Patients with Complex Needs

In the modern healthcare climate physiotherapists must provide compelling evidence about the value of what they do (Muir 2002). Additionally they must convince policy makers that, with increasing regularity, physiotherapeutic interventions are not only efficacious, but are also efficient, and suitably evidenced through appropriate scientific research (Haines and Donald 1998). The scope of practice of physiotherapy is defined by the Chartered society of Physiotherapy (CSP 2008) as “any activity undertaken by an individual physiotherapist”situated within the four pillars of physiotherapy practice where the individual is educated, trained and competent to perform that activity activities should be linked to existing or emerging occupational and/or practice frameworks acknowledged by the profession” supported by a body of evidence.” In light of this physiotherapists must reason their clinical decision making, deliver practice substantiated through appropriate evidence, and build upon their understanding and proficiency to fulfil the professional responsibilities set out by governing bodies (CSP, 2007a, b; Higgs and Titchen, 1998). Amongst peers, physiotherapists also have to justify why they follow a particular intervention approach or favour one therapeutic modality over another through evidence based practice (EBP) (Kerry et al 2008). Morris (2003) describes EBP as professionally valuable for physiotherapists explaining that it critiques conventional treatment, tests new therapeutic intervention; produces more effective therapists; and promotes an intellectually robust profession. But critics see it differently. For example, Hurley 2000 emphasises that not only are results often framed in overly technical language, but also, evidence gleaned in a research environment cannot always be replicated in a clinical setting. However, Ruth and Santaguida 2004 outline that, for many years, physiotherapists have undertaken clinical research dedicated to improving the effectiveness of rehabilitation interventions and outcome measures. They explain that when evidence-based practice takes into account patient circumstances, patient preferences, and clinical experience, it can add a positive dimension to therapy and improve patient outcomes.

In a document addressing the public regarding their falls guidelines, NICE 2004 stated that “”health professionals and practitioners in the NHS are expected to follow NICE”s clinical guidelines” there will be times when the recommendations won”t be suitable for someone because of his or her specific medical condition, general health, wishes or a combination of these.” This suggests to the public, that guidelines should be adhered to; however, if necessary to address individual needs of patients it is appropriate for health professionals to work outside the scope of the guidelines, utilising differing treatment approaches, as long as they are evidenced based and appropriate.

Falls are a leading cause of accidental death among people aged 65 years and older accounting for considerable morbidity, including fracture, impaired mobility, admission to long-term care facilities, decreased quality of life due to fear of falling and death (Ciaschini et al 2008). (This randomised controlled trial had specific inclusion criteria and addressed a large sample size, which increases its reliability, and makes its results generalisable.)

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The prevention and management of falls in older people was outlined as a key government target in the National Service Framework (NSF) for Older People (DoH 2001). Standard 6 of the NSF aims to reduce the number of falls that result in serious injury and ensure effective treatment and rehabilitation for those who have fallen. A Cochrane review by Gillespie et al 2003 on falls prevention concluded that multidisciplinary, multifactorial, environmental risk factor screening and intervention programs are likely to be beneficial with a falls risk reduction of 20%. Reiterating this Cameron ID et al 2010 suggested that interventions targeting both intrinsic and environmental risk factors for falls can reduce the risk of falls in older people. However, falls prevention programmes that include exercise for the elderly should carefully assess each individual”s suitability (Haines TP et al 2004).

Exposure to six weeks of practice with elderly inpatients revealed the importance of individual intrinsic and extrinsic assessment in relation to the effectiveness of physiotherapeutic treatment and resultant harmonious MDT discharge. Complying with NICE guidelines 21 (2004) patients were given individual multifactorial assessment. From a physiotherapeutic perspective this highlighted key issues regarding gait, balance, mobility, and muscle weakness. In the hospital setting physiotherapists assess older patients” mobility, specifically their ability to move between and maintain postures as required to complete activities of daily living. Regaining functional mobility is often a patient”s primary goal following hospitalisation and is a critical factor in discharge planning. Balance was assessed using the Tinetti Balance Scale. Raîche et al 2000 explain that the Tinetti balance scale shows acceptable characteristics as a screening test for falls; however, it is limited in its effectiveness by a possible ceiling effect as it is not sensitive to geriatric patients who score highly, have demonstrated good balance but continue to fall.

These issues could be offset by including more challenging balance items to avoid the ceiling effect and adding items related to other factors associated with falls. Gait and mobility were assessed using the Elderly Mobility Score. The EMS has good inter-rater reliability which has been demonstrated in mixed populations including inpatients and geriatric inpatients and has been shown to be reliable in its use regardless of the physiotherapists” experience. In hospitalised patients the EMS has been shown to be better able to detect mobility improvements than Barthel Index, justifying its use by physiotherapists in this setting. Smith 1994 also reported higher EMS scores for hospitalised patients who were discharged to home (range 14 – 20 points) compared to those discharged to home with a carer (range 5 – 13 points) or discharged to nursing home (range 0 – 6 points). The scores achieved by patients, in conjunction with the rest of the multifactorial assessment guided treatment plans, and helped formulate short and long term goals targeting discharge destinations.

The annual incidence of falls in elderly patients with dementia is about 70-80% (Shaw et al 2003), at least twice the incidence of falls in cognitively normal older people (Tinetti et al., 1988, Asada et al., 1996). Patients with significant cognitive impairment or dementia have been largely excluded from fall prevention studies; according to Shaw”s 2007 systematic review. Few have studied whether the risk factors for falls differ between people with and without dementia (Van Doorn et al, 2003; Kallin et al 2004). Consequently, there is a need for a deeper understanding of the contributing risk factors for falls among people with dementia (De Carle and Kohn, 2001). Teamwork is associated with better care for elderly people and homebound people experiencing mental illness (Mizrahi & Abramson, 2000)

The most effective health care interventions for complex medical conditions are thought to be delivered by multidisciplinary care teams (Wagner 2000). This team model originates from the belief that a comprehensive therapeutic approach is required to fully address the current health care needs of patients with complex or chronic diseases (Minsky 1998; Kole et al 1999). Dissimilar points of view regarding a patient”s health care needs and goals can lead to inappropriate treatment strategies, can hamper communication, (Neville 1999 et al) and can decrease the patient”s adherence (Gopinath 2000). In order to avoid critical differences between the patient”s and the health care professional”s treatment goals, the goals need to be clarified prior to planning interventions (Suarez 2001 et al). Patient centred practice is thought therefore (Stewart et al 2000) to improve health status and increase the efficiency of care delivered by health care professionals.

There is a constant demand to communicate judgements in a logical, coherent manner. Feyerabend 1993 communicated the point that physiotherapists have a choice between numerous competing theories regarding intervention, and it is within their professional and clinical judgement to choose between them, so long as they are reasoned in a suitably advanced and sensible way. He alleged that all ideas had the potential to expand knowledge, even those that did not fit in with current thought.