Therapy-led spasticity interface service

The trust had no standardised pathway for the management of spasticity, resulting in disjointed patient care and inefficient use of resources. Patients were referred directly to overbooked consultant neurology clinics for spasticity management and to be considered for botulinum toxin injections. They faced long waits to see a neurologist. Additional neurologist clinics were held at weekends but at significant cost. Physical management is key to effective spasticity management, yet pharmacological management was being prescribed in isolation, resulting in suboptimal patient outcomes. There was no provision for the ongoing or long-term management of patients with spasticity.

A therapy-led spasticity interface service (SIS) provides a one-stop shop approach to spasticity management, including assessment, pharmacological review, botulinum toxin therapy, rehabilitation, postural management, splinting and orthotics, and support for self-management. The core therapy team consists of:

• two advanced practice physiotherapists with expertise in neuro-rehabilitation, injection therapy, learning and profound disabilities and postural management; one is a non-medical prescriber
  
• an advanced practice occupational therapist with expertise in neuro-rehab, splinting and injection therapy – the first OT in the country to be trained in injection therapy and administering botulinum toxin
  
• an assistant practitioner with expertise in supporting upper limb rehab, functional rehab and functional movement disorders.

The service uses patient outcome and experience measures to monitor effectiveness and inform future development. 

Accessing funding to support the business case for the SIS. This was overcome by presenting it as a way to improve the capacity of consultant outpatient clinics and remove the unsustainable costs of increasing weekend consultant neurology clinics. 

• 57 patients were transferred to the SIS from the consultant neurology botulinum toxin (BonTA) clinics.
  
• After assessment by the SIS team, BonTA injections were discontinued in 30% of patients transferred to the SIS.
  
• Over nine months, 108 patients were assessed (including those transferred from neurology).
  
• Only 49% of patients assessed by the SIS went on to have BonTA injections.
  
• Annual predicted spend on BonTA for patients transferred to the SIS reduced by 43%.
  
• 96% patients who have BonTA injections from the SIS improve their passive/active function.
  
• Referral-to-treatment time reduced from 34 weeks to seven weeks.
  
• About 500 consultant neurology clinic slots per year were freed, reducing the need for additional weekend consultant neurology clinics.
  

• A multidisciplinary team approach is important for the management of spasticity.
  
• Physiotherapists and OTs have a significant role in managing spasticity.
  
• OTs and physiotherapists with expertise in spasticity management are well placed to be first-contact practitioners for patients with a confirmed neurological diagnosis presenting with spasticity. 
  
• Having a therapy-led spasticity service improved the effectiveness and efficiency of service delivery.
  
• Detailed assessment, review and monitoring are essential to improve patient outcomes.
  
• Having an OT trained in administering botulinum toxin was invaluable for the team.
  
• Use other professional groups for peer support when developing new roles.
  
• The value of a service flexible and responsive enough to support community teams and inpatients.

Emma Cork, Neuro-Rehab Service Lead, emma.cork@nhs.net
Julie Cox, Advanced Practice OT, jcox1@nhs.net
Sue Mason, Physiotherapist Principal ALDS,  suemason2@nhs.net

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