Effective Spasticity Management Requires a Team Approach

Effective spasticity management can be a challenge for a patient's healthcare team. Case managers (medical and vocational) and life care planners need to be aware of the variety of spasticity treatment options for optimal functioning of patients with spasticity.

Spasticity may be seen in patients with the following pathologies:

• Spinal Cord Injury
• Multiple sclerosis
• Stroke
• Cerebral Palsy
• Traumatic Brain Injury
• Other Neurodegenerative Diseases

The incidence of spasticity is not certain; however, it likely affects half a million people in the United States and over twelve million people worldwide.⁵

Ongoing patient evaluation and assessment may include one or more of the following common clinical rating scales: ⁴

• Original Ashworth Scale
• Modified Ashworth Scale
• Spasm Frequency Scale
• Global Pain Scale
• Medical Research Council Motor Testing Scale
• Adductor Tone Rating

The goals of the patient and caregiver are vital. Before treatment is initiated, the following should be considered: ⁵ Does the patient need treatment? What are the goals of treatment? What is the commitment of the patient and caregivers to the treatment?

An objective of spasticity treatment is not only to reduce treatment but rather include specific functional objective in the management of spasticity.⁵ The strategies are aimed at:

• Improving mobility: ambulation, transfers, and wheelchair mobility
• Improving ADL's: dressing and hygiene
• Maximize pain relief
• Improve ease of care
• Maintain skin integrity
• Optimize ROM, tone, and outcomes of PT/OT treatment
• Reduce spasms for improved sleep patterns
• Enhance oral/motor skills and speech
• Maintain employability
• Maximize learning for school age patients

Spasticity does not always require treatment; however, when it does, a range of therapeutic options is available.^2,3,5 Options may include one or more of the following;

• Reduction of precipitating noxious stimuli
• Traditional physical medicine and rehabilitation therapeutic exercise thermal agents electrical stimulation biofeedback
• Pharmacological Management oral medications botulinum toxin injections phenol and alcohol blocks intrathecal Baclofen
• Surgery Orthopedic: tendon transfers, musculotendinous lengthening, or joint fusions Neurosurgery: DREZotomy, selective dorsal rhizotomy

Case managers need to know the modes of spasticity inhibition, clinical effectiveness, as well as the adverse effects of the various treatment options. Treatment objectives need to be monitored for treatment effectiveness. Follow-up care is necessary to maximize treatment effectiveness. Adjunct physical therapy and occupational therapy1 is necessary for:

• Mobility training: transfers, gait, and wheelchair
• Therapeutic exercises for both stretching and strengthening
• Patient and caregiver education
• Reassessment of adaptive equipment needs, including seating, bathroom, standing, assistive
• Modification of orthotics
• Recommendation of positioning devices to maintain ROM

In summary, effective spasticity management for improved functional outcomes requires a team effort, thorough patient education, proper treatment selection, and follow-up monitoring and rehabilitation.

RESOURCES

1. Albany, K. "Physical Therapy and Occupational Therapy In Adult Patients Receiving Botulinum Toxin Injections For Spasticity". Muscle and Nerve, Supplement 6, 1997
2. Brin, M. "Botulinum Toxin: Chemistry, Pharmacology, Toxicity, and Immunology." Muscle and Nerve, Supplement 6, 1997.
3. Gracies, J., Elovic, E., Maguire, J., Simpson, D. "Traditional Pharmacological Treatments for Spasticity. Part 1: Local Treatments". Muscle and Nerve, Supplement 6, 1997.
4. "Spasticity Examination Rating Scales and Office Data Form." www.WeMove.Org
5. Vanek, Z. "Spasticity". www.emedicine.com/neuro/topic706.htm June 20, 2002