What was the problem?
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.
What was the solution?
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.
What were the challenges?
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.
What were the results?
- 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
- 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
- About 500 consultant neurology clinic slots per year were
freed, reducing the need for additional weekend consultant neurology clinics.
What were the learning points?
- A multidisciplinary team approach is important for the
management of spasticity.
- Physiotherapists and OTs have a significant role in managing
- 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.