Welcome to Community Physiotherapy Learning Disability Team Sally Spiller, Nelly Pavel, Antonio Garcia
The modernisation of the physiotherapy team. 1. Historical practice 2. How do we change? 3. Over view of physiotherapy referrals. 4. Current evidence base and guidelines 5. Developing a 24/7 postural care pathway 6. Future focus 7. Lesson s learnt!!
Historical Practice Wide unrealistic service provision A culture of physio will do it. Over complicating warm water swims with extensive programs for care staff to carry out but the basics being neglected. Lacked capacity for effective treatment blocks. Poor links with mainstream services. Low profile within our own Multidisciplinary team (MDT). Kept large caseloads and didn t discharge.
How do we change? Where to start!! Need to prioritise the service take an over view of physiotherapy referrals. What is our unique selling point? What can other services/ professionals do? Modernise Where is the research taking us?
Over view of physiotherapy referrals Service Users who are Independently Mobile (with/out Walking aid). Individuals with Acute or Musculoskeletal (MSK) Physiotherapy needs. Education/ training & Up-skilling of Care Providers Wheelchair Users with some Functional Ability Totally Dependent Individuals Profound and Multiply learning disability (PMLD). Supporting picture
Current evidence base Fulford and Brown (1976) first recognised that Body distortion was caused by the effects of gravity and can be prevented. Decades later premature death has been linked to failure to protect body shape. (Death by indifference 2007, Health care for all 2008, WHO better heath, better lives 2010, LeDer 2015).
Current evidence base Tardieu (1988) found that the soleus muscle needed to be stretch for 6 hours a day to prevent contracture. This has now been incorporated into the NICE guidelines encouraging sustained stretch through position or splinting. http://www.csp.org.uk/documents/nice-guidelines-management-spasticity-2012 Hence the adoption of the 24/7 postural management approach.
24/7? Food for Thought 5110 hours V 3400 hours Uncontrolled V Controlled If someone is lying on the settee for 5 hours per day 5 x 365 days = 1825 per year If someone has Physio/ stretching/ individual programme 1 hour per day at centre 1 x 340 days = 340 hours per year If someone is in bed in various positions but not controlled (i.e. not optimum position) 9 hours per night 9 x 365 days = 3285 hours per year Rest of time in supported seating 9 hours per day 9 x 340 days = 3060 hours
What is 24/7 postural management? A way of preserving and re-estabilishing body shape for people with movement difficulties Janet Robertson et al 2016. Assessment Interventions Education and Training Transition Role
How to achieve 24/7 postural management? Assessment Initial physiotherapy assessment Mansfield checklist Measurements clinics: Anatomical Measuring Index (AMI) validated outcome measure Rio paper work (MCA, BI, My PLAN, FACE LD) Safety Checklists considerations Health and social care considerations Plan, SMART goals
How to achieve 24/7postural management? Interventions Day and night time positioning Sleep system Wedges and other daytime positioning equipment to facilitate functional activity Standing frames Seating Orthotics, Splinting Specific Treatment Blocks for specific interventions: rebound, hydro, bobath,
24/7 EQUIPMENT PRESCRIBED Supine stabiliser Wedge Footrest Mesh Brackets Standing frame. And so on.
How to achieve 24/7postural management? Education and training 24/7 Postural management awareness sessions for: carers, family, inpatient hospital staff, day centre staff, commissioners Level one training Train the Trainer Simple staff works: key links LD Physiotherapy Team ongoing training
Brief Case example: Client age Prone sleeping +++ short hamstrings, knee contractures Scoliosis Prone sleeping for many years Unsettled at timed difficult to establish why CCD s to address shortening hamstrings; hydro leisure Aim to achieve optimum supine sleeping position
Optimum lying positions:
Postural Management Time Line 12/12 on
Aquatic Physiotherapy Care Pathway Physiotherapy assessment after allocation (See Note1) Referral to CLDT Physiotherapy referral allocation meeting and wait list prioritization meeting/discussion Physiotherapy referral discussed at Intake and External/Internal referral - accepted Clear need/clinical reasoning for Rx See note3 If limited land based treatments options Consider Aquatic physiotherapy Further Rx Ax Needs met by other pathway (Note3) Ax- GP Consent (See note 6) Risk assessment Rio( Note7) Aquatic Physiotherapy need identified YES No (Note5): Matrix: 1C+2C+3(B+C Matrix Discharge/ Recommendations Aquatic Physiotherapy assessment (Note 4) Sessions / aquatic program carried out by others with specific training (physiotherapy supervision) Aquatic physiotherapy with Physiotherapist +/- AP (See note 8) Complete aquatic physiotherapy program + care aims + OM (Note: 9 ) 6-10 sessions Education leaflet, Competency tool
Reflection lesson learned so far Importance of: Networking benchmarking Local and nationwide peer support Time to change cultures Multitasking /Juggling skills Resilience client focus Headspace / time to reflect and think More training needed Oxford PM Domino effect of service development in one areas
Future focus: Oxford postural management approach Measurement clinics and reviews Immediate and ongoing focus on waiting list Completing pathways and service specification. Bench marking with other established LD physiotherapy services Adjunct therapeutic practices: hydrotherapy, rebound
Questions, Suggestions Contributions,
REFERENCES: Association of Chartered Physiotherapists for People with a Learning Disability. (2017). Learning Disability Physiotherapy. Available at http://acppld.csp.org.uk/learning-disabilitiesphysiotherapy Department of Health. (2001). Valuing people: A New Strategy for Learning Disability for the 21st Century. Goldsmith, L., Goldsmith, J., Clayton, S., Mears, P. & Waugh, A. (2015). Postural Care: Protecting Body Shape. Staffordshire: Simple stuff Works Limited. Mencap. (2016). Postural care: protecting and restoring body shape. London. Available at https://www.mencap.org.uk/sites/default/files/2016-11/postural%20care%20presentation.pdf Simple Stuff Works. (2017). Our Products. Staffordshire: Simple stuff Works Limited.
REFERENCES: http://www.csp.org.uk/documents/niceguidelines-management-spasticity-2012 (http://www.nice.org.uk/nicemedia/live/13803/60 023/60023.pdf)Page 69. Richardson C, Jull G, Hodges P, Hides J, (1999) Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain, Churchill Livingstone Myers Thomas W (2001) Anatomy Trains Myofascial Meridians for Manual and Movement Therapists, Churchill Livingstone