The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®).

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson's disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients' needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs:a prospective cohort analysis

OBJECTIVES: To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions. DESIGN: A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012–2015. SETTING: Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation. PARTICIPANTS: All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%). INTERVENTION: Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems. OUTCOME MEASURES: Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale—version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM). Primary outcomes: (1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community. RESULTS: The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in ‘weekly care costs’ was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8). CONCLUSIONS: Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services

Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic.

The COVID-19 pandemic severely impacted the function of medical facilities and rehabilitation services worldwide, including toxin services delivering Botulinum toxin treatments for neuromuscular conditions such as spasticity, dystonia, and sialorrhea. The aim of this paper is to understand how toxin services have dealt with the situation and what strategies have been adopted to continue services. The recommendations are based on a virtual round table held with toxin services experts from different European countries who shared their experiences and discussed the best practices. The challenges for toxin services were reviewed based on the experts' experiences and on relevant literature from 2020 and 2021. A set of recommendations and best practices were compiled, focusing firstly on guidance for clinical practice, including assessing patients' health and risk status and the urgency of their treatment. Secondly, it was discussed how patients on botulinum toxin therapy can be cared for and supported during the pandemic, and how modern technology and tele-medicine platforms can be generally used to optimize effectiveness and safety of toxin treatments. The technological advances prompted by the COVID-19 crisis can result in better and more modern patient care in the future

Module 1: Pathophysiology and assessment of spasticity; Goal setting

This module discusses the pathophysiology of spasticity and the lesions underlying the condition. It considers the clinical presentation of spasticity and outlines the relevant clinical history that should be documented. The positive and negative signs of spasticity are explained. Clinical presentations of spasticity are discussed, and an illustrated table of spastic limb postures details how the muscles involved in each individual's condition may be identified. The main systems for assessing the severity of the condition, the Ashworth Scale, the modified Ashworth scale, and the Tardieu Scale, are explained. The likelihood of spasticity developing following a stroke and the probable long-term outcomes are considered. The value of involving patients in their own treatment regimens, by defining and setting goals, using the SMARTER system is explained, and the need to continually assess and refine treatment with time as the condition progresses is also discussed

A pilot exploration of staff and service-user perceptions of a novel digital health technology (Virtual Engagement Rehabilitation Assistant) in complex inpatient rehabilitation

Purpose: Digital health technologies have the potential to advance rehabilitation. The Virtual Engagement Rehabilitation Assistant (VERA) is a digital technology, co-designed to increase service-user engagement and promote self-management. This qualitative study explored staff and service-user perceptions of implementing VERA on a UK complex inpatient rehabilitation ward. Materials and methods: Purposively sampled service-users were allocated to VERA for up to six weeks. The Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework underpinned service-user post-intervention interviews and staff focus groups, and structured analysis of the data. Results: Seven service-users were interviewed. Nine staff contributed to focus groups. A framework analysis identified themes (and subthemes) structured by the NASSS framework domains: 1. Nature of Clinical Condition, 2. Technology (Ease of Use, Holding Information/Resources in a single Digital Location, Appointments), 3. Value Proposition (Structuring Time, Feedback, Unexpected Benefits) 4. Adopters (Confidence in using Technology, Usefulness), 5. Wider Organisation. Conclusions: Ease of use and storage of key information in a single location were beneficial. Reliability, and provision of accurate and timely feedback to staff and service users, were identified as essential. A blended approach is required to meet staff and service-user needs. The potential for VERA in a community setting was identified and requires further investigation. Learning from VERA will support development of other digital technologies and their implementation