**3. Provision of education and promoting self-management**

Nowadays, it has been found that the patient's awareness of the disease and the situation he/she is dealing with promotes the therapeutic process and interventions. This view and its results have also led to the development of courses known as Expert Patient Programmes [9]. The patient and his/her caregivers' understandings of the medical conditions and therapeutic interventions are crucial and effective to the treatment and therapeutic protocol selection. This is especially because different therapeutic interventions for spasticity do not have a linear nature and several treatments are sometimes considered for the patient at the same time (**Figure 1**).

exacerbate the symptoms. Even the mild infection (e.g., Candida) can aggra-

2. Maintaining skin integrity. Avoiding any skin irritation, infection, and pressure sores is effective in spasticity reduction. So skin examinations, especially in the vulnerable areas including the areas under pressure or under orthosis, as well as preventing ingrown toenails and deep-vein thrombosis are needed.

Sometimes, there are individual factors that each patient gradually realizes (e.g., in some women, symptoms exacerbate during menstruation period). Knowledge of

elimination of some of these factors or waiting for a few days (e.g., in menstruation period) and or a temporary rise in the drug dosage is very effective in solving the

Another point of patient education is that the weakness and spasticity are concomitant [2]; so the patient should know that sometimes the weakness becomes more pronounced by medication use and subsequent spasticity reduction while patients consider this effect as a drug side effect or lack of response. So, in case the spasticity is an effective factor in preserving some of the patient's functions (e.g., standing up and going to the bathroom in the morning), the medication should be

Patients should receive written information on the medication dosage, side effects, and follow-up tests for the response to treatment. There should be a telephone number in the form for convenient communication with the health care

**4. Physical management of spasticity(physiotherapy or occupational**

The key to a satisfying treatment for spasticity is to educate the patient properly and ensure that the patient follows the instructions correctly. Also, as spasticity changes during the treatment, treatment regimens should change with the patient's condition and be flexible. Proper patient management requires physiotherapy initiation immediately after the disease diagnosis and at regular intervals throughout the disease course, depending on the patient's condition and the diagnosis made by the treatment team. On the other hand, assessment and differentiation between the neuronal and non-neuronal (connective tissue, joint component, muscle, and tendon) causes of hypertonia are critical because the treatment of non-neuronal [14] (passive) causes involves physical therapies such as stretching and splinting; these

The goal of physical management is to maintain and even improve the performance level and prevent the problems secondary to spasticity. In fact, spasticity reduction is not always a treatment goal, as in some cases maintaining the patient's function requires a little spasticity and increased tone. Therefore, physical management focuses on the performance, discomfort and pain relief, and prevention of secondary complications including contractures and pressure ulcers. The key goals

some of these risk factors is important in treatment choice. In some cases,

taken after the desired activity (going to the bathroom).

problems do not respond to medical treatments.

of a physical management plan include the following [2]:

**4.1 Physical management strategies**

vate the symptoms.

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

patient's problem.

center or the physician.

**therapy)**

**91**

To improve the spasticity treatment efficacy, some instructions should be presented to the patient, either verbally or using a written material [10]. These instructions include the following:


A main factor in the spasticity treatment is to maintain the joints' range of motion, which should be performed by the patient or his/her caregiver. Moreover, maintaining muscle length is the second factor that is usually achieved by stretching or splinting [8]. Thus, sitting and standing positions are also critical.

C. Recognizing and preventing factors that may exacerbate spasticity and spasms:

Elimination of unwanted sensory triggers is an important factor in spasticity reduction. Naturally, cutaneous and visceral triggers (**Table 3**) regulate the interneuronal activity by signaling to the spinal cord. Elimination and dysfunction of some modulating pathways can inhibit polysynaptic reflexes (such as flexor withdrawal) and cause spasm [11].

Similarly, abnormal activities of spinal cord circuits induce discharges in motor neurons innervating several muscles, thereby causing a concurrent contraction of these muscles and aggravating spasticity [12, 13]. Sometimes, some patients are aware of such stimuli exacerbating their symptoms (e.g., bowel habit) while having no clue how to modulate or reduce them. The patients should consider the following:

1. Optimization of bladder and bowel management. Any defecation alteration including urinary retention, infection, constipation, or diarrhea can


**Table 3.**

*Sensory stimulations that may aggravate spasticity.*

**3. Provision of education and promoting self-management**

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

instructions include the following:

withdrawal) and cause spasm [11].

also critical.

following:

**Table 3.**

**90**

Nowadays, it has been found that the patient's awareness of the disease and the situation he/she is dealing with promotes the therapeutic process and interventions. This view and its results have also led to the development of courses known as Expert Patient Programmes [9]. The patient and his/her caregivers' understandings of the medical conditions and therapeutic interventions are crucial and effective to the treatment and therapeutic protocol selection. This is especially because different therapeutic interventions for spasticity do not have a linear nature and several treatments are sometimes considered for the patient at the same time (**Figure 1**). To improve the spasticity treatment efficacy, some instructions should be presented to the patient, either verbally or using a written material [10]. These

A.Maintaining movement and adequate positioning and B) Recognizing and preventing factors that may aggravate or trigger spasticity and spasms.

A main factor in the spasticity treatment is to maintain the joints' range of motion, which should be performed by the patient or his/her caregiver. Moreover, maintaining muscle length is the second factor that is usually achieved by stretching or splinting [8]. Thus, sitting and standing positions are

C. Recognizing and preventing factors that may exacerbate spasticity and spasms:

Similarly, abnormal activities of spinal cord circuits induce discharges in motor neurons innervating several muscles, thereby causing a concurrent contraction of these muscles and aggravating spasticity [12, 13]. Sometimes, some patients are aware of such stimuli exacerbating their symptoms (e.g., bowel habit) while having

1. Optimization of bladder and bowel management. Any defecation alteration including urinary retention, infection, constipation, or diarrhea can

> Bowel and bladder dysfunction: for example, constipation, overflow or diarrhea, infections,

retention or incomplete emptying

Elimination of unwanted sensory triggers is an important factor in spasticity reduction. Naturally, cutaneous and visceral triggers (**Table 3**) regulate the interneuronal activity by signaling to the spinal cord. Elimination and dysfunction of some modulating pathways can inhibit polysynaptic reflexes (such as flexor

no clue how to modulate or reduce them. The patients should consider the

Tight-fitting clothes or urinary leg bag straps Any systemic or localized infection

**Cutaneous stimuli Visceral stimuli**

Uncomfortable orthotics or seating systems Deep-vein thrombosis

Skin lesion (red or inflamed skin, broken skin, infected skin, pressure sores, ingrown toenails)

*Sensory stimulations that may aggravate spasticity.*

B. Maintaining movement and adequate positioning:

exacerbate the symptoms. Even the mild infection (e.g., Candida) can aggravate the symptoms.

2. Maintaining skin integrity. Avoiding any skin irritation, infection, and pressure sores is effective in spasticity reduction. So skin examinations, especially in the vulnerable areas including the areas under pressure or under orthosis, as well as preventing ingrown toenails and deep-vein thrombosis are needed.

Sometimes, there are individual factors that each patient gradually realizes (e.g., in some women, symptoms exacerbate during menstruation period). Knowledge of some of these risk factors is important in treatment choice. In some cases, elimination of some of these factors or waiting for a few days (e.g., in menstruation period) and or a temporary rise in the drug dosage is very effective in solving the patient's problem.

Another point of patient education is that the weakness and spasticity are concomitant [2]; so the patient should know that sometimes the weakness becomes more pronounced by medication use and subsequent spasticity reduction while patients consider this effect as a drug side effect or lack of response. So, in case the spasticity is an effective factor in preserving some of the patient's functions (e.g., standing up and going to the bathroom in the morning), the medication should be taken after the desired activity (going to the bathroom).

Patients should receive written information on the medication dosage, side effects, and follow-up tests for the response to treatment. There should be a telephone number in the form for convenient communication with the health care center or the physician.
