Year
2023
Degree Name
Doctor of Philosophy
Department
School of Health and Society
Abstract
Background: Spasticity is a common motor impairment following stroke, and is characterised by increased muscle tone and stiffness, which in turn makes moving and positioning the arm difficult. Post-stroke spasticity contributes to increased disability levels and has been attributed to reduced quality of life for stroke survivors. While treatment options include both pharmacological and physical therapies, much of the research to date has focused on pharmacological interventions, in particular botulinum toxin-A (BoNT-A), with little to no understanding of the benefit and impact beyond such interventions. Therefore, this research program aims to address this gap.
Aim: The overall objective of this program of research was to understand how physical therapies may better address the impairments that arise from post-stroke spasticity. A series of research studies investigated: (1) the literature for effective physical rehabilitation therapies provided in adjunct to BoNT-A injections to improve function in adults who experience spasticity following stroke; (2) the clinical impairments reported by adults who experience spasticity following stroke; and (3) clinical perspectives and decision-making in the provision of evidence-based practice interventions to treat spasticity and improve upper limb function following BoNT-A injection.
Method: Three interrelated studies were conducted to address the broad objective of the research program. Study 1 was a systematic literature review with meta-analysis, which identified what current evidence exists to support the use of rehabilitation interventions or therapies post BoNT-A injection to treat limb spasticity following stroke. Study 2 was a clinical correlates study which synthesised data from three states in Australia to identify and describe the population of stroke survivors who typically present to Australian spasticity clinics seeking access to spasticity management services. Study 3, a qualitative study, was then conducted to understand the clinicians’ perspectives on providing physical therapies to the population as identified in Study 2.
Results: Results of Study 1 (systematic review) identified that the rehabilitation therapies provided following BoNT-A injection that produced small but statistically significant improvements over injection alone included both stretch-based interventions (e.g., casting) and constraint-induced movement therapy. However, evidence for other modalities, such as functional electrical stimulation, motor training and ergometer arm cycling, had equivocal results although few trials had been conducted. Findings from this systematic review helped identify a starting point for which physical therapies could be included in rehabilitation programs following BoNT-A and mapped these therapies to specific impairments. Study 2 then identified the level of function and chronicity of disability experienced by stroke survivors who typically seek spasticity management services. Findings highlighted that this population may have limited opportunity for significant upper limb motor recovery (due to their significant concurrent disability and stroke chronicity) and, thus, that managing impairments in this group should be prioritised by health services. Understanding this finding alongside the systematic review provided an opportunity to then explore clinician expectations and experiences of delivering rehabilitation therapies identified in study 1 in Study 3. Through qualitative analysis, the experiences of clinicians who deliver therapy programs suggested that although they had received training and had experience in delivering more impairment-based interventions (such as casting), clinical decision-making and selection of interventions was seen as a complex responsibility for clinicians. It involved clinicians effectively working through clinical behaviour change and developing skills that allowed for tailored upper limb rehabilitation programs that could efficaciously achieve outcomes with stroke survivors who experience limb spasticity and often a multitude of other chronic stroke-related impairments.
Conclusion: Findings from this research program have highlighted that providing physical therapy interventions for adults who have received pharmacological management of their spasticity remains limited. Adults in Australia who access spasticity management services demonstrate significant impairments and, thus, their potential for regaining motor control is likely limited, and yet health services do not appear to routinely target their therapy at such impairments. There is a great opportunity to revise service provision to map to the presenting patient issues, and to advocate for both clinical education and research to be undertaken to decrease or ameliorate the impairments faced by adults who, though unlikely to regain motor control, nonetheless continue to experience impairments in weakness, contracture and sensation, as well as pain.
Recommended Citation
Kinnear, Bianca Zoe, Improving function in adults with spasticity after stroke or neurological impairment: Evidence-based approaches to rehabilitation therapies, Doctor of Philosophy thesis, School of Health and Society, University of Wollongong, 2023. https://ro.uow.edu.au/theses1/1826
FoR codes (2020)
420104 Occupational therapy, 420106 Physiotherapy, 420109 Rehabilitation
Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.