I have chosen to complete a reflection on the below presentations at the PMG Conference in July 2023, as I believe both approaches should always be linked when you are looking at addressing the management of posture:
- Is it time to rethink approaches to treating spasticity? by Professor Anand Pandyan (photographed)
- A client-centred, holistic approach to 24-hour postural management by Bex Oakes and Richard Millar.
As a physiotherapist in the Community Learning Disability Service (within the Hampshire area), 24-hour postural management plays a big role in our practice. The Standards of Practice for Physiotherapists - working with adults with a learning disability (S. Bruce et al 2019) describes it as an essential skill for any specialist physiotherapist to have to be able to meet the complex needs of service users diagnosed with a learning disability, who are unable to successfully access a mainstream service.
As a service we complete a complex holistic assessment to investigate and provide equipment. However, in certain situations, spasticity can present as a brick wall that leaves you unable to provide suitable equipment because of the uncontrolled and poorly managed spasticity and tone.
As Professor Pandyan underlined in his presentation, some service users will have had an “onset of spasticity … much earlier than reported”. Due to these service users depending on family members or care teams to raise referrals or liaise with GPs, by the time the therapists can intervene with a treatment plan, or positioning guidelines, it might be too late. Professor Pandyan was also able to demonstrate and present the evidence around the benefits of botulinum toxin in treating spasticity early; action that is not easily achieved in the community services, unless service users are admitted to hospital and receive an appropriate assessment and treatment plan.
At the end of conference, Bex Oakes presented a great case study which demonstrated the importance of multi-disciplinary team (MDT) work in the provision of bespoke equipment, and the immense benefit this has on an individual. This work was possible due to the way her service is commissioned to provide highly complex assessments and provision of equipment. Unfortunately, not all services receive the commissioning required to be able to look at provision of equipment; nor interventions to address the entire 24 hours a service user is being supported, from lying in bed, sitting in a wheelchair or armchair, to the level of medication that they are being administered, and activities they complete in different positions (lying or sitting).
In conclusion, there are teams and services with competent staff members who would be able to confidently complete a postural assessment, diagnose the issues an individual might present with, but who are not able to fully address these and achieve the wanted outcome.
Outcomes are instead limited by equipment provision, the lack of communication and reduced opportunities of joint working with other community services. There is often little possibility of reaching out to a rehabilitation medicine consultant in a timely manner to address the management of spasticity, to look at early interventions to reduce further deterioration in posture, which is further compounded by the length of time it takes to get funding for prescribed equipment. Bex Oakes underlined very well in her presentation that being able to assess needs holistically, and not with a service-by-service approach, can enable patients, and needed interventions should be seen as essential – not a luxury.
Although reassuring to know that other services are facing similar issues, the overall feeling is that you are letting patients down by not addressing needs that are “essential”.
Bruce S, Standley D, 2019, Standards of Practice for Physiotherapists - working with adults with a learning disability [https://acppld.csp.org.uk/system/files/documents/2019-11/9543_executive_summary_prof_final.pdf, Accessed September 2023]