I intended to travel to the USA for a period of 8 weeks where I would:

Transcription

1 Winston Churchill Memorial Trust Fellowship Report: Treatment, Rehabilitation and Management of Back Pain Louise Cooke Fellow

2 Introduction From the age of 13 I have accompanied my grandfather, James Cooke - a Fellow of 1981, to a number of East Pennines AGMs so I have long been aware of The Winston Churchill Memorial Trust and the opportunities it provides. Over the years, my grandfather encouraged me to apply for a Fellowship wanting me to share in what he always considered to be an amazing experience. This was something I always wanted to do, so I am pleased to report that, eventually, the timing was right for me and the subject matter I opted to research was worthy of the Fellowship. 2

3 Background My background is firmly rooted in sport: I ve always played, watched and loved sport. Hence, it was natural for me to want to study sport at degree level which I did at University of Durham, graduating in Sport, Health and Exercise in However, an element of the course involved studying Sport, Injury and Rehabilitation: guest lecturers all of whom were physiotherapists - were invited to lead seminars and tutorials in these modules. I enjoyed these so much that I was inspired to take up physiotherapy as a career. I qualified with a Masters in Physiotherapy in It was whilst, studying for my Masters degree that a lecturer advised that in out-patient settings up to 80% of people who walk through the door suffer from back pain/back problems and that although many people may walk through the door complaining of hip, knee, shoulder or elbow pain, the root cause of the pain often originates in the back: In the UK 50million working days are lost each year to back pain Up to ½ million people are claiming state benefits for this reason The cost to the economy is up to 5billion each year Source: Department for Works and Pensions, 2002 Having this knowledge, alerted me to the fact that, working as a physiotherapist, a significant part of my working life would be spent treating patients who had conditions related to the back. This led me to believe that gaining a much more in depth knowledge of back pain management would be of great benefit to me and support my professional development. I decided, therefore, that this would be the ideal subject for a Churchill Fellowship. The Fellowship Aims I intended to travel to the USA for a period of 8 weeks where I would: Visit leading institutes specialising in back pain and spinal injuries Gain knowledge of health systems in USA Liaise with and observe a variety of practitioners Attend lectures/seminars and enquire into research Talk to patients Absorb the culture 3

4 The Fellowship My Experience/Findings Visit leading institutes specialising in back pain and spinal injuries I visited a number of institutes, spending the most significant part of my time at Long Beach Memorial Medical Center and Rancho Los Amigos Medical Center. Gain knowledge of health systems in USA The majority of US citizens have some form of health insurance either through their employer (60%), purchased individually (9%), or provided by government programs (27%). Source: Income, Poverty, and Health Insurance Coverage in the United States: U.S. Census Bureau. Issued August Practitioners advised me that American Healthcare is a very complex matter and very difficult to understand in fact, there are university degrees dedicated to this subject. However, they did attempt to explain the basics to me. In the USA, healthcare is provided by a diverse array of individuals and legal entities. The healthcare system is not fully-publicly funded but is a mix of public and private funding. There are for-profit hospitals which are usually operated by large private corporations and there are non-profit hospitals, these may be operated by county governments, state governments or independent non profit organisations. The forprofit hospitals are market led and compete to provide the best service to their patients with patients being treated as consumers, whereas non-profit hospitals rely on subsidies and grants. In the USA employers provide health insurance as a benefit. Therefore, most people who are working (and their families) have health cover. However, the level of cover is dependent on the job: professionals enjoy a higher level of cover compared to, for example, manual workers. Those who are not employed may have only very basic cover or in the majority of cases none at all. This means that there are different tiers of patient care with some patients unlikely to be in a position to access the care they need. In comparison, in the UK although there may be a waiting list - everyone is entitled to treatment from the NHS. In the USA, when people have good insurance they obtain immediate healthcare and, when necessary, ongoing treatment since the insurance pays for all of their healthcare needs from the outset. However, if the insurance provided is at a lesser level there is a limit to the amount of money made available to the patient. Therefore, it may pay for the majority of treatment but does not cover everything and it becomes necessary to 4

5 prioritise the patient s needs. I witnessed an example of this during my time at Long Beach Memorial Medical Center. One particular patient had been treated in relation to a traumatic back injury and needed ongoing speech and language therapy, physiotherapy, occupational therapy and home care. However, the funding that was available to him was running out since it had already paid for his in-patient care and there was only sufficient left to pay for four therapy sessions although he required many more than this in order to fully recover. He, his family and the Rehabilitation Team (a team made up of a range of professionals) were forced, therefore, to prioritise which of these treatments would be most beneficial. The meeting involved a discussion on whether the patient would benefit more from speech and language which would allow him to communicate with his family and carers or physiotherapy which would aid or improve his mobility. With regard to the insurance, there would eventually have come a time when more insurance money would be available to allow further treatment to continue but it was impossible to say when. If patients have no insurance the only option for them is to attend a state hospital where care is very basic and the possibility of ongoing treatment is unlikely. Liaise with and observe practitioners I had the opportunity to talk to various practitioners from the Rehabilitation Team to discuss patient care. The Team consisted of: Physiatrist (Physician) Physical therapist Occupational therapist Speech and language therapist Neuropsychologist Nurses Social worker Dietician I was interested to find out: How patient care was co-ordinated How individualised programs were designed to suit patients needs How Rehabilitation Team worked together How patient care was divided between the Team The timescales involved in patient care About facilities and equipment Every patient receives an initial assessment from relevant team members, the results of which are used to devise an individualised rehabilitation program for that patient. The program covers the type of therapy the patient requires and how 5

6 the time during their in-patient stay should be spent to ensure the most beneficial results. Some patients may need more physical therapy input to help recovery whereas, others may need more time and access with occupational therapy and speech and language therapists. The Team meets to discuss and agree how a patient s care will be co-ordinated: it is standard practice to allocate patients a minimum of one hour with each therapist per day. However, this time can be increased when necessary and it is not unusual for a patient to be allocated, for example, two hours of physiotherapy per day. The Team continuously assesses its patients. It also meets on a weekly basis to ensure that patients progress is as it should be and that both Team and patient goals are being achieved. Depending on the outcome of this meeting, goals may be amended accordingly. The lines of communication between Team members were excellent. This was partly due to the fact that therapies were timetabled to follow on from each other enabling therapists to easily discuss patient progress and further needs at the point of handover. In addition, as well as maintaining an up to date and accurate written record of patient care, there was also much informal discussion between therapists regarding their patients. Much of this was possible due to the fact that the hospital layout sees these departments set up side by side making follow on treatment and communication much easier to achieve. With regard to the facilities and equipment available, the for-profit hospitals must ensure they provide the best service since, if they do not, they will lose their customers to the competition. This means that they strive to have the latest and most up to date equipment in doing so they often depend on big businesses and/or wealthy families for support. The hospitals often make a wish list and benefactors provide the necessary funding. This not only helps the hospital but shows the benefactors in a good light increasing their business or social kudos. I was astonished at the amount of equipment the hospitals had and facilities they boasted. With regard to the treatment and management of back pain, the majority of techniques used by the physiotherapists were the same as those taught and used in the UK. However, the difference is that in the USA there is a far greater range of equipment available and a far greater amount. This means that the actual practice differs in that, for example, a patient in the UK who needed physiotherapy to help him/her to relearn how to walk would possibly require up to three members of staff to assist and support him/her. This would involve two staff members supporting the patient with the patient using his/her hands to hold on to the staff members in order to maintain an upright posture. Whilst the patient attempts to walk, the physiotherapist continuously provides muscle stimulation, assessing and advising the patient on how best to make the next move. This process involves all four people attempting to move along at the same rate which does not lend itself to a natural situation. In contrast, in the USA, a treadmill with a harness would be used for this same activity. Being strapped into the harness means the patient is 6

7 able to walk in a more natural pattern and is not relying on, or holding on to, anyone else. The physiotherapist has more room for manoeuvre when treating the patient and the treatment time can be longer as the patient does not tire as quickly since he/she is not using the same amount of energy in trying to remain upright. All of this leads to a more effective session and outcome. In my opinion, the combination of the individualised treatment plans together with the facilities, equipment and time spent with therapists was beneficial to patients since all this would lead to a speedier recovery. Attend lectures/seminars and enquire into research One of my main contacts on the trip was Craig Newsam who is a Rehabilitation Research and Education Manager. He provided additional opportunities which weren t in my original plan, for example, visiting additional hospitals and attending a wider variety of seminars and lectures. This was most useful and increased the scope of my enquiry. I attended numerous lectures and seminars with regard to rehabilitation and management of back pain. These were most beneficial advancing my knowledge and understanding in this area. However, I was pleased to often be invited to attend seminars which whilst they related to physiotherapy, were not exclusively linked to back pain. An example of this was a seminar entitled, Advances in Neurorehabilitation: Translating Evidence to Clinical Practice presented by Katherine J Sullivan PhD, PT, a leader in this subject. All of this added a further dimension to my knowledge and furthermore, I feel I am now in a position to disseminate this information with colleagues. Talk to patients I enjoyed talking to a number of patients: they were more than happy to share their experiences with me. This was hugely beneficial, since it enabled me to become more aware of their issues and concerns in respect of their condition/s and the treatment/s they received. This will impact positively on my practice. In addition, it was a rare experience since time is at a premium when actually working with patients which means it is not possible to have such in depth discussions as I was able to in this situation. A further benefit to these discussions was that I was able to tap into what real American life is all about. I was able to learn much more about their lifestyle and culture and the affect these may have had on their condition/s. 7

8 Absorb the culture Whilst I have visited the USA for family holidays, having the opportunity through the Fellowship to spend time socially with the professionals I was involved with allowed me to gain a deeper insight into the American way of life. All of those I came into contact with were incredibly accommodating. I was invited to stay in people s homes and invited to eat and spend time with their families and friends. I was taken on sightseeing trips in the cities and towns I visited and also taken for evenings out. I am pleased to report that many of these people have now become friends and we still keep in contact with each other. This was an amazing experience and one which would not have been possible had it not been for the opportunities the Fellowship provided. Prior to embarking on my trip, I was given strict instructions by my grandfather that when I was in Long Beach I had to visit The Queen Mary. Having been a merchant seaman and having served in the Navy during WWII, he is very much into all types of seafaring vessels to say the least! He had previously visited The Queen Mary and wanted me to share his experience. When I visited it, I was surprised and delighted to find that there was a restaurant called Sir Winston s. It transpired that part of the tour of The Queen Mary was actually devoted to Sir Winston Churchill, commemorating his time spent on board. Conclusion The care provided in the USA is second to none, the organisation of hospitals, facilities available and treatment provided is of the highest quality. The equipment available together with the amount of time allocated for therapy is hugely advantageous to patient care, making recovery better, easier and faster. However, this is only provided to patients who have good insurance cover. Patients who have a lower level of cover are not always able to fully access the treatment they require and those who have no cover at all are subjected to a much lower level of care which attends only to their immediate needs and does not support ongoing treatment or after care. I had to agree with the practitioners I met when they voiced their opinion regarding the unjustness of the system. In comparison, in the NHS, whilst patients may have to wait, at least all are entitled to be treated and receive the ongoing aftercare they require regardless of their socioeconomic conditions. The information and knowledge I have gained from my experience will be put to good use in my career in the UK. I will champion the approaches used in the USA and will discuss the relevant issues with colleagues and share ideas and information accordingly. I hope this will benefit colleagues, patients and support 8

9 me in my continuing professional development. More importantly, my experience will enable me to make a difference to my practice and the patient care I provide. In summary, I am able to report that I found out much more than I expected to at the outset. People were more than willing to share information with me and this was a mutually beneficial situation since they were also interested in finding out about my experiences in the NHS and also about The Winston Churchill Memorial Trust. NB. Any reference made to NHS in this report is based solely on my experience within the NHS as a student physiotherapist. Finally My Fellowship was a truly amazing experience. I would like to take the opportunity to thank The Winston Churchill Memorial Trust for supporting me in this project and, in particular, those who were involved in the process of the same. I would also like to thank all those in the USA who welcomed me and made my trip even more enjoyable than I could have hoped for. I recognise how fortunate I have been having realised my chance of a lifetime and would encourage anyone to apply to The Trust if they have a particular interest or project in mind. Finally, I would like to thank my grandfather for encouraging me, not only in this venture, but in all areas of my life. 9