Spasticity

Who to refer:

• Patient must have a neurological diagnosis as primary presenting complaint (e.g. stroke, multiple sclerosis, cerebral palsy, acquired brain injury, spinal injury, etc.)
• Patient must be aged 16 years of age or over
• Spasticity must be having a clear negative impact on the patient
• There must be a clear treatment goal identified by the patient / referrer

Who not to refer:

• Patients with contracture*
• Patients who do not have clear rehabilitation/treatment goals
• Patients for whom spasticity has no significant negative impacts

*Patients with contracture of the hand which is causing pain and/or difficulty with managing hand hygiene or nail care or skin breakdown can be referred directly to the Hooper Hand Clinic, St. John’s Hospital who can advise whether there is a surgical management option.

How to refer:

You can refer to the Lothian Spasticity Management Service by using this referral form

You can email informal enquiries to the team to this address AAH.spasticitymanagement@nhslothian.scot.nhs.uk

Advice for managing spasticity in Primary Care

These guidelines should be read in conjunction with the “A guide to managing spasticity” document.

There are multiple trigger factors for spasticity.  These should be identified and managed effectively.  If trigger factors are not addressed, other spasticity management strategies may be less effective.

The most common trigger factors to consider are:

• Pain – neuropathic; musculoskeletal; headache; menstrual, etc
• Bladder – dysfunction; incontinence; recurring UTI; catheter issues; stones; etc
• Bowel – constipation; distension
• Skin – pressure sores; redness/rubbing; tight-fitting clothing; eczema; psoriasis; etc
• Feet – in-grown toenails; fungal nail infections
• Temperature – extremes of temperature; temperature changes; etc
• Anxiety; emotional responses.

Physical management strategies should also be considered.  These may include:

• 24 hour postural management – seating; lying; equipment
• Physical strategies – exercise; function; gait
• Splinting – hand and wrist splints
• Orthotic management

Oral antispasticity medications may be useful for some patients.  Please refer to the following medication guidelines:

	1st Line	2nd Line	3rd Line
Medication	Baclofen	Tizanidine	Dantrolene
How it works	Central Action –simulates the GABAB-receptors (therefore inhibits the release of excitatory amino acids.)	Central Action- stimulates presynaptic alpha2-receptors (therefore inhibits the release of excitatory amino acids.)	Peripheral Action– reduces calcium release within skeletal muscle cells.
Starting dose	5mg TID	2mg once daily	25 mg once daily
Dose escalation	Increase by 5mg every 3 days (if in hospital) or every week (if in community)	Increase by 2mg every 3 days (if in hospital) or every week (if in community)	Increase by 25 mg weekly Titrate down and stop if no benefit in 6-7 weeks
Maximum daily dose	100 mg (in 3 divided doses)	36 mg (in 3-4 divided doses; maximum single dose 12 mg)	400 mg (up to 4 divided doses)(Usual dose 75 mg TID)
Peak Concentration	1-3hrs post ingestion	1hr post ingestion	5hours post ingestion
Common side effects	Muscle weakness; sedation; dizziness; nausea,	Drowsiness; sedation; dizziness/light-headedness; hypotension,	Drowsiness; sedation; dizziness/light-headedness; diarrhoea
Considerations/monitoring	Epilepsy:  can lower seizure thresholdBladder:  can have effect on bladder muscle and can cause increased urinary problemsRenal impairment:  increased side effect profile	Liver:  contraindicated in hepatic impairment; can cause changes in liver function – MUST monitor LFTs monthly for first 4 monthsRenal impairment:  increased side effect profile	Liver:  can cause Severe Liver Impairment– MUST monitor LFTs monthly initially then at less frequent regular interval. Patient must be counselled about signs of liver dysfunction. Those greatest at risk of liver failure- -Higher daily doses (>400mg / day) -Duration of treatment (3-12 month) – Female – Age >30 years – prior history liver disease – on other hepatotoxic medications Renal impairment:  increased side effect profile Other:  Makes skin more sensitive to sun – advice to take precautions.
Stopping medication	Avoid abrupt withdrawal – dose should be titrated slowly down.  Abrupt withdrawal can cause a rebound increase in spasticity, hyperactive state, and can precipitate autonomic dysfunction, including hyperthermia, psychiatric reactions and convulsions.	Avoid abrupt withdrawal – dose should be titrated slowly down.  Abrupt withdrawal can cause rebound hypertension and tachycardia	Avoid abrupt withdrawal – dose should be titrated slowly down.  Abrupt withdrawal can cause hallucinations, rebound hypertension, tachycardia and seizures

STARS – Advancing Module:  Management of tone and spasticity after stroke: a role for everyone

Spasticity – a guide to managing in Primary Care

Spasticity referral form