Anticipatory Care for Long Term Conditions in Physiotherapy

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Lucinda hampton, Tony Lowe, Tarina van der Stockt, Vidya Acharya and Olajumoke Ogunleye

Introduction

Long-term conditions (LTCs), also known as chronic diseases or non-communicable diseases (NCDs), are defined as physical or mental health conditions that require management over a long period of time. These conditions currently have no cure, but can be managed/controlled by medication and other interventions. They are chronic conditions that cannot be passed on from one person to another. They are caused by various factors, including genetics, physiology, the environment and an individual's behaviour.

Examples include:

• heart disease
• stroke
• cancer
• diabetes
• chronic lung diseases like chronic obstructive pulmonary disease and asthma

Stats and Facts

• Long-term conditions are responsible for 41 million deaths each year, accounting for around 70% of all deaths around the globe. This number is estimated to reach up to 52 million by 2030.

• Based on information from the World Health Organization, cardiovascular disease accounts for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million)
• 15% of young adults aged 11-15 years have LTCs
• 15 million of all deaths attributed to NCDs occur between the ages of 30 and 69 years
• An estimated 1·7 million (4% of NCD deaths) occur in people aged less than 30 years
• In Scotland, LTCs account for 80% of all GP consultations and patients with these conditions are twice as likely to be admitted to hospital
• In England, it is estimated that only 59% of people living with LTCs are in work, compared with 72% of the general population
• NCDs disproportionately affect people in low- and middle-income countries. It has been projected that by 2040, low- and middle-income countries will see significant increases in disability, illness, and premature deaths from NCDs

Causes and Risk Factors

"The main aetiology of long-term conditions are unhealthy or harmful behaviours. [...] Another factor to take in consideration for long-term conditions are health inequalities, which refer to the unfair and avoidable repartition of health outcomes in the population." -- Matthieu Haentjens

Unhealthy or harmful behaviours:

• Harmful behaviours contribute to LTCs. These include sedentary lifestyles, unhealthy diets, exposure to tobacco smoke or the harmful use of alcohol
• A 2019 population-based cohort study found that the absence of three risk factors (smoking, hypertension, and being overweight) delayed the onset of NCDs by nine years in individuals aged more than 45 years
• Similarly, being non-smoking, not having hypertension, and not being overweight are associated with longer life expectancies (of around six years) and reduced time spent living with NCDs (of around 2 years)

"These findings underscore the potential to substantially reduce premature NCD morbidity and mortality in the general population through prevention of smoking, hypertension, and overweight."

Health inequalities:

• Defined by the World Health Organization as: "avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies."
• The COVID-19 pandemic helped uncover and highlight numerous health inequalities. In the United Kingdon, the pandemic disproportionately affected "individuals from black and minority ethnic groups, poorer socioeconomic backgrounds, urban and rurally deprived locations, and vulnerable groups of society"
• One example of this relates to smoking. Individuals from marginalised groups are more likely to smoke and have more difficulty quitting smoking. While there is a general decline in the number of people smoking, "socioeconomic inequities in smoking prevalence and cancer mortality are widening."

The World Health Organization classifies LTCs contributing factors into the following categories:

Modifiable behavioural risk factors:

• Tobacco (including second-hand smoking)
• Excess salt/sodium intake
• Alcohol use
• Lack of, or insufficient, physical activity

Metabolic risk factors:

• Hypertension
• overweight/obesity
• hyperglycemia (high blood glucose levels)
• hyperlipidemia (high levels of fat in the blood)

Environmental risk factors:

• Air pollution
  • accounts for 6.7 million deaths globally, 5.7 million of which are due to NCDs, such as stroke, ischaemic heart disease, chronic obstructive pulmonary disease, and lung cancer

Impacts on the Individual and Society

Long-term conditions are associated with multimorbidities that impact the quality of life of the individual. These multimorbidities also burden the healthcare system.

Impact on the individual:

• People with multimorbidities have poorer functional status, quality of life, working capacity and health outcomes than those without multimorbidity.
• LTCs can negatively affect an individual's mobility and have social consequences such as limiting opportunities to leave the house, affecting self-care and being unable to get out of bed. The ultimate consequence of these factors can be social isolation, family conflict and stigma.
• Coping with long-term conditions can be difficult, stressful or disabling. Loss of interest, feeling guilty or responsible for the condition and low self-esteem can worsen the development of the disease. The affected person might also lose the ability to engage in activities that bring a sense of meaning and purpose to their life.

Impact on society:

• The economic burden of LTCs is significant. The United Nations has estimated that the cumulative loss to the global economy from LCTs could reach $47 trillion by 2030. The estimated cost of long-term conditions care in the UK was at £320 million in 2017.     

Healthcare Policies

Long-term conditions are a major concern for healthcare systems, which have tended to switch their model of care from reactive care towards anticipatory care to help manage these conditions.

In proactive care, "an individual seeks medical help before the appearance of symptoms in order to prevent illness, or detect and treat it early before the disease progresses or becomes chronic."

"Anticipatory care is a broad term that includes various strategies that physiotherapists can do on a day-to-day basis to prevent people getting ill in the first place or to get worse." -- Matthieu Haentjens

As mentioned, behavioural factors have a significant impact on LTCs. Altering these factors can help prevent and manage these conditions. Healthcare models can support the prevention and anticipatory care of LTCs by preventive measures, health promotion and encouraging patient advocacy.

Making Every Contact Count (MECC) is an approach to behaviour change, introduced by the NHS in the United Kingdom, that encourages healthcare professionals to utilise day-to-day interactions to promote changes in behaviour that have a positive effect on the health and well-being of individuals, communities and populations. It is designed "to embed chronic disease prevention into everyday practice and improve public health."

MECC focuses on lifestyle changes that can influence the health of individuals, such as:

• stopping smoking
• limiting alcohol drinking to the recommended limits
• healthy eating
  • healthy diets, such as the Mediterranean diet and the New Nordic diet, have been proposed as ways of reducing risk factors associated with NCD
• promoting physical activity
• maintaining a healthy weight
• promoting mental health and well-being

Read more about MECC here.

The MECC model was integrated into the physiotherapy practice by several organisations and has had successful outcomes in improving the health conversation and promoting physical activities.

Physiotherapy and Health Promotion

Physiotherapy has an important role in the prevention of LTCs throughout different stages:

1. Medial prevention by utilising different interventions (e.g. in cardiac rehabilitation for cardiac diseases)
2. Behavioural prevention by supporting individuals and encouraging healthy lifestyle measures
3. Social/environmental aspects by providing education on environmental measures and supporting occupational policies

The Making Every Contact Count model can be integrated into physiotherapy practice in four stages:

1. Screening of health status and identifying areas of change
2. Agenda setting by discussing needed changes with the patient
3. Readiness to change by discussing and assessing obstacles to change
4. Goal setting using SMART goals
   • As is highlighted in Figure 1. Smart goals should be specific, measurable, attainable, relevant and time-based
   • For more information on designing SMART goals, please click here

Figure 1. SMART goals.

Mental readiness can be an obstacle to lifestyle changes. As shown in Figure 2 and summarised below, there are six stages of mental preparation that rehabilitation professionals need to be aware of to help patients improve their health and well-being:

• Precontemplation: the patient is aware of the problem but not willing to take an action
• Contemplation: the patient is aware of the road to change
• Preparation: rehabilitation professionals can help by using SMART goals
• Action plan: based on identified goals
• Maintenance: where most people fail
  • rehabilitation professionals can help by encouraging and supporting the patient's commitment
• Relapse: if a relapse occurs, rehabilitation professionals can help by reassessing and setting new goals

Figure 2. The stages of behaviour change.

Self-management

Self-management is the process of enabling the patients to get control over their health and their treatment. And basically, it's the idea of doing things with the patient, instead of doing things to the patient" -- Matthieu Haentjens

The role of physiotherapists and rehabilitation professionals in self-management:

• support patients to get a proper diagnosis and understand the pathology clearly
• communicating with patients using open-ended questions that encourage patients to engage and reflect on their lifestyle and behaviour
• setting goals to show patients their potential
• utilising digital/telehealth: can help rehabilitation professionals connect with patients more easily, especially when travelling/commuting is challenging for patients. The availability of videos and pictures can make treatment simpler and easier for some patients to understand. Smartphone applications offer an easy and accessible interface and a range of technologies that facilitate participation in the treatment plan, such as exercise templates, online agendas, feedback in real-time and monitoring vitals. However, using digital health has some downsides, including the risk of data breaches and compromising patient privacy, as well as the high cost incurred, especially in low-resource settings. For more information on digital health and telehealth, please see: Introduction to Telehealth
• promoting the use of self-testing and vital signs kits (e.g. for diabetes and high blood pressure)
• utilising screening tests to help identify risks, such as walking speed tests (e.g. six-minute walk test) and the timed up and go test
• working in an integrated care team and using an effective referral scheme to connect patients with other services and direct them to support when needed