Working it out

An exercise revolution

Exercise has stood as a cornerstone of physiotherapy practice throughout the profession’s history. It is deeply embedded in our heritage and remains a constant in ‘what we do’.  

During World War I, the pivotal role of exercise in physiotherapy became especially apparent. Large numbers of injured soldiers needed functional rehabilitation to return to the frontline or get back into work. Physiotherapists stepped up to the challenge, delivering individualised exercise-based rehabilitation programmes to restore physical capabilities and enhance quality of life.

This marked a turning point for the profession, highlighting our valuable role within society and paving the way for physiotherapy to not only occupy, but dominate, the field of exercise in healthcare for years to come.  

The physiotherapy profession was in the enviable position of being recognised as the most respected provider of exercise and rehabilitation for decades. Exercise is detailed within the CSP Royal Charter1, both when granted in 1920 under the term ‘medical gymnastics’ (essentially meaning ‘therapeutic exercise’) and more recently when updated to reflect current practice as ‘exercise, movement and rehabilitation’. 

Alongside this we are a statutory regulated, graduate-entry profession with a successful history of autonomous practice and adaptability across many sectors of health and care. This has brought the profession a degree of privilege and power that we must acknowledge, including public respect, recognition and opportunities for advancement2.     

Evolution

Physiotherapy, like many healthcare professions, is subject to continual change driven by various factors such as government policy, advances in medical technology, shifting demographics and evolving population needs. As a result, our professional identity – who we are and what we do – has constantly needed to adapt. 

We have used the opportunities created by change to extend our boundaries of practice. Injection therapy, first contact practice and prescribing are all great examples of this, taking strides to progress physiotherapy forwards as part of the CSP’s professional project. 

But what about exercise? Despite being the most evidence-based area of physiotherapy practice and firmly rooted within multiple clinical practice guidelines, have we devoted equivalent effort and attention to how we evolve within exercise and rehabilitation? 

Or have we been complacent, possibly taking our strong heritage and historical dominance for granted as we strive for shiny new tools with perceived higher status? 

In recent years, there has been an emergence of other exercise professions establishing their presence within healthcare. What does this mean for the future of exercise within physiotherapy? And how do we position ourselves well to ensure we remain leaders in this space?

Current and future challenges

The UK’s population is becoming older, and this trend is set to continue. It is projected that by 2041, there will be over 20 million people aged 65 and over, making up 26 per cent of the total population³. 

With longer life expectancy comes rising rates of chronic disease, multi-morbidity and complexity, and reduced levels of physical activity and independence. 

Alongside these demographic changes, healthcare funding constraints, increased demands on clinical services, unmet needs within the community, and substantial workforce shortages further compound the challenge. 

Meeting the UK population’s exercise and rehabilitation needs under these circumstances will be exceptionally demanding, if even possible, without thinking differently and adopting inclusive approaches.  

Luckily for us, physiotherapists are no strangers to innovation and adaptability. With our strong foundation in exercise and rehabilitation, some may say that we are perfectly placed to take advantage of the evolving nature of healthcare and to play a pivotal role in providing solutions.

Looking forward

The first thing we must do, hard as it may be, is acknowledge that physiotherapy does not have exclusive ownership of exercise in healthcare. Exercise stands as a vital component in promoting health and functional independence that transcends any single profession’s realm. 

This may represent a shift in perspective for some, challenging elements of professional identity and worth. To be clear, this does not mean physiotherapy ‘letting go’ of exercise. Far from it. It refers to working together, across professions, to address population needs with a shared purpose. 

The CSP’s ‘Collaborate, don’t compete’ project showcases how working together can improve patient-centred outcomes and efficiencies with innovative examples from practice ^6,7.    

We should seize the opportunity that this turbulence brings, by looking critically at ourselves and generating creative solutions for our future.

Let’s consider physiotherapy education and exercise. Upon entering the workforce, many physiotherapists report feeling unprepared to prescribe exercise^8,9. 

Various factors may contribute to this sentiment, such as limited practical experience, insufficient exposure to diverse patient cases with individual needs, and a fear of making mistakes or self-doubt.

In a recent policy statement aimed towards promoting the role of physiotherapists as global experts in exercise and activity, World Physiotherapy advocates for the integration of exercise prescription and promotion within the curriculum of all entry-level programmes¹⁰. 

However, an analysis of a limited sample of UK pre-registration programmes found that just over 60 per cent include dedicated exercise prescription modules. While content may be addressed within other modules, such as behaviour change or population health, this raises the question, is there is a need for greater emphasis on exercise prescription in physiotherapy education? 

Similarly, this question extends to post-registration education, where rehabilitation and exercise often receive less attention due to limited career progression opportunities and remuneration. Advanced clinical practice, for example, regularly focuses on master’s level study to develop multi-professional diagnostic and triage skills. How many programmes dedicate modules to exercise and rehabilitation? 

Does this need to change?   

Should we also consider if we need a shift of focus for exercise in the context of contemporary healthcare? Whereas in the 1900s, the profession’s rehab model worked by focussing on returning people to function after an injury, a large proportion of healthcare today is about holistic care with individuals as the experts of their own illness, complexity, population health and living with long-term conditions that cannot be cured. 

Here the role of exercise extends beyond traditional rehabilitation, diagnosis, and treatment and becomes more of a tool for health promotion, enhancing quality of life, and preventing disease progression. While this shift is encouraged globally^10,11, it also sparks questions about the future trajectory of the profession. 

Given the unprecedented levels of unmet rehabilitation demand, how could the profession accommodate this shift? Where would the workforce come from? What system-level changes would be needed?

We must take action to position exercise effectively within the profession for the generations of physiotherapists that will follow. It is crucial that we preserve the strengths of our past to help shape the profession for the future. 

As a well-respected and growing profession, with a rich history, public and professional trust, developed skills in the management of co-morbidity across body systems, excellence in communication and shared decision making, expertise in exercise and rehabilitation across multiple populations, and holistic care at our core, we are more than well-equipped to lead the way (with a little help from our exercise professional friends). 

Let’s keep this conversation going – this is the start of a series of articles to engage members in topical debates regarding the future of exercise and collaboration in physiotherapy.