Is Sports Rehabilitation new?
Photo Credit: Nicolas Hoizey
You could be forgiven for thinking that Sports Injury Rehabilitation is a very modern offshoot of medical science.
Take some “relatively” recent key events which have radically improved health and surgical intervention saving millions of lives.
1840: Ignaz Semmelweis - Identified handwashing as preventing cross-contamination of infection.
1850’s: Louis Pasteur - Identified that micro-organisms were responsible for disease and that they could be killed.
1867: Joseph Lister - influenced by Pasteur, realised the antiseptic power of carbolic acid solutions and established aseptic techniques and sterile conditions in the hospital where he worked and published papers in the Lancet.
Each of the above, faced opposition to the theories and the evidence they presented, which, when eventually accepted led to the saving of millions of lives. In 1873 the Lancet medical journal warned the entire medical profession against Lister’s progressive ideas with other European countries adopting it as best practice before Great Britain.
The Impact of Ancient Greece on Modern-Day Rehabilitation
Writings, practices, and beliefs from over 2500 years ago have shaped our approach to healthcare.
Herodicus - Early 5th Century BC
Herodicus is known as the “Father of Sports Medicine” and it is believed that he was one of the tutors of Hippocrates.
He was born in the city of Selymbria, Megara, and practiced medicine in various Greek cities including Selymbria, Megara, Athens, and Cnidos.
He succeeded his mentor, Euryphon, a physician at the Cnidos medical school in Cnidos, Caria.
Euryphon is significant because was the founder of what was the first medical school of importance because he practiced medicine aloof from and bereft of the then-prevalent traditions of magic and mythology.
Herodicus trained initially in sports as a gymnastic master and from then progressed onwards to be a physician, dietician, and sophist.
His experience of training and developing sports athletes gave him a unique perspective in his approach to medicine. Typically the fields of sports teachers and medical practitioners seldom overlapped.
In 484 BC Herodicus is credited with the first known study of what was termed "therapeutic gymnastics" or "gymnastic medicine” (a translation of which was published in 1748 by authors Christian Frederick Boerner and Lorenz Heister entitled Ars Gymnastica which was reproduced from the original artifact )
This was against a backdrop of war and many of his patients were warriors or athletes, an ideal “market segment” who trained regularly and readily embraced opportunities to enhance their health, athletic performance, and combat ability.
The Olympics (776 B.C. to 393 A.D ) were held every four years and contestants and attendees of the games were afforded a sacred period of truce commencing one week before, extending to one week after the end of the games to travel to and from the games to their countries of origin in safety regardless of existing wars and conflicts.
The Cnidos medical school where Herodicus practiced was in Caria, a colony of Sparta whose reputation over centuries as a land-fighting force was unequalled.
Sparta promoted three core virtues: equality among citizens, military fitness, and austerity.In contrast to Athenian women, Spartan women would exercise just as much as their warrior men and would compete in instituted athletic competitions up to the age of marriage.
The war between the Persian Empire and the Greek city-states of Sparta and Athens was from 499 BC to 449 BC.
The Battle of Marathon was in 490 BC immortalised in the tale of Pheidippides running 25 miles to Athens to deliver the news of the Persian defeat before dying inspiring the creation of the modern-day marathon. The marathon was not an event in the ancient Olympic games.
In the intervening period between the end of the Greco-Persian Wars and the start of the Peloponnesian War (431–404 B.C.) between Sparta and Athens, other conflicts occurred.
During his experience as a sports teacher, Herodicus had observed that weak wrestling and boxing athletes ( key events at the Olympics) gained strength when subjected to rigorous exercise.
He declared that sufficient physical activity and proper diet are vital to maintaining good standards of health.
He advocated the use of and specified the technique of therapeutic massage and strenuous exercise regimes combined with a strict diet as a treatment and as a preventative measure against illness.
His methods drew criticism, but his persistence paid off and he achieved significant results with his methodology which he incorporated into his own lifestyle.
The medical school attached great importance to aetiology/etiology (the cause, set of causes, or manner of causation of a disease or condition.) therapy, prognosis, and recording and taking into account the medical history of the patient.
Today this may seem entirely unremarkable, but in context was radical, almost revolutionary in an era where the Olympian Greek Gods (Mount Olympus being the perceived home of the gods and the throne of Zeus) were worshipped and would continue to be so for centuries to come, where remedies were sought from exorcists to physicians to faith healers influenced by myths and rituals.
Hippocrates (460 - c 370 BC): The Father of Medicine
A Greek physician, he was born on the Greek island of Kos and is considered to be one of the most outstanding historical figures for his contributions to medicine.
He is the author of the code of ethics now known as the “Hippocratic Oath” of the famed “do no harm” the much-cherished principles of which are still embraced by many medical school graduates today and also hotly debated in respect of euthanasia and abortion.
The Hippocratic oath has changed somewhat over the years, for example, the first line of the original version starts:
"I swear by Apollo the Physician and by Asclepius and by Hygieia and Panacea and by all the gods….”
The text in itself is significant in its acknowledgment of the cultural context of that era.
The modern version of the Hippocratic Oath written by Louis Lasagna in 1964 that is taken by many medical students upon graduation starts with:
“I swear to fulfill, to the best of my ability and judgment, this covenant:”
Hippocrates, though he himself was born into a family of priests, eliminated any religious or supernatural context when diagnosing, treating, and preventing medical diseases.
He was the first to teach a “rational” Medicine based on study, research, and accumulated knowledge.
He effectively declared that the gods were not responsible for the dispensation of disease and that sacrifices and penance for perceived wrongdoings would not alleviate them.
Apollo, whose CV is particularly impressive is the Greek God of healing, oracles, archery, music and arts, sunlight, knowledge, herds, and flocks, but also illness and plague.
God of healing, rejuvenation, and physicians.
Asclepius (of the Hippocratic Oath), the son of Apollo and a mortal royal called Coronis, is the ancient Greek god of healing, revered by the ancient Greeks and was said to have been such a skilled doctor that he could even raise people from the dead.
The Abaton Enkoimeterion at the Sanctuary of Asclepius in Epidaurus
Over 300 asclepieia (healing temples dedicated to Asclepius) have been discovered throughout ancient Greece.
The most famous of the temples was at Epidaurus which was built in the early 4th century BC and was the foremost ancient healing sanctuary, renowned throughout the then-known world, with depictions of miracles carved on stelae (stone slabs). It is claimed (much repeated elsewhere) that Asclepius was born in Epidaurus. Other temples of renown were the Asclepieion of Athens founded in the year 419–18 BCE, in Corinth and in Pergamon where Galen studied and worked as a physician.
Priests and physicians worked in the temples, the latter generally being subordinate to the priest.
Epidaurus Ancient Theatre near the Abaton
People would come to the asclepieion bearing sacrifices and offerings and sleep overnight in the “Abaton” or “Enkoimeterion'“ (dormitory/dream chamber) where, as standard in all asclepieia, non-venomous snakes would roam, and would hopefully be visited by the god Asclepius and be cured or experience dreams or visions which they would then relay to a priest for interpretation the next day. The priest would then prescribe the appropriate treatment for his interpretation of their condition, which may include being allocated to the temple physician.
Animal sacrifices, typically of oxen, goats, and sheep were the accepted offerings to the gods at an altar in front of the temple, with the assembled supplicants eating the entrails and meat of the animal offering.
On the island of Kos, over a century after Herodicus, a new healing temple dedicated to Asclepius was built.
Asclepius in the 21st Century
The World Health Organisation emblem consists of the United Nations symbol surmounted by a staff with a snake coiling around it, originating from the story of Asclepius.
The snakes, to be found, in all of the healing temples, were perceived by many as a symbol of rejuvenation and rebirth because they shed their skins many times during their life.
Consequences of rejecting the gods in ancient Greece
Socrates, credited as being the founder of Western philosophy was sentenced to execution by poison (Hemlock) in Athens in 399 BC for rejecting the gods (impiety) and corrupting the youth.
Key Influences (good and bad) on Modern Day Health Practice.
Ancient Greece is a major influence on healthcare throughout the world with practices handed down through the ages and from texts, many only surviving as a result of translation into Latin and Arabic, the originals being lost. A lot is gleaned from historians’ accounts and biographies of physicians who wrote treatises (and from those who purported to be the originators themselves) being cross-referenced to assemble a reconcilable narrative
Little or no works of Herodicus remain in existence and the same can be said of Hippocrates.
Much of what has been conveyed of ancient Greece is from biographies, surviving treatises, and indeed references to objections by opponents and critics of evolving practices that were seen to move away from entrenched superstition and the gods and writings of early philosophers and historians which sometimes, does simply not add up.
The following three extracts seem to corroborate the prescribed lifestyle disciplines:
According to Plato, (428/427 or 424/423 – 348/347 BC) Herodicus recommended that his patients walk from Athens to Megara, a distance of more than 20 miles.
Herodicus was accused by the author of Epidemics of killing patients with the intensity of his exercise routines.
Aristotle criticized his methods as being too harsh and unpleasant.
The Hippocratic Corpus
The Hippocratic Corpus is considered to be the foundation of Western medical science and consists of some 60 early Ancient Greek medical works strongly associated with the teachings of the physician Hippocrates.
These biographies and treatises heavily influenced not only Greece, but Asia Minor, which nowadays would consist of Italy, Greece, Albania, Macedonia, Bulgaria, Turkey, Egypt, Libya, Israel, and Lebanon.
Galen - Physician 129 – c. AD 216
Galen (Aelius Galenus) was a Greek physician, skilled surgeon, philosopher, and a prominent medical researcher of antiquity and is not a footnote in history.
He was a legend in his own lifetime as a physician and a writer who perpetuated Hippocrates and despite much of his original work being lost, his prolific literary output still accounts for half of the surviving literature from Ancient Greece.
He not only summarised the doctrines of his predecessors such as Hippocrates and Plato, but influenced the development of western medical science over the next 1300 years from his texts on scientific practices and views including anatomy, physiology, pathology, pharmacology, neurology, philosophy, and logic.
He was a physician to emperors and at one point had to flee Rome for fear of assassination from physicians who relied upon divination and mysticism to heal.
Translations of his texts in Arabic, Latin and Greek are still being translated today.
Ḥunayn ibn Isḥāq (808-873 AD) was an Arab scholar who made translations of many works, and notably some five hundred years later, those of Plato, Aristotle, Galen, and Hippocrates.
Many of his translations are the only surviving evidence of the original texts, especially in respect of Galen, many of whose works were lost in a fire circa 191-192 AD which destroyed the Temple of Peace in Rome.
The Evolution of Physical Rehabilitation
Seismic catalysts in the advancement of understanding the human form, treatment to increase physical performance and stamina, diet and the prevention of injury as well as surgical procedures can be linked to the incidence of war, disease and cultural shifts.
World War One
The first World War prompted a discourse on an international scale when, at the end, Britain alone had over 750,000 newly disabled people.
Casualties were a feature of war, but as the sheer scale of WW1 became apparent, the primary, military led, “rehabilitation and return to active service” scope of previous conflicts changed significantly.
Mortality rates of injured soldiers who reached medical care were significantly lower than in previous wars due to multiple factors, but antisepsis and the practice of aseptic surgery (Joseph Lister ) and the now universal recognition of bacteria (Pasteur) causing wound infections were major factors.
Rehabilitation took on more than the functional process; the remit was now to integrate the rehabilitated wounded and disabled soldiers back into a full civilian life, socially active and as independent earners.
Physical therapy was still in its infancy as a recognised specialist field that included both physicians and non-physician therapists trained to help people recover to the fullest extent of their abilities by devising and supervising exercises specific to the patient’s musculoskeletal injuries.
The decades-old practice of massage and passive motion for leaving patients languishing in beds for lengthy periods after surgery slowly evolved to adopt the practice of using physiotherapy and mobilisation post-operation at the earliest opportunity.
The experience gained in the treatment of war casualties between 1914 - 1918 and the sheer scale during and postwar rehabilitation significantly enhanced functional treatment techniques and procedures, but also nurtured the foundations of the psychological welfare of disabled veterans.
Rehabilitation centres such as Queen Mary's Hospital in Roehampton in 1915 were set up to fit veterans with prosthetic limbs, which made great strides over the previous century where the wooden “peg leg” was replaced with lightweight metal alloy versions and prosthetics with some degree of functionality replacing fixed extensions such as a hand designed primarily to conceal a missing arm.
World War Two
World War II Injury Rehabilitation
In the September of 1943 the British Government asked the neurosurgeon Ludwig Guttmann, himself a German-Jewish refugee to establish the National Spinal Injuries Centre at Stoke Mandeville Hospital in Buckinghamshire, which became the UK’s first specialist centre for treating spinal injuries.
He believed that sport was an important method of therapy for the rehabilitation of injured military personnel, helping them build up physical strength and self-respect.
At Stoke Mandeville which opened in 1944 - patients paralysed during the war began to compete against each other as part of a pioneering rehabilitation method.
On the first day of the 1948 Olympics which London hosted at very short notice after the war (the 1940 and 1944 games were cancelled due to WW2 ) a wheelchair archery competition was held on the lawns of the hospital and the Paraplegic Games (later to be Paralympics) were born from which many elite disabled athletes have since become sporting icons in their own right.
Polio
In the late 1940s, polio outbreaks in the U.S. increased in frequency and size, disabling an average of more than 35,000 people each year.
Polio (poliomyelitis) for which there is no specific cure is a crippling disease caused by the highly infectious Poliovirus, with records of people seemingly afflicted dating from ancient times.
Epidemics of the disease which can infect the spinal cord, causing paralysis or weakness in the arms, legs and the diaphragm (affecting respiration) were unknown prior to the 20th century.
Worldwide eradication of poliomyelitis through immunisation by the year 2000 was adopted by the 41st World Health Assembly in 1988. In 2022 a 99.9% reduction in wild poliovirus transmission worldwide was achieved.
Early management practices for paralysed muscles often involved being immobilized and imprisoned in splints,corsets, braces and casts often for months resulting in atrophy of both affected and unaffected muscles.
Nurse Elizabeth Kenny in August 1915
This was unchallenged until 1940 when Sister Elizabeth Kenny (1880-1952) a self-trained Australian nurse who had been rehabilitating polio patients for 12 years came to the USA advocating moist hot packs and gentle muscle manipulation and activity and exercise as early as possible after diagnosis.
This was to maximize the strength of unaffected muscle fibers and promote the neuroplastic recruitment of remaining nerve cells that had not been killed by the virus.
Neuroplasticity refers to the unique ability of the nervous system to modify and reorganise itself both structurally and functionally in a dynamic manner in response to injury.
This was her second period in the USA, the first when she travelled in 1915 from Australia at her own expense to volunteer as a nurse in the war effort.
Importantly at that time, she was experienced, but unqualified and it is thought that a letter of recommendation she carried from a Dr McDonnell in Australia who was her lifelong mentor from 1897 tipped the balance in her being accepted.
She was assigned on 28th July 1916 to the No. 1 Section, Special Transport Service as a Nurse on the crew of the HMAT Suevic which was used to carry war goods and soldiers to the front; returning with wounded soldiers.
In 1919 Kenny was honourably discharged and awarded a pension, whilst having “earned” and been officially promoted to Sister in 1917.
Her opposition to immobilising children's bodies with plaster casts or braces was controversial to the medical establishment and her lack of a nursing qualification, as opposed to an earnt rank of Sister, meant that many Australian doctors and the British Medical Association questioned her results, with New York City and Chicago doctors referring to her as a screwball.
A controversial figure, her determination, and unabashed dismissal of her critics paid off in the hard evidence of her success with her patients.
Her methods became widely accepted and she began courses for doctors and physiotherapists from many parts of the world.
In 1921 Franklin D. Roosevelt contracted polio which left him permanently paralysed from the waist down. He would go on to serve a 12-year term as president of the United States in 1933 - 1945.
In 1942 The Sister Kenny Institute was built in Minneapolis and other Kenny clinics followed.
in 1950 American President Harry Truman signed a Congressional bill giving Kenny the right to enter and leave the US as she wished without a visa in recognition of her work.
In 1951, Kenny topped the most admired man and woman poll conducted by Gallup in the USA displacing Eleanor Roosevelt.
In the same year however, whilst attending the 2nd International Congress of the International Poliomyelitis Congress, with a thousand people in attendance, 600 of whom were physicians and 37 countries represented the controversial Sister Kenny was shunned and unable to participate.
Her story is something you could make a film about and they did in the 1946 film Sister Kenny, featuring Rosalind Russell six years before Kenny died at the age of 72.
It wasn’t until 1955 three years after Sister Kenny’s death that Salk polio vaccine arrived and only then did polio become a disease that could be effectively prevented, but in the interim her treatment methods became accepted practice giving hope to people who under previous medical regimes would have had their cases categorised as hopeless.
In 2009, during the Q150 celebrations (150th anniversary of the Separation of Queensland from New South Wales in 1859) of the institution of Queensland, the Kenny regimen for polio treatment was announced as an outstanding "innovation and invention"
There are now 20 Courage Kenny Institutes in Minnesota some of which are dedicated to Sports and Physical therapy, some rehabilitation, and some to Courage Kids.
The Courage Kenny Sports & Physical Therapy – website in Richfield states:
“Her pioneering principles of muscle rehabilitation became the foundation of physical therapy. The Institute itself became one of the premier rehabilitation centers in the country, known for its progressive and innovative vision.”
The Modern Olympics
The Panathenaic Stadium, Athens
The revival of the Greek Olympics which previously ran from 776 BC-393 AD when they were banned by Emperor Theodosius was announced in 1894 and commenced in 1896 in Athens.
Since 1994, the Olympic Games have alternated between a summer and winter edition every two years within the four-year period of each Olympiad.
Eighty-Four countries participated in the 2022 Olympics.
Photo Credit: Dmitry-Limonov
The Marathon Boom
1970: The first New York City Marathon took place with 127 entrants and 55 finishers.
2019: (Pre-Covid) it had 54,640 finishers
Photo Credit: Miguel A Amutio
London Marathon
1981:The first London Marathon in 1981 had 20,000 applicants of which 7,747 were accepted.
There were 6,255 finishers out of 7,055 starters
2022: Fast Forward to (post covid) October 2022 when 49,417 runners from 147 countries were selected from 400,00 applications to run the 26.2 mile route around London
There were 40,578 Finishers: of which 23,706 (58.4%) were male and 16872 (41.5%) were female.
In addition to the mass race, there are the elite Men’s and the Women’s races and similarly the elite Men’s and women’s wheelchair races.
As public perceptions changed and marathons, half marathons (12,612 runners competed in London’s 2022 Big Half marathon) and 5k’s became accessible, so did the emergence of brands competing, advertising and sponsoring their products.
The 2022 London Marathon was watched by 4 to 5 million UK viewers and by 196 other countries and is thought to benefit the economy by over £50 million.
London Marathon Medics: Sports Medicine doctors, Physio Therapists and First Aiders
The London Marathon medical team is comprised of 160-170 cardiologists, sports medicine doctors; to deal with soft tissue injuries or joint problems, physiotherapists, and podiatrists.
In addition, the charity St John Ambulance who are the London Marathon's main first aid provider support them with 1500 St John's volunteers.
One in 20 people running the marathon makes contact with the medical support team for one reason or another.
The most common reason is because of blisters or musculoskeletal problems, like a strain or a sprain.
Public Health
We are living healthier and longer, and we are staying active later in life and this has resulted in an upsurge in demand for older people with health conditions that can benefit from physical therapy.
Communication and Discourse
Apparently, the Roman army at its height had the closest thing to a modern army in respect of sanitation, supplies, camp organisation, dispersal of camps ( to contain and isolate the spread of infectious diseases), medical staff on the front line, treating and despatching the wounded back behind the lines to hospitals.
Upon the demise of the Roman Empire which lasted for over a thousand years their military “best practices” died out with it and were forgotten.
It is a fact that throughout history more soldiers have died from infectious diseases such as malaria, dysentery, pneumonia, and typhoid than from injuries sustained in battle.
During the Napoleonic Wars, disease accounted for eight times more deaths among British soldiers than combat wounds and in the American civil war two-thirds of the approximately 660,000 deaths of soldiers were caused by uncontrolled infectious diseases, and epidemics played a major role in halting several major campaigns.
These delays, coming at a crucial point early in the war, prolonged the fighting by as much as 2 years.
Source: National Library of Medicine.
The sheer scale of WW1, WW2, the Polio epidemic, the modern Olympics, and marathon running, were events that crossed all international boundaries and created circumstances that neither society nor governments could ignore, and those that they embraced with fervour.
The successive impact of the experiences of these events and institutions led to massive investment in healthcare facilities, research, and education in the public and private sectors, and government and charitable institutions, and growth in qualified medical personnel.
Sport Rehabilitation today
The Sport Rehabilitation practitioners of today are trained in Sports and Exercise Medicine principles, with an emphasis on the design and implementation of exercise and rehabilitation programmes, and are degree-level graduates.
They have an in-depth knowledge of the clinical human anatomy and understand the neuromusculoskeletal anatomy of the upper limb, lower limb, and trunk.
Patients undergo clinical assessments of neuromusculoskeletal injury throughout the body. The patient’s clinical history is established with a view to gaining a clinical impression of the injury and potential causative factors.
They understand the principles of exercise prescription and the body’s response to exercise in multiple systems allowing them to prescribe exercises that may progress to the more complex and for those with injuries; specific form exercises.
Pain Management during Sports Rehabilitation
They are practitioners of therapeutic techniques in the acute to chronic stages of musculoskeletal injury and pain management and the application of a variety of treatment techniques, including cryo/thermotherapy, soft tissue techniques, electrotherapy, and strapping.
They understand complex pain states and current treatment strategies in the safe application of a variety of advanced treatment techniques, including Compex, hydrotherapy, and kinesiology taping.
Biomechanics
Biomechanics refers to the mechanical principles of how humans move and laboratory techniques to assess biomechanical movement.
Rehabilitation
The rehabilitation is specific to the needs of the injured athlete and the analysis of the science and evidence, leading to the planning and implementation of rehabilitation sessions and therapeutic exercise prescription that is evidence-based and grounded in the fundamental concepts of rehabilitation of musculoskeletal injuries.
So… Is Sports Rehabilitation a new offshoot of medical science?
Back to .....Semmelweis, Pasteur and Lister,
Until the late 1870's it was accepted disease and infection were caused by the process of "Miasma" which was the transmission of disease and infection via foul or noxious air.
Miasma is Greek for Pollution and “malaria” comes from the Italian - mala aria ‘bad air’.
The term was originally used to describe the unwholesome atmosphere caused by the air from marshes, to which the disease was formerly associated.
Mortality rates for surgery rehabilitation were high
Surgeons did not intentionally wash their hands or change clothes between patients and if so, probably to avoid the mess. Disease and infection were communicated readily and there was no such thing as an antiseptic.
Nobody knew about germs, or that specific germs caused specific diseases.
Hippocrates (460 - c 370 BC) posited the miasma theory and Galen some 500 years later further espoused that theory and it did indeed go into the history books which were eventually translated into Latin, Arabic, and English.
Because Hippocrates and Galen made such profound and extensive progress in their respective fields, and provided so much enlightenment, so much of which was right and built upon, it took the better part of 15 centuries before observations, circumstances, and attempts to curtail and prevent disease suggested that Miasma as a theory was suspect, that led to experimentation by the likes of Semmelweis, Pasteur, Koch, and Lister.
The world's first successful vaccine by British physician Dr. Edward Jenner in 1796, for smallpox, evolved from a Chinese practice identified in 1549.
Just as it took major events to accelerate progress in surgery, injury rehabilitation, and sports medicine there were huge lulls in progress for vast tracts of time.