VOL: 102, ISSUE: 15, PAGE NO: 26
Louise Jarrett, BA, RGN, is clinical nurse specialist spasticity management, National Hospital for Neurology and Neurosurgery, UCL Hospitals Foundation Trust, LondonThe management of spasticity remains a challenge not only for the person with spasticity but also for their family, carers and healthcare professionals. The pathophysiological nature of spasticity continues to be a focus for debate and remains incompletely understood (Stevenson and Marsden, 2006). How individuals experience spasticity and the impact that it has on their lives continue to be key resources for healthcare professionals and scientists in the advancement of knowledge.
The management of spasticity remains a challenge not only for the person with spasticity but also for their family, carers and healthcare professionals. The pathophysiological nature of spasticity continues to be a focus for debate and remains incompletely understood (Stevenson and Marsden, 2006). How individuals experience spasticity and the impact that it has on their lives continue to be key resources for healthcare professionals and scientists in the advancement of knowledge.
Spasticity is a common feature of neurological conditions such as multiple sclerosis (MS), cerebral palsy, stroke, brain and spinal injuries. In a recent survey 84% (n=20,969) of people with MS reported that spasticity affected their daily life. Its impact on a person's daily life may be minimal or extensive and can be either positive or negative - spasticity can restrict movement for some people whereas others may rely on extensor spasms to walk. The severity of spasticity ranges from minimal, through mild, moderate, severe to total with the last category preventing participation in daily activities (Rizzo et al, 2004). Managing spasticity often requires a long-term approach involving an integrated multidisciplinary team working across health and social care (Jarrett, 2006). It provides an opportunity for professionals to work in partnership with not only the person with spasticity but also other healthcare providers, dealing with issues as and when they occur.
The definition of spasticity commonly used is: 'A motor disorder characterised by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome' (Lance, 1980).
More simply, spasticity results in stiff muscles that resist passive movement and is described as one component of the upper motor neuron (UMN) syndrome (Greenwood, 1998). Pain may be an associated feature.
In addition to the neural basis, biomechanical changes occur in both muscles and connective tissue through disuse and immobility. These can often lead to a reduced range of movement or contractures. These soft tissue biomechanical changes can also contribute to the feeling of stiffness felt when passively moving a limb and this may significantly affect function (Dietz, 2003).
The term spasticity is often used by healthcare professionals not only to describe the stiffness felt on passive movement but also to describe collectively the unique range of symptoms including pain that a person with spasticity may experience resulting from a combination of upper motor neuron syndrome features and biomechanical changes.
During a European project to evaluate methods for measuring spasticity it became apparent that the working definitions of spasticity varied across the clinical and research community. It was felt a new definition might be helpful to reflect this. The group challenged the Lance definition on the following levels, stating spasticity was not:
- A pure motor disorder;
- Just a result of a hyperexcitable stretch reflex;
- Resistance to passive movement only related to muscle activity (Pandyan et al, 2005).
A new definition of spasticity that would include all the positive features of the upper motor neuron syndrome, for example, the increase in tendon reflexes and clonus, was proposed. This would relate more closely to how clinicians have been using the term spasticity in clinical practice.
This new suggested definition is: 'Disordered sensory-motor control, resulting from an upper motor neuron lesion, presenting an intermittent or sustained involuntary activation of muscles' (Pandyan et al, 2005).
New scales to measure the impact of spasticity on the person have also recently been developed (Hobart et al, 2006).
Effects of spasticity on the person
Spasticity can affect all aspects of life. It can affect physical activities such as walking, transferring, washing, dressing and sexual activity. It may also have an emotional impact, for example on mood, self-image and motivation (Currie, 2001). Safety in sitting and lying can also be compromised due to spasms or persistent poor positioning.
Symptoms of upper motor neuron syndrome are not always detrimental and may be positive in improving vascular flow and assisting in transfers and walking (Losseff and Thompson, 1995). Therefore treatment needs to be carefully selected and reviewed over time to meet the individual's aims and to maintain and promote function.
Managing spasticity takes a balance between minimising symptoms and maximising function. This can be challenging, as spasticity can vary from day to day and hour to hour.
An important aspect of overall management of spasticity is the education of the person and their family about the nature of spasticity and what could exacerbate it (Jarrett, 2006). This is to enable individuals to identify triggers unique to their own spasticity pattern. Common trigger factors for spasticity include infections, reduced skin integrity, urinary retention or change in frequency, constipation, diarrhoea, mood changes, poor positioning or even tight clothing or orthotic devices (Jarrett, 2006).
Ongoing monitoring and prompt treatment of these issues remain pertinent to overall successful management, irrespective of any drug treatments. Similarly, incorporating daily exercise, standing, or active or passive stretching is fundamental to the management of spasticity.
The input of neurophysiotherapy is important in instigating exercise programmes, which can be carried over into an individual's lifestyle (Lockley, 2004). Drug treatments can be used independently or in combination (Jarrett, 2006). In addition, the effect of new drugs such as cannabinoids on spasticity continue to be explored (Zajicek et al, 2005). Surgical options such as tenotomies and rhizotomies (Mertens and Sindou, 2001) may also be considered.
Refining assessment and measurement skills in both clinical and research practice are important to ensure the appropriateness, efficacy and safety of all treatments used.
Assessment and measurement
The two main aims of assessing spasticity in clinical practice are to:
- Establish how spasticity positively and negatively affects a person's function;
- Appreciate what the person wants to achieve from any treatments used.
Assessment is an ongoing process where the person with spasticity and the healthcare professional work together collating and integrating information to predict how treatments may affect the lifestyle of the person with spasticity. The aim is to enable the person with spasticity to choose which treatment may best achieve their aims and more readily fit their daily lives. Measurement forms part of the assessment by providing a quantifiable judgement. Measures are essential if drug doses before, after and in trial phases of drug treatments are to be titrated effectively.
There is no single measure that can be used to quantify spasticity - often a combination of measures is required. The team needs to decide which measures they want to use to enhance assessment. Nurses can play a key role in measuring spasticity, particularly where its impact on care and function are being considered, using methods such as the hygiene score (Snow et al, 1990). As the impact of spasticity on an individual varies throughout a 24-hour period, nurses are often best placed to assess how spasticity affects a person's function throughout the day and they can monitor in conjunction with the person with spasticity the effectiveness of treatments.
In addition, people being measured need support to understand and participate in the process of measurement and often the nurse is the most appropriate healthcare professional to provide this.
Being measured - people perspective
Often people with spasticity have severe complex disabilities they have been managing effectively for a significant period of time. Some can successfully merge their disability into their daily lives, whereas for others symptoms and disabilities can be a focus of how they choose to lead their lives. People with chronic illness often adopt one of two perspectives, living with their illness either in the foreground or background (Paterson, 2001).
People with chronic illness have often adapted their home and work environments to such a fine degree that they have successfully optimised their function. However, taking them out of those environments - for example visiting outpatient departments - can cause them to function less effectively, as the environment is set up for the majority of people with disabilities and not for individual requirements. This can be a stark reminder to the individual of their level of disability and may force them to confront their illness emotionally and physically.
People with complex disabilities often fear coming into hospital (Jarrett and Johns, 2005) and being admitted into hospital can alter a person's perception of their illness. People with complex disabilities may see themselves as being well even when experiencing symptoms and receiving hospital treatment for them. For example, they may not see themselves as ill if they are seeking new ways to manage symptoms such as taking part in an intrathecal drug trial.
To support a person with spasticity to select a suitable treatment for their symptoms, nurses need to acknowledge the person's expertise regarding their condition. This will enable the nurse to support individuals in appreciating how the different treatments may affect their spasticity management.
Likewise measurement can also bring a person's illness into the foreground. This can make people focus on how their body is changing, which may be a threat to how they have envisaged or constructed themselves within the context of their illness (Kralik, 2002; Charmaz, 1983).
When measuring, healthcare professionals may record the range of movement each limb can be moved through and how the limbs feel when moved. The person with spasticity is asked to focus on their main problem with that movement and what the one thing that could improve their lifestyle would be. The scores may be recorded in numerical values, such as in the Ashworth scale (Ashworth, 1964), which have little meaning for the individual being measured.
Being measured can make people feel as if they are being tested or judged. Healthcare professionals need to minimise this feeling. Nurses are often in a key position to recognise when individuals may be anxious about a pending assessment or treatment outcome. Three stages for supporting people during the measurement process are summarised in Box 1 (p27).
More recently the idea of expert practice has involved practitioners being mindful as they practise. This is more than simply being aware and taking action - it involves being actively alert to cues that may mean that a person is not coping or they are finding a situation difficult.
Such cues will have been identified through working over time with people having similar experiences; expertise is developed through acknowledging patterns and working with the individual to address them (Benner and Tanner, 1987).
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Be clear what the term 'spasticity' means;
- Understand the purpose of measurement as part of the assessment process;
- Be familiar with the positive and negative effects of measurement on the person with spasticity;
- Understand some of the techniques a nurse can use to minimise the negative effects of measurement.
Use the following points to write a reflection for your PREP portfolio:
- Discuss your area of work and why this article may be relevant;
- Remember the last time you may have come across a patient with spasticity;
- Identify a piece of information from this article that may have helped you manage that patient;
- Consider how you would use this information with your next patient;
- Explain how you will disseminate this information to your colleagues.
This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net