Therapeutic Goal: Maintain Range of Motion and Reduce Spasticity of the Leg
- Spasticity and contractures should be treated or prevented by antispastic pattern positioning, range-of-motion exercises, stretching and/or splinting. (SCORE) [Evidence Levels: Early-Level C; Late-Level C].
- For post-acute stroke patients with focal and symptomatically distressing spasticity consider use of chemodenervation using botulinum toxin injection to increase range of motion. [Evidence Levels: Early-Level C; Late-Level A].
- Consider use of tizanidine in patients with generalized spasticity. [Evidence Levels: Early-Level B; Late-Level B].
- Recommend against prescription of benzodiazepines during stroke recovery period due to possible deleterious effects on recovery, in addition to deleterious sedation side effects. [Evidence Levels: Early-Level C; Late-Level C].
Spasticity is an important problem after stroke that results in increased tone or resistance in muscles after stroke. If spasticity is not managed appropriately then there may be loss of range of motion at involved joints of the legs called contractures. These contractures may interfere with functional use of the limbs although in other cases patients may use their spasticity in a functional manner to walk post stroke.
To achieve timely and appropriate assessment and management of lower limb spasticity the organization requires
- Organized stroke care available, including stroke units with critical mass of trained staff and interprofessional team during the rehabilitation period following stroke.
- Initial assessment performed by clinicians experienced in stroke rehabilitation.
- Assessment for AFO should be considered to correct significant ankle inversion
- Timely access to specialized, interprofessional stroke rehabilitation services.
- Timely access to appropriate intensity of rehabilitation for stroke survivors.
- Change (improvement) in functional status scores using a standardized assessment tool (FIM® Instrument) from admission to an inpatient rehabilitation program to discharge.
- Change in lower limb functional status/ spasticity scores using a standardized assessment tool (e.g., Chedoke-McMaster Stroke Assessment sub scale) from admission to an inpatient rehabilitation program to discharge.
- Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
- Median length of time spent on a stroke unit during inpatient rehabilitation
There have been very few studies 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. One small RCT (n=16) 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.446 The subjects 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).
There have been fewer studies examining the use of Botulinum toxin–type A (BT-A) in the lower extremity compared with the upper. Three RCTs that compared BT-A with placebo have been published. Kaji and coworkers (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.447 There was a significant mean reduction in modified Ashworth Scale scores at weeks four, six and eight in the treatment group compared with the control group; however, there were no significant differences between groups at week 10 or 12. Pittock and colleagues compared escalating doses of BT-A with placebo and found that the highest dose of BT-A (1,500 U Dysport ®) was associated with the greatest relief of calf spasticity compared with placebo at four, eight and 12 weeks following treatment.448 Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity at week four only. Burbaud and colleagues randomized 23 adult hemiparetic stroke patients with ankle plantar flexor and foot invertor spasticity to receive a single injection of botulinum toxin and one of placebo in random order, at day 0 and day 90).449Following treatment, there was a significant reduction in spasticity associated with the ankle movement (extensors and invertors).
For further information and references, please consult the Evidence Based Review of Stroke Rehabilitation http://www.ebrsr.com/uploads/Module_9_mobility.pdf