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, Katie McGregor, Kim Jackson, Niamh Coveney, Admin, Jo Hampton, Olajumoke Ogunleye, 127.0.0.1, George Prudden, WikiSysop and Vidya Acharya  

 

 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.

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 student and registered physiotherapists as well as other allied health care professionals who will be or may be asked to treatg 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.

 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.

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 six 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)

 What to expect 

 Conditions 

Msk Conditions

 

Overview

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. 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)

Prevalence and causes

Physical inactivity

Fischer et al. (2012) found that class A drug users had high levels of physical activity prior to incarceration. Their walking activity significantly decreased during their prison term, posing a challenge to maintaining healthy activity levels.

 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

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?

  Improper use of gym equipment and excessive weightlifting  

Another  cause for the large complaints of MSK pain in prisons is due to the weightlifting culture 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. (ref LB 8/11/13).
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.

Recreational 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 etc. 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.

Elderly Prisoners

 As our population is ageing, our prison population is also ageing, 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.

Physiotherapy

From our interviews we have found that the major injuries which prisoners present to physiotherapy 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

From above, it can be seen that many prisoners lead a sedentary lifestyle, lift heavy weights or participate in sporting activities which may contribute to the high numbers of MSK patients which must be treated in prisons each year. Physiotherapy can reduce MSK pain, as well as increasing cognitive function, reducing anxiety and depression, and enhanes quality of life. (find ref). MSK problems can be treated with a variety of techniques including exercise prescription, provision of equipment, education and injection therapy, however there are barriers to some of these treatment options which need to be considered (see barriers).

  

 Chronic Obstructive Pulmonary Disease   

Overview

Recently, the CSP's Frontline magazine highlighted the need for cardioprespiratory physiotherapy in prisons due the increased number of prisoners that smoke, further reinforced by a statistic reported by Conroy (2013) stating that it is estimated 90% of prisoners smoke. Furthermore, due to the increasing ageing population, the prevalence of chronic obstructive pulmonary disease (COPD) in prisons is also likely to increase, putting a greater demand on physiotherapists treating respiratory conditions, predominantly COPD.  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).

Insert NICE table**

 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: 

Pulmonary Effects	Extrapulmonary Effects
cilliary dysfunction	muscle weakness and wasting
mucous hypersecretion	cachexia
airflow limitation and hyperinflation	cardiovascular disease
gas exchange abnomalities	metabolic syndromes (diabetes, obesity, high BP)
pulmonary hypertension	endorcine effects
systemic effects	anaemia
	depression
	malignancies

Prevalence and Causes

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.  
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.

 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). Smoking cessation can gradually reduce your risk of getting COPD, or slow its progression if diagnosed in the earlier stages of the disease.

Initiatives are being made in efforts to decrease smoking rates in prisons. Most recently, a smoking ban has been proposed from prisons in England and Wales.

 Physiotherapy
 
Physiotherapy and COPD

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

No bar to treatment

    

 Mental Health in Prisons 

Overview

Prevalence and Cause

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)

Physiotherapy and Mental Health

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

 Equipment  

 Inside Treatment Room 

Working as a physiotherapist in a prison is extremely different to that of a normal outpatient clinic in a number of ways. After speaking to three physiotherapists who had experience of treating patients in a prison setting all mentioned that you are very limited in the equipment that you can use. 

In an interview conducted on November 8 2013, physiotherapist Linda Broomfield who works in a prison once a week, found that a lack of equipment posed quite a challenge for her. She reported that she works in a small room with a plinth and no other physiotherapy equipment on display. Items such as staplers, biros and tendon hammers must be kept out of reach of the patients as these are all potential weapons that could pose a threat to her or the patient themselves. If a patient requires a steroid injection, this must all be prepared prior to their treatment and kept in a cupboard until it's needed. The trolley and sharps box must be kept nowhere near the patient as she was forewarned that prisoners would reach inside the sharps bucket to obtain a needle for personal use.

Other practicalities that we take for granted in a normal clinical setting such as provided walking aids are also an issue in the prison setting. Linda spoke about the process of providing a prisoner with a walking aid as a quite time consuming one. As she is not allowed to keep any walking aids in the treatment room, if a patient does require one she has to contact a prison officer to supervise the patient while she goes to get the walking aid which are stored upstairs.

Attempting to rehab a patient in prison is certainly more challenging than a normal outpatient setting. This was evident in an phone conversation on 15 November with physiotherapist Erin ??? who visits one patient in prison. She mentioned that she only has a small space to work in making it difficult to practice transfers with her amputee patient. She is not allowed to give out thera-bands to patients and finds that compliance is an issue during rehab. Similarly, Linda also spoke about not being allowed to provide patients with thera-bands for rehabilitation purposes as again, they could cause significant harm. This means that you have to constantly improvise and in Linda's words “make the most of health care in a situational confinement”. For example, she advises patients to lift empty lemonade bottles when doing pain-free exercises for rotator cuff injuries instead of using a theraband. This can potentially impair rehab, for example, if a patient has carpal tunnel syndrome the metal plates must be taken out of the splint they use which can reduce the support provided. If a patient requires for example, a TENS machine or a knee support, Linda must provide the patient with a permission slip that will allow a friend/relative to buy it for them and bring it in. Or does she get them??.

In the same interview, Linda mentioned that the prisoners had access to a state of the art gym however due to the competitive nature of the prisoners; this often results in more injuries due to excessive weight lifting. A cardiovascular room is also available for patients to do their rehab in but only has a small number of machines.  In an email conversation on 18 October with physiotherapist Sara Thomson, she mentioned that in the prison that she works at, she has no access to gym equipment or rehab input at the gym. She finds that the general lack of equipment and resources is a barrier to treatment in prison.

As physiotherapists, we must always be able to improvise and adapt our treatment as appropriate. This is definitely the case in the prison setting where imagination is needed to think up of effective exercises with limited equipment ensuring that the best care is provided for the patient.

Security 

Occurrence of Incidence

• Personal alarms are given to staff members
• In a 4 year period (Jan 09 to Dec 12) 20 staff members took time of work as a direct consequence of an assault, the time taken off ranged from below 5 days up to 90 days.
• In 2012:
• 21 prisonser were reprimanded for recklessly endangering the health and safety of others
• 31 were punished for intentionally endangering the helath or safety of others
• 8 prisoner were punished for being disrespectful to any person other than a prisoner who is at the prison
• 3 prisoners were punished for trying to start a fire
• 4 people commited an indecent or obscene act
• 92 were punished for commiting an assault
  
• (SPS website Reference to follow)

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

References will automatically be added here, see adding references tutorial.

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