Table I.

Summary of findings from in-depth interviews with UK healthcare professionals

Topic areas	Themes from interviews
Sources of patient referral	Physiotherapists in acute care or the community are most likely to refer patients with PSS for treatment, whereas GPs rarely refer unless advised by a therapist Some spasticity centres do not accept direct referrals from physiotherapists; they must come via a GP Seven interviewees felt that some groups of patients might be less likely to receive a referral for specialist treatment than others, for example, elderly patients in nursing homes who may have cognitive difficulties, patients with communication difficulties, and frail patients who may have difficulty complying with physical therapy
Screening and assessment of patients	8 out of 12 interviewees said that stroke patients are routinely assessed for spasticity while in acute care Assessment for spasticity on the acute ward is primarily carried out by physiotherapists Patients are rarely identified as being at risk of spasticity prior to spasticity onset
Treatment goals	Treatment goals for spasticity are mainly passive (though active treatment goals are relevant in some cases) and include improved hygiene, improved/maintained range of movement and preservation of skin integrity
Barriers to timely identification and treatment of patients with PSS	Level of awareness There is often insufficient awareness among HCPs outside the field of rehabilitation on the signs of spasticity, benefits of treatment and specialist spasticity services available Patients and their carers need to be educated about spasticity, the factors that can worsen the condition and the services and treatments that are available to help manage it High staff turnover in nursing homes can hinder measures to improve awareness of the signs of spasticity and benefits of early treatment Uncertainty among some HCPs regarding the effectiveness of some interventions may reduce the likelihood of referral Lack of capacity Capacity of specialist spasticity services varies greatly across the UK and lack of service capacity results in delays after referral Services are better developed in areas serving a larger population and with consequently larger numbers of patients more likely to be referred In some areas, individual services are not always well linked and communication between them is often limited reducing flexibility in service provision Nationally the number of stroke patients is increasing, which puts increased pressure on existing spasticity services Other barriers Emphasis on early discharge in the acute stroke setting means that most patients with PSS are referred after inpatient discharge and managed as outpatients, resulting in treatment delays Routine follow-up of stroke patients beyond the typical 6-week follow-up appointment is often limited. This reduces the opportunities for spasticity detection and referral Spasticity treatment is a small (but important) component of overall patient care and is not therefore identified as a primary focus for commissioning. In some cases, this means, individual funding requests are required for treatment with BoNT-A

BoNT-A: botulinum toxin A; GP: general practitioner; PSS: post-stroke spasticity.