national-clinical-guidelines-for-stroke-fourth-edition

C Consensus
D Consensus; Sato et al 2005
6.10 Impaired tone – spasticity and spasms
There is considerable debate on the definition, physiological nature and importance of
spasticity. Increased tone, abnormal posturing and involuntary spasms may cause
discomfort for the patient and difficulties for carers, and are associated with activity
limitation. Their close association with other impairments of motor control makes it
difficult to determine the extent to which spasticity is a specific cause of disability.
Spasticity is common, especially in the non-functional arm. Estimates of prevalence vary
from 19% at 3 months after stroke (Sommerfeld et al 2004) to 38% of patients at 12
months (Watkins et al 2002).
Evidence to recommendations
The spasticity literature contains moderately sized RCTs, two recent larger RCTs
(McCrory et al 2009; Shaw et al 2011) related to botulinum toxin, systematic reviews and
a Cochrane review related to upper limb splinting and stretching. These studies and
reviews show that improvements after botulinum toxin administration are identified in
spasticity (modified Ashworth scale), range of movement and ease of care (also referred
to as passive function). In RCTs, significant group differences have not been
demonstrated in activities performed by the patient, although a small minority of
individuals have reportedly made these changes. Inability to demonstrate improvements
in activity indicates that these changes are unlikely in the majority of patients receiving
botulinum toxin, but may also reflect limitations in some of the measurement tools used.
Improvements in activity for lower limb spasticity require further evaluation.
6.10.1 Recommendations
6 Recovery phase from impairments and limited activities: rehabilitation
A Any patient with motor weakness should be assessed for the presence of spasticity as a
cause of pain, as a factor limiting activities or care, and as a risk factor for the
development of contractures.
B For all the interventions given below, specific goals should be set and monitored using
appropriate clinical measures (eg numerical rating scales for ease of care (eg Arm
Activity measure (ArmA)) or pain (eg 10-point numerical rating scale), the modified
Ashworth scale, and range of movement).
C In any patient where spasticity is causing concern, the extent of the problem should
be monitored and simple procedures to reduce spasticity should be started. This may
include positioning, active movement and monitoring range of movement for
deterioration of function, passive movement and pain control.
D Patients with persistent or progressing troublesome focal spasticity affecting one or
two joints and in whom a therapeutic goal can be identified (usually ease of care also
referred to as passive function) should be given intramuscular botulinum toxin. This
should be in the context of a specialist multidisciplinary team service accompanied by
rehabilitation therapy or physical maintenance strategies (eg splinting or casting) over
the next 2–12 weeks following botulinum toxin injection. Functional assessment
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