Are physical intervention techniques likely to cause pain or injury when applied to manage the severely aggressive older adult? A survey of physiotherapist's expert views in the UK

AIM

To establish whether a professional consensus can be established amongst musculoskeletal physiotherapists or whether they believe certain physical intervention techniques would cause pain or injury if applied to an older adult.

BACKGROUND

Physiotherapist involvement in the context of a multidisciplinary team framework to develop adaptive techniques as required for complex physical presentations has resulted in lower injury rates than in working-age adults. Physiotherapists are experts in anatomy and human movement and are ideally placed to contribute to the safe application of physical intervention in older adults.

DESIGN

A survey design was used.

METHOD

A questionnaire was developed and tested to ascertain the physiotherapist's opinions of the likelihood of each technique causing the patient pain and/or injury. The lead author distributed 41 questionnaires to physiotherapists in two busy hospitals in the UK.

RESULTS

Thirty-four (83%) of physiotherapists returned the completed questionnaires. The physiotherapists had particular concerns about the use of wrist flexion and kneeling on the older adult in prone causing pain and/or injury. Some other techniques that we have advocated in our earlier research were approved by many of the respondents, e.g. supporting the forearm with both hands proximal to the wrist joint. None of the physiotherapists had attended a physical intervention course or applied it in the clinical setting, thus enabling them to analyse the techniques purely from a biomechanical movement perspective. Implications for nursing practice are discussed.

CONCLUSIONS

It is anticipated that this research will stimulate nurses and course providers to develop patient group-specific physical intervention techniques and thus reduce the risk of causing them pain and/or injury.

RELEVANCE TO CLINICAL PRACTICE

This study reaffirms the heightened risks associated with applying restraint techniques to older adults. An issue that needs to be addressed is whether the duty of care which is explicit and implicit within the relationship between nurse and patient is to be fully discharged. It also reinforces prior research that has called for patient-specific physical intervention techniques and highlights some commonly used techniques that may have a deleterious effect on aggressive older adults. It also identifies the professional support that physiotherapists can offer to teams implementing physical intervention techniques within the context of clinical practice.

The shoulder: taking the strain during restraint

The decision to use or utilize physical intervention techniques is a contentious one. There has been much discussion on the complex legal and ethical dimensions framing the use of force. The risk of injury has also been considered in detail, but almost all of the published work has focused on restraint asphyxia, the prone restraint hold and the use of particular pain compliance techniques such as the wrist flexion hold. This paper focuses on the structure and function of the shoulder and examines how physical interventions and a variety of risk factors can threaten its physical integrity. This paper is for practitioners such as training commissioners, trainers, frontline staff and investigators or regulators who have to make considered determinations on the potential immediate physical impact of a variety of holds and escape manoeuvres. Sound risk assessment must be premised on a sound understanding of anatomy and physiology.

Managing the risks of physical intervention: developing a more inclusive approach

Since psychiatry evolved as a professional discipline, mental healthcare professionals have had to, as a last resort, physically intervene to manage physically aggressive patients. In the United Kingdom, physical intervention techniques migrated from the prison service in the mid 1980s where there was extensive use of two particularly controversial practices; 'pain compliance' and the 'prone restraint position'. This paper examines how the classification of the 'prone restraint position' has led to a narrowed focus on one technique and a resultant misunderstanding around the wider risks associated with the applying force and managing restraints. The paper goes on to propose the 'transitional stabilizing position' (TSP) as an alternative concept and puts forward a dynamic risk assessment model. It explores how a shift in staff training away from developing pure competence in the performance of tightly specified techniques to managing the patient in TSPs could conceivably reduce the relatively low risk of death or serious injury associated with the application of restraint techniques to an even lower level.

Physical intervention in older adult psychiatry: an audit of physical ailments identified by physiotherapists and the implications for managing aggressive behavior

Aggression and violence are frequent events in healthcare settings across the globe, with mental health and old age settings often frequenting top spot in incidence lists (Hodgson et al., 2004, Behar et al., 2008). Some may underestimate the challenging nature of older age psychiatric patients, but the reality is that this population can display high levels of aggressive and violent behavior (Stewart et al., 2008). The potentially challenging nature of this population was revealed in a recent study in the U.K., which reported 2753 episodes of aggressive behavior over a three month period (Stewart et al., 2008). Over half of these aggressive displays were in the form of physical aggression, and displays of this type of behavior increase the likelihood of healthcare staff having to employ physical intervention (Stewart et al., 2008). Physical intervention is a form of hands-on physical restraint that involves trained staff employing physical holding techniques to move and restrict the movement of the aggressive patient.

Physical intervention: a review of the literature on its use, staff and patient views, and the impact of training

As a principal control measure, physical intervention is intended to be a skilled manual, or hands-on, method of physical restraint implemented by trained individuals, with the intention of controlling the aggressive patient, to restore safety in the clinical environment. Physical intervention is however a contentious practice. There have been reports in the literature of negative psychological views from staff and patients on the procedure. Although formal structured training was introduced in response to concerns around patient safety during restraint, concerns remain that PI is sometimes construed as a stand-alone violence prevention initiative. Its potential for misuse, and overuse, in corrupted cultures of care has emerged as a social policy issue. The following paper critically explores the literature on training in physical intervention in the United Kingdom.

Correspondence

I would like to comment on Kamba and Rugg's article on An occupational therapy incomegeneration group for HIV-positive women in Uganda (Vol 15 No 2: p.74). The authors are to be congratulated for their well-executed project. Their close adherence to technical dimensions of qualitative research within a modern perspective yielded credible findings. Participants' voices are relied on to convey findings that can be used to guide similar projects in future. Purposive sampling, instead of convenience sampling, might have yielded different answers to the research question; specifically if such a sample included: