More than Exercise: Physiotherapy in the Community Setting
The diversity of the individuals we work with was what first attracted me to the community/disability space. My caseload now spans early adulthood to geriatric care (my eldest client recently cracked 100 and is still going strong!) and everything in between, which has helped my growth as a clinician tremendously. I have taught adult participants how to ride a bike, helped them get back to work, reintegrate into the community during the pandemic and spend more time with their families. What I underestimated was the scope of the community therapist; through collaboration with other disciplines, this role has led me to try my hand at things as a physiotherapist that I had never considered attempting before.
The traditional model of care that you may encounter in a private practice setting is not viable in the community space – as the disabilities that our participants have are lifelong, we are not approaching our practice with the mindset of “fixing” or “treating” an issue within 6 sessions. Rather, we should ask participants the question “how can we best support you with what you want to achieve out of life?” In this sense, we are not governing what individuals should and shouldn’t do but instead act as a guide, providing options based on our expertise to enable our clients to make decisions which will allow them to achieve their goals.
Because we are working in and around people’s homes, and with the complexity of cases we encounter, community physiotherapists need to be creative, versatile, and collaborative – we would be nothing without the multidisciplinary teams that make up a person’s support network. Nevertheless, physiotherapy is often a key piece of the puzzle when it comes to enhancing one’s functional capacity, and we will often be referred by our colleagues when it is identified that limitations in movement are acting as limitations to function. It is our role as community physiotherapists to address these barriers and empower individuals to walk, run, swim, stand up, self-operate a wheelchair, drive a car – whatever is relevant to them getting the most out of their lives.
When to refer?
Some of the common referrals we receive are along the lines of “reduced strength, needs an exercise program” or “lower back pain, requires physio”. Not until meeting the participant in person will physiotherapists discover what strength reduction means in the context of the individual – it could be that they lack the power in their muscles to get out of bed in the morning by themselves or grip a knife to cut vegetables when making dinner. In our assessments, we are responsible for linking objective findings to their functional implications, while exploring the multifactorial nature of these concerns. How much is the participant’s environment a factor? Their use (or lack of) equipment? Their relationships?
There are various contextual factors which we must consider in deciding our interventions – including what the participant would like to do, and what they perceive they are capable of doing. For example, for a participant experiencing chronic lower back pain, we need to acknowledge the impact of a person’s disability on the manifestation of their pain, and how their pain is perceived. For individuals with psychosocial disability, including bipolar disorder and anxiety, they may experience chronic pain more profoundly than neurotypical individuals, due to greater pain sensitisation and altered processing of painful stimuli, and will likely encounter greater activity limitations as a result (Failde et al., 2013). As such, our role is often that of an educator, helping participants better understand chronic pain and its mechanisms, gradually chipping away at the barriers to function. We may also adopt a motivational interviewing approach, creating the foundation of a relationship over time to help elicit positive behavioural change.
Sometimes people aren’t sure when a physiotherapy referral is indicated, and that’s okay – though if you are thinking physio, chances are you are on the right track. Some of the more common reasons for referral include:
- Deviations in typical movement patterns or biomechanics
- Concerns regarding falls or reduced balance
- Reduced capacity or endurance with movement
- Management of chronic pain
- Concerns regarding posture and positioning
- Prescription of mobility aids and assistive technology
- Respiratory care
- Development of land- or aquatic-based treatment plans
Therapies can take place in a range of different environments. In all instances, we should consider which setting will promote the greatest engagement, enjoyment and therefore help our participants achieve the best outcomes.
Aquatic physiotherapy
Completing interventions in the pool is a welcome change in scenery – for participants and therapists – particularly after the numerous Melbourne lockdowns. Aquatic exercise is suitable for individuals of all ages, backgrounds, and levels of function – contrary to what some might expect, you don’t have to be able to swim to engage in pool-based interventions! For younger clients, the pool is a fun, interactive and dynamic medium in which to complete therapies. Therapies can be play-based while still having a substantial therapeutic advantage (think of the benefits of a wave pool session for enhancing proprioception or ‘joint sense’), sometimes greater than that which could be achieved on land. For older participants, the warm water is relaxing for tight muscles and stiff backs, and the buoyancy of the water helps minimise pain and reduce loadbearing on arthritic joints. For those who are at an increased likelihood of falls, the opportunity for high-level balance training is far greater and safer to practice in the water as the risk of adverse events is negated.
Additional benefits also include improved strength due to the inherent resistance of the water, hydrostatic pressure for resolution of swelling, and enhanced social and community participation (Methajarunon, 2016). Therapists will work with support workers or family members to help facilitate interventions with participants when an additional set of hands is needed or to build their capacity to continue aquatic exercises with our clients outside of physio sessions.
Assistive technology – the dream team
It is a common misconception that within the NDIS space, anything that is equipment-related is automatically the responsibility of the occupational therapist. This is a narrow perspective and does not consider the expertise that the physiotherapist (and other health professionals) can bring to equipment prescription. With specialised knowledge in biomechanics, kinesiology and anthropometry, physios can work with OTs, or independently, in the assessment and provision of complex seating solutions, particularly when deciding upon custom seating components necessary to support an individual’s posture, comfort, and functional capacity when sitting in their chair. Physiotherapists will work with OTs in conducting MAT assessments in order to determine the most appropriate seating needs and explore with their participants the range of available solutions. It is often apparent when there has been collaboration between physio and OT in an assistive technology trial; teamwork between the professions lends to all aspects of the individual being considered with a holistic approach to practice.
Physio involvement can go beyond the prescription of assistive technologies, with recommendations for home modifications, such as installation of ramps, rails, bathroom, and kitchen aids. We may also be responsible for the provision of postural solutions, such as positioning wedges or blocks, required to support 24-hour positioning.
Hand therapy – looking after the keys to our world
Hand therapy is a speciality discipline, focusing solely on conditions of the upper limb. In the community/NDIS space, this might involve improving strength in a hemiparetic arm or hand following a cerebrovascular accident (stroke), reducing upper limb spasticity and pain with cerebral palsy, or improving hand and finger coordination for someone with Parkinson’s disease. Hand therapists can be either physiotherapists or OTs, though regardless of differences in profession, the desired outcome remains the same – improving the functional capacity of what are our most important features for interacting with our environment. In some instances, an orthosis (or splint) is recommended to support upper limb positioning, where immobilization may help minimise pain, reduce tone/contracture, prevent further deformity, and optimise function. Splinting offers the opportunity for clinicians to be truly creative and think outside the box when it comes to design, as there is no one-size-fits-all approach and must consider the aesthetic and personal factors with splint fabrication.
Bringing it all together
The scope of practice of a community physiotherapist is vast and continues to grow. I have found that the more I liaise with my colleagues from other disciplines, my clinical repertoire is ever-expanding, and I continue to add more notches to my clinical toolbelt. While I wear the “physio” badge with pride, I believe that we can drop the prefix at times, in order to reflect upon the many components that make up “therapy” as a whole. By doing this it becomes clear that we are one piece of a bigger picture, for us to collaborate, innovate and deliver the best outcomes for our clients.
References
Failde, I., Duenas, M., Aguera-Ortiz, L., Cervilla, J. A., Gonzalez-Pinto, A., & Mico, J. A. (2013). Factors associated with chronic pain in patients with bipolar depression: a cross-sectional study. BMC Psychiatry, 13(112). DOI: 10.1186/1471-244X-13-112.
Methajarunon, P., Eitivipart, C., Diver, C. J., & Foongchomcheay, A. (2016). Systematic review of published studies on aquatic exercise for balance in patients with multiple sclerosis, Parkinson’s disease, and hemiplegia. Hong Kong Physiotherapy Journal, 35(12-20). DOI: 10.1016/j.hkpj.2016.03.002.
About the author
Tristan Brown is a senior physiotherapist and clinical supervisor at KEO. With over 5 years of experience in clinical practice, Tristan is responsible for supporting a diverse community caseload which includes psychosocial participants, elderly clients and paediatrics.
Tristan appreciates being a member of a robust multidisciplinary team and loves delivering education and learning from his fellow team members. His approach to practice is creative and collaborative, so he and his KEO colleagues can work effectively together towards the best outcomes.
