Timely identification of spasticity (or the risk of spasticity) in a patient is vital to ensure that they receive appropriate treatment, coupled with the right level of supervision and care from specialist healthcare professionals. In addition, delays in identification and a lack of awareness for possible triggers that can increase the severity of spasticity, further along the care pathway, can have a detrimental impact on patient outcomes and quality of life.
In this article Dr Sohail Salam, Consultant in Rehabilitation Medicine, explains how multidisciplinary teams (MDT), both within acute and non-acute care settings, can benefit from increased knowledge of spasticity and how this in turn will ensure that each individual has access to the most appropriate specialist support at each juncture on their care pathway.
Spasticity is a disruption in muscle movement patterns causing them to stiffen and become difficult to move actively or passively. The condition is triggered by damage to the nervous system and is common in patients who have had a brain injury, spinal cord injury, have suffered a stroke or have cerebral palsy or multiple sclerosis etc.
Pathophysiology of spasticity has been not clearly understood and there are many hypothesis regarding why that is. Many authors attempted to define spasticity, and Lance’s definition in 1980 is the most popular one: “Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component of the upper motor neuron syndrome.”
Spasticity can cause severe disruption to daily life. Individuals can experience significant pain, sleep disruption and subsequent fatigue. Muscle tightness can impact on active and passive functions including ease of dressing, ease of positioning and seating.
Spasticity can develop within the first few weeks after a brain and spinal cord injury. It can also significantly affect people with progressive and non-progressive conditions so it is vital that the care team can spot the warning signs for the onset of spasticity and understand how the condition develops.
Expert knowledge aids early intervention
Dr Sohail Salam is Consultant in Rehabilitation Medicine at The James Cook University Hospital in Middlesbrough and Visiting Consultant at Elysium Neurological’s service The Bridge. Dr Salam works with the MDT at the Bridge Neurological Care Centre to clinically review patients who require input from a Rehabilitation Medicine Consultant as part of the holistic team approach.
Rehabilitation medicine (RM) is a person-specific speciality and it focuses on a goal-directed holistic process of rehabilitation for people with conditions of sudden onset (e.g. head injury, limb loss, spinal cord injury) and for people with progressive conditions (e.g. multiple sclerosis, neuromuscular disorders). RM is also involved in management for people with long-term disabling conditions (e.g. cerebral palsy, limb loss, spinal cord injury and acquired brain injury).
Consultants in RM and their teams manage patients along a continuum: from rehabilitation following acute illness or injury, through inpatient rehabilitation, and into community settings. Specialist rehabilitation teams provide holistic care, including management of emotional and psychological consequences of disabling illness/injury and long-term progressive and non-progressive conditions.
Dr Salam has been working in RM for more than 13 years and as a RM consultant for more than 9 years in the UK. He is experienced in providing in-patient rehabilitation to patients with complex needs and also follows them in the community if required. Dr Salam has a special interest in management of Spasticity including Botulinum Toxin (Botox) injections. He has been actively involved in teaching, training, service development, research activities and works closely with stakeholders in the area.
As Dr Salam explains, proper awareness of the signs of spasticity and knowledge of the condition amongst the MDT is vital to ensure that early identification and intervention take place.
Dr Salam says: “If spasticity can be identified whilst a patient is within an acute setting, within the first few weeks post-injury, then the chances of them receiving appropriate specialist care from an MDT are greatly increased. A proper spasticity management plan can be put in place so the individual has more opportunities to improve their rehabilitation outcomes and they’re likely to have a better experience of care. So early intervention can improve rehabilitation outcomes, reduce length of stay in acute hospital and also improves quality of life.
Unfortunately there is a limited time frame to correctly identify spasticity in patients whilst they are within an acute setting. If those providing care do not have good knowledge of spasticity, it can be missed whilst attending to the many other complex needs that the patient may present. Sometimes individuals can be discharged without a formal assessment of spasticity, so therefore there is an important need for increased expertise within the acute setting.”
“This is the same within long-term care settings. When the care team understand spasticity, its triggers and effective therapies, patient outcomes are greatly improved. If there is a standardised training and knowledge of best practice amongst everyone involved in care, then even if there is frequent rotation of staff, quality of life for the individual can be maintained. The expertise is shared by the whole team and not just the few.
Increased knowledge and awareness of spasticity within primary, secondary and tertiary settings can make a huge difference to individuals because it also mitigates the risk of other associated problems developing such as immobility, breakdown of skin integrity, infections, loss of skills, changes in mood and even depression.”
Benefits of a multidisciplinary approach
Patients that develop spasticity as a result of a brain injury, spinal cord injury or any other neurological injury, typically often have other significant health issues that require specialist care from a team of clinicians and therapists. Therefore Dr Salam advocates an MDT approach, where expert knowledge and experience can be shared to create a spasticity management plan that responds to the unique but often complex needs of each person.
Dr Salam says: “The benefits of an MDT approach to spasticity management are manifold. When all clinicians and therapists involved in an individual’s care are familiar with the nuances of spasticity and how to provide appropriate support, then care can be more holistic and with a greater focus on individual’s requirements.
For example, physiotherapists can work with each patient on stretching and movement to aid muscles and joints. They can also help with positioning, and helping to maintain mobility. Occupational therapists provide assistance with upper limb functional tasks including kitchen activities etc, and also support interventions including splinting and lycra for upper limbs. Through team work, the provision of complex care becomes a very joined-up approach, focused on the patient’s unique healthcare needs.
Spasticity can be a used by the body to compensate for muscle weakness. For example, in some neurological conditions, we see significant weakness in quadriceps muscles (lower limb) along with muscle tightness (increased tone) which facilitates standing transfers or mobility with support. So management of spasticity requires a holistic assessment with clear goals.”
Being prepared for increased complexity
Spasticity management is a dynamic process so close monitoring and timely interventions from a MDT team improve outcomes for patients – as the classic phrase says, “a stitch in time saves nine.” An additional benefit of an MDT approach, as Dr Salam explains, is that if the spasticity worsens, the multiple healthcare professionals involved in an individual’s care can pool their knowledge and experience to provide the best possible holistic management plan.
Dr Salam says: “When training on spasticity is standardised and also consistently assessable for all colleagues, we typically see increased awareness of factors that can worsen the conditions. In that case the care team can take a proactive approach to find a potential trigger and work together to improve the management plan. This may mean that the care environment needs to adapted, the patient may benefit from a variety of interventions or therapies. However, this is less possible when there is limited clinical knowledge of spasticity and its effective management.
MDTs can conduct reviews of the management plan and spot trends or patterns in a patient’s condition to identify triggers or reasons how someone’s condition has deteriorated. An MDT approach typically results in a more joined-up method to care, with less gaps in the care provision, so the MDT is often better placed to spot less common sources of pain such as pressure sores, ingrown toenails or infections. These are all known triggers that cause spasticity to worsen.”
Combining medicine with a therapeutic approach
There are several approaches to safely and effectively managing spasticity so that quality of life for a patient is maintained, whilst also working towards outcomes that are best suited to the individual. Dr Sohail advocates a combined approach of pharmacological and non-pharmacological interventions. All medications have potential complications so it is best to have a MDT approach to set clear goals and also closely monitor response to intervention including any side effects. Sometimes less is more!
Keeping family members informed
Lack of patient and family education on spasticity means that following discharge from an acute setting, or whilst residing in long-term settings and a flare-up of spasticity is triggered, individuals are not empowered to seek the specialist care that is required. In these instances an informed and experienced MDT would have a positive impact on the family and their experience of care. Regular discussions with patients/family/care team improves their understanding of the management plan and also facilitates goal-based rehabilitation.
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Lance JW . The control of muscle tone, reflexes, and movement: Robert Wartenberg Lecture. Neurology 1980; 30: 1303–1313.