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

Transcription

1 PreScribing- another tool in the Amputee Rehabilitation Physiotherapist s toolbox? Louise Tisdale Clinical Specialist Physiotherapist Amputee Rehabilitation Royal Wolverhampton NHS Trust November 2015

2 How? UK Physiotherapists -the first in the world to achieve full independent prescribing rights 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)

3 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

4 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.

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6 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.

7 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

8 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)

9 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.

10 A guide to amputee pain management Purpose Provides 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 Abbreviations Ax: 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 No Infection: antibiotics/wound care Oedema:shrinkage Rx; co-morbidity mgt Ischaemia: investigations; vasodilators, intervention Is there local tenderness to palpitation? Cause Yes Prosthetic: socket fit/ alignment vascular Bursa/ ligament/ tendon Rx: NSAIDs, PT, injection Muscle (trigger point) Rx: PT; injection Nerve (neuroma entrapment) Rx: prosthetic Ax & mods; meds; injection; Sx External causes Internal Causes Bone (spur, HO) Rx: prosthetic mods; Sx; XRT Intensive Rx as appropriate e.g. PTSD Evaluation & Rx: education & support; clinical psychologist Residual Limb Pain RLP Psychological factors Meds: NSAIDs Tricyclics Antidepressants Vasodilators Anti-spastic agents Pain Clinic N/S opinion Pain Phantom Limb Pain PLP Patient Information. Exclude causes of RLP that may contribute to PLP e.g. prosthetic fit Medical and Therapy interventions Therapies: Desensitisation/ handling & massage Percussion Electrotherapy e.g. laser TENS Thermal Rx Night sock Mirror box Exercise CBT/ distraction/ functional activities Pain unresolved Refer for neuromodulatory or neurodestructive procedures Assessment considerations Presence 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) Are there signs of autonomic dysfunction? Where pain is unresolved consider most appropriate member of the team to assess this may depend on presentation of pain No Yes Consider LBP, radiculopathy or vascular claudication CRPS?/ RSD? Px: desensitisation; meds; injection MRI lumbar spine; Duplex arterial USS Evaluation & documentation What is effective intervention? Be aware of simultaneous interventions Be systematic with recording Px interventions and evaluation

11 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

12 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

13 Residual Limb Pain-Nerve entrapment/neuroma (NICE 2013) Amitriptyline hydrochloride Duloxetine Gabapentin Pregabalin Capsaicin Cream 0.075% 5% lidocaine medicated plaster Return to chart

14 Complex Regional Pain Syndrome (NICE 2013) Amitriptyline hydrochloride Duloxetine Gabapentin Pregabalin Return to chart

15 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 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.

16 Evaluation Department of Health Funded Evaluation Project Prescribing data Clinical outcomes data Clinical supervision Significant Event Monitoring User Satisfaction Pharmacist Feedback

17 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

18 References BNF 69. (2015). British National Formulary; BMJ Group and Pharmaceutical Press; London CSP (2013) Medicines, prescribing and Physiotherapy, 3rd edition. medicines-prescribing-physiotherapy-3rdedn?networkid= HCPC (2014) NICE (2014) Osteoarthritis; Care and management in adults. CG NICE (2013) Neuropathic pain pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings

19 References NICE (2013) Clinical Knowledge Summaries-Hyperhidrosis NICE (2010) Clinical Knowledge Summaries- Analgesia-mild- moderate pain RCP (2012) Wandsworth NHS TPCT (2010) as featured in page 46.

20 Thank YOU Any Questions?