Evolution of rehabilitation
We can only understand the present when 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? When we know the history, we will better understand many otherwise inexplicable rehabilitation and rehabilitation services aspects. I give a brief overview of the evolution of rehabilitation and its history here. War played an essential role in this history, but politics and the dominance of the biomedical model of illness also had considerable influence.
This page will show that three significant steps occurred:
- Healthcare recognised that rehabilitation was a crucial addition to services for ill people in 1916-1918.
- Spinal cord injury rehabilitation developed between 1935 and 1955 as evidence of rehabilitation’s revolutionary effectiveness.
- George Engel developed the biopsychosocial model of illness in 1977, and the World Health Organisation used it as a rehabilitation framework in 1980.
The fourth crucial significant step should be:
- To develop rehabilitation networks to cover the needs of populations between half and two million.
Table of Contents
The use of the word rehabilitation.
The word, rehabilitation, has a long history. The Oxford English Dictionary suggests its earliest use was in about 1533 when it referred to re-establishing or restoring someone’s position, rights and privileges. Its first possible use with health was in about 1858 when it was applied to “attempted rehabilitation of the earliest epochs of mental development”, but no development followed this use.
As I will show, rehabilitation was used extensively in healthcare by 1918. The close relationship between rehabilitation, war injuries to the limbs, and the emphasis on physical treatments coupled with the medical profession’s desire to have named specialities led to the term physical medicine being synonymous with rehabilitation. The vital psychological aspects of rehabilitation, identified by 1920, were overlooked.
The Oxford English Dictionary records the first explicit use of the word rehabilitation in the context of health care, in 1940 when Hansard (the written record of statements made in the British parliament) recorded M J MacDonald saying: “It is the secret of the maximum cure possible for the patient. It is the process known as rehabilitation. It is not sufficient that the wound should be healed; the wounded part of the patient must be enabled to function again so that he may once more play his part in society as a worker.‥ I have appointed an adviser on rehabilitation.” (OED, 2014)
However, the nearly 400 years of stable meaning was shattered by this new use, and before the end of World War II in 1945, it was being used about countries and economies, and its scope has grown since. (see figure below) The word is now used concerning many domains far removed from healthcare, such as:
- personal reputation and status; “this politician will be rehabilitated and rejoin the government, following his apology.”
- criminal status; the rehabilitation of offenders,
- land; “this coastal bay will need rehabilitation after the pollution episode.”
- drug and alcohol abuse; drug rehabilitation services
- economies, countries and industries
Unfortunately, many new words and terms have been introduced as labels that, in essence, apply to processes and services that are indistinguishable from rehabilitation. They include enablement, reablement, habilitation, intermediate care, convalescence, supported care, homecare services etc. The reasons behind this explosion in terminology are primarily political. For example, an organisation, such as social services, wishes to provide rehabilitation but be recognised as different, or an organisation, such as a health service, wishes to reduce expenditure by specifying a new service with rules restricting access.
Evolution - the beginning
After any injury or illness, any organism will necessarily attempt to recover lost function and will, at the same time, adapt to its new level of skills and functions. This is a natural response. However, social groups may also support the injured member, as observed in animal groups such as elephants and primates; it is like the support given to the young.
Rehabilitation can be considered a planned and systematic societal support process offered to members after injury or illness. It is a uniquely human social process because resources are specifically allocated, usually including people who develop expertise in providing support.
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, 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 2,000 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.
1914-1924: blossoming of rehabilitation.
The Great War precipitated publications using the term rehabilitation. Although the Oxford English Dictionary suggests the word was first used in 1940 in the UK parliament, the earliest publication I have found was in 1918 when Major John Todd from the Board of Pension Commissioners for Canada wrote about “The Meaning of Rehabilitation”. The word was already well established because he wrote, “It is well understood on this continent because of the many very excellent articles upon “rehabilitation” which have appeared not only in scientific and semi-scientific publications but in the popular press.”
His article mentioned significant characteristics that are still true. He stressed that civilians should have access, the person must be active in the process, the free access for service personnel needed to extend to civilians, and many different interventions, including training, treatment, job placement, and follow-up.
The US and Canada published most papers, with the Journal of the American Medical Association devoting nine pages, allowing Colonel Frank Billings to cover all aspects of “Rehabilitation of the Disabled”. The article reveals an emphasis on work tasks.
The interest was widespread. In 1918, the Annals of the American Academy of Political and Social Sciences published a piece by the President of the Olivia State Bank, Michael Dowling, entitled “A story of rehabilitation by a cripple who is not a cripple.” The author used terms we would no longer use, but his text contained an insightful aside, “In fact, I think if I may be pardoned from getting away from this personal talk just a moment, the trouble with most crippled men is that they think about those things that are gone and cannot be brought back. They keep their minds on what is gone, instead of diverting their minds to what they have left and making an effort to develop what there is left.”
Input from clinical psychology was considered crucial by 1919 when Bird Baldwin, a Chief Psychologist and Director of Occupational Therapy at Walter Reed General Hospital. He reflected on his experience from April 6th 1917, when the United States entered World War I. He immediately appreciated the “need for a synoptic picture” covering:
- Personal and social history
- Rating of educational achievements and intelligence
- Assessment of potential employment roles
- Analysis of mental attitude, interests, aptitudes, special abilities, and morale
- Evaluation of motor control
- Psychology of learning.
He highlighted the central role of medical social workers in negotiating complex systems, although he also said, “The influence of a bright, attractive social worker who depended more on her personality than on science, met the situation …” which he went on to describe. The paper includes many detailed case descriptions and aspects of specific treatments.
Last, occupational therapy was already an accepted part of a rehabilitation service. He wrote that “a number of public and private hospitals in this country, especially in Pennsylvania, Illinois, Massachusetts, New Jersey, Texas, and California, have introduced occupational therapy as an integral part of the hospital life and treatment.”
In the UK, the importance of rehabilitation for ‘shell shock’ was recognised in 1916 when Craiglockhart Hospital was opened in Edinburgh. Unfortunately, despite its success in treating people such as Siegfried Sassoon and Wilfred Owen, it was closed after 28 months. The value of treating the psychological wounds of war was lost for years.
The initial focus was on work. In the US, a Federal Rehabilitation Law was passed in 1919, and in the US, for “the promotion of vocational rehabilitation of persons disabled in industry or otherwise and their return to civil employment.”. An article in the Journal of Political Economy describes some of the debates, like current debates.
Last, the close link between effective rehabilitation services and the state was highlighted, for example, between Lieutenant-Colonel J L Biggar, who wrote “State Medicine and Rehabilitation”. He noted that “The extent of the communal duty in regard to the physically handicapped has begun to be estimated.”, one worrying statistic was that “… one man in every four of those of military age was found to be incapable of active service because of physical unfitness, and that this, in the majority of instances, was the result of preventable disease.” He argued that the economic return on rehabilitation necessitated state funding.
In other words, over no more than ten years, rehabilitation emerged into full flower, and many of its present features were established, such as the need to be holistic, the importance of psychology, and the central role of exercise. At the same time, the political debates held were like present debates.
Journals and Societies
During the 1920s and 1930s, services for people left disabled after war and other injuries continued and developed. The Second World War again drew attention to the need for active treatment of the disabling consequences of disease and injury, and at around that time, people with spinal cord injury, burns, and head trauma were all recognised as needing more than convalescence. The focus remained on working-age men, and although it was recognised that some people would not return to open employment, work was still the primary goal. Special employment services were developed for disabled soldiers, sailors and airmen.
The increasing recognition that the consequences of illness needed active treatment once the acute treatment was complete led to the medical speciality of ‘physical therapy’ or ‘physical medicine’. The focus on ‘physical treatments’, initially including radiation and electrical treatments, continued for many years. The importance of emotional factors in rehabilitating the physically disabled was overlooked. (Leon Reznikoff, 1938)
In the US, the Journal of Radiology (1920) published articles on treatments for disability. In 1926, it was renamed the Archives of Physical Therapy, X-Ray, Radium; in 1938, the name changed to the Archives of Physical Therapy; in 1945, it became the Archives of Physical Medicine; and finally, in 1953, it was called the Archives of Physical Medicine and Rehabilitation, one of the leading and most extended standing specialist rehabilitation journals.
A similar series of developments occurred in medical organisations. The first medical association in the US was the American Society of Physical Therapy Physicians, founded in 1938, becoming the American Society of Physical Medicine and Rehabilitation in 1951. In the UK, a British Association of Physical Medicine was set up in the 1930s and continued until the 1970s. The British Society of Rehabilitation Medicine was founded in 1988 (its first name was the Medical Disability Society) and was renamed the British Society of Physical and Rehabilitation Medicine in 2022. Most European countries were well ahead of Britain in forming specialist professional groups.
Evolution of services and specialists.
Initially, orthopaedic surgeons were mainly involved, and they extended their remit from correcting traumatic structural abnormalities to correcting surgically some of the structural problems associated with non-traumatic conditions such as cerebral palsy and stroke. Moreover, they operated on people with rheumatoid arthritis, a significant disabling illness, and various other skeletal problems, such as scoliosis. Thus, they had close links with rheumatologists, who often took over the management of patients who had been operated on.
This naturally led to rheumatologists often taking responsibility for rehabilitation. Indeed, there were specific posts for doctors in ‘rheumatology and rehabilitation’ for many years in the UK. In the UK, some of these services started to take an interest in other conditions, such as stroke and traumatic brain injury.
The development of surgical services and rheumatological services as the only healthcare services specialising in helping people with disabilities in the UK meant that they were, in practice, the only rehabilitation services. The spinal injury rehabilitation services developed from around 1940 onwards were also the province of surgeons, such as urologists and plastic surgeons.
One consequence of the domination of a structural approach was that services in many countries became termed ‘physical medicine’ or ‘physiatry’ services, which reflect rehabilitation’s origins in rheumatology.
Thus, the rehabilitation services that did develop in the twentieth century were initially focused on:
- men of working age, usually previously healthy, who had been
- injured in war and
- primarily with structural damage to their bodies
Over the century, the remit of the ‘active disability management services’ expanded so that by 1975 they were:
- still most interested in restoring people to work and usually had an upper age limit of 65 years
- most interested in conditions where recovery was possible and
- treatments were mostly physical, with an emphasis on biomechanical solutions
Children and older people with disabilities were responsible for paediatric and geriatric services, which provided what is now termed rehabilitation but was not usually named as such. The existing adult disability services were aware of the importance of illness’s psychological (emotional) and cognitive aspects but generally considered them outside their scope.
Spinal cord injury rehabilitation.
Interest in actively treating 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)
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 funding specialist hospitals – they still exist. The management of and rehabilitation after burns also received more attention.
An Overlooked Rehabilitation Success
Between 1935 and 1955, spinal cord injury rehabilitation revolutionised people’s lives with spinal cord injury. In 1936, Donald Munro established the first spinal cord injury unit in the US in Boston. (here) He realised that attention should move from the injury to resolving the secondary problems and started rehabilitation.
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.’“
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 average life expectancy and a return to the community and social life. By 1975, employment was also a reasonable expectation.
A Nobel prize would have been awarded if a specific treatment had led to such a transformation. There was no recognition that rehabilitation was responsible for the scale of the change. Even in 1980, when I started researching, most doctors believed rehabilitation was ineffective and a waste of money.
Then, in the 1950s, the polio epidemic left many people with long-term focal weakness, precipitating services’ development. 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 strongly emphasised 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.
A rehabilitation framework.
Perhaps the most significant single evolutionary step occurred in 1977 when George Engel published his paper on the biopsychosocial model of illness. This gave a formal framework for the synoptic picture mentioned by Baldwin in 1919.
This was immediately recognised as applying to rehabilitation, and by 1980, it had already been formalised by the World Health Organisation in their International Classification of Impairment, Disability, and Handicap (WHO ICIDH). After significant criticisms and much additional work, the WHO developed the model to publish the WHO International Classification of Functioning, Disability and Health in 2000 (WHO ICF).
The framework is now widely used in rehabilitation to structure assessment and data, to analyse how disability arises, to inform the development of measures and core data sets, and in many other ways. It has also been further developed to encompass well-being, choice, life stage, and illness stage.
Evolution of rehabilitation as a speciality
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.
Two useful historical summaries of development in the United States are available here and here, and they form the basis of the following two paragraphs.
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 it changed physiotherapy to physical medicine. 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, the British Association of Physical Medicine, founded in 1943, was the first specialist society for rehabilitation. (here) The founding members had developed their practices 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)
Marjorie Warren was the first rehabilitation physician; she cared for older people. (here) This branch of rehabilitation’s focus on older patients developed into the speciality of geriatrics. Rehabilitation expertise is still a significant proportion of the expertise of a geriatrician. (here)
The British Association of Physical Medicine held its first meeting outside London in 1956. (here) In 1968, it had a meeting at King’s College Hospital, London. The talks included (see here):
- report on a double-masked 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 the 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 became 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, and changed its name to the British Society of Rehabilitation Medicine in 1990. 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. In 2022, the name changed to the British Society of Physical and Rehabilitation Medicine.
Evolution 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.
Rheumatology incorporated rehabilitation, and, for many years, Rheumatology and Rehabilitation was the speciality; rheumatologists could not influence underlying joint diseases, and rehabilitation was their leading role. Once active medical treatments became available, interest in rehabilitation waned.
Despite the absence of a speciality, rehabilitation was expanded during the 1960s and 1970s. Unfortunately, the expansion was piecemeal, without any plan. As had been expected in 1948, services developed in response to 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, significantly as long-stay hospitals were reduced;
- stroke, especially in stroke units;
- disability associated with older age. Geriatrics was, for a while, a significant rehabilitation service,
- Trauma, traumatic brain injury, and most other neurological diseases have developed at least some specific services, and now,
- Long Covid services
Each pathology-based service was developed independently, usually focused on the disability associated with acute disease. These were usually inpatient services. Another group of specialist rehabilitation services focused on specific interventions or unusual clinical problems as they became apparent. Thus, a second 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.
No coherent framework guided these developments, and they did not liaise with or learn from each other or existing services.
At the same, the increasing numbers of people with longer-term disabilities and with disabilities associated with more than one disease generated pressure for more rehabilitation services.
The need for services was evident in 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 community patients.
This failure to distinguish between specialist and expert services (discussed here) led to many small, often short-term, community services being set up 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.
However, the solution most likely to work must accept that the current chaos cannot be rationalised; over 100 years of history and development will not be reversed. Instead, we must develop a rehabilitation network covering 0.5 to two million people in each locality.
Summary and conclusion
Services to reduce disability after injury to regain independence and return to work were first systematically developed in 1914. They focused primarily, though not exclusively, on recovery’s physical and practical aspects despite the early recognition of the crucial importance of psychological and emotional factors. The medical speciality was called Physical Medicine. In 1940, with the prospect of many more injured men, the value of rehabilitation was again recognised; the speciality of spinal cord rehabilitation grew and demonstrated how effective rehabilitation can be. Unfortunately, in 1948, 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 resources.
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. In 1977, George Engel made the most significant single evolutionary step, introducing the biopsychosocial model of illness. The vital evolutionary step required is to develop rehabilitation networks that might improve rehabilitation dramatically.
