Evidence for goal setting, attainment and integration of physical and pharmacological intervention for spasticity management


Evidence for goal setting, attainment and integration of physical and pharmacological intervention for spasticity management

Neurological damage to the brain, as a result of brain injury (traumatic/anoxic brain injury or stroke), typically leads to paralysis (primarily muscle weakness) of one or both sides of the body (partial or complete). In the early stages after brain injury, the affected limbs are often flaccid (low-toned paresis), but after a few weeks muscle tone may start to return and can lead to the development of muscle over activity or spasticity. Spasticity will often have unwanted effects, such as pain and could result in secondary problems such as muscle stiffness, contracture and pressure sores.

Goal attainment scaling (GAS) is increasingly used as an outcome measure for evaluation of focal interventions for upper limb spasticity(Ashford and Turner-Stokes 2006; Ashford and Turner-Stokes 2009; Turner-Stokes et al. 2010). Goals for treatment of upper limb spasticity are widely diverse, depending on the individual aspirations and priorities of the patient and/or their family. They may be directed at reducing impairment (e.g. preventing contractures and deformity), improving activities (such as personal care) or use of the limb for participatory activities (such as work, hobbies, recreation etc.). In other words, goals may be directed at achieving change at any level of the World Health Organisation (WHO) International Classification of Function, Disability and Health (ICF) (Wade 1992; WHO 2002) – body systems (impairment), activities or participation.

A total of 696 individualised primary and secondary goals for treatment of upper limb spasticity using BoNT injection were analysed from four of our studies. Goal classification is summarised as follows, overall 322 (46%) of goals were set in the domain of symptoms / impairment, whilst 374 (54%) goals were related to activities and participation (Ashford et al. 2015). Goal analysis has now also been expanded to evaluate goals set for lower limb spasticity with the same categories identified (Ashford et al. In press). This work has resulted in a goal setting and classification system for upper and lower limb spasticity where focal physical and pharmacological interventions are considered.

Alongside the systematic setting of patient focused goals and the evaluation of their outcome, exploration in this area has identified an ongoing requirement to carefully record the interventions patients receive from a physical perspective. Systems in the form of patient reported experience measures (PREMs) for recording this information have been developed and tested in three cohort studies to date.

These approaches to recording both outcome and what constitutes intervention in this patient group, have supported practice development in this area and are leading to improvement patient outcomes. Nevertheless there is a need to apply these findings to evidence based practice for clinicians in the field.