Rehabilitation management of post-stroke spasticity
AffiliationCentre for Neuroscience
Document TypePhD thesis
Access StatusOpen Access
© 2017 Dr. Marina Demetrios
Spasticity is a common manifestation of a neurological condition such as stroke and contributes to long-term disability. Spasticity is disordered sensorimotor control that results from damage to upper motor neurons and presents as involuntary activation of muscles that can be intermittent or sustained. The resulting limb deformity and abnormal positioning cause a diverse range of patient-centred problems such as pain; difficulty walking, transferring, feeding or dressing; and can make it difficult for a caregiver to clean the palm or apply a splint. Given the complexity of spasticity related issues, expert opinion is that spasticity management should entail a multidisciplinary rehabilitation program that may be complemented with botulinum toxin treatment. However, there is a paucity of evidence for the efficacy of rehabilitation programs for spasticity management. In this thesis, four studies address current gaps in evidence-based practice. Study 1 is a systematic review of the effectiveness of multidisciplinary rehabilitation following botulinum toxin and other intramuscular treatments for post-stroke spasticity. Despite low-quality evidence that multidisciplinary care lessens impairment and improves active function in the upper limb, the types and intensities of rehabilitation programs that improve patient-centred outcomes remain unknown. No trials to date have explored the effect of multidisciplinary rehabilitation on passive function, caregiver burden, or the individual’s priority goals for treatment. This study identifies gaps in current research relating to methodological rigour, appropriate study designs and meaningful outcome evaluation. Study 2 compares the effectiveness of a high-intensity ambulatory rehabilitation program and a usual care, low-intensity therapy program in improving patient-centred outcomes after botulinum toxin type A treatment. Goal achievement and satisfaction benefits persisted beyond the duration of spasticity reduction in both groups. While patient-centred outcomes were not influenced by the intensity of the ambulatory rehabilitation program, high-intensity therapy was associated with greater upper limb goal attainment. This suggests that intensive therapy may modify the black box of rehabilitation. Further research is required to evaluate this effect and determine which elements of therapy programs optimise outcomes. Study 3 demonstrates the use of a stroke rehabilitation taxonomy to describe the activities and interventions that therapists used during rehabilitation programs. The relationships between rehabilitation activities prescribed and treatment goals and limbs injected are also examined. Study 4 explores the key implementation processes that may affect the outcome of the high-intensity rehabilitation programs compared with usual care. The influence of program adaptations such as provision of group rather than individual sessions, contextual or organisational differences between rehabilitation centres, therapists’ experiences with managing patients following BoNT-A injections and the effect of goal-directed therapy on outcomes needs further evaluation. This work was undertaken to test the hypothesis that multidisciplinary rehabilitation programs following botulinum toxin type A injections for post-stroke spasticity improve patient-centred outcomes. The study findings guide the recommendations for future research and clinical practice that can be used to improve service delivery and the evidence base for rehabilitation interventions after treatment with botulinum toxin type A for post-stroke spasticity.
Keywordsrehabilitation; stroke; spasticity
- Click on "Export Reference in RIS Format" and choose "open with... Endnote".
- Click on "Export Reference in RIS Format". Login to Refworks, go to References => Import References