Physical Therapy

Massage, gymnastics and mechanotherapy in the 19th century

A history of the Netherlands describes mechanotherapy, which historically included exercises, manipulations and massage, as introduced there around 1840 and as a core element of physical medicine by the end of the century. Most of the people delivering it were physical education teachers known as heilgymnasts, and few physicians were active in the field until the 1880s. Later in the century, physicians specializing in physical medicine and orthopedics began to claim the field for themselves, which produced tensions with the heilgymnasts. Only the abstract of this article was available for this draft.

In the United Kingdom, the Chartered Society of Physiotherapy (CSP) dates its own origin to 1894, when four nurses founded the Society of Trained Masseuses. The CSP's history page says they wished to protect their profession after press stories warned the public about unscrupulous people offering massage as a euphemism for other services. The society became the Incorporated Society of Trained Masseuses in 1900.

Charters, renaming and international bodies

According to the CSP, it received a Royal Charter on 11 June 1920 under the name Chartered Society of Massage and Medical Gymnastics, and men were permitted to join in the same year. It adopted its present name in 1944, was a founding member of the World Confederation of Physical Therapy in 1951, and organized that body's first congress in London in 1953. These dates come from the society's own account.

Reconstruction aides and the United States profession

A 2021 historical article in the journal Physical Therapy states that Mary McMillan received an honorable discharge in 1920 as the first physical therapy reconstruction aide sworn into the US Medical Corps, and that she became first president of the American Physiotherapy Association, later the American Physical Therapy Association (APTA). The author describes the first generation of physical therapists as known for orthopedic aftercare using massage, exercise, electrotherapy and hydrotherapy.

The same author argues that McMillan and other founders probably emphasized wartime achievements to legitimize the field, especially to male physicians, and to set it apart from nursing. The sources reviewed cover the United Kingdom, the Netherlands and the United States, and they do not describe the development of the profession in other regions.

Physical therapy and physiotherapy

World Physiotherapy, formerly the World Confederation for Physical Therapy, uses the terms physical therapy and physical therapist in its 2019 policy statement and describes physical therapy as a single profession across countries. It says national associations define the profession's roles for their own health systems, so scope of practice is set locally. The UK society uses physiotherapy, and the US association uses physical therapist, and the sources treat these as the same profession under different national names.

Older and related labels

Earlier names reflect the methods used. The UK society was first the Society of Trained Masseuses and later the Society of Massage and Medical Gymnastics, and the Dutch history uses mechanotherapy and heilgymnastics. That history defines physical medicine more broadly, to include hydrotherapy, balneotherapy, electrotherapy, light therapy and thermotherapy. APTA also describes physical therapist assistants, who may carry out a treatment plan set by a physical therapist.

A Cochrane review of stroke rehabilitation notes that some physiotherapists base treatment on a single named approach, such as those classed as orthopedic, neurophysiological or motor learning, while others mix components. The review's authors concluded that no named approach was more effective than another, so a label does not by itself indicate what a session contains.

Examination, planning and review

World Physiotherapy's statement says physical therapists are qualified and professionally required to carry out a comprehensive examination, make clinical judgments, formulate a diagnosis, prognosis and plan, refer to another professional when needed, deliver an intervention programme and education in agreement with the patient, re-evaluate outcomes and recommend self-management. APTA similarly describes examining each patient, developing a plan, monitoring and adjusting it, and then discharging the person or moving to the next phase.

Interventions described in the literature

A 2024 scoping review of adverse events in physiotherapy grouped practice into streams. Musculoskeletal physiotherapy involved manual therapy, exercise and electrotherapy. Cardiorespiratory physiotherapy involved early mobilization, exercise and airway clearance. Neurological physiotherapy involved gait and balance training, and other studies involved exercise, lymphedema management and pelvic floor muscle training.

NICE guidelines on low back pain and osteoarthritis assess exercise programs, manual therapy (manipulation, mobilization and soft tissue techniques) and electrotherapies such as ultrasound and TENS (transcutaneous electrical nerve stimulation). A guideline's inclusion of an intervention does not show that it is delivered by physical therapists in every setting.

Settings and access

APTA lists hospitals, outpatient clinics, homes, schools, sports and fitness facilities, workplaces and nursing homes as settings. World Physiotherapy says physical therapists work as independent practitioners and as members of teams, and that they can act as first contact practitioners whom patients may approach without referral. Access rules differ by country and are not covered here. The sources reviewed do not report typical session length or visit frequency.

Scope as described by professional bodies

World Physiotherapy describes physical therapy as services to develop, maintain and restore movement and functional ability throughout life where movement is threatened by ageing, injury, pain, disease, disorders or environmental factors, across promotion, prevention, treatment and rehabilitation. APTA states that physical therapists help patients avoid surgery and prescription drugs, maximize mobility, manage pain and chronic conditions and prevent future problems. These are statements by professional bodies and are not evidence of effect.

Conditions covered by the sources reviewed

Systematic reviews and guidelines reviewed for this page address chronic low back pain, knee and hip osteoarthritis, recovery of function after stroke, symptomatic osteoporotic vertebral fracture and chronic pain across several conditions. Findings for one condition cannot be carried to another.

This page does not evaluate rehabilitation after joint surgery, sports injuries, tendon problems, nerve entrapment, balance disorders or pelvic floor conditions as uses, because no source reviewed here assessed them as outcomes. The absence of a review here does not mean the uses lack evidence.

Exercise for chronic low back pain

A 2021 Cochrane review of exercise for chronic non-specific low back pain included 249 randomized trials, with searches to April 2018. It found moderate-certainty evidence that exercise reduced pain compared with no treatment, usual care or placebo at the earliest follow-up (mean difference -15.2 on a 0 to 100 scale, 95% confidence interval -18.3 to -12.2), which met the review's threshold for a clinically important difference. The functional limitation difference (-6.8) did not meet its threshold.

Against other conservative treatments the differences were small (pain -9.1, function -4.1) and below the review's thresholds. Exercise was probably more effective than education alone and showed no difference from manual therapy. Most trials (79%) were at risk of performance bias, as exercise cannot be blinded.

What the NICE low back pain guideline recommends

The NICE guideline NG59, last updated on 29 July 2026, says to consider a group exercise program for a specific episode or flare-up of low back pain, and manual therapy only as part of a package that includes exercise. It advises against offering traction, ultrasound, TENS, interferential therapy or acupuncture.

Exercise for osteoarthritis

A 2015 Cochrane review of land-based exercise for knee osteoarthritis drew on 54 trials. High-quality evidence from 44 trials (3,537 participants) showed reduced pain after treatment, about 12 points on a 0 to 100 scale, and moderate-quality evidence showed improved physical function, about 10 points. Effects were smaller at two to six months, about 6 points for pain. Most participants knew their treatment.

NICE guideline NG226 (2022) says to offer therapeutic exercise to everyone with osteoarthritis and to consider supervised sessions. It says to consider manual therapy only alongside exercise, and not to offer TENS, ultrasound, interferential therapy or laser, citing insufficient evidence of benefit.

Stroke recovery and vertebral fracture

A Cochrane review of physical rehabilitation after stroke included 96 trials with 10,401 participants, described as heterogeneous and often poorly reported. Rehabilitation was beneficial compared with no treatment for independence in daily activities (27 studies, standardized mean difference 0.78, 95% confidence interval 0.58 to 0.97), persisting beyond the intervention period in nine studies.

Findings are mixed. In the PROVE trial, 615 people with symptomatic osteoporotic vertebral fracture received seven sessions of exercise or manual physiotherapy or a single one-hour session. At 12 months neither course showed significant benefit over the single session on quality of life or muscle endurance, and neither was cost-effective at 20,000 pounds per quality-adjusted life year.

Limits of the evidence

An overview of 21 Cochrane reviews of exercise for chronic pain (381 studies, 37,143 participants) judged the evidence low in quality, mainly because trials were small and follow-up rarely went beyond three to six months, with small to moderate, inconsistent effects. Evidence for exercise is not evidence for every technique a physical therapist may use.

Harms reported in trials of exercise

In the 2021 low back pain review, 86 studies reported adverse effects. One or more occurred in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). In the 12 studies that measured adverse effects systematically, the median was 0.14 per participant in exercise groups, mostly minor harms such as muscle soreness, against 0.12 in comparison groups.

The knee osteoarthritis review found eight studies reporting adverse events, all of them increased knee or low back pain attributed to the exercise, and no serious adverse event. The chronic pain overview found that only 25% of included studies reported adverse events and that most were soreness or muscle pain. Under-reporting means that rare harms may be missed.

Harms in other areas of practice

The 2024 scoping review of 58 studies reported increased pain and stiffness in musculoskeletal physiotherapy, desaturation and hemodynamic instability in cardiorespiratory work, falls and fatigue in neurological gait and balance training, increased pain and muscle strain in oncology and aged care exercise, and vaginal discomfort with pelvic floor muscle training. It maps events and does not estimate how often they occur. Its authors suggest increased monitoring and proactive safety measures may be needed.

The PROVE trial reported no treatment-related serious adverse events. NICE tells clinicians to advise people with osteoarthritis that joint pain may increase when exercise begins. No source reviewed here lists formal contraindications for physical therapy as a whole.

Training and care boundaries

APTA says that in the United States a physical therapist completes a Doctor of Physical Therapy degree from a program accredited by the Commission on Accreditation in Physical Therapy Education, typically over three years, with about 23% of the curriculum in clinical education. World Physiotherapy says entry-level education varies by country but that the first professional qualification in any country qualifies a person to use the professional title. Legal requirements to practice differ by jurisdiction and are not covered here.

The World Physiotherapy statement expects physical therapists to refer people to another professional when needed. Physical therapy does not replace medical assessment, and new or worsening numbness, weakness or severe pain are reasons to seek assessment. This information is educational and is not individualized medical advice.