An Overview of Physiotherapy in UK Prisons

Original Editor - Andrea Beznaczuk-Smyrnew, Mark Chawke, Niamh Coveney, Anthony Gorsek, Jo Hampton, Katie McGregor as part of the QMU Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Andrea Beznaczuk-Smyrnew, Anthony Gorsek, Mark Chawke, Kim Jackson, Katie McGregor, Niamh Coveney, Admin, Jo Hampton, WikiSysop, Vidya Acharya, Olajumoke Ogunleye, 127.0.0.1 and George Prudden  

 Introduction   

Physiotherapy is a constantly evolving role in United Kingdom’s health care system. An emerging role for physiotherapists is working within prisons to treat the prisoners. The CSP (Chartered Society of Physiotherapy) brought this to the forefront with an article about rising COPD rates in prisons in England and Wales and the implications for treatment. Another factor that may be contributing to the emergence of this role is that the number of prisoners in the UK has almost doubled since 1993 (Figure 1;McMillan 2013; Ministry of Justice 2013) , further indicating that physiotherapists may need to become more involved in providing health care in prisons.

graph of prison pop growth

There are a few things that a physiotherapist may want to know before they treat patients in prison. The aim of this page is to provide useful information for those who will be treating prisoners in both outpatient clinics and in prisons. More specifically, a basic understanding of why this is an emerging role in physiotherapy, what to expect when you are about to treat a prisoner, an overview of the ethics and policies that effect physiotherapy treatments in prison, the barriers and facilitators of treating a prisoner, and some general advice from physiotherapists currently treating prisoners will be presented.

Current Prison Statistics

According to the Scottish Prison Service (2013), there are currently 18 prisons in Scotland with a total of 7801 prisoners in custody and a further 353 in home detention. This equates to a total of 8154 prisoners and the BBC news (2012) state that this figure is expected to rise to around 9,500 in the next decade. In 2012, the number of long term prisoners (those sentenced to four years or greater) in Scotland was 2326. The prison population of England and Wales combined equalled 84,052 when recorded earlier this year (Berman and Dar 2013).

In 2005, there were 0.39 physiotherapists per prison in Scotland (based on a 40 hour week) with 6 prisons having no physiotherapy service (see Table 1). However this statistic produced by Graham (2007) was prior to the transfer of prisoner healthcare from the Scottish Prison Service to the NHS.

The Scottish Government (2011) emphasised that once prisoner healthcare became the responsibility of the NHS, prisoners will receive improved opportunities to benefit from NHS care in keeping with services provided to the local community. With an increasing prison population along with an aging population, more physiotherapists are likely to be required in the prison service.

***INSERT TABLE on Allied Health Staff in Scottish Prisons based on a 40hr work week. (2005)

Learning Outcomes (change)  

1. Identify and justify the knowledge, skills and values required by physiotherapists to deliver effective healthcare in prisons.
2. Recognise common medical conditions encountered by prisoners, and interpret their underlying cause.
3. Report and analyse barriers encountered by physiotherapists in providing treatment to prisoners.
4. Argue the importance of providing physiotherapy in prisons.

 What to expect 

 Conditions 

Msk Conditions

 

Millions of people are affected by musculoskeletal (MSK) disorders worldwide, and MSK injuries are a great burden to the healthcare system. (WHO website). MSK disorders include a wide range of disorders such as osteoporosis, osteoarthritis, low back pain, muscle/tendon/ligament injuries to name but a few. There is a massive variety in causes of MSK injuries which include sporting activity, trauma, poor postures and physical inactivity. Prisoners may be more exposed to these causes, and as a result MSK injuries are quite common in prisons. Physical inactivity is prisons is common and greatly contributes to the amount of MSK injuries.

How physical inactivity can cause MSK pain:
• Reduces bone mineral density causing osteoporosis
• Increases risk of obesity which can result in conditions such as osteoporosis
• Muscle weakness can cause joint instability and abnormal movement causing pain

Why prisoners may be more susceptible to MSK pain:
• Limited exercise time
• Limited/lack of training equipment
• Lack of or lack of access to appropriate training guidance
• Uneducated of the benefits of exercise
• Lack of motivation
• High levels of depression/mental health issues in prisons
• Fear of involving with other prisoners
• Prolonged bed rest/poor postures
• Unsupportive beds/chairs

As well as combating the causes of MSK pain, other benefits of physical activity include:
• Increased cognitive function
• Increased feeling of well-being
• Decreased anxiety and depression
• Other health benefits such as weight loss and prevention of development of chronic diseases
• Improves general fitness

From above, it can be seen that many prisoners lead a sedentary lifestyle which may have a dramatic effect on their health and contribute to the high numbers of MSK patients which must be treated in prisons each year.

 Improper use of gym equipment and excessive weightlifting 

<ref>MSNBC. Prison Life : Workout Tattoos and Food In Prisons. Avalible from: http://www.youtube.com/watch?v=bvjYscOZkGE[last accessed 14/11/13]</ref>

Another plausible cause for the large complaints of MSK pain in prisons could be due to the weightlifting environment in prisons. Many prisoners use their time in prison to “bulk up” and as a result, lift very heavy weights each day. This also shows them to be more masculine amongst other prisoners. Here prisoners are the opposite of the physically inactive, and are overactive. By lifting heavy weights each day, they are not giving their muscles sufficient time to recover, they develop overuse injuries. Overuse injuries occur when the rate of injury exceeds the rate of heeling and adaptation. This results in increased presentation of muscle strains and tendon injuries. A major problem for physiotherapists in prisons is that when they see patients for injuries such as overuse injuries, they are unable to keep the patients out of the gyms. Going to the gym becomes a way of life in the prisons and even with an injury, they continue to lift heavy weights, and do more harm.
Another factor which contributes to these injuries is due to the lack of qualified personal trainers to teach and supervise these weight lifters on correct technique, and advise them on resting periods. Improper technique can lead to abnormal movement with a heavy weight causing muscle injury. This poor training technique combined with reduced recovery times results in the development of MSK injuries.

As well as injuries specific to prisoners, physiotherapists commonly have prisoners present with injuries regularly seen in the public. During their recreation time, prisons have the opportunity to play a variety of sports such as soccer, badminton, basketball. Therefore, it is no surprise soft tissue injuries and fractures are also quite common. Fights are also more common in a prison environment, and this results in an increased numbers of trauma injuries.

As our population is aging, our prison population is also aging, which adds even more of a healthcare burden on the prisons. Elderly people are more at risk to developing chronic disease than younger people, and it is no surprise that elderly prisoners present with more MSK conditions in comparison to the general public. A study by Fazel et al. (2001) showed that there were over 1000 prisoners over the age of 60 in England and Wales, and this number is expected to increase in the future. Out of these 1000 prisoners, 24% had recorded MSK problems, and 43% self-reported MSK problems. Another study by Fazel et al. (2011) showed that over 20% of prisoners in Ireland, and over 15% of prisoners in England and Wales (not age specific) self-reported MSK injuries. These figures show the need for regular physiotherapy in prisons, for MSK conditions alone.

From our interviews we have found that the major injuries which prisoners present with are:
• low back pain/neck pain due to heavy weightlifting, poor postures, unsupportive beds/chairs, inactivity;
• fractures due to sports activity or fighting
• Soft tissue injuries such as shoulder or ankle injuries due to weightlifting, sports activities or fighting.
• MSK injuries amongst elder prisoners

Obesity in the UK

Obesity rates in the UK are the highest in Europe and have increased dramatically over the past few years to such an extent that in excess of 20% of the population are now obese and the costs to the UK economy exceed £3 billion per year. (University of Birmingham ref 10)
Obesity is calculated as having a BMI of ≥ 30. 

Being obese increases the risk of developing a number of serious and potentially life-threatening diseases, such as:
Type 2 diabetes
Heart disease
Certain types of cancer (i.e.breast and colon cancer)
Stroke

In addition, obesity can damage quality of life and can often trigger depression. Obesity reduces life expectancy by an average of three years, or eight to ten years in the case of severe obesity (BMI over 40) (ref 11)

Why Obesity?

The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Globally, there has been:

• an increased intake of energy-dense foods that are high in fat; and
• an increase in physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization.

Changes in dietary and physical activity patterns are often the result of environmental and societal changes associated with development and lack of supportive policies in sectors such as health, agriculture, transport, urban planning, environment, food processing, distribution, marketing and education. (WHO, 2013 REF 9)

As has already been discussed in the above section entitled ‘Musculoskeletal problems’ physical inactivity in the prison population may be high due to varying reasons therefore increasing the obesity levels in prisons.

Obesity in Prisons
Most of the 9•8 million people imprisoned worldwide are from the poorest and most marginalised sections of society and are therefore likely be at greater risk for non-communicable diseases (NCDs) e.g. heart disease, stroke, diabetes, cancer, and respiratory disease. In 2008, 36 million of 57 million deaths worldwide were attributable to NCDs. Of these, 14 million were attributable to unhealthy diet, 3 million to insufficient physical activity, and 3 million to obesity (WHO, 2011).

It is known that a high proportion of prisoners come from the poorest areas in the UK with many prisoners having a history of social exclusion, being more likely than the general population to have grown up in care, poverty, and to have had a family member convicted of a criminal offence (Social Exclusion Unit (SEU), 2002 (‘the SEU Report’); Ministry of Justice, 2010a) (ref 12).  Therefore based on this information and the findings from WHO, 2011 it would be assumed that a large proportion of prisoners in the UK will be overweight or obese.

A recent study by Herbert et al, 2012 found that male and female prisoners were less likely to participate in adequate physical activity than the general population of similar ages. However despite this fact male prisoners in the UK were less likely to be obese than the general population. More research is needed to understand more why?

 Chronic Obstructive Pulmonary Disease   

Chronic obstructive pulmonary disease, or COPD, is an umbrella term often used to define various conditions. Two of the most common conditions include chronic bronchitis and emphysema, which are characterised as a difficulty in breathing due to permanent damage to the lungs. Other diseases that contribute to COPD are obstructive bronchiolitis, pulmonary vascular disease, cor pulmonale (right sided heart failure and pulmonary heart disease), and systemic syndrome of cachexia and muscle weakness. While the damage on the lungs is non-reversible, it is a preventable and treatable condition (Kon et al. 2011). It is the most prevalent cause for morbidity and mortality worldwide and subsequently places a heavy economic and social burden on governments (Celli et al. 2004). (Go to politics) – The prevalence of COPD’s effect on economy is greatly underestimated due to its consequential late diagnosis, because people who present with moderate or severe symptoms. Onset of the disease can occur as early as 40 years old; however, it more commonly seen in individuals over the age of 65. Several factors, including late diagnosis and socioeconomic factors, are responsible for this varying age in diagnosis.

 Pathophysiology 

COPD effects four compartments of the lungs – central airway, peripheral airway, lung parenchyma, and pulmonary vasculature. The common risk factors (listed below) cause an inflammatory response in these areas leading to pathological lesions in COPD sufferers.  Additionally, the lungs are susceptible to an imbalance of proteinases and antiproteinases, and oxidative stress, causing the following physiological defects: 

• Mucous hypersecretion
• Cilliary dysfunction
• Airflow limitation and hyperinflation
• Gas exchange abnormalities
• Pulmonary hypertension
• Systemic effects

 Smoking - the leading cause of COPD 

It has been estimated that smoking contains 1017 reactive oxidant species (ROS). ROS instigate a wide range of inflammatory, mucosecretory, proteolytic, and fibrotic responses, which consequently cause the release of chemotactic factors and cytokines due to epithelial cell injury and macrophage activation. Macrophage and neutrophil involvement cause the breakdown of the extracellular matrix, which corresponds with an inflammatory response. Pathologically, an increase in cigarette smoke parallels a greater number of inflammatory and repair (fibrosis as a consequence) cycles on these response systems (Kon et al. 2011), which commonly manifests as mucus hypersecretion, fibrosis, proteolysis, and airway and parenchymal remodelling (Kon et al 2011).

 
Causes of COPD
 

Characterised by a progressive reduction in airflow resulting in an atypical inflammatory lung response to carcinogenic particles or gases, COPD is a preventable and treatable disease state. Smoking is the leading cause of COPD, however other factors, such as air pollution, environmental factors, and genetics factors, can also be precursors to the development of COPD.
1. Smoking: the most common cause of COPD. It has been estimated that cigarette smoke can contain over 1000 reactive oxidant species (ROS) (Kon et al. 2011). Smoking cessation can gradually reduce your risk of getting COPD, or slow its progression if diagnosed in the earlier stages of the disease.
2. Air pollution, environmental factors: toxic fumes, chemicals (e.g. smoke inhalation from biomass fuel, predominantly in developing countries) (Kon et al. 2011 – global burden)
3. Alpha-1-antitrypsin (A1A): genetic condition where individuals are A1A deficient, or produce low levels, of a protein produced by the liver and found in the blood. Its role is to protect lung tissues from being degraded by surrounding enzymes. COPD and symptoms can be further exacerbated with A1A deficiency and smoking.

 Diagnosis
 

Diagnosis of COPD requires the use of spirometry, which measures the amount of air expelled from the lungs in the first seconds of expiration. If the FEV1/FVC ratio is ≤ 0.70, then the bronchial tubes are narrowed, or damaged, to an extent where an individual experiences common symptoms (listed below) of COPD

Symptoms:

• Cough
• Excessive sputum production
• Dyspnoea (breathlessness; ranked on a scale of 0 to 4, where 0 = not troubled with breathlessness except with strenuous exercise and 4 = too breathless to leave the house, or breathless when dressing/undressing)
• Exposure to risk factors

The use of spirometry has been documented as being a useful tool for predicting an individual’s health status, utilisation of healthcare resources, the development of exacerbations, and mortality (Celli et al. 2004). Spirotmetry is also readily used to track the progress of the disease and establish an appropriate course of treatment (ScotPHO, 2013).

Extrapulmonary systemic symptoms:

• Muscle weakness and wasting
• Cachexia
  • Cardiovascular disease
• Metabolic syndrome (i.e. diabetes, obesity, high BP)
• Endocrine effects
• Anaemia
• Depression
• Malignancies

  Treatment 

Antibiotics

1. Corticosteroids
2. Respiratory stimulants
3. Diurectics
4. Anticoagulants

Physiotherapy and COPD

Various physiotherapy techniques have been well-documented as having appositive effect on symptoms experienced by COPD patients.
 

   Mental Health, Obesity, and other health conditions   

 Mental Health in Prisons 

Mental illness has a higher prevalence in the prisoner population. 72% of males and 70% of female (sentenced) prisoners have 2 or more mental health disorders. 20% of these prisoners have 4 out of 5 of the main mental health disorders. Drug Prescription data supports this, showing that mental health related medication is the highest dispensed in prison (4). For example, 40% of men and 63% of females have neurotic disorders, a level three times that of the general population. (1) Neurotic disorders such as borderline personality disorder include behaviours such as anxiety, anger, loss of contact from reality, difficulty maintaining stable and close relationships and threat to others. This will affect the physical health of the individual and their relationship with their healthcare worker. (3) Mental illness therefore presents a challenge to treatment and may pose challenges during treatment for healthcare workers in prisons. (1)

There are several ethical issued faced by prison healthcare workers in relation to mental health.

Consent

As mentioned previously, due to the high incidence of mental health illness' in prisons physiotherapists need to be aware of the Mental Health Act (1983). A patient must give consent to proceed with a treatment or test for the healthcare worker to be legally allowed to continue. If consent is not given and healthcare worker continues it can be deemed assault. When a patient’s mental illness is leading to behaviour which is an immediate danger to self or others, they are analysed as not having capacity, they can be treated under the mental health act 1983. They however must be transferred out of the prison and into an NHS or qualified mental health unit to be treated. All other times a patient must give consent (2).

Isolation

Patients can be put in isolation as a punishment or reward. Isolation can have detrimental effect on a patient’s mental health and healthcare workers dealing with a patient who has been in isolation must be aware of this and raise any concerns immediately (2,5)

Environment

The prison environment itself can have detrimental effect on a prisoner’s mental health with a lack of decision making, seeing family and friends and activity. These can all lead to the development of depression, anxiety and other mental health concerns (2). Any concerns regarding mental health should be referred immediately and the patient should be assessed within 24hrs (5).

Prison Staff vs. Health Staff

The priorities of prison staff and healthcare staff differ. This may become an issue when a patient requires treatment. If prison staff are thin on the ground, movement of prisoners through the prison becomes a concern and staff may pressure health care staff to go to the prisoner. Standards of care must always be met, however staff should ensure safety of themselves and others.
(2)

1. http://www.prisonreformtrust.org.uk/ProjectsResearch/Mentalhealth
2. http://www.prisonmentalhealth.org/page_view.asp?c=17&fc=012&did=272 3. http://www.nhs.uk/Conditions/borderline-personality-disorder/Pages/introduction.aspx
4. Prison health in Scotland a health care needs assessment Dr Lesley Graham Dec 07
5. Audit of the implementation of the mental health act 2003 in the Scottish prison service Oct 2005- apr 2006

Security 

Occurrence of Incidence??

• Personal alarms

Politics

The responsibility of prison healthcare was that of the Scottish Prison Service up until 2011. A decision was made by ministers in 2008 to transfer the responsibility of prisoner healthcare to the NHS. The transfer intended to ensure equity in health care so that prisoners would receive their care from NHS as does the general population and also to ensure that both European and International standards for prisoner health care were maintained (Scottish Prison Service 2013). On 1 November 2011, in accordance with Health Board Provision of Health Care in prisons (Scotland) Direction 2011, prisoner health care became the responsibility of the Health Board as oppose to the prison service (The Scottish Government 2011).

Upon this agreement being reached in 2011, both parties had a number of responsibilities to uphold in order to ensure that prisoner healthcare was meeting the EU and International standards. The main responsibilities of the NHS as outlined in the Memorandum of Understanding compiled by Scottish Government (2011, p. 6) are as follows:

• The management, training and support of directly employed health care staff, including support functions
• Ensuring that staff teams have an appropriate skill mix of professional staff, assistants and administrative staff
• Maintenance and replacement of all clinical fixed and non-fixed assets within health care premises.
• Training and development of staff for clinical and supporting purposes.
• Clinical performance management and monitoring, and prison liaison.

The Scottish Prison Service and individual prisons also undertook a number of responsibilities such as:

• Environments within prisons that protect and promote health and good hygiene.
  • Security and good order within health centres
  • General care and support of prisoners with health problems, including collaboration with care planning and delivery
  • Escorting functions for security purposes, both within and outwith the establishment.
  • Facilities management and cleaning services within the health centre
  • Training of clinical staff for purposes of working effectively and safely within the prison setting
  • Effective liaison with Health Boards and Scottish Government

Despite this agreement coming into play over two years ago, it is still evolving. Upon emailing on the 28th October (2013), a physiotherapist who is involved in the prison service mentioned that “because the transfer of prisoner healthcare to the NHS, the service is still developing and gaps in the service are being looked at”.

For example, the prison healthcare standards state that the provision of health care facilities will allow for a safe and effective delivery of healthcare with a designated area (minimum 16m²) available to conduct an initial health interview on entry to prison with conditions of privacy and confidentiality (Graham 2007). However, the issue of an aging population was highlighted by a physiotherapist who has experience of working in a prison as she acknowledges that there will be a significant amount of elderly patients in prison in the future and the cell environment is not the most appropriate for some of their disabilities and additional requirements.

Cost

Along with ensuring high standards of healthcare, the transfer of prison healthcare to the NHS may also be cost effective. A report of the prison healthcare advisory board (2007) reviewed the costs of prisoner healthcare. At the time the report was published, when the Scottish Prison Service had the responsibility for prisoner healthcare, the estimated current revenue investment in prison health services in Scotland was £16m. They emphasised that the need for healthcare in this small population was greater than both supply and demand (in that expressed need in a relatively disempowered population with multiple layers of health problem is incompletely expressed). £16m for this enhanced primary care service equates to over £2,100 per prisoner place per year. This figure is much greater than the average spend on every patient in NHS Scotland for all services. Upon transfer of responsibility to the NHS, cost saving measures could be made such as: "general practitioner services where the present agency arrangement would be replaced, avoiding potentially an element of premium cost. The buying power of the NHS through its National Procurement initiative is likely to derive cost benefits on purchasing prescription drugs and medical supplies” (Scottish Government 2007, p.27).

Focus Prisoner Education (2009) argue the point that although prisoners are entitled to NHS care as with any other British citizen, the facilities within the prison system are sometimes inadequate. This is simply because each prison cannot have its own hospital and and therefore can lack necessary equipment. The result is that prisoners often have to be moved from one prison to another, or to an outside hospital for treatment. This not only costs yet more money in direct expenses (administration, transport, guarding a prisoner while at a general hospital and so on) but can lead to delays in treatment. NHS (2006) mention that under original manual system, sick inmates requiring medical attention were taken to be assessed at hospital under a police escort incurring a charge of approx £2,500 per return visit. This cost entailed escort and bed duties only.

There is limited evidence on the cost effectiveness of NHS run prisoner healthcare however a financial review of prisoner healthcare was carried out recently by Scottish Government Finance Department (Miller 2013). The suggestion of the development of a formula for a cost per prisoner and this will be considered by the department of finance once the report has been signed off.

NHS Scotland financial summary for 2011/2012 found that the NHS had a £10 million underspend of their £10,537 million budget.  The report acknowledged that this was achieved despite managing the additional costs associated with increased activity in General Dental Services and General Ophthalmic Services and the transfer of responsibility for Prisoner Healthcare from the Scottish Prison Service (The Scottish Government 2013).

References

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