Table 1

 Spasticity management according to level of severity

Mild spasticity Emphasis on self management, education, and how to seek help to prevent secondary complications
• Clonus or mild increase in tone• Highlight potential trigger factors
• No or minimal loss of range• Education of secondary complications
• Mild spasms; generally not problematic or affecting function but annoying or inconvenient• Stretches: neurophysiotherapist identifies vulnerable areas and recommends specific, active, and regular stretches
• Discuss ways of maintaining active movement and modify patterns of movement to minimise increasing spasticity
• Low dose drug treatment targeted at problematic times of the day, with ongoing review and evaluation, maybe beneficial
Moderate spasticity Emphasis on early identification and treatment of trigger factors, review of self management knowledge, and liaison with team members involved throughout the different health care sectors; maximise the use of oral drugs and consider the use of botulinum toxin if focal
• Loss of range of movement and possible contracture• Identify trigger factors and treat as appropriate
• Walking is often effortful, may require aid or wheelchair• Targeted neurophysiotherapy; active stretching, exercise and standing programmes; consider splinting
• Difficulty releasing grip or in hand hygiene• Maximise available activity to have a positive impact on function and establish extent to which spasticity and spasms are used to enable effective movement; consider rehabilitation
• Minor adaptations required for position in lying; t-roll, wedge, pillows, lumbar roll• Accurately document assessments and treatments to enable ongoing evaluation of intervention
• Maximise oral drugs and consider if botulinum toxin could be helpful for focal spasticity
• Consider referral to specialist service
Severe spasticity Emphasis on maximising use of oral and focal drug treatments while considering use of intrathecal baclofen or phenol; review patient’s, carers’ and health team management strategies
• Marked increase in tone• Identify trigger factors and treat as appropriate
• Loss of range and probable contracture• Accurately document assessments and treatments to enable ongoing evaluation of intervention
• Often hoisted for transfers• Assess effectiveness of current treatment strategies, modify as appropriate, and consider intrathecal drugs
• Difficult positioning despite complex seating systems• If intrathecal drugs are used, review need to reassess seating, transfers, and therapy input; consider rehabilitation
• Reduced skin integrity• If treatments are or become ineffective, review management strategies including possibility of surgery
• Often reliant on a catheter and regular enemas• Identify trigger factors and treat as appropriate
• Accurately document assessments and treatments to enable ongoing evaluation of intervention
• Assess effectiveness of current treatment strategies, modify as appropriate, and consider intrathecal drugs
• If intrathecal drugs are used, review need to reassess seating, transfers, and therapy input; consider rehabilitation
• If treatments are or become ineffective, review management strategies including possibility of surgery