PreScribing- another tool in the Amputee Rehabilitation Physiotherapist’s toolbox?

Louise Tisdale

Clinical Specialist Physiotherapist Amputee Rehabilitation

Royal Wolverhampton NHS Trust

November 2015

How?

UK Physiotherapists -the first in the world to achieve full independent prescribing rights.

2013 – English Physiotherapists granted with the opportunity to gain Independent Prescribing rights(Scotland/ Northern Ireland and Wales 2014)

Enable them to give their patients rapid access to the necessary drugs they need to help with their conditions, without seeking a doctor’s agreement◦ 2000 – Patient Group Directions◦ 2005 – Supplementary Prescribing

An amendment to the Human Medicines Regulations 2013 (Physiotherapists and Podiatrists)

National Prescribing Centre’s Single Competency Framework

Initial clinical assessment

Communication

Knowledge of medicines

Evidence based practice

Clinical decision making

Shared decision making

Care planning and follow up

Documentation

Legal and ethical issues

Scope and practice

Continuing professional development

Prescribes safely

Public health issues related to prescribing

Complying with health care policy

The Physiotherapist undertakes Masters level training to meet the requirements of the Health and Care Professions Council (hcpc).

The development of the Physiotherapist was supervised by the Consultant in Rehabilitation Medicine.

90 hours of clinical prescribing preparation time

In anticipation of qualification, a review of NICE guidance for the management of hyperhidrosis, and nociceptive and neuropathic pain was carried out.

Clinical prescribing preparation time was utilised to further develop the Physiotherapist’s knowledge and skills in the Pharmacological management of pain and commonly presenting dermatological conditions in the amputee rehabilitation clinic.

Why?To improve the quality of care provided to individuals referred to a regional amputee rehabilitation service through streamlining access to pharmacological treatment of neuropathic pain, nociceptive pain (surgical and musculoskeletal) and dermatological conditions.

Aims of Physiotherapist Prescribing Medication

To widen the range of treatment modalities available to the Physiotherapist following assessment

To avoid a delay in the access to or change in medication needed

To maximise patient’s rehabilitation potential and maintain quality of life once achieved

To improve the use of the Consultant’s time in the weekly clinic

To safely improve clinical effectiveness and patient satisfaction

My Initial Formulary Gabapentin

Pregabalin (Lyrica)

Amitriptyline

Duloxetine

Tramadol (SP)

Lidocaine 5% medicated patches

Senna

Paracetamol

Ibuprofen

Codeine Phosphate (SP)

Aluminium Salts (Driclor or Anhydrol Forte)

Emollient with antimicrobial (Dermol 500 lotion)

What?An independent prescriber is someone who is able to prescribe medicines on their own initiative from the British National Formulary (BNF).

A supplementary prescriber is able to prescribe medicines in accordance with a clinical management plan. The plan is agreed between the supplementary prescriber, a doctor and the patient.

PurposeProvides an overview of the pathway for pain management in the amputee receiving rehabilitation at

Roehampton

Use as a tool to guide pain management for amputees who present with RLP

(residual limb pain) and/ or PLP (phantom limb)

Choose appropriate options and follow the pathways for

further assessment strategies or treatment

recommendations e.g. physical modalities,

medications

Highlights available resources and

modalities within the Centre

e.g. therapy interventions

Suggests alternatives if pain not

successfully managed

i.e. next stage in the

Pathway or onward

referral beyond the

Trust as necessary

Residual Limb

Pain

RLP

Phantom Limb

Pain

PLP

Yes No

Is there local

tenderness to

palpitation?

Infection: antibiotics/wound care

Oedema:shrinkage Rx; co-morbidity mgt

Ischaemia: investigations; vasodilators, vascular

intervention

Prosthetic:

socket fit/

alignment

External causes

Internal Causes

Pain

Patient Information.

Exclude causes of RLP that may

contribute to PLP e.g. prosthetic

fit

Psychological factors

Therapies:

Desensitisation/ handling &

massage

Percussion

Electrotherapy e.g. laser

TENS

Thermal Rx

Night sock

Mirror box

Exercise

CBT/ distraction/ functional

activities

Meds:

NSAIDs

Tricyclics

Antidepressants

Vasodilators

Anti-spastic agents

Evaluation &

Rx: education &

support; clinical

psychologist

Medical and

Therapy

interventions

Cause

Intensive Rx as

appropriate e.g.

PTSD

Muscle (trigger point)

Rx: PT; injection

Bursa/ ligament/

tendon

Rx: NSAIDs, PT,

injection

Pain Clinic

N/S opinion Refer for neuromodulatory

or neurodestructive

procedures

Pain unresolved

Are there signs of

autonomic

dysfunction?

Yes

Bone (spur, HO)

Rx: prosthetic mods; Sx; XRT

Nerve (neuroma entrapment)

Rx: prosthetic Ax & mods; meds;

injection; Sx

No

CRPS?/ RSD?

Px: desensitisation; meds;

injection

Consider LBP,

radiculopathy or

vascular claudicationMRI lumbar spine; Duplex

arterial USS

A guide to amputee pain management

Assessment

considerationsPresence of pain acknowledged

via routine physical Ax

Routine post-operative care, patient

information and reassurance frequently

sufficient for effective pain management

If pain persistent and interfering with rehab, perform

more specific ‘pain’ Ax e.g. apply modified McGill

Questionnaire and visual analogue scales

(ref here or whereabouts of qs)

Where pain is unresolved consider most appropriate member of the

team to assess – this may depend on presentation of pain

AbbreviationsAx: Assessment

Rx :Treatment

Sx: Surgery

PT: Physiotherapy

XRT: Radiotherapy

Mgt: Management

CRPS: Chronic regional

pain syndrome

RSD: Reflex sympathetic dystrophy

LBP: Lower back pain:

PTSD: Post-traumatic stress disorder

USS: Ultrasound scan

Evaluation & documentationWhat is effective intervention?

Be aware of simultaneous interventions

Be systematic with recording Px interventions and evaluation

Phantom Limb Pain (NICE 2013)

Amitriptyline hydrochloride

Duloxetine

Gabapentin

Pregabalin

Tramadol Hydrochloride (SP)

Choice dependent on;

Co-morbidities

Interactions

Patient choice

Potential issues with medication abuse

Adverse effects (desirable or not)

Return to chart

Residual Limb Pain- local tenderness(NICE 2014 ; BNF 2015)

1. Paracetamol

2. Topical NSAID or Topical Capsaicin (0.025%)

3. Oral NSAIDs +/- Paracetamol

4. Fentanyl Transdermal (IP) Tramadol Hydrochloride (SP) Codeine Phosphate (SP) or Dihydrocodeine (IP)

Return to chart

Residual Limb Pain-Nerve entrapment/Neuroma (NICE 2013)

Amitriptyline hydrochloride

Duloxetine

Gabapentin

Pregabalin

Capsaicin Cream 0.075%

5% lidocaine medicated plaster

Return to chart

Complex Regional Pain Syndrome (NICE 2013)

Amitriptyline hydrochloride

Duloxetine

Gabapentin

Pregabalin

Return to chart

Case Study TTA Male aged 65

Dysvascular – diabetic

Recently commenced use of the prosthesis at home

7 months post op – delayed limb fitting through wound problems

No report of significant or persistant PLP prior to onset

Patient phoned in with report of PLP

Reporting PLP – in his heel when in heel strike to mid stance, increasing with time on feet, limiting weight transference and prosthetic use

Advised patient to see GP

GP prescribed Tramadol Hydrochloride – 50-100 mg qds

Patient zonked… some benefit to pain but affecting ability to drive.

Physiotherapy treatment aimed at improving his control of hip extension to avoid excess knee extension thereby reducing pressure on posterior wall of socket.

Booked in with Consultant

Prescribed Pregabalin 25 mg nocte advice to increase to bd after one week

PLP infrequent, less severe and able to weight bear

Established Pregabalin, reduced Tramadol patient brighter and more alert.

Evaluation Department of Health Funded Evaluation Project

Prescribing data

Clinical outcomes data

Clinical supervision

Significant Event Monitoring

User Satisfaction

Pharmacist Feedback

Continuing Professional Development for Prescribing Non Medical Prescriber training

British National Formulary updates

Trust Formulary updates

Supervision by Consultant/Mentor

Development of knowledge and skills for changing guidelines for patient group

References BNF 69. (2015). British National Formulary; BMJ Group and Pharmaceutical Press; London

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

HCPC (2014) http://www.hcpc-uk.org/aboutregistration/standards/standardsforprescribing/

NICE (2014) Osteoarthritis; Care and management in adults. CG 177 https://www.nice.org.uk/guidance/cg177

NICE (2013) Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings http://www.nice.org.uk/guidance/CG173

References NICE (2013) Clinical Knowledge Summaries-Hyperhidrosis http://cks.nice.org.uk/hyperhidrosis

NICE (2010) Clinical Knowledge Summaries- Analgesia-mild- moderate pain http://cks.nice.org.uk/analgesia-mild-to-moderate-pain

RCP (2012) https://www.rcplondon.ac.uk/sites/default/files/documents/complex-regional-pain-full-guideline.pdf

Wandsworth NHS TPCT (2010) http://www.limbless-association.org/images/Guide_to_Amputee_Pain_Management.pdf as featured in http://bacpar.csp.org.uk/group-journal/bacpar-journal-issue-33-autumn-2010 page 46.

Thank YOU

Any Questions?