Therapeutic Goal: Maintain Range of Motion and Reduce Spasticity in the Shoulder, Arm and Hand
- Spasticity and contractures should be treated or prevented by antispastic pattern positioning, range-of-motion exercises, stretching and/or splinting [Evidence Levels: Early- Level C; Late-Level C].
- For patients with focal and/or symptomatically distressing spasticity, consider use of chemodenervation using Botulinum toxin to increase range of motion and decrease pain [Evidence Levels: Early-Level C; Late-Level A].
- Consider use of tizanidine for spasticity in patients with generalized, disabling spasticity resulting in poor skin hygiene, poor positioning, increased caregiver burden or decreased function [Evidence Levels: Early-Level C; 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 B; Late-Level B].
Spasticity is an important problem after stroke that results increased tone or resistance to movement in muscles after stroke. If spasticity is not managed appropriately there may be loss of range of motion at involved joints of the arms called contractures. These contractures may interfere with functional use of the limbs.
To achieve timely and appropriate assessment and management of shoulder, arm and hand range and 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.
- Timely access to specialized, interprofessional stroke rehabilitation services.
- Timely access to appropriate type and intensity of rehabilitation for stroke survivors.
- Optimization of strategies to prevent or manage spasticity both initially post stroke and at follow-up assessment.
- Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.
- Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
- Change in shoulder, arm and hand functional status scores using a standardized assessment tool (such as the Chedoke-McMaster Stroke Assessment pain 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
- A data entry process will need to be established to capture the information from the outcome tools such as the Chedoke-McMaster Stroke Assessment
- The FIM ® Instrument data can be found in the National Rehabilitation Reporting System database at the Canadian Institute of Health Information for contributing organizations.
Although it is a common clinical practice, there is a dearth of evidence that positioning, range-of-motion or stretching exercises help to prevent or treat spasticity or contracture following stroke. While the results from a few RCTs with small sample sizes, 407-410 were conflicting with regard to benefit, a recent meta-analysis, 411 reported that shoulder positioning programs were not effective in preventing or reducing the loss of shoulder external rotation range of motion.
There is strong evidence that treatment with Botulinum toxin–type A reduces focal spasticity in the finger, wrist and elbow. Among the results from five randomized controlled trials with sample sizes greater than 50, all reported statistically significant decreases in modified Ashworth Scale scores following treatment, compared with placebo.412-416 Although range of motion was not a commonly assessed outcome improvements have been reported in elbow passive range of motion.415
In cases where spasticity is generalized, and it would be impractical to inject multiple muscle groups, or where patients are adverse to receiving injections, the use of oral agents may be considered as an alternative treatment to botulinum toxin. Tizanidine has been well-studied in other conditions including multiple sclerosis and acquired brain injury. There is a single open-label trial of the use of tizandine following stroke. 417 Following 16 weeks of treatment in which 47 patients received a maximum daily dose of 36 mg (mean 20 mg), there was a decrease in mean total modified Ashworth Scale scores (9.3 vs. 6.5, p=0.038). There were also significant improvements in pain, quality of life, and physician assessment of disability. The side effect profile of tizandine is superior to that of other oral agents including baclofen. Common side effects include dry mouth, sedation, and asthenia. Rare side-effects include elevated liver enzymes and hallucinations. 418
For further information and references, please consult the Evidence Based Review of Stroke Rehabilitation at http://www.ebrsr.com/uploads/Module_10_upper_extremity_formatted.pdf