Page 84 - IDF Journal 2023

IDF – Webinar Series IDF News – Spring 2023
Management of Spasticity
Professor Anthony Ward
Spasticity occurs as part of the response to an upper motor neurone injury. Several things can occur, depending on the size, age and location of the lesion and it is necessary to understand this before successful treatment can be instituted. Classically, spasticity appears several weeks after an acute insult to the brain or spinal cord, but acute muscle changes are seen, often in the presence of muscle weakness. Therefore, different patterns are commoner in different situations seen and the experience of a clinician
in acute care may be quite different from one in a rehabilitation unit. Figure 1 gives some of the situations seen and how delicate the balance between the features of immediate and delayed effects can be. Left untreated, spasticity gives rise to many problems, such as pain, spasms, limb contracture, and deformity leading to loss of mobility and dexterity, and hygiene/care problems, which can all result in decreased functioning, participation and poor quality of life.
Acute Care
Immediate
Paralysis
immobilisation in shortened position
Contracture
Figure 1 - Pathophysiological Pathway1,2
Management
The principle of management therefore, is to diminish the impact of the neurogenic component of the problem by reducing sensory inputs, in particular nociceptive stimuli, to maintain a stretch on a complex of limb and trunk muscles and through anti-spastic medication3. At the same time, the biomechanical aspects need to be dealt. The role of the multi- disciplinary team in the management of spasticity has been well-described and good nursing care, as well as optimal posture and physical therapy, underlie the basic principles of treatment (Figure 2).
Why is it Important to Treat Spasticity?
There is good evidence that spasticity may increase disability in people
following brain and spinal cord injury4. The evidence for treating, however, is less clear in terms of functional gain,
but many studies point to benefit. Most of these do not indicate the relative treatment value, i.e. how much treatment is required to make a critical difference on cost effectiveness, but better evidence is coming on line. Firstly, not all spasticity requires treatment – the early stroke patient may utilise spasticity in a limb
to allow standing when the underlying weakness would not otherwise allow it. Reducing the tone may render him more disabled and would not be beneficial.
Rehabilitation Unit
Damage to Central Motor Pathways
Flaccidity
Delayed
Plastic rearrangements
- spinal reactivity
- supraspinal command
Spasticity
Spastic dystonia Spastic Co-contraction) Other
Overactivity
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So, the prime indication for active pharmacological intervention is harmful spasticity.
Spasticity is a consequence of an upper motor neurone injury and shortens overactive muscles. Rheological changes occur within them to stiffen the limb, which contributes to biomechanical changes in the tendon and soft tissues5. This in turn leads to contractures and limb deformity. Therefore, treating spasticity involves managing both the neurogenic and biomechanical aspects of limb stiffness and this is one of the main reasons why spasticity is so difficult to measure and treatment is so difficult to evaluate. Neurological functioning demands a sensory input and those
with altered or lost sensation (somatic or special senses), or a cognitive disturbance, will be less likely to benefit from treatment. Therefore, careful selection of patients is necessary. There is always something that can be done for someone with spasticity, but the intervention’s overall usefulness or value needs to be considered. The treatment of spasticity is primarily physical, not pharmacological. This includes good nursing care, physiotherapy and/or casting/splinting. Nurses and therapists will often advise the doctor of the need for pharmacological intervention, if they feel they cannot adequately control the situation physically.