Is Physiotherapy a Luxury?
As many of you know, my background is as a physiotherapist.
Physiotherapy, to me, is an almost perfect case study of a disciplined discipline; an imperfect and improbable event in the history of healthcare. It is my métier.
How physiotherapy even exists has been the source of enormous fascination to me over the years. My Ph.D., nearly 20 years ago now, was a Foucauldian Discourse Analysis of the conditions that made physiotherapy historically and socially possible.
And I’ve written all sorts of articles, books and chapters riffing off this question ever since.
The point of all of this work is not to excavate the historical facts of physiotherapy’s existence. It is not to place physiotherapy along the line of historical progression that begins somewhere in a primitive past and ends, presumably, at enlightenment.
No. As a loyal Foucauldian, I don’t believe history is continuous and progressive. I believe it’s discontinuous and contingent; made up of ruptures operating in parallel, not in series.
So, one of the most interesting questions for me has always been why physiotherapy emerged when it did.
Most histories of the profession suggest that it came into its own as a result of the devastation wrought by World War I and the polio epidemics that followed.*
But there have been wars and pandemics throughout human history, and the physical therapies (massage, movement, exercise, hot and cold, electrotherapy even) have been practiced since the dawn of humanity. So this particular war and this pandemic alone cannot explain the profession’s emergence.
In a paper just published (free, open source, link here) I try to tackle this with a novel data source. Using accounts of the sailors injured during the Napoleonic Wars, I ask why it is that there are absolutely no accounts of anyone receiving any physical therapy.
Injuries were horrific on board a Napoleonic sailing ship, and the majority would have been specifically suited to physical therapy (fractures, traumatic brain injuries, amputations, etc.). Time or resources were not a factor; in fact, most Napoleonic sailing ships were like open water gymnasiums, and neither was the availability of necessary space, skill or knowledge, since the onboard crew — which often included a fully-trained surgeon — were adept at many physical things and could easily have turned their hand to therapy.
A few years ago I found the same data studying the complete absence of physical therapies from 19th century Aotearoa New Zealand, despite the fact that the colonists would have known and experienced the extraordinary boom in physical therapies in continental Europe during the period.
The inescapable facts I have kept coming back to is that the physiotherapy profession owes its existence to two Western cultural phenomena: the emergence of the middle classes, with both the surplus time and money to indulge in these conservative therapies, and the aspiration to develop new professional roles as a way to acquire social prestige; and the shift towards industrial capitalist market economies that needed to extract the maximum productivity and functional capacity from working bodies.**
Throughout the history of industrial Europe and America, the physical therapies were unavailable to people who lived in squalor, rank-and-file soldiers and sailors, or those injured in the many mines, mills, and factories of the Industrial Age. Working-age men fared a little better, but women, children, and those with congenital disabilities suffered appallingly. And, of course, the impact of war, overcrowding and poor urban sanitation, unprotected workplaces, and the lack of affordable and effective healthcare services disproportionately affected the working-class poor.
And all of this becomes critical because of what it can tell us about the future for the physical therapies today.
If physiotherapy only exists as either a middle-class indulgence or because of a robust welfare state, then the profession’s future looks deeply insecure. If the profession is dependent on a set of Victorian values, a Protestant Work Ethic, and the principles of early capitalism, then those of us with an interest in the physical therapies should ask what the future is for the physiotherapy profession in today’s postmodern, AI-inflected, morally ambiguous, globalised and atomistic late capitalist world?
The final chapters of Physiotherapy Otherwise turn to this question of the post-professional future for healthcare professions. Spoiler alert: my conclusion is that the physical therapies will always have a place in people’s lives, but that physiotherapy as a profession is in its last days. How we secure the best possible physical therapies for the everyone — not only those with surplus time and money — seems to me to be the challenge for the immediate future.
So the question of the postprofessional future for healthcare is a subject I’ll start digging into in these *Stackposts in the weeks to come.
Vive la revoluçion.
*The actual origins of physiotherapy as a profession are contentious. See www.history.physio for more information. However, the argument that physiotherapy really established itself after WWI is accepted by most.
**This argument forms the backbone of the case I make in the book Physiotherapy Otherwise Free to download here. It should also be borne in mind that the turn towards social welfare for injured servicemen after WWI and into the 1930s and 40s only served to secure physiotherapy’s enclosure of the physical therapies and reinforce its Calvinistic and industrial capitalistic views of the body, function, and work.