Welcome, I am Natasha Romanosky. This talk aims to provide you with a brief overview of physical and therapeutic modalities for spasticity management. I have no disclosures. The learning objectives for this lecture are as follows. Identify how therapy services are used in spasticity management. Understand the indications for prefabricated versus custom orthoses. Recognize the consideration for serial casting. And review the role of neuromuscular electrical stimulation. When you are considering non-pharmacological and non-interventional options for spasticity management, one should consider physical and occupational therapy services. Speech and language pathology may be considered for orophacial dystonias. However, we will focus on spasticity within the extremities for the purpose of this talk. We will also consider bracing options with custom and prefabricated orthotics. We will discuss serial casting. And lastly, the emergence of neuromuscular electrical stimulation within spasticity management. When considering use of any of these options, it is important to first consider you and your patient or caregiver goals. These may include active goals such as improving function, assisting with a home exercise program, or modalities to reduce pain. Alternatively, passive goals may be considered to optimize positioning, prevent contracture or other anatomical deformity, or to enhance either passive or active stretch. Establishing goals prior to implementation of a management plan is necessary for optimal outcomes. Let's start with physical and occupational therapy services. Therapy can be performed in various settings, including acute care, inpatient rehabilitation, and within the outpatient and home setting. It is important to determine which setting is most appropriate for your patient. This may depend on various factors such as medical stability, nursing needs, and social and financial support. Regardless of setting, it is always important to collaborate with your therapy team to determine goals for your patient. Your therapy prescription is a simple place to communicate goals in which you and your patient or caregiver have established. Your prescription should include such things as the patient's diagnoses, the frequency and duration of therapy requested, as well as any specific precautions in which the therapist should be aware of. Lastly, your goals for therapy and any requested services or modalities should be stated. This may include a variation of treatment plans, such as passive versus active range of motion, positioning goals, gait training, modalities requested, among others. So what will happen when your patient receives therapy services for spasticity management? Therapists will first provide their own assessment. They will then work on identifying measurable goals in order to monitor progress across the duration of visits. Once these measurable goals are determined, they will then align this with appropriate therapeutic interventions and establish reassessment timelines. It should be noted that our therapy colleagues have established techniques such as biomechanical, neurophysiological, or cognitive strategies for neuromuscular reeducation. They will likely use a combination of strategies to individualize goals for your patient. The next consideration in spasticity management is orthotics. Orthotics are defined as a brace or device that corrects alignment or provides support for a limb or the spine. Strategies for spasticity management may be either static or dynamic. Static orthotics are often used to promote a passive stretch to optimize positioning. They may work to reduce risk of deformity or contracture. Static orthoses are less likely to be used for functional purposes, however, there are many instances in which static positioning of a joint may in fact enhance function. For example, when a static ankle foot orthoses improves gait by reducing foot drop. Dynamic orthoses may allow for active dynamic or functional movement of a limb. Additionally, the dynamic orthoses may have adjustable joints to promote continuous stretch and tissue lengthening. When ordering an orthoses, you must consider whether your patient can use a prefabricated orthotic or if a custom orthoses is required. Prefabricated orthoses can be used for simple application of an orthotic across a joint without deformity and which passive flexible stretch can be safely applied. These are usually indicated when there is reasonable expectation to correct or improve positioning of the joint. A custom orthoses, on the other hand, should be considered for patients who cannot be fit with a prefabricated orthoses. These are for patients who may require permanent or chronic use or when there is a need to control a joint across various planes. They can be used to prevent tissue injury and to assist with fracture healing in an anatomically altered joint. It should be noted that both prefabricated and custom orthoses both require a physician's prescription and your documentation should reflect the medical necessity for the specific orthotic which is being prescribed. Let's next discuss the role of serial casting. Serial casting has historically been used for patients with cerebral palsy and a quinovaris deformity in order to provide a constant force that improves joint positioning. This is often used in conjunction with injection therapy which helps to first reduce spasticity followed by the casting to optimize positioning. Other joints may also benefit from serial casting such as the elbow. Serial casting works by reducing excitatory input on muscle spindles. Serial casting is used in a stepwise approach by repeating, on average, three weekly applications of a cast with progressive adjustment to the positioning of a joint. Casting should be avoided in areas at high risk for skin breakdown. The skin should be closely monitored and casting should be discontinued if breakdown occurs. When serial casting is considered, some individuals may also consider what is called bivalve casting which is essentially placing a custom cast and then cutting it in half down both sides into a top and bottom portion which can be easily donned and doffed with the use of Velcro straps. Lastly, let's review the role of neuromuscular electrical stimulation within the management of spasticity. As previously stated, there are various modalities which may be used and continue to undergo evaluation for efficacy. Neuromuscular electrical stimulation has likely been the most recently studied modality for spasticity management. Neuromuscular electrical stimulation or NMES is stimulation used at a high frequency to coordinate muscle contraction. Functional electrical stimulation or FES is NMES when used functionally such as in certain cycling applications. NMES has shown to reduce electromyography or EMG activity. NMES is also often used in conjunction with other treatments such as neurotoxin injection and attempts to enhance the benefits. Despite positive effects on spasticity, much remains unknown such as the variability within stimulation parameters between devices as well as the variation in recommended frequency and duration of use as there are no current established guidelines. Many studies have concluded short-term benefits, however, the long-term benefits remain variable and further research is needed regarding its use. Which of the following is known regarding neuromuscular electrical stimulation in the management of spasticity? A, a long-term reduction in spasticity occurs. B, heat is used for muscle contraction. C, high frequency settings are used for muscle contraction. D, established validated guidelines exist. The correct answer is C. A short-term reduction in spasticity has been shown, however, there is a lack of evidence regarding long-term reduction in spasticity. Heat is a therapeutic modality but is not used nor needed with NMES. High frequency settings are used for muscle contraction with NMES. No current established or validated guidelines exist. In summary, physical and occupational therapy should be individualized in the management of spasticity. Bracing or orthotics including serial casting can be an effective intervention when used alone or in conjunction with other treatments. Consider prefabricated versus custom orthotics when appropriate as well as static versus dynamic orthoses. And lastly, modalities such as neuromuscular electrical stimulation have been shown to have a short-term positive effect on spasticity control while other emerging modalities are continually being investigated. References are as stated. Thank you.

spasticity management

physical therapy

orthotics

neuromuscular reeducation

serial casting