CRC - Spasticity Management: A Practical Multidisciplinary Guide
|Publication Date:||26 July 2006|
The impact of spasticity on an individual can be devastating. It can cause a myriad of symptoms, and each individual's experiences are different. Although spasticity is often considered a disorder of motor function, some people with spasticity will perceive pain while others will experience discomfort or stiffness, and spasms may be described as simply annoying or as extremely painful. Chronic pain or spasms frequently interfere with sleep, and can also have an emotional impact on, for example, mood, self-image or motivation.
The presence of spasticity or spasms can obviously also impact on function. With regard to mobility, walking may be slower or more difficult, falls more frequent, or the ability to self-propel a wheelchair or transfer compromised. Likewise, activities of daily living, including washing, dressing, toileting and sexual activity, can all be affected.
All of these aspects can have a detrimental affect on the ability of an individual to continue in employment or education, or impact on fulfilment of life roles, including those as a parent or partner.
Poorly managed spasticity can also have serious long-term consequences. Muscle shortening and tendon or soft tissue contracture can lead to restriction of passive movement or physical deformity. Once contractures are present, these are often very difficult to treat and can have major functional implications, including difficulties in carrying out personal hygiene or dressing. With severe contractures, positioning can be affected, resulting in an inability to seat an individual, which will inevitably lead to restricted community mobility and social isolation. In addition, through compromising positioning in sitting or lying, contractures can lead to the development of pressure sores, which may in turn increase the severity of spasticity and spasms, resulting in a vicious circle.
Awareness of these implications, early identification, and intervention to treat spasticity and associated symptoms such as spasms can minimise development of these long-term secondary complications.
Finally, it must not be forgotten that, as well as contributing to these complications and loss of function, spasticity may also be useful for an individual, perhaps allowing them to stand or walk when their weakness would not otherwise permit it.
With these issues in mind, it is imperative that management always be individualised and function focused rather than simply being aimed at the reduction of spasticity as a sign or symptom.
So, is another book on spasticity really needed? Several books and review articles dealing with spasticity have been published over recent years, so it could be argued that there is no need for another. This would indeed be the case if this book simply explained the pathophysiology of spasticity and listed its possible causes and treatments. Several excellent publications have covered this area; however, none of these is a truly practical guide relevant to all members of the multidisciplinary team involved in management of the individual with spasticity. Several of these previous publications are excellent sources of information - and are referenced here accordingly - but often the information that is needed by a multidisciplinary team faced with a particularly challenging problem or with developing a service is nowhere to be found. Anyone who has been involved in setting up a new service knows how difficult and how protracted a process this can be, so any help or guidance is usually greatly valued.
The idea for this book has been growing over the last few years and has been nurtured by visitors to our service, of all disciplines from many different National Health Service (NHS) Trusts in the UK, as well as visitors from overseas. Feedback has on the whole been very good, but the recurring theme from visitors has been the desire to take our protocols and guidelines and replicate the service elsewhere. This seems to be a good idea, but a busy NHS clinic has not proved an appropriate place to be able to impart details of our experience to others.
Consequently, the basis of this book is to collect together the experience and knowledge of a multidisciplinary team who have worked in this area for over 10 years. It draws together several areas, including basic knowledge of pathophysiology, how to set up and develop a service, as well as useful management strategies and treatment interventions. On a practical note, it includes complete copies of the patient information that we have developed and found useful, proformas for assessing individuals, protocols for different interventions, nursing care plans, and an integrated care pathway for outpatient spasticity management. These protocols are, of course, specific to our service, but could easily be adapted and tailored specifically for use in other centres.
This is not, however, an exhaustive text, and there are clearly some areas that are not covered in detail as they fall outside our area of expertise - for instance, specialist seating and orthotics, and the details of neurosurgical procedures. These areas are clearly referenced to allow easy access to more information.
We are not claiming that this is the 'right' or only way to run a spasticity service, and there is certainly room for improvement, but we hope that by sharing our experience we can help others to develop their own service and thus improve management for all individuals with spasticity.
One of the recurring themes throughout this book is the emphasis on the importance of all team members being involved in providing education to the person with spasticity and if appropriate their carers and families. We believe strongly that by facilitating individuals with spasticity to learn how to manage their own symptoms and become 'expert patients', many of the previously common consequences of suboptimally managed spasticity can be avoided. Before we can educate others, we do of course need a sound knowledge base of our own. Optimum management of spasticity is dependent on an understanding of its underlying physiology, an awareness of its natural history, an appreciation of the impact on an individual, and a comprehensive approach to minimising that impact that is both multidisciplinary and responsive over time.