Chapter 8 Learning Disabilities
Introduction
• The basis of any intervention when dealing with a person with learning disabilities (LD) is no different from any other physiotherapy intervention, but a different set of skills will need to be developed so as to make the interventions accessible, appropriate for the needs of the individual and enjoyable.
• Failure to ensure this happens may lead to the individual becoming non-compliant, resulting in a poor outcome to treatment interventions.
Treatment planning based on assessment findings
• The assessment as covered in the assessment volume will define the physiotherapy intervention.
• The interventions must be person-centred to meet the individual’s needs.
• As described by Barrell (2007), often the identified therapeutic intervention is not appropriate or not acceptable to the person with a LD, e.g. a client may wish to walk without pain and without a walking aid.
• They may not be happy or are unable to follow a specific exercise programme.
• Alternative options will then have to be devised to involve participation of the individual, in order to ensure that they undertake the necessary exercises.
• These options may include Jabadao, aquatic physiotherapy, or suitable leisure activities adapted to meet the needs of the client.
• In addition Barrell (2007) also highlights that the needs of parent carers, carers and support staff must also be considered.
• People with LD are often semidependent or totally dependent on their carers.
• There may be differing opinions between carers concerning perceived needs of the individual and success in delivering treatment is dependent on good communication and understanding of what is required between all involved.
• Assessment results and intervention plans need to be very clearly identified, discussed and communicated between the multidisciplinary team (MDT), the client and carers.
• Interventions tend to be based on exercise that will enhance movement and the client’s functional ability.
Types of interventions
• The type of interventions given by the physiotherapist can be divided into the following categories:
• The following will describe interventions that are commonly implemented in LD service, taking into account the specific needs of each person with a LD and providing practical tips.
• It may be that the person with LD needs information about or access to community activities such as appropriate gym classes, swimming clubs, walking groups, riding for the disabled, or wheelchair dancing.
Complex handling assessment
• Manual handling is defined as ‘transporting or supporting a load (including lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force’ (HSE 2004).
• To the HSE definition may be added guiding, facilitating, manipulating or providing resistance.
• Thus any treatment where force is applied through any part of the physiotherapist’s body to any part of the patient, involves manual handling.
• Physiotherapists are often considered the experts in manual handling and as such are often asked to advise on safer handling for an individual.
• However ‘Physiotherapists cannot dictate to another profession how to handle a patient.’ (CSP 2008), but as the health care professional with the knowledge of the individual’s physical presentation the physiotherapist may be best placed to contribute to the risk assessment and to the development of a handling plan for an individual.
• Manual handling techniques as taught in the majority of training situations and described in most of the literature cover a generic handling approach for care staff. Individuals who present with challenging behaviour either physically or behaviourally are a relatively small population and their handling needs may differ from those of the general population.
• Physical challenges may include:
• Behavioural challenges may include:
• Many individuals with a learning difficulty present with a combination of both physical and behavioural challenges. Therefore manual handling advisors, physiotherapists and carers may find themselves with a conundrum to solve, i.e. as the handling needs will generally not be met through a conventional approach, in order to meet the individual’s needs appropriately and maintain the safe involvement of all parties involved, there will need to be careful planning of the processes and use of equipment.
Consent
• In relation to any physical intervention, which includes manual handling, individuals have the right to be consulted and involved in the formulation of any ‘treatment’ and/or care plans that directly affect them.
• If an individual is unable to give consent regarding their handling plans, as in any other situation, a solution must be in their best interests and documented as such, following a multiprofessional discussion.
• A physiotherapist is often called upon in these situations for their advice and recommendations.
Risk assessment
• The law is clear on the duty of employers to fully assess all risks to their employees in relation to manual handling, where there is the risk of injury; and where there is the possibility of violence or aggression directed towards staff, other clients or any other persons.
• Many individuals who present challenges resulting in complex manual handling situations may also present risks of injury through violence or aggression. Therefore, these clients require greater in-depth risk assessment and detailed management plans in order to reduce the risks to the lowest reasonably practicable level.
• Balanced risk assessment and management plans need to take the human rights of the individual as well as the safety and human rights of the health care staff or carers into account. It is not always possible to have one handling solution that will meet all of the individual’s transfer needs. Each transfer situation must be assessed separately with all relevant risk factors taken into account.
• The individual should be involved, where possible, in the devising of safer handling management plans.
• In addition any plans should be devised on a multiprofessional basis, including the care staff who often have the best knowledge of the individual and their behaviours in specific circumstances.
• The risk assessment process should follow the guidelines defined in the Manual Handling Operations Regulations 1992 and subsequent Health and Safety Executive Guidance (HSE 2004). The risk assessment will need to consider risk factors in relation to: the task, the individual capability of the carer(s) carrying out the handling task, the load (individual) and all environmental factors.
• With individuals who present with challenging behaviours, there may be triggers in the environment which could affect their behaviour and influence the handling situation. These must be incorporated into the assessment of the environment along with the other factors such as the height of surfaces or lighting of the area.
Additional risk situations associated with complex handling
• There are often situations where an individual may have to be moved in what would be considered emergency situations in other contexts.
• Plans need to be considered and put into place to manage such foreseeable risks as they often occur in unforeseen circumstances.
• Such situations may include:
• These examples are not exhaustive, but merely serve as examples to emphasise where so-called ‘general safer handling guidelines’ cannot be applied.
• With complex handling situations, it may not always be possible to reduce environmental or handling risks with the provision of suitable equipment. By introducing equipment other situational risks may be presented. Therefore, alternative methods for managing the situation in the safest manner have to be found.
• The ideal posture and position for performing a particular task may not be possible to achieve, as this could place the carer in a position where they could be the recipient of physical aggression. Therefore, alternative postures and positions may have to be adopted in order to maintain carer safety.
• In such situations, the risk assessor needs to have an in-depth understanding of the presenting behaviours (both physical and behavioural) of the individual, the ‘culture’ of the organisation and carers undertaking the day-to-day care of the individual and a range of possible solutions to the presenting problems.
• Where individuals pose an additional risk to handlers through challenging behaviours, the behaviours of concern need to be highlighted, including who might be at risk and how. Additionally a record must be made of the details of triggers and situations that are likely to lead to such behaviours being displayed, the probability of such an occurrence, followed by the stages of intervention in the event of such an episode.
• Complex handling plans should only be put in place having been devised around specific individuals in specific situations.
• They should never be used as generic plans to cover all individuals in any situation. It is essential that any carers that are likely to be involved in carrying out the plan are individually assessed for their suitability in carrying out the plan and receive specific training in the techniques required with regular updates.
Recording complex handling plans
• Any safer handling management plan must be documented and be available for all parties involved to read and understand. It is also important that the process through which the decision was arrived at is documented, so that all carers reading the plan are aware of the potential risks involved.
• Recording personal information regarding the ability of carers to carry out the handling task needs to be recorded in individual staff files. This information is confidential and as such should not be recorded on a client’s management plan. It is important that staff make their line manager aware of any physical condition that could affect their ability to carry out a safer handling plan.
• A complex manual handling risk management plan must include additional information over and above that which is usually recorded in a handling plan, for example:
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