Neurological Rehabilitation and The Management of Spasticity

NEUROLOGICAL REHABILITATION
Neurological Key points

rehabilitation and the C The World Health Organization International Classification of
management of spasticity Function, Disability and Health (ICF) provides a framework for
assessing patients and determining potential interventions
Valerie L Stevenson C Goal-setting allows clinicians to work with patients to target

Diane Playford interventions related to the patients’ perceived needs
C Spasticity management should aim to optimize function and

prevent complications rather than simply reduce tone
Abstract
Neurorehabilitation is often thought of as a stand-alone process
C Bladder and bowel dysfunction are common in neurological
occurring in a defined unit. However, patients with neurological condi-
disorders, but careful assessment can lead to effective man-
tions make up a large proportion of general medical admissions and
agement regimens
general practitioner consultations. They often present with an upper
motor neurone syndrome that requires careful management of their
weakness, disordered motor control, spasticity and bladder/bowel and distress as to diagnosing and treating disease. Rehabilitation
dysfunction. Spasticity management can be particularly challenging, processes should run parallel to neurological care at all times and
but is rewarding if physical and pharmacological measures are used in all settings.1 This introduction focuses on the rehabilitation
appropriately and in a timely manner. This review attempts to explain approach and identifies simple interventions that can in acute
the process of rehabilitation and how it can improve the care of neuro- settings improve the care of people with long-term neurological
logical patients in all settings. Through the basic principles of rehabil- conditions and prevent complications.
itation e assessment, goal-setting, intervention and evaluation e
function can be optimized while preventing complications and mini- What is rehabilitation?
mizing distress to patients, families and carers.
A rehabilitation service comprises a multidisciplinary team who
Keywords Bladder; bowel; goal-setting; MRCP; neurorehabilitation; work towards common goals for each patient. They involve and
rehabilitation; spasticity; upper motor neurone syndrome educate the patient and family, and aim to resolve common
problems their patients face. Rehabilitation is an iterative, active,
and educational problem-solving process with the following
components:
assessment e identification of the nature and extent of the
Neurorehabilitation in context patient’s problems and the factors relevant to their reso-
lution. This is best done by a multidisciplinary team using
Neurological conditions are common: 17% of general practi-
the shared language and framework of the World Health
tioner (GP) consultations are for neurological symptoms, and
Organization’s International Classification of Function
19% of hospital admissions are with a neurological problem
(WHO ICF)2
requiring treatment from a neurologist or neurosurgeon; typically
treatment-planning e usually through patient-centred
long-term conditions such as stroke, multiple sclerosis (MS) and
goals that focus on participation
Parkinson’s disease.
intervention e treatments that can be medication based,
People with long-term neurological conditions often express
physical (occupational therapy, physiotherapy, speech and
concern that acute care is not tailored to their needs, their
language therapy), psychological or surgical, and are tar-
expertise in their condition is ignored and basic care needs are
geted at pathology, impairment, function or the environ-
not met (e.g. if they cannot access a shower in hospital). Reha-
ment, as well as care that maintains the patient’s quality of
bilitation should always be central to healthcare, with as much
life
attention given to a patient’s functional activities, social roles
evaluation e to check on the effects of any intervention.
Rehabilitation should maximize patients’ participation in their
social setting and minimize distress for patients and their carers.
Valerie L Stevenson MD MRCP MB BS is a Consultant Neurologist and
Clinical Director for Rehabilitation at The National Hospital for Assessment
Neurology and Neurosurgery, UCLH Trust, Queen Square, London,
Definitions in the ICF are shown in Table 1. The relationship
UK. She leads the Multidisciplinary Spasticity Management Team
within Neurorehabilitation Services. Competing interests: none between impairments, activities and participation is not linear
declared. and is moderated by personal factors such as education, family
beliefs and environmental factors (Figure 1). The latter can be
Diane Playford MD FRCP is a Professor of Neurological Rehabilitation
physical (a lack of hoists or shower chairs preventing access to
at Warwick Medical School, University of Warwick and Honorary
Consultant in Rehabilitation Medicine at the Central England bathrooms in hospital) or social; this includes legislation such as
Rehabilitation Unit, South Warwickshire Foundation Trust, UK. the UK Equality Act 2010 or the attitudes of others (e.g. people
Competing interests: none declared. with disability being labelled as ‘bed-blockers’). Formulating the
MEDICINE xxx:xxx 1 Ó 2020 Published by Elsevier Ltd.
Please cite this article as: Stevenson VL, Playford D, Neurological rehabilitation and the management of spasticity, Medicine, https://doi.org/
Descargado para Manuela Gomez Gutierrez (mgomezgut@unbosque.edu.co) en Universidad El Bosque de ClinicalKey.es por Elsevier en septiembre 05, 2020.
10.1016/j.mpmed.2020.06.003
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
learn a new technique in physiotherapy or performs poorly in a

Definitions in the World Health Organization simple task in the kitchen. Ideally, the multidisciplinary team
International Classification of Function should comprise the patient and their family, a doctor, a phys-
iotherapist, an occupational therapist, a speech therapist, a nurse
Body functions and a psychologist. However, on acute wards the nurse and
C Physiological functions of body systems (including psychological doctor often form the core team and should recognize when
functions) assessment by a physiotherapist or occupational therapist would
Body structures
be helpful.
C Anatomical parts of the body such as organs, limbs and their
Once the multidisciplinary team has assessed the patient, it is
components
worth considering relevant risks. For example, a patient who has
Impairments
difficulty moving around in bed is at risk of pressure sores, and if
C Problems in body function or structure
Activity unable to do stretching exercises or stand, could develop con-
C The execution of a task or action by an individual tractures that would hinder their return home. To prevent this, a
Activity limitations goal-oriented programme is put in place.
C Difficulties an individual can have in executing activities
Participation Goal-setting
C Involvement in a life situation A goal is described in terms of ‘will be’ at some specified time in
Participation restrictions the future. It is a desired state that requires both action and effort.
C Problems an individual can experience in involvement in life Typically, goals are ‘SMART’, i.e. Specific, Measurable, Achiev-
situations able, Relevant, Timely.
Goals require a process of discussion and negotiation in which
Table 1 the patient and staff determine the key priorities for that indi-
vidual, and agree the performance level for defined activities that
patient’s functioning in this way allows a consideration of how the patient should attain within a specified time frame.3 Goals
their difficulties should be tackled. should be distinguished from staff actions, such as prescribing
Table 2 illustrates the typical problems and diagnostic antibiotics. There is no consistent evidence that goal-setting im-
formulation for a patient with MS who previously walked short proves people’s functional abilities after rehabilitation or how
distances with a frame and was independent for self-care but has hard they try with therapeutic interventions during rehabilita-
been admitted to hospital with a urinary tract infection (UTI). It tion, but there is a growing view that the process of goal-setting is
highlights issues and allows goals to be set so the patient can important as it builds self-efficacy.
work towards successful treatment of the UTI, optimization of For the patient described above with MS, a UTI and lower
bladder management and a return to usual function. limb spasticity who is in hospital, a generic long-term goal might
Assessment is best carried out by a multidisciplinary team. read:
Nurses may be in a better position than doctors to notice pressure To go home on Monday 9th:
sores. Cognitive impairment that is not immediately apparent on having learnt how to do intermittent self-catheterization
bedside examination may be identified when a patient fails to able to walk short distances indoors with a frame
using a wheelchair outdoors
able to wash and dress myself with set-up from my
partner.
Short-term goals might read:
To complete my stretching programme twice daily with
support from the physiotherapist.
Or
To maintain my current level of function by standing twice
daily for 30 minutes to manage my tone.
A more personalized goal in which all the above issues, and
some others, would be addressed might be: ‘To go home on
Monday 9th confident I can return to my job as a teacher, be able
to get around home and school by walking and using a wheel-
chair for longer distances, and managing each session teaching
without having to go the bathroom.’
Interventions
Interventions are treatments involving all the means available.
They can target: pathology (treating the UTI with antibiotics);
impairments (increasing the dosage of baclofen to manage
muscle tone); activities and participation (practice with sitting,
transfers, walking and dressing, going to work, attending a place
Figure 1 of worship, going out with friends and family); and the
10.1016/j.mpmed.2020.06.003
Case analysis: a patient with MS and a UTI admitted to an acute ward

Impairments
C Cognitive impairment, particularly difficulties in executive function (problem-solving, reasoning, attention) and memory
C Poor visual acuity
C Weakness affecting all four limbs, lower limbs worse than upper limbs
C Sensory loss including loss of joint position sense to ankles
C Spasticity affecting lower limbs, with spasms and clonus
C Bowel and bladder dysfunction
Activity limitations and participation restrictions
C Difficulty remembering medication and slow to learn new skills
C Difficulty reading small fonts, such as lists of medications
C Difficulty sitting unsupported
C Needs a hoist for transfers
C Dependent on assistance to wash and dress
C Dependent on a catheter to manage bladder
C Dependent on medication (baclofen) and regular standing and stretching programme for tone management
Environmental factors
C Lives in a second-floor flat accessed by a lift, one step inside flat to access kitchen
Table 2
environment (providing a supportive wheelchair, pressure- What is spasticity?

relieving mattress, standing frame, sliding board, shower chair Spasticity has several components, including increased tone,
or hoist). Targeted delivery of interventions can help to maintain clonus and spasms. It can cause pain, sleep disturbance,
function through activity and participation in the face of wors- impaired mobility and contractures. It can also have a positive
ening impairments. impact, sometimes allowing the person to stand or walk when
A comprehensive review of the range of different interventions is their weakness would not otherwise permit this.
outside the scope of this brief review but two common problems that
demand careful attention are management of the upper motor Increased muscle tone: the pathophysiology of spasticity is
neurone syndrome and incontinence. complex but includes an enhanced and prolonged response to
muscle stretch, decreased task- and phase-dependent modulation
Spasticity and the upper motor neurone syndrome of stretch reflexes caused by a reduction in spinal cord inhibitory
control and intrinsic changes in the motor neurone. Prolonged
Many patients presenting to GPs or secondary care have features
plateau-like potentials of motor neurone discharges combined
of upper motor neurone pathology caused by a single insult
with reduced inhibitory spinal cord control mean that muscle
affecting the brain or spinal cord (head or spinal cord injury,
contraction, once triggered, can continue unabated.
stroke, cerebral palsy) or as part of a chronic progressive
neurological condition (MS, hereditary spastic paraparesis,
Clonus: this is a rhythmic pattern of contraction at a rate of
motor neurone disease).
several times per second, caused by alternate stretching and
The upper motor neurone syndrome involves both positive
unloading of the muscle spindles. If the stretching force is sus-
(additional motor activity such as stiffness, spasms, clonus) and
tained, there is continuous triggering of the phasic stretch reflex.
negative features (loss of motor activity resulting in weakness,
This can be seen with rhythmic contractions of the gastrocne-
reduced postural responses and poor dexterity). These can occur
mius and soleus muscles in response to dorsiflexion of the ankle.
independently, but the combination and interaction of different
aspects of the upper motor neurone syndrome (positive and Spasms: these sudden involuntary (often painful) movements
negative) with their functional consequences often make man- can be caused by muscle stretching or a variety of noxious pe-
agement challenging. Furthermore motor features usually pre- ripheral or visceral afferent stimuli (Table 3). Spasms can also
sent along with sensory involvement and bladder and bowel occur as a result of disinhibited polysynaptic reflexes such as the
dysfunction, particular features of spinal cord pathology. Addi- flexor withdrawal reflex; in addition, they can reflect abnormal
tionally other features of the individual’s neurological condition activity within spinal cord circuits that have the effect of syn-
such as ataxia, tremor, cognitive impairment or mood distur- chronizing the discharge of motor neurones supplying multiple
bance can contribute to functional difficulties. All these should muscles.
be considered when devising the individual’s goal-oriented
programme of rehabilitation, keeping in mind that goals Management
should focus on function and not simply be about treating Assessment: an accurate history is essential. It should identify
impairments. common triggers (Table 3) and include details of seating,
10.1016/j.mpmed.2020.06.003
A management algorithm for spasticity management
Assess for > Any infections; red or broken skin; urinary frequency,
Assess spasticity trigger and urgency or retention; constipation or diarrhoea; pain;
and document aggravating tight clothing or orthoses; poor posture and positioning;
of spasticity
outcome measures factors or infrequent changes in position?
> Identify and manage as appropriate
> Is soft tissue and joint range maintained?

Devise
> Consider splinting, standing and rehabilitation
physiotherapy
> Optimise positioning and seating
and nursing
> Educate for self management
treatment plan
> Continue to monitor and manage trigger factors
> Assess spasticity and

No Does the > Would treatment aid function?
document outcome measures
spasticity need > Is there a negative impact on range, care or function;
> Continue with treatment
further treatment? is spasticity causing pain?
plan and monitor for change
Yes
No Is spasticity
focal? limb or a few small muscles?
Yes
> Consider botulinum toxin in conjunction with
Focal
physiotherapy or splinting programme
Is spasticity
generalized? Spasticity > Assess trigger factors
continues to be > Ongoing therapy and nursing interventions
a problem > Consider generalized therapies
Yes
Generalized > Ongoing therapy and nursing interventions with

monitoring of effectiveness
> Assess trigger factors
Generalized – Usually gabapentin, baclofen or tizanidine

spasticity
continues to second agent
be a problem – Usually gabapentin, baclofen or tizanidine
> Ongoing therapy and nursing interventions with
> Assess trigger factors

> If suboptimal effect on oral agents or intolerable
Generalized
side-effects:
spasticity
– Consider THC:CBD if spasticity is multiple sclerosis
continues to
related
be a problem
> Ongoing therapy and nursing interventions with
Generalized
spasticity > Assess trigger factors
continues to > Consider intrathecal baclofen or phenal
be a problem
THC:CBD = delta-9-tetrahydrocannabinol/cannabidiol
Adapted from Stevenson VL. Managing spasticity in multiple sclerosis—a focus on the role of delta-9-tetrahydrocannabinol/cannabidiol.
Guidelines in Practice, 2015; 18(4): supplement.
Figure 2
10.1016/j.mpmed.2020.06.003
exercise or standing programme, previous drug and therapy foot deformities, and obturator nerve blocks in ambulatory pa-
input and the use of any orthotics or splints.4 The examination tients with a scissoring gait, to improve ease of perineal hygiene
allows an opportunity for quantitative measurement, as well as and aid in seating posture.
assessing the role of spasticity in the individual’s function,
leading to goal identification (e.g. transferring independently, Intrathecal therapies
being able to sleep through the night). From this, an individu- If lower limb spasticity is difficult to control, intrathecal therapies
alized management plan can be devised using the following should be considered.
treatment options (see Figure 2 for an example of a treatment Intrathecal baclofen can be administered via an implant-
algorithm). able pump. The concentration of g-aminobutyric acid receptors
in the lumbar spinal cord allows very small dosages of baclo-
Physical intervention: a physical management programme to fen to be effective without causing systemic adverse effects.
maintain range and strength is essential and must be realistic, The programmable pump is implanted into the abdomen, and a
with attention to posture and positioning. For instance, a daily catheter conveys the baclofen from there into the intrathecal
stretching programme can be successfully incorporated into a space. Intrathecal baclofen is an extremely effective treatment
person’s morning regime and care package, or regular standing in the management of severe spasticity of either cerebral or
can provide a prolonged stretch and promote anti-gravity muscle spinal origin, and the benefit has proved to be sustainable over
activity. time. It has also recently been recognized that intrathecal
baclofen can aid ambulation and should not be seen as a last-
Pharmacological treatment resort treatment. Potential complications, some fatal, necessi-
There is no agreed evidence-based model to guide the choice of tate a robust clinical governance framework and a coordinated
agent or dosing schedule. Much of what is done is based on a approach by an experienced team with clear goals of
logical and pragmatic approach.4 The identification of specific treatment.
treatment goals helps to optimize drug therapy, in terms of both Intrathecal phenol offers an effective permanent solution in a
choice of agent, as well as timing and dose (Table 4). It is few patients with severe spasticity who cannot be effectively
sometimes preferable to use a combination of drugs at low managed in other ways. Careful patient selection and informed
dosage to enable effective treatment within the realm of tolerable consent are vital because of the irreversibility of the procedure
adverse effects. and potential impact on bladder, bowel, sexual and sensory
function. Although it is considered permanent, the effects can, as
Focal pharmacological treatment with focal phenol blocks, wear off over time, and injections may
Botulinum toxin is the most widely used treatment for focal need to be repeated after 6e9 months.
spasticity.4 It acts by reversible inhibition of acetylcholine release
at the neuromuscular junction, the effect of the injection lasting a Bladder and bowel dysfunction
few months. It is essential that injections are given in conjunc-
tion with physiotherapy in the context of a clear goal of Bladder, bowel and sexual dysfunction are common in in-
treatment. dividuals with neurological conditions, particularly those with
Peripheral phenol blocks cause chemical neurolysis that re- spinal cord damage, as in MS. Bladder and bowel dysfunction
sults in destruction of neural tissue by protein coagulation. They can be made worse by poor fluid intake; education is paramount
are said to be irreversible but partial nerve regeneration and in preventing people restricting their fluids in the hope of
sprouting can occur; therefore the clinical effect can ‘wear off’ avoiding embarrassing symptoms.
after several weeks or months. Injections can be targeted at pe- Common bladder symptoms are frequency, urgency and
ripheral nerves or motor points. The most commonly used are nocturia. As bladder dysfunction increases incontinence, reten-
tibial (medial popliteal) blocks for managing children developing tion and UTIs can occur. Most result from a combination of
detrusor hyperreflexia (causing urgency and incontinence) and
sphincter dyssynergia (causing failure to empty with consequent
residual volumes and UTI’s). The aetiology of urinary symptoms
Common factors influencing spasticity and spasms is often mixed, so bladder emptying must be measured by esti-
Cutaneous triggers Visceral triggers mating the post-micturition residual volume before starting
therapy. This is easily done by ultrasound or ineout
Inflamed or broken skin Any systemic infection catheterization.
Pressure sores Bladder dysfunction: infection, If there is minimal residual urine (<100 ml), detrusor hyper-
retention, detrusor overactivity reflexia can be treated with oral agents: antimuscarinic drugs
Ingrown toenails Bowel dysfunction: constipation, such as oxybutynin, solifenacin or tolterodine, and the selective
impaction, diarrhoea b3-adrenoceptor agonist mirabegron. Intravesical botulinum
Skin/nail infections Fractures toxin and posterior tibial nerve stimulation have recently trans-
Inappropriate seating or Deep vein thrombosis formed the management of neurogenic detrusor overactivity.5
postural support Incomplete bladder emptying can be treated using clean, inter-
Ill-fitting or tight clothes mittent self-catheterization. Patients may require a combination
Uncomfortable orthotics of therapies, but bladder control and quality of life are usually
greatly improved. Control occasionally remains poor and an
Table 3
10.1016/j.mpmed.2020.06.003
Drug treatment in spasticity

Drug Starting dose Maximum dose Main adverse effects Mechanism of action Special considerations
Baclofen 5e10 mg daily 100 mg in three Drowsiness, weakness GABA analogue, Use with caution in epilepsy
divided doses binds to GABAB and avoid abrupt withdrawal
receptors e seizures
Tizanidine 2 mg daily 36 mg in three or Drowsiness, weakness, a2-Adrenoceptor Monitoring of liver function
four divided doses arrhythmias, dry mouth, agonist required
postural hypotension
Gabapentin 100e300 mg daily 3600 mg daily in Drowsiness, dizziness, Can be particularly useful for
GABA-ergic: appears
three divided doses appetite changes, weight spasms or when pain
to act at the a2d
gain subunit of calcium
present. Caution in people
channels with history of substance
abuse
Dantrolene 25 mg daily 400 mg in four Anorexia, nausea, vomiting, Acts peripherally by Can be useful for spasms.
divided doses drowsiness, weakness, suppressing calcium Monitoring of liver function
paraesthesia, rare hepatic release from the essential
failure sarcoplasmic
reticulum of skeletal
muscle
Clonazepam 0.25e0.5 mg usually 2 mg at night Drowsiness, reduced Stimulation of GABAA Useful for nocturnal spasms.
at night time attention, memory receptors Avoid abrupt withdrawal e
impairment dependency syndrome
Diazepam 2 mg daily 40e60 mg daily in Drowsiness, reduced Stimulation of GABAA Best avoided because of
three or four divided attention, memory receptors tolerance, dependency and
doses impairment withdrawal syndromes
Pregabalin 25e50 mg daily 600 mg in two or Drowsiness, dizziness, GABA-ergic: appears Can be particularly useful for
three divided doses appetite changes, weight to act at the a2d spasms or when pain is
gain subunit of calcium present. Caution in people
channels with history of substance
abuse
D9- One spray 12 sprays/day Dizziness, fatigue, Partial agonist action Licenced as an add-on
tetrahydrocannabinol Each 100 microlitre unsteadiness, psychotropic at CB1 and CB2 therapy for moderate to
(THC) and spray contains 2.7 effects (anxiety, mood receptors of the severe spasticity in MS
cannabidiol (CBD) e mg THC and 2.5 mg disturbance, paranoia) endocannabinoid
Sativex CBD system
GABA, g-aminobutyric acid.
Table 4
indwelling catheter is needed; if this is long term, a suprapubic standardized outcome measures. Outcome measures use stan-
catheter is usually preferred. dardized approaches to record different aspects of function, such
Bowel dysfunction is less frequent than urinary dysfunction as disability, quality of life or mood. For measures to be mean-
but can be extremely distressing. Individuals usually complain of ingful, they should be:
constipation and urgency; incontinence is less frequently re- valid e measure what they set out to measure
ported. Management is more difficult than with bladder reliable e produce the same results when used at different
dysfunction, but it is important to establish a routine. Regular use times with the same, stable patient, and when used by
of oral agents (lactulose, senna, Movicol) is often enough, but different people
glycerine suppositories and micro-enemas can be extremely responsive e i.e. change when the patient changes.
useful. In severe cases, transanal irrigation systems can be life- Psychometrics, the science underpinning outcome measures,
changing. Bowel incontinence often linked to urgency can be has grown in recognition of their importance. The most
helped with loperamide. commonly used measure on acute wards is the Waterlow Index
(for risk of pressure sores). The most common one in rehabili-
Evaluation tation is the Barthel Index (a measure of dependency). Measures
The final step in the rehabilitation pathway is evaluation. This also exist for spasticity (e.g. Ashworth Scale), and incontinence
can be undertaken by looking at goal achievement or by using (e.g. the Qualiveen.)
10.1016/j.mpmed.2020.06.003
In summary, an individual’s function and experience of botulinum toxin. National guidelines. 2018. London: RCP, https://
disability is dependent on the underpinning pathology and the www.bsrm.org.uk/downloads/spasticity-in-adultsfinal-version-
resulting impairment and moderated by personal and environ- published23-4-18.pdf.
mental factors. Careful analysis of the causes of disability can 5 Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunc-
inform a comprehensive multidisciplinary rehabilitation plan tion in the neurological patient: clinical assessment and manage-
which can be targeted at the level of pathology, impairment, ment. Lancet Neurol 2015; 14: 720e32.
activity or at environmental factors and individual factors. A
FURTHER READING
Hobart JC, Cano SJ, Zajicek JP, Thompson AJ. Rating scales as
KEY REFERENCES outcome measures for clinical trials in neurology: problems,
1 Wade D. Rehabilitation e a new approach. Overview and part one: solutions, and recommendations. Lancet Neurol 2007; 6:
the problems. Clin Rehabil 2015; 29: 1041e50. 1094e105.
2 World Health Organization. International classification of func- Levack WM, Weatherall M, Hay-Smith JE, Dean SG,
tioning, disability and health (ICF). http://www.who.int/ McPherson K, Siegert RJ. Goal setting and strategies to
classifications/icf/en/ (accessed 20 Apr 2016). enhance goal pursuit in adult rehabilitation: summary of a
3 Dworzynski K, Ritchie G, Playford ED. Stroke rehabilitation: long- Cochrane systematic review and meta-analysis. Eur J Phys
term rehabilitation after stroke. Clin Med (Lond) 2015; 15: 461e4. Rehabil Med 2016; 52: 400e16.
4 Royal College of Physicians, British Society of Rehabilitation Management Spasticity. In: Stevenson VL, Jarrett L, eds. A practical
Medicine, The Chartered Society of Physiotherapy, Association of multidisciplinary guide. 2nd Edition. Boca Raton: CRC Press, 2016.
Chartered Physiotherapists in Neurology and the Royal College of ISBN 9780429171857.
Occupational Therapists. Spasticity in adults: management using
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NEUROLOGICAL REHABILITATION

Neurological Key points

Valerie L Stevenson C Goal-setting allows clinicians to work with patients to target

C Spasticity management should aim to optimize function and

MEDICINE xxx:xxx 1 Ó 2020 Published by Elsevier Ltd.

learn a new technique in physiotherapy or performs poorly in a

MEDICINE xxx:xxx 2 Ó 2020 Published by Elsevier Ltd.

Case analysis: a patient with MS and a UTI admitted to an acute ward

environment (providing a supportive wheelchair, pressure- What is spasticity?

MEDICINE xxx:xxx 3 Ó 2020 Published by Elsevier Ltd.

A management algorithm for spasticity management

> Is soft tissue and joint range maintained?

> Assess spasticity and

Generalized > Ongoing therapy and nursing interventions with

> Assess trigger factors

Generalized – Usually gabapentin, baclofen or tizanidine

> Assess trigger factors

MEDICINE xxx:xxx 4 Ó 2020 Published by Elsevier Ltd.

MEDICINE xxx:xxx 5 Ó 2020 Published by Elsevier Ltd.

Drug treatment in spasticity

GABA, g-aminobutyric acid.

MEDICINE xxx:xxx 6 Ó 2020 Published by Elsevier Ltd.

MEDICINE xxx:xxx 7 Ó 2020 Published by Elsevier Ltd.

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