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Pharmacological Treatment
All pharmacological treatments are adjunctive to good physical management. This article does not describe the use
of oral anti-spastic drugs and deals specifically with the management of focal spasticity with botulinum toxin. There
is good evidence that botulinum toxin improves function and Brashear’s paper is of seminal importance in this respect6,7. In addition, there is a new way of assessing the impact of treating focal spasticity and the Disability Assessment Score, used by Brashear allows a principal therapeutic target to be chosen6. This actually reflects clinical practice and is therefore valuable as a clinical, as well as a research, tool. There are still, however, ways of utilising impairment changes to reflect functional change. Reduction of, for instance, adductor spasticity is known to have implications on ambulation (walking speed, stride length, etc.), symptomatic relief, and carer burden. Botulinum toxin
followed by physical treatment can prolong the clinical effect of the drug8 and treating the increased muscle tone early before rheological changes occur has been shown to allow a lower dose of the drug to be used with positive effects9,10.
Management of Long-Term Spasticity
The management of spasticity is thus based on having clear goals. The algorithm in figure 21 is applicable to patients in the long term. The decision
to stop treatment or to move from an active to a maintenance management programme is often difficult and there are no indications in the literature to guide the clinician. Another difficulty is that patients with progressive neurological diseases may have their spasticity governed by the disease rather than by their activities and may respond to spasticity treatment, but the pattern of their symptoms and signs simply change. It is therefore important
to have short and long-term goals and also that patients are assessed regularly to update those goals. When they do not achieve them, consideration can then be given to alternative means of management, such as surgery.
The most important feature in long-term care is good physical management.
The use of oral agents should probably be maintained, where active signs of spasticity persist and focal spasticity treatment, such as botulinum toxin should be given where the focal aims are clear. When a patient no longer responds to,
or does not maintain, the benefits of previous treatment for a sufficiently long time to justify either botulinum toxin treatments, then other means should be employed, such as surgery, but this article does not include this.
REFERENCES
1. Ward A B. Journal of Rehabilitation Medicine 2003; 41 (Suppl 1): 60-65.
2. Gracies J-M. Muscle and Nerve 2005; 31: 535–551
3. Bakheit AMO, Thilmann AF, Ward AB, at al. Stroke 2000; 31 (10): 2402-2406.
4. Ashford S, Turner-Stokes L, Ward AB, et al. Royal College of Physicians Report. March 2018.
5. Sheean G. Neurophysiology of spasticity. pp12-78. In: Upper Motor Neurone Syndrome & Spasticity. Eds. Barnes MP, Johnson GR. Cambridge. 2001. CUP. (ISBN 0 521 79427 7).
6. Brashear A, Gordon MF, Elovic E, et al. New England Journal of Medicine 2002; 347: 395-400.
7. Ward AB. Journal of Neural Transmission 2008; 115 (4): 607-16.
8. Shaari CM, Sanders I. Muscle & Nerve. 1993; 16: 964-969.
9. Cousins E. Ward A. Roffe C.et al. Clinical Rehabilitation. 2010; 24 (6): 501-513.
10.Lindsay C, Ispoglou S, Helliwell B, et al. Clinical Rehabilitation. 2021; 35 (3): 399- 409
11.Barnes MP. Overview of the clinical management of spasticity. pp1-11. In Upper Motor Neurone Syndrome & Spasticity. Eds Barnes MP, Johnson GR. (ISBN 0 521 79427 7) Cambridge. 2001. Cambridge University Press.
Professor Anthony Ward MBE BSc MD FRCPEd FRCP
The Basford Consulting Rooms 540, Etruria Road, Basford, Newcastle under Lyme, Staffs, ST5 0SX
T: 01782 614419
E: abward2017@outlook.com
EDUCATIONAL OFFERINGS
No
Treatment required to prevent complications
Spasticity Does it cause harm?
No
Yes
Monitor Only
No
Yes
Identify goals
Is the patient educated Yes about spasticity
Start self-awareness programme
Involve therapist ± orthotist for posture programme splinting, etc.
Spasticity still a Yes problem?
No
Treatable provocative factors
No
Yes
Remove
Spasticity still a problem?
No
Monitor
Yes
Consider oral medication
Spasticity still a problem?
Yes
Focal techniques (botulinum toxin type A, phenol, intrathecal baclofen.)
Spasticity still a problem?
Yes
Consider surgery
Figure 2 - Management of Spasticity1,4,11
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