MANAGEMENT OF POST-STROKE UPPER AND LOWER LIMB SPASTICITY: A CONSENSUS DOCUMENT OF THE HELLENIC NEUROLOGICAL SOCIETY, HELLENIC SOCIETY OF CEREBROVASCULAR DISEASES AND HELLENIC SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE

Abstract

Stroke is the second cause of death and the leading cause of disability in individuals above 60 years old. Spasticity is a movement disorder characterized by a velocity dependent hypertonia, and is a common post-stroke complication present in up to 30% of cases. The most common sites involved are the elbow, wrist and ankle. Spasticity significantly contributes to the worsening of motor deficits, and if left without prompt treatment, it may lead to permanent joint deformities, muscle contractions, local pain, involuntary movements, deterioration of disability, and skin complications. The diagnosis of post-stroke spasticity is primarily clinical, whereas the implementation of well-established clinical scales (Fugl-Meyer Assessment Action Research Arm Test, Barthel Index, Modified Ashworth Scale, Modified Tardieu Scale) in the initial patient evaluation and follow up is highly recommended. The management of spasticity should be initiated early by a multidisciplinary team consisting of Neurologists and Physical Medicine and Rehabilitation (PM&R) physicians (Physiatrists). The therapeutic goals include the overall clinical and functional improvement of the patient, the resolution of neurological symptoms and the prevention of complications and contractures. Treatment involves non-pharmacological approaches such as rehabilitation sessions with specialized techniques, administration of oral muscle relaxants, intramuscular injections of botulinum toxin, and sometimes the surgical release of contractures. Oral muscle relaxants show moderate efficacy with high rates of side effects. On the contrary, botulinum toxin injections may significantly contribute to the resolution of spasticity. Treatment is safe and is recommended as first line in association with rehabilitation sessions. In refractory cases introduction of an intrathecal baclofen pump is recommended.