How Can We Improve Current Practice in Spastic Paresis?

European Neurological Review, 2016;11(2):79–86 DOI: https://doi.org/10.17925/ENR.2016.11.02.79

Abstract:

Spastic paresis can arise from a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia. It is associated with muscle contracture, stiffness and pain, and can lead to segmental deformity. The positive, negative and biomechanical symptoms associated with spastic paresis can significantly affect patients’ quality of life, by affecting their ability to perform normal activities. This paper – based on the content of a global spasticity interdisciplinary masterclass presented by the authors for healthcare practitioners working in the field of spastic paresis – proposes a multidisciplinary approach to care involving not only healthcare practitioners, but also the patient and their family members/carers, and improvement of the transition between specialist care and community services. The suggested treatment pathway comprises assessment of the severity of spastic paresis, early access to neurorehabilitation and physiotherapy and treatment with botulinum toxin and new technologies, where appropriate. To address the challenge of maintaining patients’ motivation over the long term, tailored guided self-rehabilitation contracts can be used to set and monitor therapeutic goals. Current global consensus guidelines may have to be updated, to include a clinical care pathway related to the encompassing management of spastic paresis.

Keywords: Assessment, botulinum toxin, cerebral palsy, guided self-rehabilitation contract, hereditary spastic paraplegia, multiple sclerosis, neurorehabilitation, rehabilitation, spasticity, spinal cord injury, stroke, traumatic brain injury
Disclosure: Preparation of this paper was supported by Ipsen. The authors are responsible for the content of the paper. Ipsen did not contribute to the content of the manuscript, with the exception of a courtesy review. Klemens Fheodoroff has received unrestricted research grants from Ipsen and Merz, and honoraria for instructional courses from Ipsen, Allergan and Merz. Jorge Jacinto has received unrestricted research grants, as well as honoraria for instructional courses, conferences and advisory boards from Ipsen, Allergan and Merz. Alexander Geurts has received unrestricted research grants from Ipsen and Merz, and honoraria for instructional courses from Ipsen. Franco Molteni has received unrestricted research grants from Ipsen and Merz and honoraria for instructional courses from Ipsen, Allergan and Merz. Jorge Hernández Franco reports no conflicts of interest. Tharaga Santiago reports no conflicts of interest. Raymond Rosales has received unrestricted research grants, as well as honoraria for instructional courses, conferences and advisory boards from Ipsen and Allergan. Jean-Michel Gracies has served as a consultant and received research grant support from Allergan, Ipsen and Merz.
Acknowledgments: The ‘Global Spasticity Masterclass’ meeting was co-chaired by Professor Michael Barnes (UK) and Professor Jean-Michel Gracies (France). The authors thank all participants. Editorial Assistance was provided by Vanessa Lane at MedSense Ltd., High Wycombe, UK, which was funded by Ipsen.

Authorship All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given nal approval to the version to be published.
Received: March 08, 2016 Accepted May 09, 2016
Correspondence: Klemens Fheodoroff, Department of Neurorehabilitation Gailtal-Klinik, Radniger Str. 12, 9620 Hermagor, Austria. E: klemens.fheodoroff@me.com
Support: This CME meeting was supported by an unrestricted educational grant from Ipsen.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit.

Spastic paresis may be caused by a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, retroviral and other infectious spinal cord disorders, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia.1 The exact prevalence of spastic paresis (in which spasticity is the most commonly recognised manifestation) is not known. However, it is estimated that around 30% of stroke survivors are affected by significant spasticity2 and 50% who present to hospital with stroke develop at least one severe contracture.3

Spastic paresis is a complex condition that may be associated with soft tissue contracture, pain and limitations of day-to-day activities, which have a substantial impact on patients’ and caregivers’ quality of life.4 Although treatment guidelines have been developed for (focal) spasticity,5 there remains a lack of consensus on key aspects of diagnosis, approaches to care and the care pathway that would help healthcare practitioners to more fully understand and manage this condition.

To address some of these limitations, a group of physicians and a physiotherapist with expertise in the management of spastic paresis developed a global spasticity masterclass for healthcare practitioners working in this field in order to share best practices and to discuss issues and current trends in the management of patients with spasticity. The outputs of this masterclass are presented here.

Pathophysiology and definitions
Spastic paresis
Spasticity is one of several components of spastic paresis, also known as the upper motor neuron (UMN) syndrome. Spastic paresis is primarily characterised by a quantitative lack of command directed to agonist muscles involved in performing movements.1,6,7 In addition, hyperactive spinal reflexes mediate some of the positive phenomena seen in spastic paresis, while other positive symptoms are related to disordered control of voluntary movement in terms of an abnormal efferent drive or are caused

References:
1. Gracies J-M, Pathophysiology of spastic paresis. I: paresis and soft tissue changes, Muscle Nerve, 2005;31:535–51.
2. Watkins CL, Leathley MJ, Gregson JM, et al., Prevalence of spasticity post stroke, Clin Rehabil, 2002;16:515–22.
3. Kwah LK, Harvey LA, Diong JH, et al., Half of the adults who present to hospital with stroke develop at least one contracture within six months: an observational study, J Physiother, 2012;58:41–7.
4. Zorowitz RD, Gillard PJ, Brainin M, Poststroke spasticity: sequelae and burden on stroke survivors and caregivers, Neurology, 2013;80(suppl 2):S45–S52.
5. Centre for Rehabilitation and Engineering Studies (CREST), SPASM. A European Thematic Network to Develop Standardised Measures of Spasticity. CREST, University of Newcastle; 2014. Available from: http://research.ncl.ac.uk/spasm/Projdescr.htm (accessed 11 November 2015).
6. Gracies J-M, Pathophysiology of spastic paresis. II: emergence of muscle overactivity, Muscle Nerve, 2005;31:552–71.
7. Sheean G, The pathophysiology of spasticity, Eur J Neurol, 2002;9(suppl 1):3–9, 53–61.
8. Gorassini MA, Knash ME, Harvey PJ, et al., Role of motoneurons in the generation of muscle spasms after spinal cord injury, Brain, 2004;127:2247–58.
9. Olsson MC, Krüger M, Meyer L-H, et al., Fibre type-specific increase in passive muscle tension in spinal cord-injured subjects with spasticity, J Physiol, 2006;577:339–52.
10. Lieber RL, Steinman S, Barash IA, et al., Structural and functional changes in spastic skeletal muscle, Muscle Nerve, 2004;29:615–27.
11. Ada L, Vattanasilp W, O’Dwyer NJ, et al., Does spasticity contribute to walking dysfunction after stroke? J Neurol Neurosurg Psychiatry, 1998;64:628–35.
12. Malhotra S, Pandyan AD, Day CR, et al., Spasticity, an impairment that is poorly defined and poorly measured, Clin Rehabil, 2009;23:651–58.
13. Lance JW, The control of muscle tone, reflexes, and movement: Robert Wartenberg Lecture, Neurology, 1980;30:1303–13.
14. Kheder A, Padmakumari K, Nair S, Spasticity: pathophysiology, evaluation and management, Pract Neurol, 2012;12:289–98
15. Gracies JM, Pathophysiology of impairment in patients with spasticity and use of stretch as a treatment of spastic hypertonia, Phys Med Rehabil Clin N Am, 2001;12:747–68, vi.
16. Ashworth B, Preliminary trial of carisoprodol in multiple sclerosis, Practitioner, 1964;192:540–2.
17. de Niet M, Latour H, Hendricks H, et al., Short-latency stretch reflexes do not contribute to premature calf muscle activity during the stance phase of gait in spastic patients, Arch Phys Med Rehabil, 2011;92:1833–9.
18. Burke D, Wissel J, Donnan GA, Pathophysiology of spasticity in stroke, Neurology, 2013;80(suppl 2):S20–S26.
19. Vinti M, Couillandre A, Hausselle J, et al., Influence of effort intensity and gastrocnemius stretch on co-contraction and torque production in the healthy and paretic ankle, Clin Neurophysiol, 2013;124:528–35.
20. Gracies J-M, Coefficients of impairment in deforming spastic paresis, Ann Phys Rehabil Med, 2015;58:173–8.
21. Gracies J-M, Bayle N, Vinti M, et al., Five-step clinical assessment in spastic paresis, Eur J Phys Rehabil Med, 2010;46:411–21.
22. Gracies JM, Marosszeky JE, Renton R, et al., Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients. Arch Phys Med Rehabil, 2000;81:1547–55.
23. Ben-Shabat E, Palit M, Fini NA, et al., Intra- and interrater reliability of the Modified Tardieu Scale for the assessment of lower limb spasticity in adults with neurologic injuries, Arch Phys Med Rehabil, 2013;94:2494–501.
24. Bohannon RW, Smith MB, Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther, 1987;67:206–7.
25. Sunnerhagen KS, Olver J, Francisco GE, Assessing and treating functional impairment in poststroke spasticity, Neurology, 2013;80(3 Suppl 2):S35–S44.
26. Aloraini SM, Gäverth J, Yeung E, et al., Assessment of spasticity after stroke using clinical measures: a systematic review, Disabil Rehabil, 2015;37:1–11.
27. Allen GM, McKenzie DK, Gandevia SC., Twitch interpolation of the elbow flexor muscles at high forces, Muscle Nerve, 1998;21:318–28.
28. Gandevia SC, Allen GM, Butler JE, et al., Supraspinal factors in human muscle fatigue: evidence for suboptimal output from the motor cortex, J Physiol, 1996;490(Pt 2):529–36.
29. Newham DJ, Hsiao SF, Knee muscle isometric strength, voluntary activation and antagonist co-contraction in the first six months after stroke, Disabil Rehabil, 2001;23:379–86.
30. Riley NA, Bilodeau M, Changes in upper limb joint torque patterns and EMG signals with fatigue following a stroke, Disabil Rehabil, 2002;24:961–9.
31. Musampa NK, Mathieu PA, Levin MF, Relationship between stretch reflex thresholds and voluntary arm muscle activation in patients with spasticity, Exp Brain Res, 2007;181:579–93.
32. Trompetto C, Marinelli L, Mori L, et al., Pathophysiology of spasticity: implications for neurorehabilitation, Biomed Res Int, 2014;2014:354906.
33. United Nations, Standard rules on the equalization of opportunities for persons with disabilities. United Nations 1994. Available from: www.un.org/disabilities/default.asp?id=26 (accessed 11 November 2015).
34. Kong K-H, Chua KS-G, Lee J, Symptomatic upper limb spasticity in patients with chronic stroke attending a rehabilitation clinic: frequency, clinical correlates and predictors, J Rehabil Med, 2010;42:453–7.
35. Ashford S, Fheodoroff K, Jacinto J, et al., Common goal areas in the treatment of upper limb spasticity: A multicentre analysis, Clin Rehabil, 2015:[Epub ahead of print].
36. Rentsch HP, Bucher PO, Tesak J, [ICF in rehabilitation: the practical application of the international classification of functioning, disability and health in rehabilitation everyday] In German, Idstein: Schulz-Kirchner Verlag GmbH; 2005.
37. Foley N, Mehta S, Jutai J, et al., Upper extremity interventions. In: Teasell R, ed. Evidence-based review of stroke rehabilitation. London, Ontario: Sockit Solutions; 2013:1–163:chap 10. Available from: www.ebrsr.com/evidence-review/10-upperextremity- interventions (accessed 12 November 2015).
38. Sheean G, Lannin NA, Turner-Stokes L, et al., Cerebral Palsy Institute. Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement, Eur J Neurol, 2010;17(suppl 2):74–93.
39. Hu X, Tong KY, Song R, et al., Variation of muscle coactivation patterns in chronic stroke during robot-assisted elbow training, Arch Phys Med Rehabil, 2007;88:1022–9.
40. Katalinic OM, Harvey LA, Herbert RD, Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review, Phys Ther, 2011;91:11–24.
41. Ada L, Goddard E, McCully J, et al., Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial, Arch Phys Med Rehabil, 2005;86:230–4.
42. Bütefisch C, Hummelsheim H, Denzler P, et al., Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand, J Neurol Sci, 1995;130:59–68.
43. Feys HM, De Weerdt WJ, Selz BE, et al., Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial, Stroke, 1998;29:785–92.
44. Feys H, De Weerdt W, Verbeke G, et al., Early and repetitive stimulation of the arm can substantially improve the long-term outcome after stroke: a 5-year follow-up study of a randomized trial, Stroke, 2004;35:924–9.
45. Gracies JM, Blondel R, Gault-Colas C, et al., [Guided self-rehabilitation contract in spastic paresis] In French, ©Association Neuroloco, Paris 2013, 108p, ISBN 978–2–35327– 169–6
46. Langhorne P, Coupar F, Pollock A, Motor recovery after stroke: a systematic review, Lancet Neurol, 2009;8:741–54.
47. Lo AC, Guarino PD, Richards LG, et al., Robot-assisted therapy for long-term upper-limb impairment after stroke, N Engl J Med, 2010;362:1772–83.
48. Westlake KP, Patten C, Pilot study of Lokomat versus manualassisted treadmill training for locomotor recovery post-stroke, J Neuroeng Rehabil, 2009;6:18.
49. Langhorne P, Bernhardt J, Kwakkel G, Stroke rehabilitation, Lancet, 2011;377:1693–702.
50. Dipietro L, Krebs HI, Fasoli SE, et al., Submovement changes characterize generalization of motor recovery after stroke, Cortex, 2009;45:318–24.
51. Metrot J, Mottet D, Hauret I, et al., Changes in bimanual coordination during the first 6 weeks after moderate hemiparetic stroke, Neurorehabil Neural Repair, 2013;27:251–9.
52. Veerbeek JM, van Wegen E, van Peppen R, et al., What is the evidence for physical therapy poststroke? A systematic review and meta-analysis, PLoS One, 2014;9:e87987.
53. Simpson DM, Gracies JM, Graham HK, et al., Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Neurology, 2008;70:1691–8.
54. Gracies JM, Bayle N, Goldberg S, et al., Botulinum toxin type B in the spastic arm: a randomized, double-blind, placebocontrolled, preliminary study, Arch Phys Med Rehabil, 2014;95:1303–11.
55. Ozcakir S, Sivrioglu K, Botulinum toxin in poststroke spasticity, Clin Med Res, 2007;5:132–8.
56. Rosales RL, Dressler D, On muscle spindles, dystonia and botulinum toxin, Eur J Neurol, 2010;17(suppl 1):71–80.
57. Caleo M, Antonucci F, Restani L, et al. A reappraisal of the central effects of botulinum neurotoxin type A: by what mechanism? J Neurochem, 2009;109:15–24.
58. Nigam PK, Nigam A, Botulinum toxin, Indian J Dermatol, 2010;55:8–14.
59. Rosales RL, Dystonia, spasticity and botulinum toxin therapy: rationale, evidences and clinical context. In Rosales RL, ed. Dystonia – many facets. Rijeka, Croatia: InTech; 2012:83–98. Available from: www.intechopen.com/books/dystonia-themany- facets. (accessed 11 November 2015).
60. Shaw LC, Price CI, van Wijck FM, et al., BoTULS Investigators. Botulinum Toxin for the Upper Limb after Stroke (BoTULS) Trial: effect on impairment, activity limitation, and pain, Stroke, 2011;42:1371–79.
61. Diserens K, Ruegg D, Kleiser R, et al., Effect of repetitive arm cycling following botulinum toxin injection for poststroke spasticity: evidence from FMRI, Neurorehabil Neural Repair, 2010;24:753–62.
62. Veverka T, Hluštík P, Tomášová Z, et al., BoNT-A related changes of cortical activity in patients suffering from severe hand paralysis with arm spasticity following ischemic stroke, J Neurol Sci, 2012;319:89–95.
63. Francis HP, Wade DT, Turner-Stokes L, et al., Does reducing spasticity translate into functional benefit? An exploratory meta-analysis, J Neurol Neurosurg Psychiatry, 2004;75:1547–51.
64. Turner-Stokes L, Fheodoroff K, Jacinto J, et al., Results from the Upper Limb International Spasticity Study-II (ULISII):a large, international, prospective cohort study investigating practice and goal attainment following treatment with botulinum toxin A in real-life clinical management, BMJ Open, 2013;3:e002771.
65. Cousins E, Ward A, Roffe C, et al., Does low-dose botulinum toxin help the recovery of arm function when given early after stroke? A phase II randomized controlled pilot study to estimate effect size, Clin Rehabil, 2010;24:501–13.
66. Hesse S, Mach H, Fröhlich S, et al., An early botulinum toxin A treatment in subacute stroke patients may prevent a disabling finger flexor stiffness six months later: a randomized controlled trial, Clin Rehabil, 2012;26:237–45.
67. Rosales RL, Kong KH, Goh KJ, et al., Botulinum toxin injection for hypertonicity of the upper extremity within 12 weeks after stroke: a randomized controlled trial, Neurorehabil Neural Repair, 2012;26:812–21.
68. Rosales RL, Dystonia, spasticity and botulinum toxin therapy: rationale, evidences and clinical context, dystonia – the many facets. 2012 Prof. Raymond Rosales (ed), ISBN: 978–953– 51–0329–5, InTech, DOI: http://dx.doi.org/10.5772/27435. Available from: http://www.intechopen.com/books/dystoniathe- many-facets/dystonia-spasticity-and-botulinum-toxintherapy- rationale-evidences-and-clinical-context (accessed 12 December 2015).
69. Rosales RL, Kanovsky P, Fernandez HH, What’s the “catch” in upper-limb post-stroke spasticity: expanding the role of botulinum toxin applications, Parkinsonism Relat Disord, 2011;17(suppl 1):S3–S10.
70. Pascual-Pascual SI, [Use of botulinum toxin in the preventive and palliative treatment of the hips in children with infantile cerebral palsy], Rev Neurol, 2003;37:80–2.
71. Pascual-Pascual SI, Pascual-Castroviejo I, Safety of botulinum toxin type A in children younger than 2 years, Eur J Paediatr Neurol, 2009;13:511–15.
72. Druschel C, Althuizes HC, Funk JF, et al., Off label use of botulinum toxin in children under two years of age: a systematic review, Toxins (Basel), 2013;5:60–72.
73. Placzek R, Siebold D, Funk JF, Development of treatment concepts for the use of botulinum toxin a in children with cerebral palsy, Toxins (Basel), 2010;2:2258–71.
74. Mills PB, Finlayson H, Sudol M, O’Connor R, Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity, Clin Rehabil, 2015;pii: 0269215515593783. [Epub ahead of print]
75. McIntyre A, Lee T, Janzen S, et al., Systematic review of the effectiveness of pharmacological interventions in the treatment of spasticity of the hemiparetic lower extremity more than six months post stroke, Top Stroke Rehabil, 2012;19:479–90.
76. Zondervan DK, Palafox L, Hernandez J, et al., The Resonating Arm Exerciser: design and pilot testing of a mechanically passive rehabilitation device that mimics robotic active assistance, J Neuroeng Rehabil, 2013;10:39.
77. Jang SH, A review of the ipsilateral motor pathway as a recovery mechanism in patients with stroke, NeuroRehabilitation, 2009;24:315–20.
78. Orihuela-Espina F, Fernández del Castillo I, Palafox L, et al., Neural reorganization accompanying upper limb motor rehabilitation from stroke with virtual reality-based gesture therapy, Top Stroke Rehabil, 2013;20:197–209.
79. Bhimani RH, McAlpine CP, Henly SJ, Understanding spasticity from patients’ perspectives over time, J Adv Nurs, 2012;68:2504–14.
80. Wood JP, Connelly DM, Maly MR, ‘Getting back to real living’: A qualitative study of the process of community reintegration after stroke, Clin Rehabil, 2010;24:1045–56.
81. Donnellan C, Hevey D, Hickey A, et al., Defining and quantifying coping strategies after stroke: a review. J Neurol Neurosurg Psychiatry, 2006;77:1208–18.
82. Demetrios M, Khan F, Turner-Stokes L, et al., Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post-stroke spasticity, Cochrane Database Syst Rev, 2013;6:CD009689.
83. Van Cranenburgh B, Neurorehabilitation: neurophysiologische Grundlagen, Lernprozesse, Behandlungsprinzipien. Munich: Elsevier GmbH, Urban & Fischer Verlag; 2007.
84. Hartmann M, Bäzner E, Wild B, et al., Effects of interventions involving the family in the treatment of adult patients with chronic physical diseases: a meta-analysis, Psychother Psychosom, 2010;79:136–48.
85. Kleim JA, Jones TA, Schallert T, Motor enrichment and the induction of plasticity before or after brain injury. Neurochem Res, 2003;28:1757–69
86. Martin LR, Williams SL, Haskard KB, et al., The challenge of patient adherence, Ther Clin Risk Manag, 2005;1:189–99.
87. Meimoun M, Bayle N, Baude M, et al., [Intensity in the neurorehabilitation of spastic paresis], Rev Neurol (Paris), 2015;171:130–40.
88. Veerbeek JM, Koolstra M, Ket JC, et al., Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: a meta-analysis, Stroke, 2011;42:3311–15.
Keywords: Assessment, botulinum toxin, cerebral palsy, guided self-rehabilitation contract, hereditary spastic paraplegia, multiple sclerosis, neurorehabilitation, rehabilitation, spasticity, spinal cord injury, stroke, traumatic brain injury