Healthcare for Refugees: The Role of Physiotherapy
In recent years, over 1 million refugees and migrants have crossed borders into Europe. This migration represents a major challenge for health care systems. Refugees and migrants can have complex health needs as a result of trauma experienced in their home countries, during their dangerous journey, or in the period of adjustment to their new country. They also can face barriers to accessing healthcare services because of language and cultural differences, differences in socio-economic status, and a lack of familiarity with the local environment and healthcare system.
Many of the complex health needs of refugees can be addressed by physiotherapy. However, there is a lack of definition regarding the competencies that physiotherapists need to best serve this diverse population and a lack of common strategies to address the challenges of migration which have negative implications for health.
Physiotherapy and Refugee Education Project
Dr Emer McGowan and Dr Emma Stokes are members of the Physiotherapy and Refugee Education Project (PREP). This Erasmus+ funded research group is made up of researchers and clinicians from seven organisations across six countries. PREP aims to design, develop and deliver an online educational programme for physiotherapists to enable them to provide optimal services for people with refugee experience.
The first stage of the project was to conduct a scoping review to explore the available evidence and identify the competencies needed by physiotherapists working with people with refugee experience.
Analysis of included literature identified three key themes with five sub-categories:
- Determinants of health
- Physical health
- Mental health
2. Cultural competence
- Cultural sensitivity
3. Refugees and the healthcare system
The first theme encompassed the physical and mental health of refugees and factors that can have an influence on these. The second theme explored the cultural competence physiotherapists need to work with refugees. This theme included cultural influences on health and healthcare and communication strategies that can be used to optimize healthcare for refugees. The final theme described refugees’ experiences of healthcare and encompassed the challenges that they can face in accessing healthcare and navigating the healthcare system. The main physiotherapy competencies detected in the literature were an understanding of refugee health, the administration of culturally competent care and knowledge of healthcare systems as they relate to refugees.
This comprehensive search identified three themes that can be used to inform competencies that are needed by physiotherapists who are working with refugees. These themes are, however, rather vague and non-specific and signal the need for research to further examine the physiotherapy competencies necessary to provide the highest quality of care for this growing population.
Implications for practice
The review highlighted implications for clinical practice that physiotherapists working with refugees should be aware of. These include:
- Physiotherapists should be aware of the complex physical, mental and social problems which can contribute to poor health outcomes for refugees and impede their social integration.
- A significant proportion of refugees have been subject to torture (physical or psychological) which can have long-term consequences for their physical and mental health.
- Chronic pain is common in refugees, especially those who have experienced trauma and/or torture, and can have a significant impact on both physical and emotional well-being.
- Treatment plans should be tailored to the individual and a biopsychosocial approach that includes physical, psychological and social-contextual factors is needed to assess the total experience of pain.
- Physiotherapy interventions for patients with mental health issues can include psychoeducation about PTSD, breathing exercises, grounding exercises, basic body awareness therapy, mindfulness training, physical training, relaxation massage and cognitive behavioural training.
- Physiotherapists should be aware of the range of barriers that refugees can face to accessing care. Cultural barriers, stereotyping, communication difficulties and health professionals’ lack of cultural awareness can be difficulties experienced by refugees.
- Physiotherapists should be conscious of their own cultural background and how it may affect their responses to and care of patients in pain.
The scoping review has been published in Physiotherapy and is available at the following link:
Dr Cuisle Forde and Dr Emer Barrett’s national survey on physical activity behaviour during the COVID-19 pandemic features in the Irish Times & several other national papers.
Read the full preliminary report here; https://www.tcd.ie/medicine/physiotherapy/news/
COVID-19 Survey on Physical Activity Finds That The Majority Of People Are Exercising More During Restrictions
Researchers from the Discipline of Physiotherapy in Trinity College Dublin, Dr Cuisle Forde and Dr Emer Barrett, have released preliminary results from their national survey examining physical activity behaviours during the COVID-19 pandemic. The survey investigated whether people’s physical activity levels were impacted by the COVID-19 restrictions and looked at motivators and barriers to physical activity and exercise during this time.
The online survey was launched on May 2nd 2020, during nationwide stay-at-home restrictions aimed at reducing the spread of the virus. At first people were permitted to exercise within a 2 km distance from home, with the exception of those advised to cocoon. On May 5th, the distance permitted to exercise was extended to 5km from home and people cocooning could leave their homes to exercise.
To date, the survey has received almost 1500 responses, the majority of which were received after May 5th.
How have people’s physical activity levels been impacted since the COVID-19 restrictions?
- More than four in ten people felt they were exercising more since the restrictions.
- Almost three in ten people felt they were exercising less since the restrictions.
- Fifty four percent of people were meeting the recommended physical activity guidelines, which equates to a minimum of thirty minutes moderate intensity physical activity (enough to raise your breathing rate) on five days of the week.
- This compares to forty six percent of the population meeting the recommended guidelines in the last Healthy Ireland Survey 20191. Whilst our survey demonstrates increased levels of physical activity during the pandemic, differences in the way the data were gathered and measured may account for some of the variance between surveys.
- Almost nine in ten people reported walking in the last seven days.
- Almost half of people had found new ways to be active since the restrictions.
- Many people finding new ways to be active reported using online workouts.
What are the main motivators and barriers to exercise during the COVID-19 restrictions?
- More than nine in ten people were physically active because it benefited their mental and physical health.
- More than seven in ten people felt that it was more important to exercise since the outbreak.
- The main barrier to exercise was a person’s usual means of exercise being unavailable to them. This was reported by almost half of people.
- One in five felt that being unable to meet their friends limited their ability to be physically active.
- One in five felt that an increased workload limited their ability to be physically active.
Dr Emer Barrett said of the results: “The really striking positive result from this survey is the finding that almost half of all people report that they are exercising more during the COVID-19 restrictions. People haven’t let the closure of gyms, classes or the 5 km distance restriction limit their ability to exercise and are finding new ways to be active. It is very encouraging to see that there is a strong awareness of how physical activity can positively impact mental and physical health particularly at this time of crisis. We need to understand the factors that have facilitated or motivated this increase in activity with a view to maintaining them once restrictions are lifted”.
Dr Cuisle Forde added: “What we have to focus on now is understanding the reasons why almost 30% of people reported exercising less than usual. Our research will allow us to identify whether the decline in their activity is as a result of cocooning, work commitments, or caring for children or dependant others. Whilst the COVID-19 pandemic has impacted on everybody’s lives, it is likely that some people are experiencing more negative consequences than others and not having the opportunity to be physically active is one such example”.
The research team are currently analysing the data and preparing a publication which will present full results from the survey.
1. Ipsos MRBI (2019). Healthy Ireland Summary Report 2019. Available at https://assets.gov.ie/41141/e5d6fea3a59a4720b081893e11fe299e.pdf (accessed 12/05/2020)
Exercise prescription MOOC in collaboration with futurelearn now open.
If you work with clinical populations and are considering taking our online Certificate or Diploma in Clinical Exercise this free 2 week course might interest you. Our MOOC on exercise prescription for the prevention and treatment of disease runs twice a year in collaboration with Futurelearn and Trinity Online Services. Click the link below to join today.
Dr Cuisle Forde speaks about the benefits of exercise during a breakfast radio interview on the Voice of Islam.
Listen back to Dr Cuisle Forde speaking about the benefits of exercise on the Voice of Islam last week with Khalid. The recording of the interview, which begins at: 1:04:04, is available here https://soundcloud.com/voislam/breakfast-show-podcast-29-04-2020
Title: The role of physiotherapy throughout the COVID-19 recovery trajectory
From information available so far it appears the majority of people who get COVID-19 will suffer a mild to moderate disease and will recover. A smaller number (13.8%) will have severe disease and 6.1% are critical (https://www.who.int/publications-detail/report-of-the-who-china-joint-mission-on-coronavirus-disease-2019-(covid-19). Physiotherapists have a role throughout the COVID-19 disease trajectory from initial acute illness to recovery.
In the acute hospital setting, physiotherapists remotely screen referred patients using electronic records where possible and available medical information. This is to minimise unnecessary exposure to COVID-19 patients. They also link in with the health care team and access tests such as x-rays and arterial blood gases and will weigh up on a case-by-case basis if there is an indication or a need for physiotherapy treatment at this stage. Their skills in relation to the acute management of COVID-19 are mainly focussed on the following two areas;
(1) Respiratory focussed treatments in the critical care setting where specialised care is delivered and constant monitoring takes place
About one third of patients with COVID-19 in the critical care setting will have excess secretions or mucus which the physiotherapist will help to clear using a variety of methods. Techniques will be adapted to prevent spread of the virus, for instance the physiotherapist will position him/herself out of the path of expelled air if a patient coughs or huffs (exhalation though an open mouth) as part of treatment. Where necessary, suctioning (removing mucus secretions using a small tube or catheter) will be conducted as part of a closed circuit if possible rather than ‘open’ suctioning which involves temporarily disconnecting the person from the ventilator and thereby increasing the risk of air droplets spreading. A number of techniques to improve oxygenation can also be applied in this setting, such as ventilator hyperinflation or machine generated ventilator ‘big breaths’. They can also assist with prone positioning or placing the patient ‘face down’ to improve oxygen levels in the lungs.
(2) Physical focussed treatments in the critical care and ward settings
Physiotherapists will also help manage the complex physical rehabilitation needs of patients with COVID-19 in the critical care setting to try and prevent physical aspects of the ‘post intensive care syndrome’ or PICS.
Anecdotally, physiotherapists are finding many people recovering from COVID-19 in the critical care setting are extremely deconditioned or weak. Some need assistance with very basic tasks such as sitting up and need to progressively develop their strength and endurance with the assistance of a physiotherapist and the wider health care team. They can de-saturate or their oxygen levels can drop with the slightest physical effort. Some are confused and disorientated in this setting which can influence their ability to comply with treatment at times.
‘Early rehabilitation’ (or getting patients moving as soon as possible) is the aim where possible. Some patients can be complex, for instance many can be older and suffer from other comorbidities or conditions which need to be considered in terms of rehabilitation planning. Also they may have developed other complications such as kidney, liver and cardiac problems which makes treatment decisions complex and requires close collaboration with the multidisciplinary team such as intensive care doctors, other medical specialities, critical care nurses and other allied health professionals among others.
When it is safe, physiotherapists will deliver a progressive rehabilitation programme which may start at a very low level such as moving the limbs in bed and then sitting at the edge of the bed with assistance. Where possible, this will progress to standing, potentially with the use of electronic equipment and then walking based on the condition and endurance of the patient. These treatments will minimise the physical decline which can result from a critical care stay and help facilitate ‘weaning’ or coming off the ventilator and early discharge to less intensive settings.
Not all patients with COVID-19 will need to be admitted to the critical care setting. Many patients will be managed on a hospital ward where physiotherapists will also help manage respiratory and physical rehabilitation needs of patients. They will also continue treatment of patients who have been stepped down from the critical care to the ward setting to facilitate discharge home. Ideally, once home, patients should continue to exercise as building back muscle mass and restoring fitness is expected to take time.
Physiotherapists can also advise the following categories of people:
(1) People who have COVID-19 and don’t need hospitalisation who are self-isolating at home; for those that are physically vulnerable, it appears that low intensity exercise can be performed in the home environment, based on tolerance levels. People without any prior disease are likely to recover their physical capacity quicker but robust data is lacking on recovery profiles at this time.
(2) People who don’t have COVID-19 but who are vulnerable as well as those >70 years who are ‘cocooning’ at home should try to remain physically active and ideally do some strengthening exercises to prevent declines in muscle mass and endurance. For exercise advice while cocooning see this information from the Irish Society of Chartered Physiotherapists (ISCP), Health Service Executive (HSE) and gov.ie website.
Exercise during the COVID-19 pandemic - a lifeline, a privilege, an opportunity
The COVID-19 pandemic has changed the way we live and brings challenges for everyone on a daily basis. One such challenge is keeping physically fit. From the very outset of this pandemic, the importance of keeping fit was mentioned by the government, but with gyms, clubs, swimming pools and other such amenities closed, many people cannot get the exercise they’re used to. On the other hand, some people who may have been “time poor” due to work or long commutes may now find the time, but are out of practice. If you are lucky enough not to be sick, then whether you are self-isolating, cocooning or working from home, it’s important to stay healthy.
The benefits of exercise on your health are undisputed. If we stay moving during this pandemic we have a better chance of bouncing back to our pre-pandemic selves when this is over. People who exercise regularly are less likely to get ill and end up in hospital. Yes, keeping yourself healthy now will help our front-line health workers during and after this pandemic. As well as that, being active helps reduce stress and has proven benefits for our mental health, something many of us will be struggling with in these trying times.
A privilege and opportunity
Being able to exercise outdoors daily is a privilege during this crisis. It is something we should respect and use wisely. Exercise safely and alone or with members of your household. For many people, exercise is a social activity but learning to exercise alone is a skill that will stand to you. Those who can self-motivate to exercise are more likely to stay physically active over time. Challenge yourself to self-motivate and reap the benefits for a lifetime.
What can you do to keep fit?
It is important that we exercise safely. Those who do not usually engage in regular physical activity may choose to begin with walking or jogging. Healthy Ireland guidelines recommend at least 30 minutes of moderate activity a day, 5 days a week. That’s 2 and a half hours a week.To find out if you’re exercising at the correct rate for you, take the “talk test”. While exercising try to sing, if you are not able to sing properly but you are able to talk, then you are exercising at a moderate intensity. Keep it up! Another way to see if you are exercising at the right intensity is to count your steps. Taking 100 steps or more per minute when walking is moderate exercise for a healthy adult. Walking also helps your mental health, helping to reduce stress and anxiety. Perhaps the most interesting thing that all the research shows is that moderate exercise, like walking and jogging, has no negative effects. Walking may seem like a mundane activity, but evidence continues to mount in support of Hippocrates’s claim that it is in fact “man’s best medicine”.
Add an extra layer to your shield
For those who are cocooning or shielding it is also still possible to stay fit. There are safe exercise options you can do using little or no equipment that do not require much space. If you are not used to being active try marching on the spot for 30 seconds and gradually increasing the time to several minutes. You can do this while standing or sitting. Try exercising to music to keep movements rhythmical and help you to stay motivated. Going from a seated position to a standing position several times in a row with your arms crossed across your chest is a great exercise to strengthen your legs. It may sound, easy but even healthy young adults will feel their legs burn after three minutes of this exercise– try it!
Exercise isn’t just about being strong, it is also important to maintain flexibility, coordination and balance and these types of exercise can easily be done in the home. Challenge your balance by standing on one leg (touch a solid surface like the kitchen table to steady yourself if needed) or walk along a line (the join between floorboards for example). For more examples of exercises you can do while cocooning, PCC Physiotherapists in Cork along with the ISCP have published a brochure which is free to download here.
Think of being active today as a lifeline, a privilege and an opportunity. Imagine yourself looking back at your time well spent stacking health odds in your favour during the pandemic by keeping active. The take-home message? Keep moving, at a distance from others.