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Rehabilitation and Recovery following Stroke

5.2. Range of Motion and Spasticity in the Shoulder, Arm and Hand

6th Edition - 2019 UPDATED


Recommendations

Definition: For the purposes of these recommendations ‘early’ refers to strength of evidence for therapies applicable to patients who are less than 6 months post stroke, and ‘late’ refers to strength of evidence for therapies applicable to patients who are more than 6 months from index stroke event.

 

  1. Spasticity and contractures may be managed by antispastic pattern positioning, range-of-motion exercises, and/or stretching [Evidence Levels: Early- Level C; Late-Level C].
    1. Routine use of splints is not recommended [Evidence Levels: Early- Level A; Late-Level B].
    2. In some select patients, the use of splints may be useful and should be considered on an individualized basis [Evidence Level C]. A plan for monitoring the splint for effectiveness should be implemented and followed [Evidence Level C].
  2. Chemo-denervation using botulinum toxin can be used to increase range of motion and decrease pain for patients with focal symptomatically distressing spasticity [Evidence Levels: Early-Level B; Late-Level A].
  3. Oral medications can be considered for the treatment of disabling spasticity, but side effects of fatigue and drowsiness are common and the benefits for treating spasticity appear to be marginal:
    1. Tizanidine can be used to treat more generalized, disabling spasticity. [Evidence Levels: Early-Level C; Late-Level B].
    2. Baclofen can be used as a lower cost alternative to treat more generalized disabling spasticity  [Evidence Levels: Early-Level C; Late-Level C].
    3. Benzodiazepines should be avoided due to sedating side effects, which may impair recovery [Evidence Level: Early-Level C; Late-Level C].

 

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, people who have had a stroke may experience a loss of range of motion at involved joints of the arms, which can result in contracture and decreased quality of life.

System Implications +-

To achieve timely and appropriate assessment and management of shoulder, arm and hand range and spasticity the organization requires:

  • Availability of and access to organized stroke care, including stroke rehabilitation units with critical mass of trained interdisciplinary staff during the rehabilitation period following stroke.
  • Timely access to specialized, interdisciplinary stroke rehabilitation services, where assessments and therapies of appropriate type and intensity are provided.
  • Expertise within the interdisciplinary stroke team to prevent and/or ameliorate post stroke spasticity and remediate its complications and functionally related limitations.
  • Optimization of strategies to prevent or manage spasticity both initially post stroke and at follow-up assessments.
  • Funding for chemo-denervation and associated post injection rehabilitation services where necessary.
  • Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.
  • The development and implementation of an equitable and universal pharmacare program, implemented in partnership with the provinces, designed to improve access to cost-effective medicines for all people in Canada regardless of geography, age, or ability to pay. This program should include a robust common formulary for which the public payer is the first payer.
Performance Measures +-
  1. Change (improvement) in functional status scores using a standardized assessment tool from admission to an inpatient rehabilitation program to discharge.
  2. Change in shoulder, arm and hand functional status scores using a standardized assessment tool (such as the Chedoke-McMaster Stroke Assessment pain scale or the Modified Ashworth Scale) from admission to an inpatient rehabilitation program to discharge.
  3. Median length of time from stroke admission in an acute care hospital to assessment of rehabilitation potential by a rehabilitation healthcare professional.
  4. Median length of time spent on a stroke rehabilitation unit during inpatient rehabilitation

Measurement Notes:

  • A data entry process will need to be established to capture the information from the outcome tools such as the Disability Assessment Scale
  • FIM® Instrument data is available in the National Rehabilitation Reporting System (NRS) database at the Canadian Institute of Health Information (CIHI) for participating organizations.
Summary of the Evidence +-

Evidence Table and Reference List

 

Spasticity 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 arms, which can result in contracture. Although it is a common in clinical practice to use range-of-motion or stretching exercises and splints to prevent or treat spasticity or contracture following stroke, there is a lack of evidence supporting their benefit.  Harvey et al. (2017) included the results of 49 RCTs in a Cochrane review including participants with neurological condition, advance age, those with a history of trauma and those with underlying joint or muscle pathology. Of these, 11 trials included stroke cohorts treated for upper limb impairment. Trials evaluated the effect of stretching programs (casting, splinting, self-administered, positioning, and sustained passive stretch) on preventing contractures. Stretching programs did not significantly increase joint mobility, improve spasticity, activity limitations, or pain either after the intervention or at follow-up, when compared with usual care. Splints have been widely-used in clinical practice with the aim of the prevention of contractures and reducing spasticity; however, evidence of their effectiveness is lacking. Basaran et al. (2012) randomized 39 participants to participate in a 5-week, home-based exercise program in which patients were advised to stretch wrist and finger flexors for 10 repetitions and to try reaching and grasping an object for 10 repetitions 3x/day, in addition to conventional therapy. Patients in the 2 experimental groups wore either a volar or dorsal splint for up to 10 hours overnight throughout the study period, while patients in the control group wore no splint. At the end of the study period, there were no significant differences among groups in terms of reductions in spasticity or wrist passive range of motion. 

 

While it is well-established that treatment with Botulinum toxin–type A (BTX-A) reduces focal spasticity in the finger, wrist and elbow, it remains uncertain whether there is also improvement in upper-limb function. In the BOTOX® Economic Spasticity Trial (BEST), 273 persons with chronic post-stroke upper and lower limb spasticity were randomized to receive a single dose of BTX-A with an optional second dose offered ≥ 12 weeks after the first, or placebo in addition to usual care. Dosing and site of injection was based on clinician judgement. In the publication of the trial that was dedicated to functional outcomes (Ward et al. 2014), there were no significant differences between groups at weeks 12, 24 or 52 with respect to the percentage of patients who achieved their principal active functional goal (33.1% vs. 28.9%, 40.9% vs. 33.3% and 45.0% vs. 52.4%, respectively), although a higher number of persons in the BT-XA groups achieved their secondary passive functional goals at 24 weeks, (60.6% vs. 38.6%, p=0.016), but not at weeks 12 or 52. BTX-A was more effective than placebo in reducing pain from baseline to week 12 (Wissel et al. 2016). Higher proportions of patients with pain in the BTX-A group achieved ≥30% and ≥50% reductions in pain. Shaw et al. (2011) randomized 333 subjects < 1 month following stroke with spasticity of the elbow (MAS>2) and/or spasticity of the shoulder, wrist or hand with reduced arm function to receive 100 or 200 U Dysport in addition to a standardized therapy program provided for 1 hour/day, 2x/week for 4 weeks) or therapy program only. Repeat injections were available to subjects in the intervention group at 3, 6 and 9 months. There was no significant difference in the percentage of patients who had achieved a successful outcome (defined by 3 different levels of improvement on the Action Research Arm Test, depending on baseline arm function) at one month following treatment: 25% of patients in the treatment group compared with 19.5% of patients in the control group (p=0.232). However, significant differences in favor of the intervention group were seen in muscle tone at 1 month; upper limb strength at 3 months; basic arm functional tasks (hand hygiene, facilitation of dressing) at 1, 3, and 12 months, and pain at 12 months. McCrory et al. (2009) reported there were no significant between group differences in Assessment of Quality of Life scale change scores, pain, mood, disability or carer burden at 20 weeks in 102 patients with moderate to severe spasticity of the arm, who received 750-1,000 U Dysport or placebo an average of 6 years following stroke.

In cases where spasticity is generalized, and it would be impractical, or contrary to patients’ wishes to inject multiple muscle groups with BTX-A, the use of oral agents may be considered as an alternative treatment. Traditional pharmacotherapies for spasticity include centrally acting depressants (baclofen and tizanidine) and muscle relaxants; (dantrolene) however; these treatments are only partially effective in treating spasticity and have the negative side effects of weakness and sedation. Treatment with oral baclofen has not been well studied in the stroke population and is used more frequently in patients recovering from spinal cord injury.  Tizanidine has been well-studied in other conditions including multiple sclerosis and acquired brain injury, and has a better side effect profile than other oral agents.  There is only a single open-label trial of the use of tizanidine post stroke (Gelber et al. 2001). 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 combined 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.

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