Spinal Practitioner Service

The spinal Advanced Physiotherapist Practitioner (APP) service has been running for over 10 years. The team is an integral part of the NUH spinal service and includes clinical and admin staff. 

What is a spinal Advanced Physiotherapist Practitioner?

A spinal APP is a physiotherapist who has specialised in spinal assessment, management and care. 

Training includes post-graduate qualifications such as a Master’s degree and / or specialised training with the spinal surgical consultant team.  APPs are accountable to the Health and Care Professions Council.  APPs are required to keep up to date with evidence-based practice, role specific competencies and to demonstrate their ongoing capability, usually in a portfolio format.

What services do spinal Advanced Physiotherapist Practitioner offer at NUH?

The APP team work in the spinal outpatient department (elective pathway) and on the Neuro Spinal Assessment Unit (NSAU).  In outpatients, APPs run clinics for adult patients with spinal degenerative conditions and adolescent scoliosis patients.

On NSAU we run an emergency service for appropriate patients from A&E or patients referred urgently from the community.

Why are you seeing a spinal Advanced Physiotherapist Practitioner?

As most people with spinal problems do not need surgery, guidance in the UK recommends that you are seen an APP for specialist assessment and further investigations if required.  APPs can request MRI, XRs, injections and bloods tests. 

Neuro-spinal assessment area (NSAU) is an adult neurosurgery/neurology/spinal assessment area to help improve Emergency Department (ED) flow and reduce unnecessary admissions. The unit provides specialist triage for urgent and emergency presentations. The spinal component of NSAU is led by a Spinal Physiotherapy Consultant and includes highly experienced physiotherapists with advanced knowledge and skills in the assessment, diagnosis and treatment of spinal pain. Please read the attached leaflet (ST3 booklet v3.pdf [pdf] 444KB) for more information about what to expect if you attend NSAU (previously, ST3).

ST3 is our Same Day Emergency Care (SDEC unit). This Unit is designed to provide rapid access assessment and treatment planning for suspected serious spinal and neurosurgical conditions. The Unit’s remit is to assess you to decide if you need emergency surgery or other emergency intervention. You may be seen on the same day as attending the emergency department, the day after or a few days after seeing another health care professional, depending on the symptoms you have.

In these clinics we see patients with all manner of age-related conditions for consideration of spinal surgical management. Typically, patients are referred to see us by General Practitioners, Musculoskeletal (MSK) Triage services or other medical specialities following diagnostic imaging (MRI scans, X-Rays).

Patients will be seen by one of our Spinal Practitioner team who will take a detailed history, perform an in-depth examination and explain the results of any prior investigations in context. Via a shared decision making approach, the options for management will be discussed and the next steps agreed upon. This may well include further investigations, diagnostic injections, referral to other specialities or discussion for spinal surgery with our Consultant Surgeon colleagues.

The most common conditions seen include;

• Back and Leg symptoms due to nerve compression (Lumbar Radicular pain / Lumbar Stenosis)
• Neck and Arm symptoms due to nerve or spinal cord compression (Cervical Radicular pain / Cervical Myelopathy)

Who are Non-medical prescribers?

In our team we have several individuals who can prescribe medication that are not doctors. They have achieved a separate qualification for this and their prescribing is overseen by their professional body, which has a code of standards. This has to be within their scope of practise, which in our case is mostly pain relief and its associated medications.

What is Non-medical prescribing?

Non-medical prescribing (NMP) is the term used to describe any prescribing completed by a healthcare professional other than a doctor or dentist.

How do they become NMP’s?

Suitable practitioners complete an appropriate programme from a university. Non-medical prescribing programmes provide the knowledge, skills and training to prescribe medication safely and competently.

The Royal Pharmaceutical Society has created a Prescribing Competency Framework for all prescribers that has been designed to help student education, maintain prescribing standards and give guidance for those involved in NMP.

Why don’t we just have doctors prescribe?

Non-medical prescribing (NMP) builds on the practitioner’s ability to care and treat their patients. This ultimately enhances patient care by giving patients’ quicker access to treatment with medicines, helping to decrease waiting times and reducing hospital admissions. So you can get the right medication, quicker and hopefully feel better sooner.

As a progressive, research-based spinal service, we provide spinal injections as per the GIRFT (Getting It Right First Time) Guidelines for lumbar radicular (nerve root) pain. Specifically, our practitioners are trained to perform nerve root blocks under X-ray guidance inclusive of L4-S1 region of the lumbar spine. As practitioners, we are an integral part of your clinical assessment, discussion of MRI imagery and treatment planning. We aim to inform the decision-making of all patients concerning the judicious use of spinal injections as both diagnostic and therapeutic tools. We are there to fully explain and discuss the indications to inject and any common risks/complications of the procedures as part of the consent process.

Following the injection, all patients are reviewed at 6-8 weeks post-procedure to discuss their current presentation, queries and assistance with ongoing clinical planning. As injecting practitioners, we undertake regular reviews with senior spinal/pain consultants to ensure clinical currency and competence and collect data to allow for service / individual review. This also enables us to share good practice between hospitals to assist in the ongoing development of practitioner-led spinal injections services across the NHS.

Young people that get referred to the spinal unit who have a spinal curvature (kyphosis, scoliosis and/or spinal pain) may see one of the Advanced Physiotherapy Practitioner (APP) team for their initial assessment and future conservative management.  During this clinic appointment the APP will seek information about the history, ask questions about any previous medical intervention and perform a physical examination.  Part of this assessment may also involve certain tests or diagnostic images such as an X ray or an MRI scan.

For young people with a spinal curvature there is a possibility that the curve particularly during growth will become more exaggerated.  Monitoring for curve progression is achieved during a clinic follow up appointment where individuals will re- reassessed and further x rays taken at specific intervals.  In some circumstances a spinal curvature may require different forms of intervention such as physiotherapy and/or bracing.  This aims to halt the curve through growth.  Surgical intervention is also performed in some specific cases.

The options and management for all individuals will be very specific to their presentation and is developed through a process of outcomes shared decision making and choice between the young person and their parent (s) / carer and the APP and surgeon.