DOCUMENT 13 FOI 24/25-0889
Research Request – Botox, Splinting and Serial Casting
Research into Botox and splinting i.e. who can provide, what level of Brief professional needs and in what setting. Purpose is to assist planning practice guidance development.
Date 14 August 2019
Requester Kate s47F - persona
Researcher Aanika s47F - personal pri
Key issue ……………………………………………………………………………………………………………………………….. 2
What is Botox, splinting and serial casting? ………………………………………………………………………………. 2
Clinical use of botulinum toxin ……………………………………………………………………………………… 2
o Focal Spasticity Treatment – Difference between Adults and Children ………………………………. 3
o Botox neurotoxin ‐ Medicare Benefits Schedule ……………………………………………………………… 4
Serial casting ………………………………………………………………………………………………………………. 4
Splinting …………………………………………………………………………………………………………………….. 5
Who can administer Botox, splinting and serial casting? …………………………………………………………….. 5
Gaps in guidelines ………………………………………………………………………………………………………………….. 6
Where does it need to be administered? ………………………………………………………………………………….. 7
Commonly linked health conditions and impairments ………………………………………………………………… 7
Can splinting or serial casting be delegated? …………………………………………………………………………….. 7
NDIS documents to inform this position: …………………………………………………………………………………… 7
Key sections of Board Paper …………………………………………………………………………………………. 8
Key section of Attachment A ………………………………………………………………………………………… 8
Key sections from Plain English Guide ……………………………………………………………………………. 9
Key COAG APTOS passages …………………………………………………………………………………………. 10
Key Legislative passages……………………………………………………………………………………………… 11
External NSW Health paper …………………………………………………………………………………………………… 12
Recommendations ……………………………………………………………………………………………………………….. 13
Reference List ………………………………………………………………………………………………………………………. 14
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Note: The information in this document has been collated from various websites (mostly copy and pasted information). Where possible, journal articles and Australian based credible clinical sources have been used in the first instance, however provider websites have been used to fill in gaps.
Below each subheading in this document a summary of issues that may need to be considered in the development of planning guidance is included (purple table format as this one).
Key issue
The key NDIS planning issue with post-Botox therapies such as splinting and serial casting, is whether under NDIS legislation these health interventions should be reasonably considered to be a maintenance and therapy support OR a time-limited rehabilitation intervention.
What is Botox, splinting and serial casting?
Botox injections are used in conjunction with multiple types of rehabilitation therapies, splinting and serial casting are the ones that have received reasonable and necessary requests and have been raised by states and territories, particularly NSW.
Clinical use of botulinum toxin
Botulinum neurotoxin type A inhibits the release of acetylcholine from cholinergic motor and autonomic nerves. Intramuscular injection leads to muscle relaxation, and intradermal injection reduces sweat gland secretion. Repeat doses are usually required as the effect of the toxin wears off after 3-4 months. Therapy including stretching, splinting and strengthening may prolong the effect of muscle relaxation.1
Clinical indications
Considering whether to start a patient on botulinum toxin depends on balancing the risks of treatment against the potential improvements in active and passive function, level of pain, secondary effects of unwanted muscle over activity and quality of life. In Australia, specialist medical practitioners such as ophthalmologists, neurologists, surgeons, rehabilitation specialists and paediatricians may access the government’s Section 100 scheme. This provides reimbursement for the cost of botulinum toxin type A for the following conditions: blepharospasm spasmodic torticollis dynamic equinus foot deformity associated with cerebral palsy in children two years or over spasticity following stroke.
Botox is also approved for the treatment of strabismus in children and adults, focal spasticity of the limbs, primary hyperhidrosis of the axillae, and spasmodic dysphonia2.
Note: Information about all of these conditions can be found on the footnoted website – information about focal spasticity is included below as this is likely to be the most common support request in the NDIS context.
Focal spasticity
1 A Scheinberg, ‘Clinical use of botulinum toxin’, NPS Medicine Wise, 1 April 2019, https://www.nps.org.au/australian‐prescriber/articles/clinical‐use‐of‐botulinum‐toxin accessed 15 August 2019. 2 Ibid.
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Spasticity is one component of the upper motor neurone syndrome and is defined as a velocity dependent increase in muscle tone. Botulinum toxin type A is often used for managing hypertonicity in conjunction with other treatments such as splinting, stretching and strengthening antagonist muscles3.
Maximise gains of Botulinum Toxin-A (BoNT-A) with therapy
If there is enough clinical evidence to provide BoNT-A in the first place then there are gains to be made for the client and these should be maximised by therapeutic intervention - preferably a combination of OT and PT to ensure gains are made in muscle length, muscle strength, movement patterns, splinting is provided and as well as placing this into functional movement patterns and translated into task performance4.
Note: A 2015 study by Cusick et al. into ‘Upper limb spasticity management for patients who have received Botulinum Toxin A injection: Australian therapy practice’, found that there were significant issues with the lack of nationally consistent clinical guidance around Botox use and associated therapy access.
The report found that (1) shared care between the physician and therapist was not occurring, (2) post-injection therapy was not available to some patients, (3) therapist numbers were inadequate for demand and coordinated goal directed care was not being implemented5.
This highlights the need for a clear handover/delegation from the physician to the therapist providing the post-Botox splitting or casting.
o Focal Spasticity Treatment – Difference between Adults and Children
Focal spasticity is just one condition, but it highlight’s the difference between therapy support needs for children and adults.
Children
Ideally, children receiving treatment should have access to a multidisciplinary clinic where other interventions for spasticity can be considered. The largest group of children receiving botulinum toxin type A for spasticity are those with cerebral palsy.
Treatment has been shown to be effective in reducing equinus gait pattern in these children (injections to calf, hamstring and hip flexor muscles), improving upper limb function (injections to shoulder, elbow, wrist and finger flexor muscles), reducing pain (injections to hip adductors) and reducing the need for orthopaedic surgery.
Children with dystonia may also improve with botulinum toxin type A treatment, although muscle selection and dosing is clinically challenging.
Children with spasticity and minimal contracture, who have functional or care goals, may benefit from treatment as early as 12–18 months. In general, botulinum toxin type A is less effective, particularly in the lower limbs, beyond the first decade.
Adults
Spasticity in adults is seen most commonly after acquired brain injury, stroke, multiple sclerosis and spinal cord injury.
3 Ibid. 4 A Cusick, N Lannin & N.Z Kinnear, Upper limb spasticity management for patients who have received Botulinum Toxin A injection: Australian therapy practice’, Australian Occupational Therapy Journal, 2015, 62 (1), 27‐40, Table 3 ‐ ‘Issues related the therapy access’, https://ro.uow.edu.au/cgi/viewcontent.cgi?referer=&httpsredir=1&article=2360&context=sspapers accessed 14 August 2019,. 5 Ibid.
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Setting goals before treatment, along with the pattern of affected muscle groups and the tone abnormality, determines muscle selection. Early treatment with botulinum toxin type A after stroke has been shown to reduce disability and carer burden6. o Botox neurotoxin - Medicare Benefits Schedule Botox neurotoxin type A injections are covered under ‘Therapeutic Procedures’ under the Medicare Benefits Schedule.
There are approximately 18 MBS item numbers for different types of Botox injection therapeutic procedures.
Items for the administration of botulinum toxin can only be claimed by a medical practitioner who is recognised as an eligible medical practitioner for the relevant indication under the arrangements under Section 100 of the National Health Act 1953 (the Act) relating to the use and supply of botulinum toxin7. Serial casting
Note: Research indicates that serial casting is a more common therapy that accompanies the use of Botox than splinting.
Serial casting is a common procedure used to stretch and lengthen muscles. Children may have shortened muscles due to limited movement, muscle tightness or muscle stiffness called spasticity. Casting is a common treatment for the management of children who walk on their toes. For children with spasticity, serial casting may be used after Botulinum Toxin injections. The prolonged stretch provided by the cast may: increase the length of the muscle reduce the spasticity in the muscle improve your child’s walking pattern improve tolerance of ankle foot orthoses8
Serial casting is the application of plaster and/or synthetic casting materials, with cast changes until the desire length of muscle is achieved. The period of casting will depend on the child’s response and the outcome required. Most casting is completed within 3 weeks9.
Serial casting is an evidence based intervention for children with CP, to increase passive ankle range and the changes, while often small, are deemed clinically meaningful for children that require more dorsiflexion to walk. Botulin toxin injections are also clinically indicated for children with CP to help manage spasticity in the lower limbs10.
It is not uncommon for serial casting to follow Botox injections as evidence shows it can lead to a better result than Botox or serial casting alone when treating spasticity with muscle shortening.
The reduction in lower limb spasticity and improved ankle range of movement in children with CP is likely to lead to better functional outcomes when part of a multimodal intervention11.
The role of Botox in serial casting
Botulinum toxin, or Botox®, injections into the tight muscle can provide relaxation of the contractile tissue of the muscle and make serial casting more successful. This medication will block the release
6 Sheinberg, loc cit. 7 Medicare Benefits Schedule, Category 3 – Therapeutic Procedures – botulinum toxin injections, http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=18360&qt=item, accessed 14 August 2019. 8 Children’s Health Queensland Hospital and Health Service, ‘Serial Casting – lower limb’, https://www.childrens.health.qld.gov.au/fact‐sheet‐serial‐casting‐lower‐limb/, accessed 16 August 2019. 9 Ibid. 10 I Novak, et al, ‘A systematic review of interventions for children with cerebral palsy: state of the evidence’, Developmental Medicine & Child Neurology, Cerebral Palsy Alliance Research Institute, 2013, p. 11 Clinical practice Guidelines – Cerebral palsy, The Royal Children’s Hospital Melbourne, https://www.rch.org.au/clinicalguide/guideline_index/Cerebral_palsy/ , accessed 14 August 2019.
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of acetylcholine, a neurotransmitter, at the neuromuscular junction, which results in weakness or paralysis in the muscle (Cincinnati Children’s Hospital, 2009) and a reduction in spasticity. This effect usually takes 10 to 14 days, and it is best to wait until the injection is fully effective before putting on the cast. Serial casting is much more comfortable for a patient when the muscle is weakened and stretched out versus a muscle that is still fully contracting. This will increase the tolerance and the outcome when incorporated with the serial casting12.
Splinting
It was difficult to find academic information on splinting.
This information is from an OT provider:
Botox treatment is not permanent because nerve endings usually grow new connections to muscles that have not been exposed to Botox. In order to maximise the benefits of the Botox injections, Southern OT occupational therapists work with the clients treating Medical Consultant to fabricate a customised splint and provide rehabilitation. Rehabilitation focuses on retraining of the muscles around the site of the Botox injections and then retraining of the muscles injected as the effects of Botox wears off13.
Who can administer Botox, splinting and serial casting?
Only a physician can administer Botox injections. Injection therapy with botulinum toxin type A is only available on prescription from a doctor. It should always be given by a trained medical professional who is familiar with the correct technique. Your doctor will be able to let you know whether this treatment is suitable for you14.
The follow up therapy will be provided usually by a Physiotherapist or Occupational Therapist.
A NDIS / Rehabilitation provider has the following information on their website:
In Australia, Botox injections for spasticity are only given by Doctors15. They will usually either do so in private rooms or as part of a hospital spasticity clinic.
Prior to injection there should be a comprehensive assessment of the level of spasticity and what the goals of injection would be. An example of some goals may include weakening a muscle such as the calf to enable the opposite muscle an opportunity to strengthen, such as the dorsiflexors; weakening inappropriate muscle contractions to prevent contracture and tissue shortening, often seen at the biceps or weakening a muscle to prevent damage to skin integrity and maintain hygiene, often seen in the tight fists.
Goal planning is often best done in consultation with your physiotherapist. Once you have had the injection it takes around 4-7 days to take effect. You can then expect it to last around 3-4 months. Due to this, the minimum time you can have between injections is 3 months.
When your injection has started to take effect you should visit your physiotherapist to start on a program achieve your goals.
Physiotherapists and Occupational Therapists will work with you to get the most out of your injection by formulating a comprehensive treatment plan including a home exercise program. It is important to remember that this home program is a crucial part of your therapy, as the
12 Rainbow Rehabilitation Centers, Serial Casting, ‘Therapy News’, <http://www.rainbowrehab.com/RainbowVisions/article_downloads/articles/art‐fa12‐ therapy_serialcasting.pdf>, accessed 14 August 2019. 13 Southern OT, Post Botox Splinting and Rehabilitation, 2015, <http://www.southernot.com.au/post‐botox‐ splinting‐rehabilitation.html>, accessed 14 August 2019. 14 MyDR.com.au [website], ‘Botox Injections’, https://www.mydr.com.au/skin‐hair/botox‐injections, accessed 14 August 2019. 15 Advanced Rehab Centre, ‘Physiotherapy and Botulinum Toxin’, Feature article Multiple Sclerosis, 3 July 2013, https://www.archealth.com.au/2013/07/03/physiotherapy‐and‐botulinum‐toxin/, accessed 16 August 2019.
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limited visits with your therapist can never make up for the hours you can spend practicing and exercising at home.
The following are some different forms of therapy that may be used following Botox injection: Splinting – used to provide a prolonged stretch to a muscle by wearing the splint for a designated period of time each day. Orthotics – may be used to assist your walking by correcting foot position. Stretching – a manual stretching program may be given if splinting is not appropriate. Strengthening – now that a particular muscle group is more relaxed, it may be possible to strengthen another group of muscles that you previously couldn’t Electrical Stimulation – may be used in conjunction with a strengthening program to stimulate a particular muscle group. Functional Task Training – this can help you steer your therapy in the direction of your functional goals.
The important thing to remember is that the therapy after the injection is as important as the injection itself if you want to make any lasting meaningful change. The injection will relax the muscles, but the therapy associated with this will help you achieve your goals and improve your function. If you are thinking about having, or your doctor has mentioned, a Botox injection, then talk to your therapist now to enable you to get the most out of it16.
The Royal Children’s Hospital website says that:
Physiotherapists from the community and the physiotherapy department fill an important role in the early interventions and assessment for CP and play an important role in the ongoing assessment of treatment of children throughout their development.
Botulinum toxin (Botox) is sometimes indicated as an aid to dealing with spastic muscle disease. In some cases its use delays and prevents the need for surgical intervention. It is sometimes also used as an adjunct to surgery17.
This makes it clear that the actual administration of the Botox and the consumable is well within the health space and helps to delineate the responsibilities.
A physician will administer the Botox and create a treatment plan based on the person’s health needs. The follow up therapy aspect of this may then be provided by an NDIS funded OT or Physio.
It really highlights the need for a handover of health information.
Gaps in guidelines
At present Australian therapists must practice in the absence of national BoNT-A spasticity management guidelines and without therapy-specific guidelines in particular18.
16 Ibid. 17 Royal Children’s Hospital, ‘Cerebral Palsy and relayed conditions’, https://www.rch.org.au/ortho/department_sections/Cerebral_Palsy_and_related_conditions/, accessed 15 August 2019. 18 Cusick et al, 2015, p.9.
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In the 2015 study by Cusick et al, one research participant’s comment illustrates current gaps:
Most adult patients I have had experience with rarely see a therapist pre-injection. They also rarely receive post-injection therapy. If patients do have access to therapy services it is extremely uncommon that the therapist has the required skills to provide appropriate interventions such as casting, splinting and movement based interventions. The most significant issue is related to the model of service delivery for adults with a disability. Patient follow-up and monitoring over time is completely inadequate and patients are given their immediate post injection therapy and discharged. This is not appropriate for this patient population as their complex impairments need ongoing review and intervention.
The research concluded that:
Australian guidelines for BoNT-spasticity management and therapy specific guidelines are urgently required. Guidelines will provide a national benchmark for local practice improvement. Meanwhile therapists can improve their own process of care through professional development and consider implementing quality improvement activities to enhance local organization of care19.
Where does it need to be administered?
Botox must be administered in a clinical setting.
In Australia, therapeutic Botox injections for spasticity are only given by Doctors20. They will usually either do so in private rooms or as part of a hospital spasticity clinic.
Commonly linked health conditions and impairments
Botulinum toxin type A injections can be used to treat several medical conditions. Muscular conditions that can be treated include:
blepharospasm (twitching or spasm of the eyelid); cervical dystonia, or spasmodic torticollis (a type of muscle spasm in the neck); facial or other localised muscle spasms; muscle spasticity due to cerebral palsy; and strabismus (a condition where the eyes are not properly aligned)21.
Can splinting or serial casting be delegated?
No. Splinting, serial casting and other rehabilitation therapies must be performed by an appropriately trained allied health professional.
NDIS documents to inform this position:
To inform the practice guidance development on splinting, Botox and serial casting there are key sections of documents or legislation that need to be considered. Board Paper & Attachment A Plain English guide COAG APTOS
19 Ibid. 20 Advanced Rehab Centre, loc cit. 21 MyDR.com.au [website], loc cit.
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Supports for Participant Rules 2013 NDIS Act
Key sections of Board Paper
Exceptions
1.1. Exceptions would be items and services which require delivery or are provided in a hospital and/or clinical or clinical-like setting.
The clinical or community setting aspect of the post-Botox therapy is a key issue in this policy as many providers are now saying that the serial casting/splinting can be done in the home. This does not change the actual nature of the therapy though.
Key section of Attachment A
The Attachment A document states that:
Support Type 8: Botox and Splinting
Clinical intervention: NDIS Responsibility Therapeutic Botox Unlikely to be funded by the NDIS given clinical (Administration) use. However, funding assessed on a case by case and may be provided when it is a regular Splinting and rehabilitation after part of the participant’s daily life and results Botox from the participant’s disability. PBS impacts Botox is required for the rehabilitation or will need to be considered. treatment of a health condition. The treatment provides short term relief from muscle spasticity and is clinical in nature. Health System Responsibility All supports provided in a hospital setting or when not a regular part of the participant’s daily life or resulting from the participant’s disability.
Consumable: NDIS Responsibility Botox neurotoxin type A Nil. Botox neurotoxin type A is a Health System Responsibility pharmaceutical which is covered under the The Health System via PBS is the most Medicare Benefits Schedule (MBS) and appropriate provider for pharmaceuticals. Pharmaceutical Benefits Scheme (PBS).
The clinical rehabilitation versus maintenance therapy support question is still not answered with this information.
It simply notes that for some participants, in rare circumstances, splinting and serial casting will be a regular part of the participant’s daily life and result from the participant’s disability, and for others it will be related to the time-limited rehabilitative treatment of a health related condition.
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Key sections from Plain English Guide
How to determine if a support is related to a participant’s disability
In determining whether a health support is related to the participant’s disability, use the following determination: “The participant would not require this health support BUT FOR his/her disability”.
o If answered ‘yes’ the health support IS RELATED to the disability and the support is NDIS funded provided it is required on a regular basis.
o If answered ‘no’ the health support is NOT RELATED to the disability and the support is not NDIS funded.
What health supports will we not fund?
NDIS will not fund disability-related health supports provided in a clinical setting such as a hospital, health care centre, hospital-in-the-home or General Practitioner Practice Although there may be times when supports are provided in a health setting but still provided by the NDIS
o For example, in a rural, remote, or regional setting where the supports might be provided in a health centre due to thin markets or ease of delivery. that do not relate to a participant’s disability that are not required on a regular basis.
Again this information about supports related to disability does not clarify the Botox/splinting/serial casting support queries.
Splinting or serial casting may be related to the participant’s disability, but it is not necessarily required on a regular basis.
Botox and Splinting: caring for participants suffering from muscle spasticity
NDIS will only fund Botox/splinting supports OUTSIDE of a hospital or clinical environment
Administration of therapeutic Botox
o NDIS will fund the administration of Botox outside of a clinical setting where it is required as a direct result of the participant’s disability and needed on a regular basis
this is to be assessed on a case-by-case basis the likelihood of Botox being administered outside of a clinical setting is rare Administration of splinting and rehabilitation after Botox
o NDIS will fund the administration of splinting (and rehabilitation after Botox) outside of a clinical setting where it is required as a direct result of the participant’s disability and needed on a regular basis
this is to be assessed on a case-by-case basis
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the likelihood of splinting being administered outside of a clinical setting is rare Purchase of Botox neurotoxin type A
o NDIS will not fund the purchase of Botox neurotoxin type A Botox neurotoxin type A is covered under the Medicare benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS)
This policy basically states that NDIS funding can be used to fund post-Botox therapy:
If it is in a home or community setting
o (which was not usually the practice, however we are seeing providers now saying it can be done in these settings to get funding)
It is related to the disability
o (which will be argued for every NDIS participant case) Is needed on a regular basis
o (this is a point of contention because while it is a time-limited therapy, it is often provided in intervals e.g. every 3-4 months. If someone has a physician saying that a participant requires this periodic therapy as maintenance for an extended period of time it would meet R & N.
o If it is a one off treatment, it would be rehabilitation as per the COAG APTOS passages below).
Key COAG APTOS passages Health systems are responsible for funding time limited, recovery-oriented services and therapies (rehabilitation) aimed primarily at restoring the person’s health and improving the person’s functioning after a recent medical or surgical treatment intervention. This includes where treatment and rehabilitation is required episodically. The NDIS will be responsible for supports required due to the impact of a person’s impairment/s on their functional capacity and their ability to undertake activities of daily living. This includes “maintenance” supports delivered or supervised by clinically trained or qualified health professionals (where the person has reached a point of stability in regard to functional capacity, prior to hospital discharge (or equivalent for other healthcare settings) and integrally linked to the care and support a person requires to live in the community and participate in education and employment. NDIS: Allied health and other therapy directly related to maintaining or managing a person’s functional capacity including occupational therapy, speech pathology, physiotherapy, podiatry, and specialist behaviour interventions. This includes long term therapy/support directly related to the impact of a person’s impairment/s on their functional capacity required to achieve incremental gains or to prevent functional decline. Also includes allied health therapies through early intervention for children aimed at enhancing functioning. Health: Rehabilitative health services where the purpose is to restore or increase functioning through time limited, recovery oriented episodes of care, evidence based supports and interim prosthetics, following either medical treatment or the acquisition of a disability (excluding early interventions). When a participant is receiving time limited rehabilitation services through the health system, the NDIS will continue to fund any ongoing ‘maintenance’ allied health or other therapies the person requires and that are unrelated to the health system’s program of rehabilitation. Joint: Provision of specialist allied health, rehabilitation and other therapy, to facilitate enhanced functioning and community re-integration of people with recently acquired severe conditions such as newly acquired spinal cord and severe acquired brain injury.
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Key Legislative passages
NDIS Supports for Participant Rules
2.3 In relation to both general supports to be provided and reasonable and necessary supports to be funded, the CEO also needs to be satisfied of a number of matters, including the following:
(a) the support will assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations;
(b) the support will assist the participant to undertake activities, so as to facilitate the participant’s social or economic participation;
(c) the support represents value for money in that the costs of the support are reasonable, relative to both the benefits achieved and the cost of alternative support;
(d) the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice;
(e) the funding or provision of the support takes account of what it is reasonable to expect families, carers, informal networks and the community to provide;
(f) the support is most appropriately funded or provided through the NDIS, and is not more appropriately funded or provided through other service systems (service systems is defined in paragraph 6.4).
6.4 In these Rules:
service systems means general systems of service delivery or support services offered by a person, agency or body, or systems of service delivery or support services offered:
(a) as part of a universal service obligation; or
(b) in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability.
Health (excluding mental health)
7.4 The NDIS will be responsible for supports related to a person’s ongoing functional impairment and that enable the person to undertake activities of daily living, including maintenance supports delivered or supervised by clinically trained or qualified health practitioners where these are directly related to a functional impairment and integrally linked to the care and support a person requires to live in the community and participate in education and employment.
7.5 The NDIS will not be responsible for:
(a) the diagnosis and clinical treatment of health conditions, including ongoing or chronic health conditions; or
(b) other activities that aim to improve the health status of Australians, including general practitioner services, medical specialist services, dental care, nursing, allied health services (including acute and post-acute services), preventive health, care in public and private hospitals and pharmaceuticals or other universal entitlements; or
(c) funding time-limited, goal-oriented services and therapies:
(i) where the predominant purpose is treatment directly related to the person’s health status; or
(ii) provided after a recent medical or surgical event, with the aim of improving the person’s functional status, including rehabilitation or post-acute care; or
NDIS Act 2013
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34 Reasonable and necessary supports
(1) For the purposes of specifying, in a statement of participant supports, the general supports that will be provided, and the reasonable and necessary supports that will be funded, the CEO must be satisfied of all of the following in relation to the funding or provision of each such support:
(a) the support will assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations;
(b) the support will assist the participant to undertake activities, so as to facilitate the participant’s social and economic participation;
(c) the support represents value for money in that the costs of the support are reasonable, relative to both the benefits achieved and the cost of alternative support;
(d) the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice;
(e) the funding or provision of the support takes account of what it is reasonable to expect families, carers, informal networks and the community to provide;
(f) the support is most appropriately funded or provided through the National Disability Insurance Scheme, and is not more appropriately funded or provided through other general systems of service delivery or support services offered by a person, agency or body, or systems of service delivery or support services offered:
(i) as part of a universal service obligation; or
(ii) in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability.
(2) The National Disability Insurance Scheme rules may prescribe methods or criteria to be applied, or matters to which the CEO is to have regard, in deciding whether or not he or she is satisfied as mentioned in any of paragraphs (1)(a) to (f).
External NSW Health paper
A collaborative position paper on serial casting for children with physical disabilities put together by Cerebral Palsy alliance, Hunter New England Local Health District, Sydney Children’s Hospital Network and the Benevolent Society concludes that funding of this intervention rests with the NDIS as the therapy is
a. Directly related to maintaining or managing a child’s functional capacity
b. Directly related to the impact of a child’s impairment/s on their functional capacity and required to achieve incremental gains or to prevent functional decline
c. Required to achieve incremental gains or to prevent functional decline
d. It may also be part of early intervention for children aimed at enhancing functioning.
The paper states that Serial casting for children with physical disabilities is the application of plaster and/or synthetic casting materials to upper and/or lower limbs for the purpose of providing a prolonged stretch to the muscles over time. Serial casting for children with disabilities is a routine part of managing the impact of abnormal growth in children who have difficulty maintaining muscle length and joint range due to their underlying condition.
Serial casting is used for the management of muscle and joint contracture acquired through impairments associated with spasticity and muscle weakness in children with physical disabilities. Serial casting is not an intervention related to recovery from illness or injury. It is directly related to addressing functional goals by managing a common feature of an individual’s disability and the impact of growth and/or progression of the condition on function.
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Serial casting is only one intervention that can contribute to the maintenance of muscle length/joint range of movement and the achievement of functional goals related to the child’s underlying condition.
Several of the TAT advisors have had visibility of this collaborative position paper.
It should be noted that the NDIS did not have input into this position paper. It should also be noted that the Benevolent Society has been chosen to operate the NSW government’s specialist disability support services so has a vested interest in transitioning disability services to community settings22
While points a-d in the paper are all valid, TAT’s opinion is that elements of the paper are misleading, or do not provide the full picture of serial casting. For example: The position paper states that serial casting is the only disability related intervention for muscle length management, which has been deemed not the responsibility of NDIS (emphasis added). While, surgery is sometimes considered appropriate in managing contracture/deformity for children with CP. The paper also states that health services should remain responsible for acute and sub– acute casting such as required post-surgery or for acute intervention for fracture management, neglecting medical management. Whereas, later in the paper serial casting is noted to be an important part of the intervention post-Botox to help support the effectiveness of the botulinum toxin therapy.
Recommendations
The intent of the new disability related health support policy direction is to fund supports that are regular and ongoing health supports related to the participant’s disability.
While serial casting and splinting therapies are not realistically going to be a permanent part of someone’s ‘daily life’ for their entire life, these therapies may be an intervention that is regularly provided at intervals for the participant’s foreseeable future e.g. every 3-4 months for a few years with the aim of reducing further need for supports.
22 L Caneva, ’Benevolent Society to Take over NSW Govt Disability Support Services’, Probono Australia, 2 March 2017, <https://probonoaustralia.com.au/news/2017/03/benevolent‐society‐take‐nsw‐govt‐disability‐ support‐services/>, accessed 15 August 2019.
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Advanced Rehab Centre, ‘Physiotherapy and Botulinum Toxin’, Feature article Multiple Sclerosis, 3 July 2013, https://www.archealth.com.au/2013/07/03/physiotherapy‐and‐botulinum‐toxin/, accessed 16 August 2019.
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