Stroke Training and Awareness Resources (STARs)

Guidelines and recommendations for positioning and spasticity treatment

Physical management to include:

  • Active movement, encouraging proximal control, alignment and normal patterns of movement
  • Early weight-bearing through both arm and leg

 

Royal College of Physicians Guidelines

 

Summary of the recommendations

Click through the slides 1–7 below using the controls ◄ ►

Royal College of Physicians Guidelines

National clinical guideline for stroke

Select the Recommendations buttons below for more information

Recommendations for positioning:

A Patients with acute stroke should have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital.

B Healthcare professionals responsible for the initial assessment of patients with acute stroke should be trained in how to position patients appropriately, taking into account the degree of their physical impairment after stroke.

C When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.

Recommendations for spasticity:

A People with motor weakness after stroke should be assessed for spasticity as a cause of pain, as a factor limiting activities or care, and as a risk factor for the development of contractures.

B People with stroke should be supported to set and monitor specific goals for interventions for spasticity using appropriate clinical measures for ease of care, pain and/or range of movement.

C People with spasticity after stroke should be monitored to determine the extent of the problem and the effect of simple measures to reduce spasticity e.g. positioning, passive movement, active movement (with monitoring of the range of movement and alteration in function) and/or pain control.

D People with persistent or progressive focal spasticity after stroke affecting one or two areas for whom a therapeutic goal can be identified (e.g. ease of care, pain) should be offered intramuscular botulinum toxin. This should be within a specialist multidisciplinary team and be accompanied by rehabilitation therapy and/or splinting or casting for up to 12 weeks after the injections. Goal attainment should be assessed 3-4 months after the injections and further treatment planned according to response.

E People with generalised or diffuse spasticity after stroke should be offered treatment with skeletal muscle relaxants (e.g. baclofen, tizanidine) and monitored for adverse effects, in particular sedation and increased weakness. Combinations of antispasticity drugs should only be initiated by healthcare professionals with specific expertise in managing spasticity.

F People with stroke should only receive intrathecal baclofen, intraneural phenol or similar interventions in the context of a specialist multidisciplinary spasticity service.

G People with stroke with increased tone that is reducing passive or active movement around a joint should have the range of passive joint movement assessed. They should only be offered splinting or casting following individualised assessment and with monitoring by appropriately skilled staff.

H People with stroke should not be routinely offered splinting for the arm and hand.

  • Rollover with practical examples of physical management, physio, OT, nursing
  • Splinting and Lycra.

Spasticity in adults: management using botulinum toxin

Postural management:

Postural management can enhance not only physical comfort, respiration, communication and visual abilities, but help to prevent or limit the development of secondary complications such as adaptive muscle shortening, exacerbation of spasticity, pain, and pressure areas.

A 24-hour approach to postural management requires a planned approach encompassing all activities and interventions that impact on an individual’s posture and function (Gericke 2006).

  • For immobile patients this typically involves the use of profiling beds, sleep systems, wedges, T rolls, wheelchairs and seating to optimise the position of the head, pelvis, trunk and limbs.
  • For ambulant patients, mobility equipment (walking sticks/frames) should be selected carefully and set at the correct height.

Summary of the recommendations:

1 Overarching statement Grade of evidence* Strength
1.1 Botulinum toxin type A (BoNT-A) is a safe and effective treatment for upper and lower limb spasticity, resulting in both passive and active functional gains:

  • Commissioning of spasticity management programmes should include provision for use of BoNT-A injection, when administered in line with the recommendations below.
 RA E1 E2 Strong
2 Principles of coordinated spasticity management Grade of evidence Strength
2.1 The management of spasticity should be undertaken by a coordinated multidisciplinary team (MDT), rather than by individual clinicians working in isolation. E1 E2 Moderate
2.2 Before using BoNT-A, the team must ensure that:

  • all remediable aggravating factors have been addressed
  • an appropriate physical management programme is in place
  • a suitable programme of ongoing coordinated management is planned.
 E1 E2 Strong
2.3 BoNT-A must only be injected by clinicians who have:

  • appropriate understanding of functional anatomy
  • experience in the assessment and management of spasticity, and the use of BoNT-A in this context
  • knowledge of appropriate clinical dosing regimens and the ability to manage any potential complications.
 E1 E2 Strong
2.4 BoNT-A injection must be part of a rehabilitation programme involving physical management and/or rehabilitation to achieve an optimal clinical effect. RA E1 E2 Moderate
3 BoNT-A injection Grade of evidence Strength
3.1 Patients should be selected for BoNT-A on the basis of:

  • focal or multi-focal problems due to spasticity
  • a dynamic spastic component as opposed to contracture
  • clearly identified goals for treatment and anticipated functional gains (taking into account the risks of any negative impact where patients rely on their spasticity for function).
 E1 E2 Strong
3.2 Patients and their families/carers should:

  • be given appropriate information
  • have an understanding of the realistic goals and expected treatment outcomes
  • agree treatment goals before any treatment, including BoNT-A, is given.
 E1 E2 Strong
3.3 Informed consent should be obtained from patients prior to injection.
If the patient does not have the mental capacity to consent, current local (eg trust) E1 E2 policies for obtaining consent or making ‘best interests’ decisions should be followed with reference to the Mental Capacity Act 2005.		 E1 E2 Strong
3.4 Clinicians must be aware that different BoNT-A products have different dosage schedules.
The current recommended maximum doses per treatment session within licensed usage for spasticity are:

  • 200-240 units (arm); 300 units (leg) BOTOX®
  • 1,500 units Dysport®(total body dose arm and leg)
  • 500 units Xeomin® (arm).

Clinicians should refer to Appendix 2 for the recommended doses for individual muscles.

 A Very strong
3.5 Electromyogram, electrical stimulation and/or ultrasound should be used to localise the BoNT-A injection, according to the site and purpose of the injection. RC E1 E2 Moderate
4 Concomitant therapies Grade of evidence Strength
4.1 Individuals at risk of contracture or loss of joint range should receive interventions (eg splints, casts or positioning) to provide passive stretch of sufficient duration and intensity when there is still potential for reversibility. RA E1 E2 Moderate
4.2 Task-practice training (repetitive practice) should be considered when RA E1 E2 Moderate improvement in activity performance and motor control are the target or goal of treatment. RA E1 E2 Moderate
5 Prescribing, supply and administration by non-medical practitioners Grade of evidence Strength
5.1 When provided as part of a multidisciplinary programme, prescribing and injecting of BoNT-A by non-medical practitioners is safe, effective, and potentially highly cost-efficient.

  • Providers should consider the development of these roles to support optimal clinical services for patients.
  • Summaries of product characteristics for BoNT-A preparations should be updated to reflect current practice and legislation with respect to non-medical injectors in the UK.
 RB E2 Strong
5.2 Processes for the administration and/or prescription of BoNT-A by non-medical practitioners (eg nurses, physiotherapists and other allied health professionals) are now well established in the UK.

  • As for all spasticity interventions, the administration of BoNT-A by medical and non-medical practitioners should be in the context of an MDT decision.
  • Support must be available from a medical clinician who has the appropriate expertise and knowledge of BoNT-A injections, and may provide medical back-up in the event of any complications.
  • Non-medical clinicians with appropriate qualifications and prescribing rights may undertake prescription in accordance with UK statutes.
  • If the clinicians involved do not have prescribing rights, a formal system (such as a Patient Specific Direction or a Patient Group Direction) should be produced to enable the administration of BoNT-A under sound clinical governance principles.
  • Careful attention should be given to the additional training needs of all staff involved, eg sterile intramuscular injection techniques, anatomical assessment.
 E2 Strong
6 Follow-up, documentation and outcome evaluation Grade of evidence Strength
6.1 All injections should be followed by:

  • therapy review in 7-14 days for assessment and if necessary orthotics/splinting
  • MDT review at 4-6 weeks to assess effect and patient status
  • MDT review at approximately 3-4 months to plan future management (although re-injection intervals may be longer than this, depending on the stage, trajectory and types of goal).
 E1 E2 Moderate
6.2 Injections should be followed by a formal assessment of outcome that includes:

  • severity of presentation at baseline
  • achievement of intended goals for treatment using Goal Attainment Scaling
  • standardised measures selected according to the goals for treatment.
 RA E1 E2 Very strong
6.3 Outcome evaluation should be standardised as far as possible to support comparison for quality benchmarking and research.

  • The Focal Spasticity Index described in these guidelines represents a standardised framework incorporating a limited range of widely-used validated measures, classified within the six main goal areas.
 E1 E2 Moderate
6.4 Documentation for all injections should include:

  • patient and carer expectations for outcome
  • risks of treatment discussed
  • a clear statement of agreed treatment goals
  • baseline outcome measures appropriate to those goals
  • BoNT-A product, batch number, dose, dilution and muscles injected
  • follow-up treatment plan
  • evaluation of outcome and repeat measures
  • plans for future management.
 E1 E2 Strong
7 Services Grade of evidence Strength
7.1 Services administering BoNT-A should have access to staff with the relevant expertise and facilities, including adequate space, therapy staff and equipment for splinting/orthotics. E2 Strong
7.2 Clinicians should have access to facilities to aid assessment, selection and treatment planning, eg electromyography, nerve/muscle stimulation, ultrasound etc. RC E2 Moderate
7.3 A clinical service should routinely use a single preparation to avoid confusion over dosage and to ensure knowledge of the product characteristics (see Summary of E2 product characteristics at www.emc.medicines.org.uk). E2 Strong

*The evidence to underpin these recommendations is summarised in Appendix 10.

Page last reviewed: 05 May 2020