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The role of the specialist physiotherapist in the management of spasticity

Louise Lockley, Clinical Specialist Physiotherapist in MS and Spasticity Management, The National Hospital for Neurology and Neurosurgery, London

Way Ahead 2004;7(4):6-7

Development of a new specialist physiotherapist role

Spasticity is a common problem in multiple sclerosis (MS). In a survey carried out by the UK MS Society in 1999, 64% of people with MS had muscle stiffness and 51% had muscle spasms. Furthermore 31% reported that muscle spasms and stiffness were responsible for difficulties with daily activities [1]. A more recent study confirmed that spasticity is highly prevalent in the MS population and is significantly associated with a reduced level of functional independence [2]. In MS spasticity and spasms may occur at any stage from mild impairment to severe disability and the physiotherapist has a role throughout.

Physiotherapists specialising in the management of spasticity are rare in the UK but a few posts exist. The need for a specialism in this area is being increasingly recognised as the management of spasticity can be highly complex and requires the skills of a physiotherapist within a team to assist in assessment and the formulation of a comprehensive plan of intervention. The strength of the physiotherapist lies in their knowledge and practical experience in human movement and the ability to identify reasons for deviations in movement and function.

A clinical specialist post in MS and spasticity management was established in March 2003 at The National Hospital for Neurology and Neurosurgery with half of the role specifically allocated to the spasticity service. The core spasticity team now consists of the consultant neurologist, nurse specialist and this new post. It is timely to share the various components of this post.

This specialist role incorporates three key elements:

1. Expert clinical practice in the field of spasticity management that spans the disease process from new diagnosis to severe disability.

In the management of spasticity accurate assessment is critical to the formulation of a plan of intervention. My specific role with regards to assessment is to:

  • identify the trigger factors of spasm and increased tone with particular reference to those related to posture and movement
  • determine the relationship of the neural (active component) and non-neural (bio-mechanical changes) aspects of the spasticity
  • assess the usefulness and need for the spasticity and spasm to aid function
  • identify current and future detrimental effects of the spasticity or spasms, particularly the impact on soft tissue shortening, and the subsequent effect this may have on function
  • identify underlying muscle weakness and the impact this may have on function if the tone and spasms are reduced by an intervention
  • explore the potential for movement patterns and functional ability to be changed or improved
  • determine whether physiotherapy will be useful and whether other members of the team need to be involved

From the assessment, suitable individualised plans of intervention are made with the person to maximise the management of tone and spasms. Interventions range from advice to hands-on treatment but always with an emphasis on self -management in the long term.

Within this role the clinical caseload covers the outpatient multi-disciplinary (MDT) spasticity clinic, outpatients and specific interventions to those people admitted to the hospital for intrathecal baclofen or phenol trials. Essential to the clinical role is close working with all team members.

Integral to clinical work is liaison with other teams involved in people’s care, with lots of referrals identified to therapy and wheelchair and seating teams.

2. Education and advisory role

This is a resource role that forms a large part of my post. It is not only for the users of the service but also for other professionals within and outside the hospital. Calls are answered frequently from therapists around the country for questions on topics ranging from general information on physiotherapy intervention after botulinum toxin injections or intrathecal therapy to specific advice regarding individualised patient difficulties. If I do not know the answer then I generally know someone who may do.

Within the hospital the physiotherapy team uses my role to access expert advice, usually on a one-off basis. The most common requests are for an opinion on the appropriateness of botulinum toxin and the use of other adjuncts such as oral medication or splinting.

Education for the therapy and rehabilitation department is also part of this role. When this post was first established, a learning needs analysis was carried out with the physiotherapy team to identify where education was needed in individual areas. This led to a focussed plan of training being developed, which is now integrated into existing training programmes.

Requests are often made from outside groups for presentations on spasticity management and are undertaken where possible. This has provided a great deal of networking and useful contacts and an opportunity for sharing our skills and experience and learn from other practices. This also generates income that allows funding for subsequent courses and conferences. It has been highly valuable to present with the nurse specialist on the team so that we can give a more holistic view of spasticity management and promote effective teamwork.

3. Research and development of the service

The team is proactive in developing ideas to improve the service and part of my role is to be actively involved in this. The key development so far has been the introduction of an integrated care pathway to improve the patients’ pathway before, during and after the outpatient spasticity clinic.

My role also requires an up to date knowledge and awareness of progress in the physiotherapy world in general with regard to spasticity. To do this it is important to be involved in national groups and, of course, to keep abreast of new research participation and studies, and also to attend key conferences and study days. New information I acquire in this way is disseminated to the wider therapy and rehabilitation team to ensure that knowledge is shared and not kept only within the spasticity team.

Summary

This role was developed from physiotherapy input to the monthly MDT outpatient spasticity clinic to a greatly expanded post that provides specialist physiotherapy for the management of spasticity. The post incorporates various components, from clinical expertise to education, research and service development. Essential to the success of this role is the close working between the specialist spasticity team and the people who use the service.

References

  • 1. MS Society. MS symptom management survey. 1999; London: Multiple Sclerosis Society.
  • 2. Barnes MP, Kent RM, Semlyen J et al. Spasticity in multiple sclerosis. Neurorehabil Neural Repair 2003; 17(1):66-70

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