The present follows on from the past and is determined by the past. Rehabilitation is currently of low priority, not recognised as an expert service (in contrast to almost all other healthcare services), poorly organised, and widely misunderstood or simply not understood. Looking back at the history of rehabilitation may help us analyse the present situation and plan a way to a better future. This page considers, first, the development of rehabilitation and other words describing rehabilitation. It then considers the history of rehabilitation services.
Words, words …
In 1500, the word, rehabilitation, was first used, and it referred to the restoration of someone who once had had high status back to their original position. They had usually lost it through some socially unacceptable misdemeanour. In around 1850 it was used in relation to a moral state, but this use was short-lived. The timeline of the words use is shown here.
Then, about 440 years later, in 1940, it was first used in relation to health, in the context of returning wounded young men back to a productive state.
“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.”MJ MacDonald. Written reply to Parliament. Hansard. 1940
Over the next five years the word was used to refer to the restoration of many other things broken by war – the economy, land, cities, and so on. Then is was also generalised to other situations – prisoners, people addicted to drugs etc. Indeed its original meaning has be restored, as sometimes politicians may be rehabilitated after some unacceptable behaviour.
Other words have been used. From around 1480, the word convalescence was used in relation to recovery from illness. It means “time spent recovering from an illness or medical treatment; recuperation” [OED]. Then, in the nineteenth century, a more active approach to recovery developed, with terms like ‘medical gymnastics’. The practitioners also used ‘electrotherapy’.
In the early twentieth century, the First World War precipitated a greater interest in helping injured soldiers to recover, and the term ‘Physical Medicine’ arose (interestingly in relation to radiology, as X-rays were one aspect of clinical practice). Physical Medicine remains a term used, though only by doctors.
After 1940, rehabilitation was the main term used for about 40 years, sometimes associated with physical medicine. In the 1980s other words started to be used to describe a process that was and is identical to rehabilitation. The have proliferated over the last 40 years, such that now there are many services with many names all practicing rehabilitation without using the word.
The graphic illustrates the use of rehabilitation as a term, and the many other names used for the same process.
The main message is that the word, rehabilitation is now used in relation to many things, some quite concrete and some quite abstract. Its essence is a process of restoration. It use in relation to health and disability is only one of the contexts it refers to. At the same time, many quite different words have been applied to the process both before and since the word was since introduced into health. It is not surprising that understanding is low.
The first rehabilitation services were, probably, run by the Roman army to return wounded soldiers to work. They were called a valetudinarium, with the same Latin root as convalescence. It is likely that most major armies developed services to help wounded soldiers to return to fighting.
In the mid nineteenth century, the services (medical gymnasia etc) were largely for richer people. There were also sanatoria for people with tuberculosis.
The first big stimulus to the development of formal rehabilitation services was the First World War. There was a service, at Craig Lockhart, for people with ‘shell shock’, but very limited. Services were developed for people with amputations and other musculoskeletal injuries; the Artificial Limb and Appliance Service was founded. (see here). Exercise, occupation and electrical treatments featured. (see here)
In the mid 1930s attention moved to people with spinal cord injury, and the second world war not only precipitated the use of the word, rehabilitation, but it also saw a great expansion in rehabilitation for people with spinal cord injury, with specialist hospitals being founded – they still exist. The management of and rehabilitation after burns also received more attention.
Then, in the 1950s, the polio epidemic and the large number of people with long-term focal weakness again precipitated a development of services. Up to this point, the main but not only interest had been in practical, physical approaches to rehabilitation – exercise and equipment featured. Children born after their mothers took thalidomide benefited from equipment too.
Children with cerebral palsy were also a focus of rehabilitation in the 1950s, with the main driving force being surgeons. The interest was in surgically overcoming contractors and other musculoskeletal abnormalities.
During the 1960s and 1970s, there was a piecemeal expansion of rehabilitation, not with any plan but developing 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; geriatrics was, for a while, a major rehabilitation service although acute medical care has come to be more predominant; and more recently trauma, traumatic brain injury, and most other neurological diseases have developed at least some specific services.
At the same, the increasing numbers of people with longer-term and with severe disability needing both rehabilitation and long-term support has generated pressure for more services. However several factors influenced these developments. Social Services could see the need but could not set up anything that appeared as a Health Service. Health services did not really know what rehabilitation was, and thought that it was ‘highly specialist’ and expensive; they wanted services that were cheaper. This failure to distinguish between specialist and expert (discussed here) led to many small, often short-term services being set up. All the new services developed independently without any coherent plan to guide the development.
Also at the same time, the huge scope of rehabilitation led to the development of services specialising in one aspect such as assistive technology, patients with brain injury who were behaviourally disturbed, multiple sclerosis, or Huntington’s disease. Again there was no coherent framework guiding these developments.
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 simply fail to obtain expert rehabilitation, as illustrated for patients after trauma here.
Summary and conclusion.
This historical overview explains why rehabilitation is not well supported with resources or provided for people who need it. There is an opportunity to remedy this state of affairs – discussed here.
The word, rehabilitation, arrived after rehabilitation services had already been running for over 20 years. The limited scope of services, to an extent, then limited the use and understanding of the word. This was exacerbated by the widespread use of the word for a multitude of services and processes outside health. Second, as if this lack of clarity was not enough, many services that delivered rehabilitation were given other names which further compounded they lack of understanding of the basis rehabilitation process. Third, the completely piecemeal development of services without any integration, or sharing of expertise, has worsened the understanding and left all services quite small and isolated. This also explains the fourth major problem: there is no organisation that advocates for and represents rehabilitation. The British Society of Rehabilitation Medicine and the Society for Research in Rehabilitation are the only two national societies with an explicit interest in rehabilitation.