Physical Education, Exercise, Fitness and Sports: Early PM&R Leaders Build a Strong Foundation

Abstract

The popular physical education movement involving exercise and athletic activity to achieve physical fitness was a significant factor in the early development of physical medicine and rehabilitation (PM&R) in the United States (U.S.) Influenced by European gymnastics programs in the late 19th and early 20th centuries, the movement in the U.S. was led by physicians Dudley Sargent, Luther Gullick, and R. Tait McKenzie 1, 2. McKenzie was a physical medicine clinician and teacher whose academic work in exercise physiology was influential in both physical education and medicine 3. His teaching, writing, and leadership during World War I (WWI) influenced other pioneers in physiatry (Figure 1). R. Tait McKenzie, MD. Courtesy of the University of Pennsylvania archives. World War II (WWII) further proved the value of fitness, physical training and restoration of function among the war wounded. Programs led by physiatrists George Deaver (Figure 2) and Howard Rusk promoted the application of rehabilitation principles and practice within the military 4. During WWII, the Baruch Committee, established by financier, philanthropist, and statesman Bernard Baruch, emphasized the relevance of physical fitness in the development of the new field, and funded academic centers of physical medicine led by physiatrists with expertise in exercise and fitness 5. These centers influenced the field of PM&R for decades. The tradition of “exercise is medicine,” pioneered by R. Tait McKenzie, has been endorsed in recent years by the American Medical Association (AMA) and the American College of Sports Medicine (ACSM) 2. Exercise was also the central theme of the 2014 Annual Assembly of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) in San Diego, CA. George Deaver. Available at Images from the History of Medicine (IHM), U.S. National Library of Medicine. Our purpose in this discussion is to demonstrate how involvement in the science and practice of physical education, exercise, and fitness by physical medicine physicians in the first half of the 20th century influenced the future development of PM&R, including the emphasis on the team approach to rehabilitation. The gymnastics movement, historically connected to the growth of the nation state, patriotism, and military preparation, began in Germany and Sweden during the 18th and 19th centuries. The German gymnastics system involved the extensive use of apparatus, such as the vaulting horse, the parallel and horizontal bars, and free weights 6. Swedish physicians Per Henrik Ling and Gustave Zanders led the Swedish gymnastics movement. Their gymnastics programs were noted for the use of exercise to treat impairments and also the systematic approaches to exercise using mechanical devices. Exercises were specific to particular parts of the body, used a method of fixed progression, and involved sports activity such as fencing and swimming 6. Immigration from Europe influenced communities in the U.S. to establish gymnastics and sports programs as early as the 1820s 1. In 1889, Boston philanthropist Mary Hemenway financed a pivotal international conference, chaired by the U.S. Commissioner of Education, William Harris, to evaluate U.S. exercise programs. The conference stimulated the development of physical education and exercise programs in the U.S. throughout the early 20th century 1. Leadership in this development was from physicians and focused on health outcomes 1, 2. The most prominent of these physician pioneers in physical fitness was Dudley Allen Sargent, MD, an 1878 graduate of Yale Medical School. Sargent established a gymnastics program at Bowdoin College in 1869 that used exercise apparatus and focused on “a philosophy of mechanized human development” 7. In 1879, Sargent became Director of the Hemenway Gymnasium at Harvard. His goal was “the healthiest student possible to be realized … by using machine technology… and ergonomics,” and this effort was long before ergonomics was widely promoted 7. Through the use of technology for exercise, accompanied by the precise measurement of heart, lung, vision, and muscular function, Sargent established a scientific basis for exercise programs 7. Through the Sargent School of Physical Education and Harvard summer programs on fitness and exercise, Sargent influenced many leaders in physical education and physical medicine 3. Sargent's student Luther Gullick became Founding Superintendant of the first school of physical education at the International YMCA Training School, Springfield College 1. Extending physical education to sports, Gullick and James Naismith invented the game of basketball at Springfield College in 1891 1. During the 20th century, Springfield College and the YMCA movement influenced physical education, exercise physiology, and future leaders of PM&R: R. Tait McKenzie 3 and George Deaver 4, and, later in the 20th century, William Fowler, AAPM&R President from 1980 to 1981. Early leaders in physical medicine often entered the field because of an interest in physical education and athletics 5. Among those leaders was R. Tait McKenzie, whose role in establishing a scientific basis for exercise in physical education and medicine is well documented by Ditunno and Mason 3, 8. An expert gymnast himself, McKenzie established a gymnastics program at McGill University while pursuing his medical degree 3. After medical school graduation in 1892, McKenzie directed the McGill Gymnasium and conducted a medical practice focused on the application of exercise in the treatment of scoliosis and similar disabling conditions, publishing frequently on these topics 8. At the request of YMCA leader Luther Gullick, McKenzie trained the first 12 directors of the Montreal YMCA 3. In 1904, McKenzie joined the University of Pennsylvania faculty to direct its newly constructed gymnasium. He became a professor of physical education and physical therapy in the medical school and was referred to by Frank Krusen as the “first professor of physical therapy in a medical school in the U.S.” 9. In 1909, he published a classic text, Exercise in Education and Medicine, which influenced the practice of physical medicine in its early years 3, 8. After graduating from Springfield College where he trained in physical education, Deaver attended the University of Pennsylvania Medical School while McKenzie taught there and was likely instructed by him 3, 4. Both pioneered the development of physical education and PM&R while serving in WWI 4, 10. WWI produced carnage on an extraordinary level. Of the 65 million troops mobilized from all countries, 9 million died and 15 million were wounded 11, 12. The war presented both problems and opportunities for physicians: a military force not physically fit for service and large numbers of wounded needing medical care and rehabilitation 13. One-third of the 3 million American men drafted during WWI were estimated to be physically unfit and in need of physical training 2. According to McKenzie, “The sporadic wounds that peaceful life produced have been multiplied in our military hospitals… the exception has become the ordinary; torn and mangled bodies have been patched and remade, the functions lost gradually coaxed back toward the normal” 14. A Canadian citizen, McKenzie volunteered for service in the British Royal Army Medical Corps in 1915 and was assigned to inspect training camps on England's south coast 8. He observed there “many men stationed in the camps of such poor physical condition they could not undertake physical training… and a great number of injured men lingering in camp hospitals for whom physical training would expedite recovery” 8, 15. McKenzie reorganized the training and hospital facilities “to emphasize fitness and restorative therapy to improve function of the wounded and allow them to return to duty” 8, 10. He “substituted health education, physical training and recreational therapy in the place of rest and inactivity” and, from his pilot studies, the program gained acceptance among medical professionals 10. The U.S. entered WWI in 1917. Upon returning to the University of Pennsylvania after his sabbatical ended, McKenzie was summoned by U.S. medical leaders to make his war expertise available to the U.S. military. Physician Colonel Frank Billings, in charge of the Reconstruction Hospitals, and surgeon Harold Mock, his assistant, invited McKenzie to “take charge of physiotherapy to standardize and secure the proper personnel to do that work well” 16. McKenzie's publication, Reclaiming the Maimed: A Handbook on Physical Therapy, became the official physical therapy manual for the United States, Britain, Canada, and France in WWI, and influenced early leaders of PM&R—Deaver as well as John Coulter and Frank Granger 3, 8. Frank Granger served as chief of physiotherapy programs in the U.S. Surgeon General's Office, and visited England to observe the rehabilitation programs established there by McKenzie and renowned orthopedist Sir Robert Jones 17. According to Hansson, John Coulter was assigned to France, where he headed the “first overseas convalescent and rehabilitation center. Here Coulter first became associated with physical therapy and occupational therapy” 18. Granger used schools of physical education for the training of the U.S. “Reconstruction Aides” who provided physical therapy in Reconstruction Hospitals. According to historian Beth Linker, “Such women, they believed, would be more like a drill sergeant who could stretch and manipulate heavy limbs…” 13. Mary McMillan and Marguerite Sanderson, founders of the physical therapy profession in the U.S., were trained in physical education programs at Liverpool University, England, and Boston Normal School of Gymnastics respectively and served in WWI as Reconstruction Aides 19. McMillan served under orthopedist Sir Robert Jones in England during WWI before returning to the U.S. 19. McMillan and Sanderson organized training programs for Reconstruction Aides in the U.S. using physical education programs 19, 20. After WWI, with the support of Granger and Coulter, physical education schools became the foundation for physical therapy education in the U.S. 19. Upon graduation from the University of Pennsylvania Medical School, Deaver volunteered for military service in WWI and was assigned to the British Egyptian Expeditionary Force in Egypt. Finding servicemen in training and convalescent facilities unfit for service as McKenzie had, Deaver established an exercise regimen to make them fit for military duty 4. He also established a physical therapy program for the wounded and was recognized by the International YMCA movement for his “scientific plan for rehabilitating the wounded” in Egypt 4. Medical authorities throughout the armies observed the “remarkable benefit” of the program through which 150,000 men passed 4. In the 1919 Journal of the Society of YMCA, Deaver described his WWI experience with wounded soldiers, recommended active exercise programs supplemented by passive exercise and massage, and advised against bed rest and inactivity 21. McKenzie and Deaver emphasized the importance of sports, games, occupational therapy, and vocational training in the rehabilitation of the war wounded, setting the stage for the establishment of comprehensive medical rehabilitation programs in the 1960s through the 1980s 14, 21. At the end of WWI, physical therapists and physicians who had worked with them during the war desired to ensure a continued supply of well-trained therapists and physicians for service in the civilian sector. To encourage the training of therapists, McMillan and Granger organized at Walter Reed Hospital what became the American Physical Therapy Association (APTA) and founded the Physical Therapy Review, its official journal; McMillan served as the first president 19. Granger and Harvard colleague and orthopedist Joel Goldthwait spoke at the first annual meeting and subsequently continued to assist the association in its research and educational efforts 19. Coulter organized physical therapy education programs and contributed articles to the Physical Therapy Review from 1928 until his death in 1949 19. His articles on standards for hospital physical therapy programs referenced the relevance of physical education schools for the initial training of physical therapists 19. In 1940, the U.S. Surgeon General asked Coulter to assess the need for physical therapists in another war effort, and Coulter responded with a comprehensive assessment of physical therapy needs for both the war effort and civilian health care 17. After WWI, Deaver resumed his physical education career with the YMCA, serving as director of programs and teacher of physical training at YMCA-affiliated George Williams College 4. In 1927, he published texts for the YMCA program directors on treatment of common injuries 4. In 1930, Deaver shifted his career emphasis to medicine and joined Coulter at Northwestern medical school, where both taught in the new physical therapy program 4. In 1932, he became Education Director of the New York University (NYU) physical therapy school and, later, Medical Director of the Institute for the Crippled and Disabled (ICD) in New York 17. While at ICD, Deaver became a leader in the rehabilitation of severely disabled individuals 5 and, with Mary Eleanor Brown, published the classic article on activities of daily living (ADL) measurement, applying his knowledge of fitness and human performance to the lives of persons with disabilities 22. According to Knapp and Kottke 5, “Deaver was the progenitor of medical rehabilitation in that he was the very first to initiate programs for rehabilitating the very severely handicapped.” Like Deaver, Frances Hellebrandt was interested in physical education. Physical exercise and sports were part of a Czech tradition to which she had exposure when she was growing up in Chicago. Hellebrandt pursued an undergraduate education in physical education at the University of Wisconsin–Madison, taught in the anatomy department, and received her medical degree there. After residency training in PM&R at the Mayo Clinic, Hellebrandt joined the faculty of the University of Wisconsin–Madison, where she taught in the women's physical education program, held a faculty position in physiology, and directed the distinguished Laboratory of Exercise Physiology 23 (Figure 3). Hellebrandt became Chair of the Department of PM&R at the Medical College of Virginia in the 1940s, published frequently, and “is perhaps best known for her theory of muscle overload and pacing” 23. Her academic interests in exercise physiology were similar to those of McKenzie, following that field of study several generations later. She collaborated in her research with Peter Karpovich, MD, an exercise physiologist at Springfield College and a founder of the American College of Sports Medicine. Her work in exercise physiology had a substantial influence on the development of PM&R and sports medicine 24. Frances Hellebrandt. Image courtesy of Special Collections and Archives, Tompkins-McCaw Library, Virginia Commonwealth University. During this period, physicians interested in physical education, fitness, and physical therapy applied physical therapy techniques to the treatment of sports injuries, thereby establishing a basis for today's PM&R sports medicine practice. After WWI, McKenzie influenced the field of physical education in the application of exercise and physical training activities to athletes with injuries, and was recognized as a pioneer in sports medicine by leaders of the ACSM and by athletic and sports historians 3, 10, 24, 25. At NYU, Deaver practiced sports medicine and coauthored the text Prevention and Treatment of Athletic Injuries in 1936 4. He and Coulter coauthored an influential article, “Physical Medicine Applied to Athletic Injuries” 4, 25. Frank Krusen, considered the father of physical medicine, served as physician for the Temple University football team and has been referred to as “the first sports medicine physiatrist” 26, 27. In 1935, Krusen recruited Temple University sports medicine colleague and physical therapist Frank Wiechec to head the Mayo Clinic physical therapy department 25, 28. Wiechec became athletic trainer for professional baseball and football teams in Philadelphia from 1948 to 1962, after leaving the Mayo Clinic, and he joined Krusen again at Temple in the 1960s 25. Early in WWII, Howard Rusk, like McKenzie and Deaver in WWI, successfully demonstrated that aggressive rehabilitation using early ambulation, exercise, and physical therapy was vastly superior to passive convalescence 5, 29. Rusk enlisted Deaver to assist him in training military physicians in these rehabilitation techniques 4. In 1948, Ludwig Guttmann, MD, a German neurosurgeon, introduced wheelchair sports as part of the spinal cord rehabilitation program for wounded soldiers at Stoke Mandeville in England. This spinal cord injury program evolved into the Paralympics Games that continue to give opportunities for people with many types of disabilities 30. During WWII, the Harvard Fatigue Laboratory (HFL) produced important research for the military focused on physical fitness under extreme conditions; these studies contributed to the development of the academic discipline of exercise physiology 24, 31, 32. The HFL was established in 1927 to promote interdisciplinary practice, to apply physiologically based techniques, and to work with industry to assess fitness among workers in extreme conditions. The HFL exercise physiology roots were among the early physical education and fitness programs of Harvard, Springfield, and other universities 24, 32. G. Edgar Folk, Jr, a respected researcher at HFL, refers to colleague Robert Darling as one of the most brilliant scientists at the laboratory 31 (Figure 4). Darling was Director of the HFL until 1945, when he joined the Columbia College of Physicians and Surgeons faculty as a renowned cardiovascular researcher and the first chair of the department of rehabilitation medicine. He served as president of the AAPM&R from 1967 to 1968. Robert Darling. During WWII, financier and statesman Bernard Baruch established a committee of medical and scientific experts in 1943 that included Krusen, Rusk, and Coulter, to plan for and invest in the development of the medical specialty of PM&R 5, 17, 26. A subcommittee on physical fitness, chaired by Darling, reflected the importance of physical fitness and exercise physiology to the development of PM&R, and its report, published in the Journal of the American Medical Association, describes the functional and holistic focus of PM&R in its definition of fitness. The report stated, “Physical fitness is the functional capacity to perform a task and encompasses the psychological will to do the task as well as the physical attributes such as cardiovascular, muscular, and nervous system attributes” 33. The report also recommended that all physical examinations include assessments of physical fitness and function especially for persons with disabilities and recommended, where necessary, a prescription identifying specific training or therapy 33. In 1944, the year after its establishment, the Baruch Committee made grants for research and education to implement its recommendations. This historic achievement was the catalyst for the development of PM&R over the next 50 years 5, 26. These grants funded 3 model academic centers at Columbia University, the Medical College of Virginia, and NYU, each directed by an expert in exercise and fitness: Darling, Hellebrandt, and Rusk, respectively 5, 26. Among the more than 50 Baruch fellowships established to provide future leadership to the field were those awarded to Edward Gordon (Figure 5) and Frederick Kottke (Figure 6), both physiatrists trained in physiology who would make future contributions to the development of PM&R and sports medicine 17, 34. Gordon, formerly of the HFL, joined Darling at Columbia, and Kottke joined Krusen at the Mayo Clinic, for fellowship training. Kottke served as president of the AAPM&R from 1978 to 1979. Edward Gordon. Available at Images from the History of Medicine (IHM), U.S. National Library of Medicine. Frederick Kottke. Reprinted from Arch Phys Med Rehabil 2014;95:1991. Sports medicine, with its emphasis on fitness and therapeutic exercise, influenced and pioneered by McKenzie, Deaver, Coulter, and Krusen, has been a major part of the practice of PM&R over recent decades. The Physiatric Association of Sports, Spine, and Occupational Rehabilitation (PASSOR) organization, which existed with its own governance structure within the AAPM&R for approximately 15 years, fostered educational and training programs in sports medicine and successfully advocated for fellowship training and board certification in sports medicine 35. Physiatrists have been active in promoting sports medicine in both the AAPM&R and the ACSM. Increasing numbers of physiatrists are getting involved in treating amateur and professional athletes who have sustained sports concussions. Physiatrists have been very involved nationally and internationally in research and in guideline development, for example contributing to publications such as the International Consensus Statement on Concussion in Sport in the AAPM&R's scientific journal, PM&R, in 2009 36, 37. Of the 321 physicians who took the first brain injury medicine examination and became board certified in 2014, 271 were physiatrists 38. Recreational activity and sports, including the training of elite athletes with disabilities, are now integrated into the rehabilitation of people with disabilities, and physiatrists have provided leadership in these developments 30, 39, 40. In the 1970s, the independent living movement emphasized social integration of persons with disabilities, including participation in sports activity, and gave rise to the disability rights movement's advocacy for access to athletic and fitness activities 17. The enactment of the Americans with Disabilities Act (ADA) represents a milestone in the inclusion of persons with disabilities in all aspects of life activity including sports and recreation. Title III of the ADA requires accessibility for persons with disabilities to recreational and exercise facilities including swimming pools, bowling alleys, golf courses, boating docks, and athletic fields 41. Similarly, the Individuals with Disabilities Education Act of 1990 (IDEA) requires access to physical education programs for students with disabilities 3-21 years of age 41. PM&R embraces health promotion through fitness and exercise for everyone, thus linking its early pioneers to the more recent initiatives endorsed by the AMA and the ACSM in 2007 2, 35. The theme of the 2014 AAPM&R annual meeting was “a focus on function through exercise” and included sessions related to pediatrics, aging, the Paralympics and the theme Exercise Is Medicine™ by the ACSM. The physiatrist of yesterday, today, as well as tomorrow recognizes that exercise is essential to the restoration and maintenance of optimal functioning, and that the science and art of accurate prescription of exercise is fundamental to beneficial outcomes for all people. PM&R leaders in the first half of the 20th century established a foundation from which exercise, fitness, recreational activity, and sports medicine were integrated into the current practice and research of the specialty. Fitness, exercise, and competitive games to restore function and self-esteem became the essential elements for the rehabilitation of individuals disabled during war, and these elements gained the endorsement of medical authorities and public officials during WWI and WWII. Leaders in exercise and fitness during these 2 major wars embraced the team approach as essential to comprehensive rehabilitation and promoted the development of the profession of physical therapy after WWI. The Baruch Committee emphasized the value of fitness and exercise and promoted the development of PM&R by funding the first 3 academic centers focused on PM&R training and research. These centers, led by physiatrists expert in exercise and fitness, became the catalysts for academic expansion of PM&R in the second half of the 20th century. These early PM&R leaders who focused on fitness and exercise also produced metrics of function that evolved into current evidence-based practices, validating the benefit of therapeutic exercise 22, 33. PM&R is indebted to these early leaders in exercise, fitness, and recreational activity for their enduring contributions to the field.