{"id":21035,"date":"2024-10-02T09:57:42","date_gmt":"2024-10-02T08:57:42","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=21035"},"modified":"2024-12-12T08:38:33","modified_gmt":"2024-12-12T08:38:33","slug":"spasticity","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/rehabilitation\/neurorehabilitation\/spasticity\/","title":{"rendered":"Spasticity"},"content":{"rendered":"\n<p><strong>The Lothian Spasticity Management Service<\/strong> is a multidisciplinary team comprising medical, nursing and physiotherapy specialists.&nbsp; The service aims to provide assessment, advice and, where appropriate, treatment for adults with troublesome spasticity due to a neurological cause.<\/p>\n\n\n\n<p>Information about spasticity and general principals of spasticity management can be found <a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/A-guide-to-managing-spasticity-sent-05Mar18.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">in A Guide to Managing Spasticity<\/a>.&nbsp; This information will help your clinical reasoning and management plan before considering referral to this specialist service.<br><br>The Lothian Spasticity Management Service aims to provide:<br>&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Multidisciplinary Team (MDT) assessment of spasticity and impacts on daily life<\/li>\n\n\n\n<li>A patient-centred and goal orientated approach to addressing patient needs<\/li>\n\n\n\n<li>Education and advice about aspects of self-managing spasticity e.g. trigger factor management, appropriate medication use, physical management strategies<\/li>\n\n\n\n<li>Evidence-based interventions that are compliant with current national standards and guidelines<\/li>\n<\/ul>\n\n\n\n<p><strong>M.A. &amp; I.N. 02-10-24<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\"><strong>Who to refer:<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patient must have a neurological diagnosis as primary presenting complaint (e.g. stroke, multiple sclerosis, cerebral palsy, acquired brain injury, spinal injury, etc.)<\/li>\n\n\n\n<li>Patient must be aged 16 years of age or over<\/li>\n\n\n\n<li>Spasticity must be having a clear negative impact on the patient<\/li>\n\n\n\n<li>There must be a clear treatment goal identified by the patient \/ referrer<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Who not to refer:<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients with contracture in the absence of spasticity*<\/li>\n\n\n\n<li>Patients who do not have clear rehabilitation\/treatment goals<\/li>\n\n\n\n<li>Patients for whom spasticity has no significant negative impacts<\/li>\n<\/ul>\n\n\n\n<p><strong>*<\/strong>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&#8217;s Hospital who can advise whether there is a surgical management option.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Who can refer:<\/strong><\/h4>\n\n\n\n<p>We accept referrals from any healthcare professional<\/p>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>How to refer<\/strong>:<\/h4>\n\n\n\n<p>Refer via SCI Gateway <strong>Astley Ainslie Hospital &gt; Neuro Rehabilitation &gt; LI Spasticity<\/strong><\/p>\n\n\n\n<p>You can refer to the <strong>Lothian Spasticity Management Service<\/strong> by using <a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Spasticity-Referral-Form.docx\" target=\"_blank\" rel=\"noreferrer noopener\">this referral form<\/a><\/p>\n\n\n\n<p>You can email informal enquiries to the team to this address <a href=\"mailto:AAH.spasticitymanagement@nhslothian.scot.nhs.uk\" target=\"_blank\" rel=\"noreferrer noopener\">AAH.spasticitymanagement@nhslothian.scot.nhs.uk<\/a><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><strong>Advice for managing spasticity in Primary Care<\/strong><\/p>\n\n\n\n<p>These guidelines should be read in conjunction with the &#8220;<a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/A-guide-to-managing-spasticity-sent-05Mar18.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">A guide to managing spasticity<\/a>&#8221; document.<\/p>\n\n\n\n<p>There are multiple <strong>trigger factors<\/strong> for spasticity.&nbsp; These should be identified and managed effectively.&nbsp; If trigger factors are not addressed, other spasticity management strategies may be less effective.<\/p>\n\n\n\n<p>The most common trigger factors to consider are:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Pain \u2013 neuropathic; musculoskeletal; headache; menstrual, etc<\/li>\n\n\n\n<li>Bladder \u2013 dysfunction; incontinence; recurring UTI; catheter issues; stones; etc<\/li>\n\n\n\n<li>Bowel \u2013 constipation; distension<\/li>\n\n\n\n<li>Skin \u2013 pressure sores; redness\/rubbing; tight-fitting clothing; eczema; psoriasis; etc<\/li>\n\n\n\n<li>Feet \u2013 in-grown toenails; fungal nail infections<\/li>\n\n\n\n<li>Temperature \u2013 extremes of temperature; temperature changes; etc<\/li>\n\n\n\n<li>Anxiety; emotional responses.<\/li>\n<\/ul>\n\n\n\n<p><strong>Physical management<\/strong> <strong>strategies<\/strong> should also be considered.&nbsp; These may include:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>24 hour postural management \u2013 seating; lying; equipment<\/li>\n\n\n\n<li>Physical strategies \u2013 exercise; function; gait<\/li>\n\n\n\n<li>Splinting \u2013 hand and wrist splints<\/li>\n\n\n\n<li>Orthotic management<\/li>\n<\/ul>\n\n\n\n<p><strong>Oral antispasticity<\/strong> medications may be useful for some patients.&nbsp; Please refer to the following medication guidelines:<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>&nbsp;<\/strong><\/td><td><strong>1<\/strong><strong><sup>st<\/sup><\/strong><strong> Line<\/strong><\/td><td><strong>2<\/strong><strong><sup>nd<\/sup><\/strong><strong> Line<\/strong><\/td><td><strong>3<\/strong><strong><sup>rd<\/sup><\/strong><strong> Line<\/strong><\/td><\/tr><tr><td><strong>Medication<\/strong><\/td><td><strong>Baclofen<\/strong><\/td><td><strong>Tizanidine<\/strong><\/td><td><strong>Dantrolene<\/strong><\/td><\/tr><tr><td><strong>How it works<\/strong><\/td><td>Central Action \u2013simulates the GABAB-receptors (therefore inhibits the release of excitatory amino acids.)<\/td><td>Central Action- stimulates presynaptic alpha2-receptors (therefore inhibits the release of excitatory amino acids.)<\/td><td>Peripheral Action<strong>&#8211; <\/strong>reduces calcium release within skeletal muscle cells.<\/td><\/tr><tr><td><strong>Starting dose<\/strong><\/td><td>5mg TID<\/td><td>2mg once daily<\/td><td>25 mg once daily<\/td><\/tr><tr><td><strong>Dose escalation<\/strong><\/td><td>Increase by 5mg every 3 days (if in hospital) <strong>or<\/strong> every week (if in community)<\/td><td>Increase by 2mg every 3 days (if in hospital) <strong>or <\/strong>every week (if in community)<\/td><td>Increase by 25 mg weekly &nbsp; Titrate down and stop if no benefit in 6-7 weeks<\/td><\/tr><tr><td><strong>Maximum daily dose<\/strong><\/td><td>100 mg (in 3 divided doses)<\/td><td>36 mg (in 3-4 divided doses; maximum single dose 12 mg)<\/td><td>400 mg (up to 4 divided doses) <em>(Usual dose 75 mg TID)<\/em><\/td><\/tr><tr><td><strong>Peak Concentration<\/strong><\/td><td>1-3hrs post ingestion<\/td><td>1hr post ingestion<\/td><td>5hours post ingestion<\/td><\/tr><tr><td><strong>Common side effects<\/strong><\/td><td>Muscle weakness; sedation; dizziness; nausea,<\/td><td>Drowsiness; sedation; dizziness\/light-headedness; hypotension,<\/td><td>Drowsiness; sedation; dizziness\/light-headedness; diarrhoea<\/td><\/tr><tr><td><strong>Considerations\/monitoring<\/strong><\/td><td><strong><u>Epilepsy:<\/u><\/strong>&nbsp; can lower seizure threshold <strong><u>Bladder:<\/u><\/strong>&nbsp; can have effect on bladder muscle and can cause increased urinary problems <strong><u>Renal impairment:<\/u><\/strong>&nbsp; increased side effect profile<\/td><td><strong><u>Liver:<\/u><\/strong>&nbsp; contraindicated in hepatic impairment; can cause changes in liver function \u2013 <strong>MUST monitor LFTs monthly for first 4 months<\/strong> <strong><u>Renal impairment:<\/u><\/strong>&nbsp; increased side effect profile<\/td><td><strong><u>Liver<\/u><\/strong>:&nbsp; can cause Severe Liver Impairment\u2013 <strong>MUST monitor LFTs monthly initially then at less frequent regular interval.<\/strong> Patient must be counselled about signs of liver dysfunction.<br>Those greatest at risk of liver failure-<br>-Higher daily doses (&gt;400mg \/ day)<br>-Duration of treatment (3-12 month)<br>&#8211; Female<br>&#8211; Age &gt;30 years<br>&#8211; prior history liver disease<br>&#8211; on other hepatotoxic medications<br><br><strong><u>Renal impairment<\/u><\/strong>:&nbsp; increased side effect profile <strong><u>Other<\/u><\/strong>:&nbsp; Makes skin more sensitive to sun \u2013 advice to take precautions.<\/td><\/tr><tr><td><\/td><td><\/td><td><\/td><td><\/td><\/tr><tr><td><strong>Stopping medication<\/strong><\/td><td>Avoid abrupt withdrawal \u2013 dose should be titrated slowly down.&nbsp; <em>Abrupt withdrawal can cause a rebound increase in spasticity, hyperactive state, and can precipitate autonomic dysfunction, including hyperthermia, psychiatric reactions and convulsions.<\/em>&nbsp;<\/td><td>Avoid abrupt withdrawal \u2013 dose should be titrated slowly down.&nbsp; <em>Abrupt withdrawal can cause rebound hypertension and tachycardia<\/em>&nbsp;<\/td><td>Avoid abrupt withdrawal \u2013 dose should be titrated slowly down.&nbsp; <em>Abrupt withdrawal can cause hallucinations, rebound hypertension, tachycardia and seizures<\/em><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Trigger-factors-patient-information-leaflet.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Trigger-factors-patient-information-leaflet.pdf<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/A-guide-to-managing-spasticity-sent-05Mar18.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">A guide for managing spasticity<\/a><\/p>\n\n\n\n<p><a href=\"http:\/\/www.strokeadvancingmodules.org\/node.asp?id=spasticity\" target=\"_blank\" rel=\"noreferrer noopener\">STARS \u2013 Advancing Module:&nbsp; Management of tone and spasticity after stroke: a role for everyone<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>The Lothian Spasticity Management Service is a multidisciplinary team comprising medical, nursing and physiotherapy specialists.&nbsp; The service aims to provide assessment, advice and, where appropriate, treatment for adults with troublesome spasticity due to a neurological cause. Information about spasticity and general principals of spasticity management can be found in A Guide to Managing Spasticity.&nbsp; This<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":4171,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[1168],"class_list":["post-21035","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-spasticity"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/rehabilitation\/neurorehabilitation\/https-apps-nhslothian-scot-refhelp-spasticity\/\" rel=\"tag\">Spasticity<\/a>","rttpg_excerpt":"The Lothian Spasticity Management Service is a multidisciplinary team comprising medical, nursing and physiotherapy specialists.&nbsp; The service aims to provide assessment, advice and, where appropriate, treatment for adults with troublesome spasticity due to a neurological cause. Information about spasticity and general principals of spasticity management can be found in A Guide to Managing Spasticity.&nbsp; This","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21035","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=21035"}],"version-history":[{"count":5,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21035\/revisions"}],"predecessor-version":[{"id":21910,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21035\/revisions\/21910"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4171"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=21035"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=21035"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}