Physiotherapy can help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice, supporting people with a range of conditions, in particular neurological, musculoskeletal and cardiorespiratory problems.

The incidence of such musculoskeletal problems is thought to be three times higher among homeless people than the general population, sometimes due to traumatic injury, assaults or falls due to intoxication.

Research suggests that 78% of people who are homeless have physical health problems and many of these lie within domains where physiotherapists contribute to care.

However, homeless people’s health problems commonly include a ‘tri-morbidity’ of mental ill health, physical ill health, and drug or alcohol misuse, making it more challenging for them to engage with healthcare services than the general population.

Brain Injury

Research by the Disabilities Trust Foundation has shown that homeless have a high incidence of brain injury – as high as 48%. Symptoms can include paralysis, weakness, spasticity, poor balance and co-ordination, chronic pain and loss of stamina, impacting on people’s mobility and functional ability. Physiotherapists working with people who have neurological problems may provide exercise to help strengthen weak muscles, offer strategies to improve balance, improve pain with interventions such as Transcutaneous Electrical Nerve Stimulation (TENS) or acupuncture and provide walking aids to improve mobility, gait and balance.

Respiratory Health

Research by the charity Groundswell reveals incredibly poor respiratory health among homeless people, with diagnosed health conditions and lung diseases being dramatically higher than the general population. A key contributory factor is the high rate of smoking tobacco and illicit substances. Moreover, it is very likely that there is a high incidence of undiagnosed respiratory problems among homeless people. Respiratory symptoms can include shortness of breath, cough, reduced energy levels and low capacity for physical activity. Physiotherapists working in respiratory health can provide strategies for managing shortness of breath, advice on inhaler technique, clearance of respiratory secretions and help improve strength and physical activity levels using exercise prescription.

Barriers to Access

Rapid access to physiotherapy is vital in preventing acute musculoskeletal problems from becoming chronic, but recent research suggests that there are many barriers to homeless people accessing it. These barriers include logistical problems reaching clinics, the need for GP registration and an address to send appointments to. Consequently, homeless people can miss out on early interventions and can present later with more advanced and complex problems, compromising their health, and potentially increasing societal costs.

However, on the assumption that homeless people do not have the means to pay for private physiotherapy, the NHS should be the primary provider of physiotherapy to the homeless population.

NHS Physiotherapy can be accessed via GP referrals, hospital consultant referrals, or self-referrals. Although 98% of the English population is registered with a GP, statistics reveal that only 83% of single homeless people with accommodation, 89% of ‘hidden homeless’ people and just 65% of rough sleepers are registered. Despite guidance from NHS England stating that people without a fixed address should able to register with a GP, it is recognised that many still struggle to register. In these cases, a lack of GP registration will generally mean that primary care physiotherapy is inaccessible. Although in some cases it is possible to self-refer to physiotherapy, self-referral is not consistently offered UK-wide. For example, only six out of 32 London boroughs facilitate it.

Innovators in Practice

In some cities, specialist GP practices providing primary care for homeless people have an in-house physiotherapist working with them; however, these practices are very much in the minority. The voluntary sector also offers some provision of physiotherapy, for example, both Edinburgh and Leeds have volunteer-run services working in partnership with charities, offering basic physiotherapy assessment and treatment within hostels and drop in centres.

Another well-established service is Crisis at Christmas in London – a volunteer initiative providing homeless people with shelter, practical support and health services, including physiotherapy over the Christmas week. Although it only runs six days a year, 218 physiotherapy sessions were provided in 2016, suggesting that there is a demand, which may currently be unmet by mainstream services.

Summary

Homeless people are a heterogeneous population with complex and multiple comorbidities, but whose circumstances can inhibit access to physiotherapy. Bearing these difficulties in mind, and the difference simple physiotherapy interventions can make, perhaps it’s time to consider how to reduce barriers to services and focus on how to make it more accessible to this ‘easy to ignore’ population.

Jo Dawes

Senior Lecturer in Physiotherapy, Kingston University and St George’s, University of London

@DawesJo

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