The last time prior to this crisis I did anything close to being useful on a ward was 24 years ago. 4 weeks ago I was back with a ward team. I wanted to reflect and share some thoughts as it might help a little with the conversations that are already happening around rehabilitation, silos of practice, the future, patient cohorts and Physiotherapy in general.
When I turned up to the ward I was assigned to, I have to say I was nervous, thinking ”I am so out of date!” However, good support, a drag out of the memory bank and some common sense and I made a start. Quite quickly, in the days following, the ward was 90% COVID-19 +ve and although this changes your thinking, it didn’t detract from the job in hand.
What I quickly began to see were that patients in these scenarios, the frail, fractured hips, complex multi-morbidity and COVID-19 symptoms, needed to be approached with the model of what some may consider basic function: sit and reach, turn in bed, sit to stand and reverse, standing safely, weight transference, walking with and without support. The clinical reasoning really underpinned building these “basic” life functions into a fatigue resistant, safe and successful model but, most importantly, in a bespoke way towards their own social and medical needs. What I quickly realised; the assumed “basics” are complex.
Using ADL (activity of daily living) equipment with grounded clinical reasoning behind such choices, understanding the home situation and the context of the patients’ lives were vital in working towards the “basic” goals. Although these “basic” functional tasks are static in someways, the way they are approached from a therapist perspective is complex, due to the fact that they really are so person/life/home/socially centred. The patients’ perception of themselves and their situation leading the narrative around what might be possible is a communication challenge, and one that had to be undertaken sensitively at all times.
I reflected this reasoning experience against my own practice. Firstly, it really emphasised the over complexity that MSK practice may make on a number of presentations that are seen within the general population. The close scrutiny of identifying muscular imbalances, “weakness”, inhibition, “dysfunction” have been challenged of late as not being a valid, reliable observation or even an entity. Although, I am sure there is a debate to be had here, what is not, in my mind, is the validity of a patient not being able to achieve life functions. So, I once again had a really good rebalance of getting to the root need of what might be a successful outcome for a patient before embarking on anything progressive. Basic loss of function and the mechanisms around that achievement underpin the complexity of reasoning. Multiple causes, medical, social, emotional, biochemical, pathological in multiple domains and relationships lead to the observations we see. As we try to “analyse” this, much of it is beyond what perhaps is possible, but what we can do is look to resolve a persons clear lack of capacity in a simple but broad way using multiple methods as appropriate.
This requires looking outside of our normal MSK pathways of practice as well as utilising the grounded skills we learned as new graduates as part of our early rotations and wider experiences. One problem is that using a linear model of practice fails in the multi-morbidity model of population healthcare. As part of my work in First Contact Practice I cited system knowledge as a key element of requirement needed in primary care, and this was not only biological systems but health systems as well, including the knowledge of how the system offers care in the widest sense to serve our patients as effectively as possible.
So, to my second point of reflection and the thorny subject of the Bio-Psychosocial approach and all its interpretations. My experience made me really think about the word “social” in the context of MSK and also from the ward/community rehabilitation context. Many times early in my career, I tried to understand MSK patients’ social elements as sports, interests, work, hobbies etc. then as my knowledge and experience developed, I sought to understand the person perspective, values, beliefs based on their lives, interactions, culture, expectations and this proved valuable and much has been cited around these constructs. But in the context of ward to community rehab, I realised that the word “social” also links to the care sector, and this was an area I knew very little, if nothing about.
How the care sector operates and works, the pathways, the potential support available were all new processes that I had not taken into account at really any level other than a low level of understanding from working in primary care. This network is VITAL in the future planning for these patients, and although I was OK (just) on the wards it was in this area I was of little benefit.
Therefore, opening up the word Social in the BPS model for me now needs to include a knowledge base around health AND SOCIAL CARE. I wonder how many of my MSK colleagues can truthfully say they know the local social care network well enough to give good advice but also link into really widening the support systems that patients will need to attain the “basics”. So in this context attaining the Basics is Complex. If anything I am now consciously incompetent in this area which is a move forward from where I was previously.
We might be great in MSK at giving a range of progressive knee and shoulder exercises, but contextually, is this the rehab that meets the patient needs or are our heads slightly in the sand here in the current climate? Is exercise on its own really enough? If we are working much of our practice in a digital way, then let’s use this opportunity to offer the widest health and social support we can. I believe that the broad skills of our profession are ideally suited here as our community colleagues can provide huge value and support in determining the development of practice. Let’s really drive down the barriers and get integrated where we can, not just an MSK pathway in a linear way, but broadly across the health and social care sectors.
I know that there have been challenges where physiotherapists are accused of lacking exercise prescription skills within certain cohorts of patients. I would now start to argue that if this is so we can improve that very easily, but where we can really have a significant impact is around supporting the needs of the population suffering in this crisis. Perhaps, at this moment, we need to judge that the low level MSK aches and pains that we have seen in the past is just not a priority.
My third point therefore is around silos of practice. Not in MSK as such, but in truly integrated care for patients in these situations and in this crisis. Is it time to reconsider how MSK practice in the NHS is really utilised and what skills in the future are going to be important for the populations we serve? My MSK team have been amazing in redeploying (as many others have) across frailty, community services and ward support. The learning after this will be so rich, we must take this opportunity forwards into the future.
There is much learning to be had, but to start that, questions need to be posed. These will inevitably be tough questions around using resources wisely. So, is MSK an independent area of practice when it comes to rehab or should we be better at using our broad skills to approach MSK, frailty, pulmonary rehab, community enablement, social care referrals in one hit? Time to stop moving patients about and perhaps reconsider rehabilitation in its broadest sense possible? Where can really impact the NHS Long Term Plan? We have directors of Nursing and AHPs leading the professional line, we have Medical Directors as well. There is no better time to consider the need for Directors of Rehabilitation that have a focus in community, public health and rehabilitation across all domains?
So, lastly what is expertise going to look like in MSK in the future as a result of what is happening right now? I don’t know, but my experience so far would suggest that we need to serve the population right now and in the immediate future. I am less confident that we need an in-depth knowledge of the rotator cuff, transversus abdominus, or best surgical approaches for traumatic knee injuries. In my opinion, we need expertise in multi-morbidity rehabilitation, with a focus on MSK, but integrated as part of “life function rehabilitation” that sits alongside an improved knowledge of the “social” element of care at its broadest and supportive context.
Defining MSK expertise differently from knowing all about the possible surgical options and high performance level/elite principles as opposed to knowing more about social care options may not look quite so jazzy and expert, but right now it’s a whole lot more useful to the folk that really need our help.
Can we ready ourselves for this? It can only make MSK practice more valuable to the population we serve if we do embrace this knowledge and perspective.
How we will understand this will be an iterative process, and it will require commissioners to think differently, STPs to work far more rapidly and the profession to see MSK Physiotherapy as integrated and not separate from our ward and community colleagues.
It has been humbling to see the work, contributions and support our profession has so far offered, but perhaps there is even more to come.
Thanks to all!
Neil Langridge
Consultant MSK Physiotherapist