Early Identification, Intervention and Management of Post-stroke Spasticity: Expert Consensus Recommendations

Abstract

Stroke patients with spasticity usually require long-lasting care and interventions but frequently report that outpatient and community treatment is limited, reflecting a significant unmet need in health and social care provision. Rehabilitation and spasticity management services are essential for patient recovery, with improvements in both activity and participation reducing the burden on patients, family and society. Current clinical guidance provides scope for improvements in both post-stroke management and spasticity prevention. However, access to specialist services can be limited and the patient journey does not always match national recommendations. Identification of spasticity and its predictors and lack of subsequent referral to rehabilitation or specialist spasticity services are key issues in the management of post-stroke spasticity. Implementation of a traffic light classification system prioritises patients at an increased risk of spasticity and promotes early and consistent management across the spectrum of primary and secondary care. The proposed system is based on clinical evidence, expert consensus and recent clinical guidelines. It provides simple and straightforward criteria for management, multidisciplinary consultation and referral to specialist spasticity services, with patients allocated by monitoring requirements and a low (green/periodic monitoring), medium (amber/routine referral) or high risk (red/urgent referral) of spasticity.

Keywords: consensus; guidelines; recommendation; spasticity; stroke.

Figure 1.

Post-stroke spasticity risk classification system. ∗ Based on the clinical expertise of Dr Rhoda Allison, Dr Ganesh Bavikatte, Professor Philippe Marque, Associate Professor Barry Rawicki, Dr Maria Matilde de Mello Sposito, Dr Paul Winston and Professor Jörg Wissel. (a) Mildly increased muscle stiffness is a Modified Ashworth Scale (MAS) 1 or +1, while moderately is MAS 2, markedly is MAS 3 and severe is MAS 4∗ (cf Bohannon RW, et al 1987 for more information). (b) Measured using the Fugl-Meyer Upper Extremity Scale (cf Fugl-Meyer AR, et al 1975 for more information). (c) Muscle contractions may occur due to spasms, disturbed reciprocal inhibition or spastic dystonia and should be differentiated from contractures. (d) Visual inattention includes hemianopsia, scotoma or visual neglect. (e) Can be measured with the Barthel Index (low score) and EQ-5D (low score).