Chapter 9 Medicine
Introduction
• For the student or novice physiotherapist commencing work on a medicine ward they may be wondering ‘what conditions will I see?’ and ‘what is the treatment approach I will be expected to follow?’
• There is no ‘recipe’ book of treatments that covers every diagnosis or presentation encountered on an acute medical ward and the specific treatment interventions. The aim of this chapter is to indicate the types of assessment approaches that may be used and how these enable the therapist to choose the appropriate interventions.
• The authors anticipate providing the reader with an insight into the role of the physiotherapist in the medical management of patients, the hospital multidisciplinary team (MDT), professional documentation, discharge planning and on-going referral.
• By understanding the role of physiotherapy within acute medicine the reader will be able to make their own conclusions about what working in medicine as a physiotherapist entails.
Admission to an acute medicine ward
• The reasons for admission to a medical ward are varied with each patient’s presentation having associated medical issues. Each patient seen by a physiotherapist on a medical ward will be different and will need to be approached as an individual.
• Even a similar diagnosis will not guarantee that a patient will present in the same way and this will mean that they will require a different approach from the MDT and the physiotherapist.
• The diagnosis may not necessarily directly influence or dictate physiotherapy intervention; however, it is important in relation to an individual’s prognosis in terms of the course of the condition, life expectancy, possible fatigue, impact cognition, physical ability. All these factors could then influence the decisions to be made regarding the rehabilitation potential or discharge destination, e.g. home, residential or nursing home.
• The variation of presentations/diagnoses to be encountered should not be viewed as a daunting or intimidating prospect, if the physiotherapist has confidence in the assessment findings and reasoning associated with this.
Assessment and goal planning
• The most fundamental thing to remember above everything else is that the assessment should, and needs to, identify the problems that physiotherapy treatment intervention can where possible, work towards resolving or reducing them.
• Equally important is ensuring that the assessment findings and subsequent treatment intervention are defined as a result of patient-related goal planning, which includes inclusion within an MDT framework.
• Talking to some patients about goal planning and it may be difficult to engage them. However, talking about what they feel they need to achieve in order to return home may stimulate a different and far more enthusiastic response.
• It may seem obvious, but it is worth emphasising that both the physiotherapy and the overall MDT intervention goals should be focused on the patients’ needs as defined by them, rather than what ‘we’ as professionals consider should be the outcomes.
Patient demographics
• The type of patient being admitted to an acute medical ward has changed significantly over the years, not surprising if the changes in population demographics are considered.
• The UK has a population that has been aging over the last 25 years, with the percentage of the population aged 65 and over increasing from 15% in 1984 to 16% in 2009, an increase of 1.7 million people.
• The most potentially influential statistic is that the fastest population increase has been in the number of people aged 85 and over, the ‘oldest old’.
• In 1984, there were around 660 000 people in the UK aged 85 and over. The total number has more than doubled, reaching 1.4 million in 2009.
• By 2034 it is projected that the number of people aged 85 and over will be 2.5 times larger than in 2009, reaching an estimated 3.5 million and accounting for 5 per cent of the total population (ONS 2010).
• Considering these significant demographic changes it is suggested that more services will be required within the local health community to manage the associated health needs of this population.
• The way in which these services are delivered will continue to change as more patients are managed in primary care settings rather than the secondary care that is commonplace in present day service delivery.
Profile of patients on medicine wards
• Physiotherapists working on a medical ward are likely to encounter patients with complex medical, physical, social and emotional needs that can no longer be managed safely and effectively within the community resources.
• Patients admitted to hospital from the community require a co-ordinated MDT assessment in order to ensure that they and their family/carers have a realistic plan for the future.
Preadmission status
• Ascertaining the pre-admission status and function of patients is essential for the physiotherapist in order to formulate appropriate, meaningful and realistic problem lists, treatment plans and goals with the patient (where possible).
• Above all else this information is fundamental to safe and successful discharge planning.
• The patient’s preadmission functional status can be acquired from a variety of sources, e.g. medical and nursing notes (if separate) may have some information regarding an individual’s social history.
• The physiotherapist and OT will require a greater depth of information than that provided by the medical and nursing records. This information must be obtained either directly from the patient, or next of kin/family or carers.
• If the patient has been admitted from a residential or nursing home it is useful to contact the establishment as they can provide valuable information.
• This may be particularly important as some residential/nursing homes may not accept the patient back as a resident unless they have regained their pre-admission status.
• The specific areas of preadmission function that need to be ascertained are:
• Along with the gathering the previous information it is also essential to record if there are any concerns or difficulties with any of the activities and establishing why these difficulties are occurring.
• One of the most important pieces of information to substantiate is whether the patient has experienced any falls and what the circumstances were.
• Wherever possible a ward physiotherapist would be aiming to assist a patient back to their preadmission levels of function, as in some cases independence is solely compromised by an acute illness.
• A number of NHS hospitals have developed acute medical wards and rehabilitation ward/beds where patients who no longer require acute medical care may be transferred. Physiotherapy and MDT colleagues will require a handover including a copy of the professional documentation completed up to this stage of the patient’s admission.
• It is important to identify if a patient is having a decline in their functional ability which may become evident during the subjective assessment or from information gathered during previous admissions.
• It is then the role of the MDT to identify why this decline may be taking place. Is it the result of a pre-existing condition or some other factor such as poor levels of support in the community? When planning a patient’s discharge these are factors to consider and appropriate and additional support on discharge can make the difference between the patient remaining in their own home and being readmitted within a short timeframe.
Treatment interventions relating to speciality assessments
• In this chapter commonly encountered conditions are covered along with a range of ideas for treatment that may be used.
• Hopefully, whilst working under supervision the student will realise that the most effective plans for intervention are generated from a combination of knowledge of anatomy, physiology, pathologies, the effects of treatment interventions and the assessment findings. Senior clinicians will draw on clinical experience in addition to these factors to ensure that the patient receives the most appropriate management.
• As mentioned previously, there is no specific ‘recipe’ to follow when treating patients in an acute medicine setting, students and novice physiotherapists will need to develop their theoretical knowledge base and integrate their experiences into the clinical reasoning process that underpins the choice of interventions.
• Patients often present with a complex medical history and the student/novice will be expected to discuss the complexities with their supervisor or senior clinician in order to develop their ability to reassess and progress treatments appropriately.
• It is important to gather feedback from other members of the MDT, e.g. nursing, OT or care support workers. The knowledge of the MDT assessment findings can assist the physiotherapist in planning the patient’s treatment programme.
• As an example a patient who is standing well in a standing hoist with other members of the team may progress quicker if the physiotherapist informs the team that the patient is initiating the stand. The MDT discussion may lead to the patient being assessed for their suitability to use a rotastand or Zimmer frame in order to progress the independent function during transfers with other MDT members.
• Sometimes successive treatments will be a combination of assessment and treatment to determine the most effective approach for a patient. This tends to be the case with patients who have conditions such as Parkinson’s disease (PD) where it may be necessary to trial what cues work best for them. When treating patients with varying degrees of cognitive impairment it may require the use of a number of different approaches before the optimum method of communication is identified that will ensure the patient engages with their therapy.
• Assessment should have identified a list of problems that are affecting the function of the patient:
• When considering the treatment of patients in medicine it is important to remember that there is no specific ‘medical’ approach as such, the management requires a combination of knowledge and skills from the ‘core’ areas of musculoskeletal, neurology and respiratory practice. To be effective the physiotherapist will need to incorporate all their skills in order to treat their patients effectively.
• Providing walking aids and walking patients does not address the fundamental problems that have brought the patient into hospital. If walking aids are provided include an exercise sheet for the patient to enable them to progress their mobility following your instructions.
• The assessment will have identified specific issues that need specific interventions, e.g. it is more effective to spend 10–15 minutes working on balance and ROM than just walking someone. Set goals and ensure that these are incorporated into the patient’s routine to enable them to achieve the best outcomes during their time on the ward.
Communication
• There are three main ways of communicating:
• It is essential that patients are addressed by the name of their choice and they should be asked this question on initial contact. Do not assume that patients like to be addressed by their forename. It is not appropriate to refer to patients as ‘dear’, ‘babe’, ‘love’, ‘duck’, ‘ pet’, ‘honey’, or any similar term. These terms are unprofessional and can be viewed as being derogatory and patronising.
• Remember that the hospital admission of a family member is an anxious time for relatives. They will often feel out of control of the situation and be keen to acquire as much information and reassurance as possible. It is imperative that communication channels with relatives and carers are established (it is essential to remember that consent is required from the patient before the disclosure of any patient-related information to a third party).
• It is essential to be able to adapt methods of communication with patients.
• Some patients may respond better to instructions that are given in short sentences, have pauses between sentences and use positive language, e.g. ‘move your bottom nearer the edge of the chair’ (pause), ‘put your hands on the arms of the chair’ (pause), ‘slide your feet back’ (pause), ‘on the count of three stand up’ (pause), ‘1, 2, 3, stand up’.
• Provide further instructions such as ‘keep standing’ rather than ‘don’t sit down’.
• Using the word ‘don’t’ – your patient will invariably end with the patient doing what you don’t want them to do.
• The ability to adapt your voice when giving instructions will also help to influence the outcome.
• If you are working with another member of staff (PT, PTA or OT) ensure you are both aware of who is leading the session, so the patient doesn’t become confused about who they should be following.
• Written communication can be effective for patients with hearing problems and also for those patients who themselves are unable to speak, e.g. cerebrovascular accident (CVA) patients, motor neuron disease, multiple sclerosis (MS).
• Non-verbal communication, such as your body posture and body language, eye contact, can help to develop a rapport with the patient to get them to engage in their treatment.
• This is a useful skill to use with patients who have cognitive impairment, when demonstrating what you want them to do.
Musculoskeletal and orthopaedic problems: treatment options
• The following list highlights the common musculoskeletal presentations/past medical histories frequently seen in a medical environment:
• Commonly, musculoskeletal problems tend to be part of the past medical history (PMH) and they usually contribute to a patient’s loss of function when they are admitted, e.g. a patient admitted due to heart failure may have OA in their knees that affects their ability to mobilise.
• Patients may also be admitted for elective or trauma surgery and postoperatively may develop a deep vein thrombosis (DVT) or pulmonary embolus (PE). It is important to be familiar with postoperative precautions, contraindications and complications when attempting to increase a patient’s independent mobility.
• It may be part of the role of the physiotherapist to inform nursing staff about any precautions as they may not be familiar with them. What may be obvious to one member of the MDT may not be obvious to other members and therefore the ability to communicate and educate other MDT members is an important skill to develop.
• For a number of patients it is important that they have pain relief prior to any intervention in order to maximise the outcomes from the treatment sessions.
• Time treatment sessions to coincide with medication, in order to maximise therapy and patient outcomes. If pain relief is not adequate, then liaise with the medical teams and/or pain management clinical nurse specialists; this may be beneficial in ensuring the patient has adequate pain relief to get the most benefit from physiotherapy intervention.
• For patients with musculoskeletal problems it is important for them to be given exercise programmes to do whilst they are in hospital and to continue following discharge.
• After their assessment, tailor the programme around their problems, e.g. reduced ROM, decreased muscle strength. Use skills that may have been developed in outpatients and or trauma/orthopaedics in order to treat the patient holistically, e.g. if a patient also has an OA knee provide an exercise programme incorporating strengthening exercises and ROM and provide advice about positioning, ice packs and pain relief.
• It is important to document accurately the exercise programme in the notes in addition to giving patients a copy of the exercise programme or you may wish to photocopy the sheet given to the patient. Also stress the importance of the patient taking responsibility for their own management of the problem as you would in outpatients. For patients who have cognitive decline, you may need to discuss this with the patient’s relatives or carers. You may also want to refer to community-based services or to a Day Hospital for further rehabilitation if you feel this is appropriate. Discharge planning is discussed in more detail later in the chapter.
Walking aids
• There are a number of walking aids that can be used to assist with a patient’s rehabilitation to promote independence and safety, e.g.:
• It is always essential to consider different types of gait pattern and weight bearing when providing mobility aids as well as a patient’s ability to follow instructions and their cognitive abilities.
• Zimmer frames can also be adapted by OTs with a Buckingham caddy to assist patients with transporting meals and drinks and to carry belongings.
Muscle atrophy and sarcopenia
• Muscle atrophy is a decrease in the mass of a muscle which can be partial or complete. Atrophy results in weakness as the overall muscle is unable to exert the force in relation to its mass. Conditions which can result in atrophy include cancer, congestive heart failure, COPD, renal failure and burns, liver disease and starvation, which are all conditions commonly seen in patients on the medical wards.
• Atrophy results in a decrease in the quality of life for the individual as performing tasks such as standing and walking become more difficult and become associated with an increased risk of falls. Causes of atrophy include exercise, hormones, nutrition, denervation and motor neurone death.
• Sarcopenia is the loss of muscle tissue that occurs over a lifetime and is also commonly used to describe its clinical manifestations (Lang et al 2010). Age-related loss of muscle mass results from loss of slow and fast motor units with an accelerated loss of fast motor units (Lang et al 2010). Clinical manifestations of sarcopenia include loss of mobility and independence and increased risk of injury secondary to denervation, changes in hormonal and inflammatory environment, mitochondrial dysfunction combining to produce losses in the bulk properties of muscle tissue such as muscle mass and strength (Lang et al 2010). Maintenance of muscle mass and strength is critical for preservation of physical activity in older age and important in decreasing the risk of falls and skeletal fractures (Lang et al 2010).
Neurological problems: treatment options
• Common presentations encountered on medical wards include:
• Neurology is a ‘core’ topic area that is not intended to be covered in any depth by this book. The reader is advised to consult a core neurology textbook (e.g. Edwards 2002). However, ideas and treatment suggestions are provided for the three conditions commonly seen on medical wards.
Parkinson’s Disease (PD)
• Patients commonly present with problems associated with the initiation of tasks, e.g. sit to stand, gait, bed mobility; especially rolling.
• They may also present with a simian posture, i.e. a stiff thoracic spine, decreased ROM in shoulders.
• The physiotherapist should be thinking about function at home, e.g. reaching into cupboards, washing and dressing.
• Always check medication prescribed and discuss with the patient if they find it effective. In more severe cases treatment may be more effective if timed to coincide with the effects of medication.
• It may be necessary to liaise with the medical team about medications as the patient may benefit from a medication review.
• These patients respond well to different types of cuing:
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