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NHS Trust
London North West Healthcare
Independent prescribing by physiotherapists in neurological rehabilitation:Management of spasticity with botulinum toxin
Dr Stephen AshfordRegional Hyper-acute Rehabilitation Unit, Northwick Park HospitalDepartment of Palliative Care, Policy & Rehabilitation King’s College London
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www.kcl.ac.uk/palliative
Spasticity - What and Why?• Result of brain or spinal injury• Muscle over-activity
• Upper Motor Neurone syndrome (UMN)– Positive feature
• Results in unwanted effects• Pain• Contracture• Increased contribution to disability
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www.kcl.ac.uk/palliative
Botulinum Toxin (BoNT)
• Produced by Clostridium botulinum• Serotypes A – G• Clinical preparations A or B• Licensed for spasticity in UK
– Products: Botox®, Dysport® & Xeomin ® (All type A)
• Effects• Blocks pre-synaptic transmission
– Neuromuscular junction
Dressler et al 2005
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www.kcl.ac.uk/palliative
BoNT – The Technical bit!
• Injection • Target muscles• Anatomical expertise required
• Electromyogram, Ultrasound• Expertise developed
• Prescribing/ Administration
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www.kcl.ac.uk/palliative
Physiotherapy prescribing• Integration of:
• Physical management– Different categories of patient need
– Active function – task practice training– Passive function – physical management
• Pharmacological management– Not just botulinum toxin
– Focal, regional, systemic
– Inpatient and community– Review and removal of unnecessary
medications
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www.kcl.ac.uk/palliative
Totality of treatment
• A complex intervention• Within an overarching rehabilitation or
management programme
• Physiotherapists can offer• Integration of care and treatment• Cost efficiency in providing
– all intervention in one place
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www.kcl.ac.uk/palliative
Independent prescribersPhysiotherapy Vs Medical
• N =139 undergoing spasticity management.
• Prescriber and injector• Physiotherapy n = 112• Medical n = 27
• All received concurrent therapy or a management programme
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www.kcl.ac.uk/palliative
Results• Goal Attainment Scale (GAS mean ‘T’ score)
• Physiotherapy = 50.2• Medical = 49.6
• No significant difference in:• GAS ‘T’ score• Arm Activity measure (ArmA)• Modified Ashworth Scale
• Significant clinical improvement in• Whole group for these measures
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www.kcl.ac.uk/palliative
Goal Attainment Scaling (GAS) -Outcome
Ashford and Turner-Stokes (2009)
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www.kcl.ac.uk/palliative
Research: BoNT Goal Categorisation• Goal-setting from
• five published studies of botulinum toxin treatment for upper limb spasticity
• To develop a goal classification for• Development of a structured approach to goal
setting and outcome evaluation
Ashford and Turner-Stokes (2006); Ashford and Turner-Stokes (2008); Turner-Stokes et al (2010); Turner-Stokes et al (2013); Turner-Stokes et al (2013)
Ashford, Fheodoroff, Jacinto, Turner-Stokes (2015)n
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www.kcl.ac.uk/palliative
Goal categories from GASConfirmation from ULIS II (n = 927)
0
50
100
150
200
250
Set
Achieved
Chart1
PainPain
Invol movementInvol movement
ImpairmentImpairment
Passive functionPassive function
Active functionActive function
MobilityMobility
OtherOther
Set
Achieved
145
120
90
76
207
173
235
195
174
127
28
22
7
4
Sheet1
SetAchievedSeries 3
Pain1451202
Invol movement90762
Impairment2071733
Passive function2351955
Active function174127
Mobility2822
Other74
To resize chart data range, drag lower right corner of range.
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www.kcl.ac.uk/palliative
Practice development:Goal directed care
• A system for:• Discussion of goals with patient and carers• Classification of goal• Evaluation of goals using
– Goal Attainment Scaling
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– Goal negotiation with patients, carers and MDT– Development of rehabilitation programmes
– Integration with spasticity intervention– Independent Physiotherapy Prescriber
– Undertaking botulinum toxin injections
– Research– Outcome measurement and goal attainment– Quantification of the totality of treatment
Physiotherapist contribution:
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www.kcl.ac.uk/palliative
AcknowledgementsThis paper presents independent research funded by the National Institute for Health Research (NIHR) UK and NIHR CLAHRC Northwest London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, NIHR CLAHRC Northwest London or the Department for Health, UK.
www.kcl.ac.uk/lsm/research/divisions/cicelysaunders/resources
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www.kcl.ac.uk/palliative
Resources• Ashford S, Siegert RJ, Alexandrescu R, (2015) Rasch measurement: The Arm Activity Measure (ArmA) passive
function sub-scale. Disability and Rehabilitation.• Turner-Stokes L, Rose H, Ashford S, Singer, B. (2015) Patient engagement and satisfaction with goal planning: Impact
on outcome from rehabilitation, International Journal of Therapy and Rehabilitation.• Fheodoroff K, Ashford S, Jacinto J, Maisonobe P, Balcaitiene J, Turner-Stokes L. (2015) Factors influencing goal
attainment in patients with post-stroke upper limb spasticity following treatment with botulinum toxin A in real-life clinical practice: sub-analyses from the Upper Limb International Spasticity (ULIS)-II Study. (2015) Toxins. 7, 1192-1205; doi:10.3390/toxins7041192
• Ashford S. Jackson D. Turner-Stokes, L. (2015) Goal setting, using goal attainment scaling, as a method to identify patient selected items for measuring arm function. Physiotherapy, 101, 88-94, http://dx.doi.org/10.1016/j.physio.2014.04.001
• Ashford, S Breckenridge, S Nyein, K (2014) Supplementary prescribing for spasticity management following acquired brain injury (ABI) – integration of physical and pharmacological management. Nurse Prescribing. 12; 9, 400-407.
• Ashford, S Brown, S Turner-Stokes, L (2014) Systematic review of patient reported outcome measures (PROMS) for functional performance in the lower limb, Journal of Rehabilitation Medicine. DOI: 10.2340/16501977-1889.
• Ashford S. Slade M. Nair A. Turner-Stokes L. (2014) Arm Activity Measure (ArmA) Application in Recording Functional Gain Following Spasticity Treatment, International Journal of Therapy and Rehabilitation, 21(1), Pages 10-17
• Ashford S. Turner-Stokes L. Goal Attainment Scaling (GAS) in adult neurorehabilitation. Chapter 7; Pages 119-137 In: Siegert R. Levack W. Ed’s. Handbook of Rehabilitation Goal setting. TAYLOR & FRANCIS (2014).
Independent prescribing by physiotherapists in neurological rehabilitation:�Management of spasticity with botulinum toxin�Spasticity - What and Why?Botulinum Toxin (BoNT)BoNT – The Technical bit!Physiotherapy prescribingTotality of treatmentIndependent prescribers�Physiotherapy Vs MedicalResultsGoal Attainment Scaling (GAS) - OutcomeResearch: BoNT Goal CategorisationGoal categories from GAS�Confirmation from ULIS II (n = 927)Practice development:�Goal directed carePhysiotherapist contribution:�AcknowledgementsResources