Independent Prescribing in Spasticity Management

Gary Morris Advanced Physiotherapy Practitioner: Neurological Rehabilitation Glangwili General Hospital, Carmarthen Associate lecturer – Cardiff University

Plan

• Overview of spasticity management

• Physiotherapists & medicines

• Developing a service

Who does spasticity effect?

Stroke 54%

MS 20%

Spinal cord injury

8%

Traumatic brain injury

8%

Cerebral palsy 4% other

6%

Primary diagnosis of (non-LD) adults attending Carmarthenshire spasticity management service

What problems does it cause?

Spasticity

Skin damage

Difficulty with function

Pain Contracture

Restricted movement

Spasticity Management

Physical management

Medical management

Oral agents Intra

muscular agents

Intrathecal agents

Surgical management

Adapted from: Royal college of physicians et al (2009)

Therapists Patient Carers

Spasticity Management

Physical management

Medical management

Oral agents Intra

muscular agents

Intrathecal agents

Adapted from: Royal college of physicians et al (2009)

Assessment

• Diagnosis & history

• Aggravating factors

• Severity

• Distribution

Physical management

Therapists Patient Carers

Doctors

Spasticity Management

Physical management

Medical management

Oral agents Intra

muscular agents

Intrathecal agents

Adapted from: Royal college of physicians et al (2009)

Physiotherapists & medicines

Medicines

Administering

Patient specific direction (PSD)

Patient group direction (PGD)

Non medical Prescribing

Supplementary Prescribing

Independent prescribing

Administering

Spasticity Management

Physical management

Medical management

Oral agents Intra

muscular agents

Intrathecal agents

Adapted from: Royal college of physicians et al (2009)

Medicines

Administering

Patient specific direction (PSD)

Patient group direction (PGD)

Non medical Prescribing

Supplementary Prescribing

Independent prescribing

independent prescribing

“…prescribing by a practitioner responsible and accountable for the assessment of patients…and decisions about the clinical management required, including prescribing”

(Human Medicines Regulations, 2012)

What can physio’s prescribe?

• “…may prescribe any licensed medicine from the BNF” (apart from controlled drugs)

• “…for any condition within the practitioner’s area of expertise and competence”

• “…within the overarching framework of human movement, performance and function”

Chartered Society of Physiotherapy (2013)

Training

• At least 3 years of post grad experience & working in an area of advanced practice

• Up to 1 year part-time to train

• Minimum 38 days to include

– 26 days in University

– 12 days in mentored clinical practice with a designated consultant/GP

Training themes

• Initial clinical assessment • Communication • Knowledge of medicines • Evidence based practice • Clinical decision making • Shared decision making • Care planning and follow up • Documentation • Legal & ethical issues • Scope of practice • Continuing professional development • Prescribes safely • Public health issues relating to prescribing • Complying with healthcare policy

Independent prescribing

• Subject to the same competency framework as all prescribers

National Prescribing Centre (2012)

Independent prescribing

Adapted from: Royal college of physicians et al (2009)

Case study

• 24 yr old lady seen in Neuro outpatients

• Diagnosis: incomplete T5 SCI following removal of a vertebral tumour

• Presenting with:

– Clonus in ankle during weight bearing limiting progress with rehab

Developing a service

Get a doctor on board

Train as an injector

Prescribing solution

Medicines

Patient specific direction (PSD)

Patient group direction (PGD)

Independent prescribing

Support from pharma?

Sell the benefits

Conclusion

• Many people with long term neurological conditions will need a combination of physical and medical management to meet their needs

• Physio’s working in advanced practice are in a key position to meet these needs as prescribers

• Within spasticity management there is

experience, guidance & evidence available to support you to develop these roles

References • Chartered Society of Physiotherapy (2013) Practice guidance for

physiotherapist supplementary and/or independent prescribers in the safe use of medicines, 2nd edn. http://www.csp.org.uk/documents/pd026-practice-guidance-prescribers?networkid=226227

• Human medicines regulations (2012) http://www.legislation.gov.uk/uksi/2012/1916/pdfs/uksi_20121916_en.pdf

• National Prescribing Centre (2012) Single competency framework for all prescribers. http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf

• Royal college of Physicians, British Society of Rehabilitation Medicine, Chartered Society of Physiotherapy, Association of Chartered Physiotherapists Interested in Neurology (2009) Spasticity in adults: Management using botulinum toxin: National guidelines. https://www.rcplondon.ac.uk/publications/spasticity-adults-management-using-botulinum-toxin

Bibliography

• Chartered Society of Physiotherapy (2013) Medicines, prescribing and physiotherapy, 3rd edn. http://www.csp.org.uk/documents/pd019-medicines-prescribing-physiotherapy-3rd-edn?networkid=226227

• Healthcare Professions Council (2013) Standards for prescribing. http://www.hpc-uk.org/aboutregistration/standards/standardsforprescribing/

• Ben Goldacre (2013) Bad pharma: How medicine is broken an how we can fix it. 4th estate publishing, London

NHS: Gary.Morris2@wales.nhs.uk Cardiff University: MorrisGR2@cardiff.ac.uk Twitter: @Gary_y_ffisio