How Can We Improve Current Practice in Spastic Paresis?

European Neurological Review, 2016;11(2):79–86 DOI:


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.
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.
Received: March 08, 2016 Accepted May 09, 2016
Correspondence: Klemens Fheodoroff, Department of Neurorehabilitation Gailtal-Klinik, Radniger Str. 12, 9620 Hermagor, Austria. E:
Support: This CME meeting was supported by an unrestricted educational grant from Ipsen.

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

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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