Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews

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Read Full Text: Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews
Journal: Annals of Physical and Rehabilitation Medicine
Year Published: 2019
Ranked 31st on our 2019-2023 list of the 100 Most Influential OT Journal Articles
CEU Podcast: #57: OT for Spasticity in Adults with Scott Thompson

Spasticity can be present in many of the conditions we treat as occupational therapy professionals.

And, it can add significant cost and burden for our patients.

This week’s article provides a big-picture overview of the science behind what we know (and don’t know!) about spasticity.

You’ll find that some approaches (some of which I’ve personally used!) have NOT been supported by the research—but, you’ll also see which modalities have a growing body of evidence behind them.

In two weeks, we’ll be joined on the podcast by neuro OT Scott Thompson, OTD, MOT, OTR/L, CRSR, LSVT-BIG, to discuss the implications for your practice!

Let’s dive in.

What is spasticity?

Spasticity results from a lesion to the upper motor neurons. It presents as intermittent or sustained involuntary activation of muscles. The primary feature of spasticity is hyper-excitability of the stretch reflex.

In simple terms:

Spasticity is a condition in which muscles stiffen or tighten—thus preventing normal, fluid movement.

Types of spasticity include:

Prevalence in common conditions and increased burden with comorbidity

Spasticity is common in the following neurological conditions. The percentage indicates the proportion of that population estimated to experience spasticity.

  • Primary lateral sclerosis (PLS) (92% of patients)
  • Multiple sclerosis (MS) (60–90% of patients)
  • Stroke (38% of survivors affected after 12 months)
  • Brain injury (16% of patients)
  • Cerebral palsy (prevalence not given)
  • Spinal cord injury (prevalence not given)

The literature suggests that in addition to increasing the physical and functional impairments experienced by patients themselves, comorbid spasticity increases the burden on—and reduces quality of life for—their care partners.

Existing research also points to a significant increase in financial burden for patients who are affected by both a neurological condition and comorbid spasticity. The direct cost for stroke survivors with spasticity is almost 4x higher than those without spasticity.

Current treatments

Patients with spasticity can manage their condition with:

However, standalone pharmacological and surgical management is NOT recommended for patients with comorbid spasticity. Instead, these treatments should be used in combination with other therapeutic modalities as part of an interdisciplinary approach.

Which leads us to:

As you can see, there are many non-pharmacological treatments for spasticity—but even though this general category of interventions is recommended for this population, there is a lack of evidence to guide clinicians on choosing the right one(s) for each individual client. Which leads us to this paper…

Why this review was needed

While research exploring various non-pharmacological approaches to spasticity has been done, it has varied in scope and quality.

The aim of this systematic review of systematic reviews was to:

Comprehensively synthesize evidence to establish the benefit and harm associated with non-pharmacological approaches to treating spasticity, with an ultimate goal of providing guidance for clinicians.

Methods

Systematic reviews were included if they:

  • Evaluated and defined non-pharmacological interventions aimed at reducing spasticity.
  • Were conducted with an adult population (18+).

Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.

The quality of evidence for each individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

Results

18 systematic reviews were included. They focused on spasticity presenting with:

  • Stroke (6)
  • MS (1)
  • Brain injury (1)
  • Spinal cord injury (1)
  • Mixed or other populations (9)

The findings of this review suggest:

There is moderate-quality evidence showing spasticity reduction for:

There is low-quality evidence for:

  • Rehabilitation programs targeting spasticity in stroke patients and those with other neurological conditions. These included:
    • mCIMT
    • stretching
    • dynamic elbow splinting and OT
    • electrical stimulations
  • Extracorporeal shockwave therapy in patients with brain injuries.
  • tDCS in stroke patients.
  • TMS and TENS for patients with other neurological conditions.
  • Physical activity programs and repetitive magnetic stimulation in MS patients.
  • Vibration therapy for patients with SCI and other neurological conditions.
  • Stretching for patients with neurological conditions.

There is very low-quality evidence for:

  • Passive movement in patients with neurological conditions.

Discussion

Spasticity is a complex disorder—but given its clinical importance, it is a critical condition to address.

Evaluating and treating spasticity remains difficult, despite growing evidence around treatment. This is due to a lack of specific guidance on which interventions to choose for individual patients, as there is such varied presentation of spasticity within this population.

There is also a lack of definition around optimal timing, type, duration, and intensity of intervention.

Additionally, there remains a need for multi-disciplinary neuro-rehab programs to specify treatment goals that:

  • Incorporate the patient’s perspective.
  • Rationalize the benefits and risks of treatment.

These goals should aim to:

  • Improve patient function and participation.
  • Focus on patient education.
  • Encourage self-management.

With respect to assessment, the ordinal scales we’ve used historically may not be providing enough information. This suggests the need for innovation. Currently used scales include:

Future research should focus on multi-disciplinary programs to develop effective care pathways; support long-term functional outcomes; and engage, educate, and empower patients.

Takeaways for OT practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. This article aligns with our focus in the Club on fully understanding the biological mechanism of our treatments.

As a new therapist, I was really intimidated by spasticity—mainly because I lacked the tools and knowledge to properly address it. So, I almost always resorted to stretching.

This article really drove home to me that spasticity is an impairment with a neurological basis (UMN lesions), which means we must consider treatments that have a more direct neurological impact. When we think about spasticity in a neuro context, it makes sense that things like neuromuscular electrical stimulation have strong evidence behind them (and thus, should be part of our toolkit).

2. New technologies will bring more spasticity management into the home (and our business models will need to adjust).

In preparing for this topic, I’ve been looking at websites like Neubie, which promote their products to both providers and patients. I think this is a window into the future of these technologies and how our patients will access them. As therapists, we need to start considering business models that promote self-management.

This is exactly why I am so excited to talk with Scott Thompson on the podcast. His past experience as clinical director for Saebo—and his current focus on running his own business, Thompson Neurotherapy—gives him a unique perspective on how we can work within our current medical systems to provide holistic care, as well as where we might be headed in the future.

Here’s the full APA citation for this article:
Khan, F., Amatya, B., Bensmail, D., & Yelnik, A. (2019). Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews. Annals of physical and rehabilitation medicine, 62(4), 265–273.

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Scott Thompson. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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I have questions more than comments for this topic. Is electroacupuncture the same as a percutaneous intervention such ad dry needling in conjunction with NMES clips on the needles? I have observed a PT do this for post-stroke patient and an athlete. OTs are restricted from dry needling in most states due to a lack of policy advocacy from state boards. This is too bad, IMO, as it would be an excellent addition in our toolbox for pelvic health, UE, and neuromuscular reeducation interventions.
My second question for the low quality list of interventions (systemic review collected up to 2017) : I recall throughout my OT program hearing about the dearth of high quality EBR and the emphasis on advocating for OT both through documentation and research. If the low quality intervention list is not easily reimbursable, is it possible there’s less research incentive?
On the flip side, as OTs we promote patient autonomy and agency. I can see how NMES with AROM provides that for the patient immediately whereas the other interventions are “done to” the patient passively. I am surprised that mCIMT is on the low quality list, but again I question the amount of of OT produced research in this area.
This article is by an MD in physical rehab Australia, & an impressive bio: Prof Fary Khan

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I have had some success with NMES combined with other interventions for moderate spasticity in stroke survivors. Severe spasticity is hard to treat with non-pharmacological methods.
I have not seen electroacupuncture used for spasticity yet. It appears to be acupuncture with the use of electrodes to pass a small current that gives a vibratory effect. I am not exactly sure how it works but would like to know more about this kind of intervention if anyone has used it.
I currently have a client with min/mod elbow flexor spasticity who is getting good return in her wrist and fingers (even after 1.5 years post-stroke) but is limited with elbow spasticity. Functionally, she is doing very well (lives alone, drives, and cooks). We have made her some 3-D assistive devices to help with clipping her fingernails and chopping with an adapted 3-D device. I would love for her to get a small dose of Baclofen or Botox for her elbow flexor spasticity but she does not have any insurance and our grant-funded clinic does not have a neurologist on board.
NMES to fatigue the elbow flexors and stimulate the triceps is working well with her so hoping that she continues to improve. She is very good with doing all her self-ROM exercises and has full ROM at all joints (except end range of elbow extension on the affected side).
This article is timely and I look forward to the podcast next week. Thank you, Sarah.

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Wow! Lot’s of great questions in here!

@scott2 We didnt talk much about electroacupunture in the episode. Do you know much about it? All of my knowledge would just come from a Google search :slight_smile:

I also like your call out about thinking through which interventions promote agency, and which are more passive. The author clearly thought a focus on self-management was the way of the future.

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Btw, that Neufit Neubie — awesomesauce!!! They give just enough information on their site for the hook and you can see that by opening a path for personal purchase it promotes autonomy and gives agency back to the patient in controlling progress AND pain. $18k to start, $500 for training and additional to onboard per the link for a private practice. Patient purchase begins at $15k so I’m guessing there’s a variation in channel usage for currents but I didn’t check the details. However, for the generation of patients who are highly educated and actively seek knowledge in managing and controlling all aspects of their body, I can see how this is a five star sell.
I would compare it to the pelvic health insertion devices that connect to an app on your phone. I attended a BCIA certification course with Tiffany Lee, OTR, who also promoted a private practice device with an option for patient purchase at home device. In my mind, giving agency back to the patient is the most therapeutic support OTs promote!

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Sanchala, what NMES settings for amplitude, frequency etc., do you find most effective for fatiguing elbow flexors? I do well w/ stimulating the extensors but have had less luck w/ fatiguing the antagonist…

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The subject for this week’s article review is SO welcome! Spasticity management is a key area of concern for a lot of my patients. I use NMES frequently in clinic, but often am left wondering how effective that 1-2x/wk is toward the goal of improving tone regulation, when neurological change requires so much repetition? A couple of my patients have been able to get a home NMES unit for use, which has helped them progress better w/ spasticity management since they can do sessions at home… but for those who can’t afford to do so, I really feel challenged in helping them make as much progress. Wondering how other clinics approach this issue…

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Hello Sarah,

I personally have never used electro-accupuncture but have seen it work well for sports/acute injuries, but never for spasticity.

I have a local acupuncturist that is healing veterans using this technique, however, she also has an in-depth knowledge of acupuncture and utilizes auricular, plantar, and whole-body qi approaches to compensate for healing. Succinctly, I think it’s faster acting than the Neubie, by mere minutes, but that’s because it’s invasive. You have to pierce the skin and find motor points to induce the action potential between two needles. My buddy’s wife sprained her ankle the other day with a big, swollen ankle. She randomly went and saw the acupuncturist I mentioned, and was chasing her two young kids the next day with only brusing and mild swelling.

Recently, I asked the acupuncturist to work with a former client who has moderate spasticity, so, hopefully, I can report positive results here shortly.

As for the self-treatment, that’s really where we need to have more support and focus in all aspects of recovery. Patient/caregiver training is something we should do more of, but we are always limited by time, liability, and what the CEOs are telling our directors to allow us to do. But as I think I said in the podcast, the education and training for ease-of-use of products is definitely an uphill battle. I remember a local client that I spent two sessions per caregiver (that’s 10 treatments) teaching them and coaching them, and having them demonstrate their ability to place pads and use e-stim for my client. And within two weeks no one was using it because “it was too difficult/cumbersome.”

Keep the questions coming!

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Hey PJ! Here is an article @scott2 shared with more recent research- this one was related to Parkinson’s.

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Hi everyone. Thanks for posting this article, Sarah. ‘Upper limb hypertonicity management’ is my favourite area of practice, so I’m excited to see this article!

Re. your first comment about ‘takeaways’. I agree it’s important to understand the causes and impacts of spasticity. This SR focuses on spasticity, however when treating clients (both children and adults), I think about ‘hypertonia/hypertonicity’ which is a combination of a neural component (spasticity, dystonia, clonus, central weakness/paresis etc) and a non-neural, biomechanical component (soft tissue stiffness, shortening/contracture, muscle weakness etc). Differentiating the components like this guides intervention options because some things work better for addressing the neural components (inhibitive casting, Botulinum toxin, casting, functional movement against resistance [Saeboflex], vibration, compression etc), and other modalities are more effective for the non-neural components (serial casting, Functional Electrical Stimulation/NMES on antagonists to increase strength, functional splinting to facilitate improved mechanical advantage of weakened muscles etc). This point is not made clearly in the article - this may be because it is written by medical practitioners who tend to focus on spasticity reduction, rather than therapists who tend to focus on function!

The other point that I think is important, which isn’t made in the article, is that, in my experience, intervention type is most effectively chosen depending on the stage of the person’s recovery journey in combination with the severity of their condition. So for example, in stroke and brain injury, the first 4 weeks are characterised by flaccidity, central weakness and loss of movement, all ‘negative’ UMN signs. Spasticity, soft tissue stiffness/contracture and deformity, or ‘positive’ UMN signs, tend to develop over time as the condition becomes more chronic, although of course there are exceptions (in fact, all presentation due to a neurological condition are a mix of negative and positive signs). This means that the most effective interventions are somewhat different along the journey. Many of the stroke resting splint studies have been performed in that ‘acute/flaccid/non-functional’ period, so posing the question “do splints improve function post-stroke” is poor clinical reasoning (in my opinion!)

The way I think about interventions is to focus on those that promote positioning for future upper limb function (resting and functional splints) if there are mainly negative signs/acute phase. Include modalities that focus on strengthening, such as NMES/FES/functional tasks as movement starts to emerge. As the chronic phase develops, there are more likely to be positive signs, such as moderate-severe, severe spasticity, +/- contracture, and this is where we need to include modalities focused on reducing/managing spasticity (Botulinum toxin, pharmacology, possibly acupuncture, NMES, inhibitive casting, compression etc) and contracture (serial casting, stretch, positioning using resting splints, and surgery).

I have opinions about splinting too but that’s so controversial it would need another whole post!! LOL

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Wow, @kathy4 this is such a gift to see your clinical reasoning around spasticity. This is how I was thinking we need to be reasoning about intervention- but you are actively doing it!

AND, I just googled you, and it looks like you actually WROTE THE BOOK on managing spasticity!

@scott2, I wanted to make sure you se this in case anything just out to you!

Seeing your level of expertise, I’d love to know some of your thoughts on splinting… if you have time to share. Or any resources you’ve found helpful! Also, given your expertise, never hesitate to share new research with me on this topic that you think is important. This is an area we will continue to circle back to over the years!

Wow, I just feel so lucky to have you in here, Kathy!

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Oh, thank you Sarah! :slight_smile:

Yes, my friend, Jodie, and I are co-authors. The book aims to be a practical guide, so it has “how to’s” on splinting and casting. And it’s set up around a structured, decision-making guide that we’ve called the HIPM (Hypertonicity Intervention Planning Model). This steps the clinician through decision-making based on the client’s amount/type of function, severity of impairment (mild, mild-moderate, moderate-severe, severe), influence of positive and negative UMN symptoms and the person’s preference. Then it provides guidance on the types of interventions that are most suitable for each of those categories.

My PhD research indicated that the HIPM improved clinical reasoning of both novice and expert therapists, and (amazingly!) increased the client-centred focus of expert therapists!! Jodie currently has a PhD student investigating the use of the HIPM in clinical practice. Really, the aim of the HIPM is to promote consistency of intervention across time for each client, and across changes in therapists, because spasticity/hypertonicity is a lifelong condition.

Happy to discuss splinting in another post - just running off now!

Thank you so much for what you do - it’s great for clinicians to be able to talk about research in a safe space!

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Hey PJ. Great questions. Yes, electro accupuncture is exactly like dry needling. Dry needling is a type of accupuncture. Also, I would like to say this because I sat on the state association board, look into your practice act and talk with your licensing board to see if you are NOT allowed to do dry needling, or if it is not mentioned in the practice/licensing acts/laws. If it’s not listed, that’s not the same as NOT being allowed to do it.
As for NMES, you can make gains with this process, but most of the time you’ll fight the AC current and muscles “locking up.” I utilized a device called the Neubie that uses pulsed DC current with a carrier wave at 10,000 Hz. This “pushes” the electrical signaling allowing for much better intervention and success.
Lastly, don’t worry about low level evidence…I didn’t mention it in the episode, but referencing ebrsr.com for stroke intervention is a great way to see what is or may work. I also never count out the low level evidence for intervention unless it repeatedly says it doesn’t work. If it works for the clients in the study it MAY work for your client. Cheers.

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Hello Sanchela. Great to hear that you are making gains with your intervention approach. I’d suggest getting ahold of an EMG-triggered e-stim device or another biofeedback device to allow her to train the flexors and extensors that limit her elbow flexion. I find that this can be tedious at first, but when people see their electrical signals go up by 20, 30, 60 microvolts in a session, you also see their spasticity decrease. And post that last comment, you can also see the electrical signals heighten and lower in the spastic muscles thus showing the ability to volitional “turn off” the muscle.

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Hello Jenna. I used to be a Director at Saebo and think their hand-held NMES device is still the best on the market for home-use. It has preset frequencies for UE/LE/Shldr Subluxation/Edema/TENS, but also has a Program 14 which is microcurrent that hits the sensory e-stim realm and changes spasticity. Lastly it is the only device I know of in the US that has a trigger button and it has a program 15 that allows you to set up a custom e-stim. Hope this helps you for home management because you’re right to ask how much a 1-2/wk treatment will really do for a client. I tell clients all the time that I’m just 10% of the work that needs to be done. I ask them “What are you doing for your recovery the other 165 hours in the week?”

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Wonderful to have your expertise Kathy! Is there an update version, or plans for such, for your Neurorehabilitation of the Upper Limb Across the Lifespan text? I would hope information on best practices have evolved since 2014 :wink:

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@sanchala - I was reading your comment and read that you made some 3 D assistive devices. Could you share some details about that or any picture? That seems a very creative solution. Thanks

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We made a one-handed nail clipper and knife holder so she could chop vegetables. I will post pictures for you once I go to work tomorrow.
Thanks for asking.

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