firmly establish the speciality of Physical Medicine amongst physicians.” The membership was restricted to doctors to distinguish it from physiotherapy. (also see here)
- report on a double-blind controlled trial of physiotherapy exercises for people with backache (Dr P Hume Kendall)
- an estimate of the prevalence of disability, from Dr George Cochrane
- a discussion on rehabilitation for people with severe mental health problems
- a talk from Dr J C Brocklehurst, a well-known geriatrician on rehabilitation in the elderly
- a talk from Dame Cicely Saunders, founder of the speciality of Palliative Medicine in the UK, who made two notable statements. First, that terminal care was care of “the state that commences when somebody else said that there was nothing further to be done.” and, second, that “patients should die peacefully but, until that time, they should live fully.”
In 1970 the Association added rheumatology to its name, becoming the British Association for Physical Medicine and Rheumatology, registered as a charity in 1972. It later changed its name to the British Association for Rheumatology and Rehabilitation (BARR).
Then, in 1983, the British Association for Rheumatology and Rehabilitation split into two specialist societies. The rheumatology half merged with the Heberden Society to become the British Society for Rheumatology. The rehabilitation half became the Medical Disability Society, founded in 1984. In 1990, it changed its name to the British Society of Rehabilitation Medicine. The speciality of Rehabilitation Medicine initially started with a limited scope, but the latest 2021 curriculum (here) has revived the broad range of conditions covered in 1968.
Development of rehabilitation services in the UK
The National Health Service in Britain was founded in 1948. Although a specialist society, the British Association of Physical Medicine, was already active, the Department of Health decided that there would not be a speciality in Rehabilitation. They expected that each health speciality would undertake rehabilitation of its patients as a regular part of their service. This did not occur.
Later, the rheumatology speciality incorporated rehabilitation. For many years Rheumatology and Rehabilitation was a speciality. Initially, rheumatologists could not influence underlying joint diseases, and rehabilitation was their leading role. Once active medical treatments became available, interest in rehabilitation waned.
Nevertheless, despite the absence of a speciality, during the 1960s and 1970s, there was an expansion of rehabilitation. Unfortunately, it was piecemeal, without any plan. As had been expected in 1948, services developed in response to particular perceived needs:
- musculoskeletal, driven by such diseases or disorders as rheumatoid arthritis, ankylosing spondylitis, and back pain;
- cardiac driving by ischaemic heart disease;
- pulmonary, associated with chronic obstructive pulmonary disease and a host of industrial chest diseases;
- psychiatry, especially as long-stay hospitals were reduced;
- stroke, especially in stroke units;
- disability associated with older age. Geriatrics was, for a while, a major rehabilitation service. And, more recently,
- trauma, traumatic brain injury, and most other neurological diseases have developed at least some specific services.
Each service was developed independently, without any existing rehabilitation expertise to guide the development. Most services focused on the disability associated with acute illness, usually for inpatients, and few services took on long-term care. Most services only considered the specific disability and, except for geriatrics and, more recently, trauma, did not attend to multi-morbidity.
Furthermore, the need for specialist rehabilitation services focused on specific interventions and/or unusual clinical problems became apparent. Consequently, another disparate range of services arose, such as those providing assistive technology, those for patients with brain injury with challenging behaviour, patients with a learning disability, patients after stroke, and people with Huntington’s disease. There was no coherent framework guiding these developments, and they did not liaise with each other or existing services.
At the same, the increasing numbers of people with longer-term disabilities and with disability associated with more than one disease generated pressure for more rehabilitation services. The need was evident to Social Services, but they could not set up anything that appeared as a Health Service. Few senior people in healthcare services understood what rehabilitation was. Most people perceived rehabilitation as a ‘highly specialist’ and expensive service; they wanted cheaper services available to many people in the community. This failure to distinguish between specialist services and expert services (discussed here) led to many small, often short-term services being set up, again independently and without any coherent plan to guide the development.
The consequence is that there is a catastrophically incoherent, disorganised patchwork of services, as discussed here and illustrated here and here, such that many patients fail to obtain expert rehabilitation, as described for patients after trauma here. There is an opportunity to remedy this state of affairs – discussed here.
Summary and conclusion
Services to reduce disability after injury so that people could regain independence and work started in 1914. They focused primarily though not exclusively on the physical and practical aspects of recovery. The medical speciality was called Physical Medicine. In 1940, with the prospect of many more injured men, the word rehabilitation was used for the services needed, and that word has been used since. Unfortunately, the NHS decided that rehabilitation would be the responsibility of each speciality, to be part of their overall healthcare management of patients. Hospital specialities did not take on the role, and the community specialist, the General Practitioner, was not given any rehabilitation resource. Consequently, each time a need for a specific rehabilitation service became compelling, someone set up a new specific service leading to a patchwork of incompatible services. Evolution is unlikely to end with a coherent, well organised, efficient and effective service. Only a revolution will achieve this. Covid may offer the opportunity. (here)