Bernadette Porter

Managing Spasticity in People With Multiple Sclerosis: A Goal-Oriented Approach to Intrathecal Baclofen Therapy

ABSTRACT The effectiveness of intrathecal baclofen therapy (ITB) in the management of severe spasticity in people with multiple sclerosis (MS) was reviewed retrospectively. The multidisciplinary team reviewed the medical, therapy, and nursing notes of 19 people with MS who were treated with ITB. The audited information included surgical procedures, postoperative complications, medical side effects, dose requirements, and multidisciplinary input. Seventeen people were included in the audit. A total of 23 problems and 34 functional goals as objects for ITB treatment were recorded. Eighty-seven percent of the patients had sustained improvement in at least one problem, and 79% in at least one goal. Only two patients had no sustained improvement in any problem or goal. These results suggest that ITB can be an effective intervention in people with severe spasticity in MS. However, this approach requires careful patient selection, a dynamic goal-oriented approach, expert implantation, and ongoing evaluation of i...

Connecting to the future--the promise of telecare.

Telemedicine has been described as ‘the use of communication technologies to assist in the diagnosis and treatment of medical conditions through the transmission of data between two different physical locations.’1 Clinical applications include telephone advice lines, tele-consultations, video link consultations, clinical decision-making support software and vital sign monitoring services. Over the years, the name has evolved from ‘Telemedicine’ to ‘Telecare’ to reflect the multidisciplinary, integrated nature of modern health and social services. Programmes of telemedicine date back to the 1960s, coinciding with the development of the telecommunications industry. Early pioneering programs were restricted by technological challenges, high costs and lack of evidence on efficacy. In the past decade, new telecommunication technologies have created an explosive growth worldwide. Telecare is now well-established and has many mature applications, although global exploitation of the potential benefits remains fragmented. Spain, Italy, France, Norway, Switzerland, Scotland, Japan, USA and Australia are world leaders in the adoption of telecare.2 These leading countries have employed radical approaches to ensure that telecare is an essential part of service redesign, or is incorporated into preventive and selfcare agendas. Other countries are now beginning to realise that scaling telecare within a whole systems approach may radically improve health outcomes. This approach has been endorsed by the European Parliament, which concluded that ‘Telemedicine will only realise its full potential if Member States engage actively in integrating it into their health care systems.’3 Governmental support for telecare may reflect the growing realisation that many countries struggle to meet the ever-increasing demand for healthcare by people with longterm conditions. The escalation in numbers of people living with long-term diseases coupled with a global recession mean that health systems are under huge pressure to embrace new ways of working. In particular, there is a move away from a largely reactive approach towards integrated systems that enable people to self-manage and make choices. In the United Kingdom (UK), the Department of Health has funded a large-scale randomised controlled trial that cost more than £30m to test the capability of new technologies to support the remote management of over 6000 people with long-term conditions. The trial, known as the Whole System Demonstrator Programme, has recently published preliminary results. The headline findings show that if used correctly, telehealth applications can deliver a 45% reduction in mortality rates, a 20% reduction in emergency hospital admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs.4 The full trial results are due to be published in March 2012. As a chronic, long-term neurological condition, the management of multiple sclerosis (MS) could potentially benefit from telecare pathways. The fluctuating nature of MS means that timely assessment is essential; however, this is often difficult for health organisations to deliver. It is not unusual for MS clinics to be based within specialist tertiary care units, which means that people often have to make long journeys in order to access advice. In addition, mobility, cognitive, sensory and other physical disabilities that are associated with MS may restrict a person’s ability to attend and actively participate in clinic appointments. Despite the obvious potential advantages of applying telecare within the field of MS, its adoption has been slow. This may reflect a sluggish uptake within neurology in general, confusion over cost and reimbursement plans, and the absence of a robust scientific evidence base. Although anecdotal and quasi-experimental studies support the use of telemedicine, few high-quality studies exist. A systematic review of 1323 telemedicine papers identified many methodological flaws, including the fact that less than 5% of the studies reviewed had used a valid comparison group and few had follow-up data on clinical outcomes.5 The poor quality of the majority of research to date may be a consequence of the lack of funding in this area. Clinical sources of funding often deem telecare developments as research, while research funders often categorise telecare as clinical. This division can prove very challenging.6 One way forward may be to commission research projects that improve practice in relation to the organisation and delivery of healthcare, such that they build capability and capacity skills amongst those who manage, organise and deliver services.7 The pilot study by Zissman et al.8 published in this issue of Multiple Sclerosis Journal assessed the value of telemedicine in MS within a specialised MS centre. The findings suggest that people who are supported by a home telecare model experienced improvements in their level of symptom severity, lower medical costs and a high level of care satisfaction when compared to a control group of MS patients who received the standard care. The authors argue that home telecare offers an added value level of support. Connecting to the future – the promise of telecare 441273 MSJ18410.1177/1352458512441273Porter and ThompsonMultiple Sclerosis Journal 2012