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

stephen.ashford@nhs.net

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

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

www.kcl.ac.uk/palliative

BoNT – The Technical bit!

• Injection • Target muscles• Anatomical expertise required

• Electromyogram, Ultrasound• Expertise developed

• Prescribing/ Administration

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

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

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

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

www.kcl.ac.uk/palliative

Goal Attainment Scaling (GAS) -Outcome

Ashford and Turner-Stokes (2009)

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

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.

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

– 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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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.

stephen.ashford@nhs.net

www.kcl.ac.uk/lsm/research/divisions/cicelysaunders/resources

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