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Lower Limb Spasticity Following Stroke

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Lower Limb Spasticity following Stroke, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale

Spasticity, defined as a velocity dependent increase of tonic stretch reflexes (muscle tone) with exaggerated tendon jerks can be painful, interfere with functional recovery and hinder rehabilitation efforts. If not managed appropriately, stroke survivors may experience a loss of range of motion at involved joints of the ankle and foot, which can cause difficulties with ambulation.

 

System Implications

To achieve timely and appropriate assessment and management of lower limb spasticity the organization requires:

  • Organized stroke care, including stroke rehabilitation units with a critical mass of trained staff and an interprofessional team during the rehabilitation period following stroke.
  • Initial and ongoing assessments performed by clinicians experienced in stroke rehabilitation both in hospital and in the community.
  • Assessment for an orthotic/splint/brace should be considered to ensure safety.
  • Timely access to specialized, interprofessional stroke rehabilitation services as defined within the best practice recommendations.
  • Timely access to appropriate intensity of rehabilitation for stroke survivors as defined within the best practice recommendations.
  • Funding for chemodenervation and associated post injection rehabilitation services where necessary. May require access to electromyography or ultrasound to facilitate localization of the motor points for injections.

 

Performance Measures

  1. Extent of change in functional status scores using a standardized assessment tool (e.g., FIM® Instrument) from admission to an inpatient rehabilitation program to discharge (average and median).
  2. Extent of change in lower limb functional status using a standardized assessment tool (e.g., Chedoke-McMaster Stroke Assessment sub scale) from admission to an inpatient rehabilitation program to discharge.
  3. Extent of change in lower limb spasticity scores using a standardized assessment tool (e.g., Modified Ashworth Scale) from admission to an inpatient rehabilitation program to discharge.
  4. Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
  5. Median length of time spent in active rehabilitation on a stroke rehabilitation unit during inpatient rehabilitation.
  6. Median total length of time spent on a stroke rehabilitation unit during inpatient rehabilitation.

Measurement Notes:

  • Ensure consistency in start time for all time-based measures, and document the definition of start and stop times for transparency and replication.

 

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

 

Summary of the Evidence

Evidence Table 6.2: Lower Limb Spasticity following Stroke

Few studies have been published examining the prevention or treatment of spasticity or contracture using antispastic pattern positioning, range of motion exercises, stretching and/or splinting in the lower extremity. Kluding et al. (2008) reported that eight sessions of functional task practice combined with ankle joint mobilizations, provided over four weeks, resulted in increased ankle range of motion, compared with a group that received therapy only, in the chronic stage of stroke. The participants in the intervention group gained 5.7 degrees in passive ankle range of motion compared with 0.2 degree degrees in the control group (p<0.01).

The use of Botulinum toxin–type A (BTX-A) for the lower extremity is not as well-studied compared with the upper extremity. A meta-analysis (Foley et al. 2010), which included the results from 8 studies reported a moderate increase in gait speed associated with BTX-A (SMD= 0.193±0.081, 95% CI 0.033 to 0.353, p<0.018). In a recent randomized controlled trial Picelli et al. (2014) compared three different treatments among chronic stroke patients. Individuals were randomized to receive ultrasound, transcutaneous electrical stimulation, or Botox®. Picelli et al. (2014) reported that patients receiving Botox® had significantly greater improvement of spasticity (modified Ashworth Scale) compared to individuals in the other treatment groups. Dunne et al. (2012) randomized 85 stroke patients (≥ 6 weeks post stroke) to receive a single injection of 200 U (n=28), 300 U Botox ® (n=28) or saline. When the results from the two Botox ® groups were combined, there was significantly greater improvement in Ashworth Scale scores, pain, spasm frequency, and the number of patients who experienced at least a 15% increase in ankle dorsiflexion, at 12 weeks. Kaji et al. (2010) randomized 120 patients with lower limb spasticity following stroke greater than six months to receive a single treatment of 300 U Botox® or placebo. There was a significantly greater mean reduction in modified Ashworth Scale scores at weeks four, 6 and 8 in the treatment group compared with the control group; however, there were no significant differences between groups at week 10 or 12. Two pre-post studied the effect of Botox® on lower limb spasticity (modified Ashworth Scale) and found significant improvement at both 30 and 90 days post-injection (Sanamato et al. 2013a, 25-100 U; Sanamato 2013b, 250-340 U). Pittock et al. (2003) compared escalating doses of BTX-A with placebo and found that the highest dose (1,500 U Dysport ®) was associated with the greatest relief of calf spasticity compared with placebo at four, eight and 12 weeks following treatment. Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity at week four only. Burbaud et al. (1996) randomized 23 adult hemiparetic stroke patients with ankle plantar flexor and foot invertor spasticity to receive a single injection of BTX-A and one of placebo in random order, at day 0 and day 90). Following active treatment, there was a significant reduction in spasticity associated with the ankle movement (extensors and invertors).

Intrathecal baclofen is popular treatment for spasticity in many populations including stroke, spinal cord injury, and cerebral palsy. Meythalar et al. (2002) performed a cross-over randomized controlled trial among individuals with chronic stroke. At one year the authors noted that spasticity had improved, as evidenced by a decline in Ashworth scores and reflex scores (p<0.01 for both); spasm frequency scores did not improve (p>0.05).