Marking 100 years since WWI – Physiotherapy then and now

One hundred years ago the world was at war – a war that was to have a huge influence on the physiotherapy profession.

AUT associate professor David Nicholls says that while physiotherapy (then called massage) was established in 1894 in the UK, World War I changed everything in terms of rehabilitation.

“The First World War was the turning point for us as a profession.”

In the 19^th century, migrants to New Zealand were focused on establishing settlements.

“If you chopped your arm off in a threshing machine in the fields, in simple terms, you just got on with it. You didn’t have rehab or six months off work. You just had to carry on.”

A greater focus on physical rehabilitation around WWI came partly because governments, including New Zealand’s, didn’t want injured soldiers sitting idle.

“The whole rhetoric was: we can’t afford to have these people on pensions – we’ve got to get them back into work.”

At the start of the 20^th century, antibiotics and antisepsis had come into their own, giving physicians and surgeons new drugs and approaches to focus on. This left a vacuum for the physical rehabilitation they used to perform.

“Somebody needed to do the physical rehab – the massage, the moving and the handling. That’s where we came in.”

If a soldier’s injury was minor, the aim was to get him back to into service. If major, there was now an expectation he would continue contributing to society and not be pensioned off.

David says if a tailor lost an arm, for example, he could learn to continue tailoring with his remaining arm.

“You either adapt the person for the job or you adapt the job to the person, which is where ergonomics comes in.”

If a returned serviceman could not return to his old job, then new work might be found (eg office work instead of labouring).

The School of Massage was started at the University of Otago in 1913 and the war saw large numbers joining the massage profession. It was a key part of a triumvirate –doctors doing diagnosing, medicine and surgery; nurses doing caring; and masseurs doing rehabilitation.

Another big change WWI brought about was women being able to practice on men.

“Prior to 1914, there were major concerns over women touching men for massage. It was only the First World War with so many men coming back who needed to be treated, that forced the physiotherapy profession to deal with its problems with gender. Returned servicemen were considered a noble reason to treat men.”

David says for the women in the profession it would have been an incredible experience. Surgeons were doing pioneering work and it was the physio’s job to splint the patient, manage sores, keep them comfortable, exercise them and get them fit again.

“We’re used to the idea now, but at the time to be so active in rehabilitating people back to health would have been quite amazing.”

Prior to WWI, only women were allowed to train to be masseurs and this also now changed. In New Zealand the first men only trickled in, but numbers became more significant after World War II, (when it became a career opportunity for returned servicemen).

By then the profession had helped people through WWI and the polio, influenza and TB epidemics, and had been respected for some time. Major future advances in rehab medicine came from the public health system’s development; later wars had a less profound effect on the profession.

“When they formed the welfare state in the 1930s and 40s in New Zealand, we were already the principle provider of physical rehab.”

David says although wars are terrible, they often result in improved surgery and rehabilitation techniques.

“I was a respiratory physio by training and a lot of the techniques managing people with dodgy lungs in intensive care and medical and surgical wards were learned after the gunshots and mustard gas inhalation of the First World War.”

With WWI centenary commemorations underway, David says it is timely to reflect on the war’s impact on physiotherapy.

“Who knows? Without the war, the profession might have looked very different. It seems a shame to say, or a bit crass, but we gained as much from the war as people in the war gained from having us there to help them. It wasn’t all one way. We certainly benefited as a profession from the opportunity to be the people on the frontline who were responsible for the physical rehabilitation of injured veterans.”

David says the high regard physiotherapy is held in by the public may stem from the work physios have done in the last 100 years in situations like war rehabilitation.

One hundred years on, physiotherapy still plays an important role in the armed forces.

Physiotherapist Captain Anna Wylie has been with the New Zealand Defence Force for 18 months and previously served in the British Army for six years.

She says the people are the best part of her job.

“People are motivated and grateful for their treatment. It’s quite rewarding seeing people going back to doing their job.”

She says she has had a lot of great experiences.

“In the British Military – I got to travel and do some really cool things. I did adventure training and I went skiing in France when I was there and trekking in Peru.”

She was also lucky enough to have her Masters studies paid for by the British military. The British military also deployed her to Afghanistan, where she says the biggest challenge was being away from home for so long (deployments last four to six months).

“You work really hard and have long hours. You tend to work six or seven days a week so it’s really full on when you’re out there.”

Working in a really close team was very rewarding and she dealt with being away with phonecalls, letters and keeping busy.

“We’d work during the day and then everyone would get together and watch movies or play volleyball after work – you just do things to keep the hours ticking by. When you’re with the people you’re working with, they understand the different challenges you’re facing. Because you know each other, you end up watching out for each other.”

The clinical work when deployed is similar to the regular day job, treating people for musculoskeletal injuries.

“But over there, a lot of it is giving reassurance. People get sore knees from being out carrying a whole lot of kit and stiff spines from carrying the load and sleeping in camp cots. So it’s reassuring people that when they get back home things sort themselves out.”

Anna always felt safe and well-looked after while deployed.

“Generally we were back [from the frontline] – it wasn’t like we were in the middle of a conflict zone. Although somewhere like Afghanistan there’s always potential isn’t there? You have basic training for that.”

She says she would like to be deployed with the New Zealand Defence Force.

“That’s one of the things we’re looking at, at the moment, trying to develop that deployable capability.”

In New Zealand, she works as part of a multi-disciplinary team, with a lot of liaison with the army doctors, nurses and medics.

One of the different things about working in the army is talking with patients’ bosses about what they can and can’t do after an injury or surgery.

“There is a lot of liaising that goes back and forward with this job. [Outside the military] if someone’s rolled their ankle playing tennis it doesn’t impact their job – it’s not so difficult. Whereas if you’ve got a soldier who’s rolled an ankle and is supposed to be going on field exercises and can’t, that’s when you really have to talk to people’s bosses.”

She sees a lot of lower limb injuries and lower back problems – degenerative knee or back conditions in older soldiers and medial tibial stress syndrome in younger ones.

“Because the recruits generally haven’t been wearing boots or carrying packs previously, all of a sudden you change their footwear and put this load on them and then you see injuries as a result.”

Anna looks at what caused the injury and picks up on trends – assessing why injuries are happening and mitigating against them, with the aim of preventing injuries in the first place.

“Things like footwear are reviewed and we’ve had input into boots and changing the programme so there’s not so much loading all stacked up.”

In returning servicemen she sees a lot of knee and Achilles problems because they are in boots for longer periods.

“Because they’re going out on patrol, and they’ve got body armour and weight on as well, they’re quite stiff through their thoracic spine.”