Spasticity Treatment During COVID-19 Pandemic: Clinical Recommendations

Abstract

Spasticity is a symptom that describes involuntary muscle hyperactivity in the presence of central paresis due to several neurological conditions (1). It can consist of various clinical forms, and it has been reported (2, 3) that spasticity showed a prevalence of 28–38% in patients with stroke, 41–66% in patients with multiple sclerosis, 13% in patients with traumatic brain injury, and up to 80% of children with cerebral palsy. Spasticity can affect quality of life, impair function and heighten economic burden (4, 5), and it could be associated with several complications, including contractures, pain, fall risk, pressure ulcers, and infections (6). In addition, caregivers of patients affected by spasticity are more likely to experience anxiety and depression (7). Spasticity management aims to reduce its negative impact on patients and carers and to prevent irreversible soft-tissue changes and tendon contractures by maintaining muscle length and normalizing limb positioning (8, 9). Identifying and treating clinically relevant spasticity is key to decreasing patients' impairments (10, 11). Interventions must be tailored to meet the problems faced by the person and their goals, including focal (e.g., chemodenervation with Botulinum Toxin, chemical neurolysis) and general treatments (e.g., oral antispasticity drugs, cannabinoids, intrathecal baclofen) (10, 11). Besides, a multidisciplinary team including doctors, physiotherapists, occupational therapists and nurses, is required: in fact, other physical modalities can optimize the effect of pharmacologic treatment (e.g., stretching, splinting, postural management, exercise, electrical stimulation, casting, splinting, extracorporeal shock waves, body vibration) (10, 12). Noteworthy, it should be pointed out that patients affected by spasticity require periodic access to the health care facilities. In particular, Intrathecal baclofen infusion (ITB) systems, proposed in case of severe generalized spasticity, imply a close follow-up for safety purposes; notably, ITB pump refill is a programmed procedure that requires regularity in its execution, and that cannot be postponed due to the risk of withdrawal symptoms (13). Again, Botulinum toxin Type A (BoNT-A), the gold standard for focal spasticity treatment, requires a regular administration (every 3–6 months) in order to maintain the clinical effect (14); moreover, BoNT-A must be proposed by a multidisciplinary team, since optimal treatment involves physical therapy in conjunction with intermittent pharmacological treatment (14, 15). It is well-known that when spasticity worsens, patients may experience a variety of symptoms (10). In particular, prolonged suspension can potentially accelerate the morphological alterations connected with spasticity (e.g., myotendinous and joint contractures, pain) which could potentially cause a long-term negative impact on the patients' level of activity and participation, as well as to a deterioration in their quality of life (8, 9). The recent reorganization of non-urgent clinical activities, connected to the emergency generated by the COVID-19 pandemic, has also significantly involved the treatment of patients with spasticity. As per institutional indications, most of these activities have been suspended or postponed (16, 17). This situation, necessary in consideration of the pandemic, has nevertheless exposed patients suffering from spasticity to the risks connected to the interruption of the treatment as described above. Based on these considerations, it seems reasonable to continue planning the spasticity treatment, carefully monitoring those that cannot be delayed. However, several factors must be taken into account to guarantee both patients' necessary care and indications for minimizing a further spread of the pandemic. For this purpose, an ad-hoc treatment protocol is summarized in the next section. Some of these aspects are part of the general indications for patients' access to healthcare facilities (18). Still, some specific elements must consider the patients' characteristics (19) and the specific settings where the treatments are carried out (16, 17). In this case, spasticity treatment is part of the rehabilitation program of the patient hospitalized for this purpose. The hospital organization must consider the general indications for the containment of the infection (18, 20); therefore, all the appropriate procedures must be put in place to avoid exposing the patient to the risk of contracting COVID-19 (21), and in particular: - adequate clinical monitoring of patients to identify clinical signs of potential COVID-19 onset (18) - adequate use of personal protective equipment (PPE) about the procedures and clinical characteristics of the patients (18, 22, 23) - monitoring of the health status of involved staff (18) - training of staff and patients on compliance with hygiene rules (18) - availability and easy retrieval of suitable indications (e.g., explanatory material distributed in hospital areas) and material (e.g., hand sanitizing gel) (18) - blocking (or severe limitation) of access to visitors (18). In this case, since the patient's access to the hospital or outpatient facility takes place from the outside, it is necessary to consider a series of procedures to ensure the safety of the patient and operators (24). In particular, several aspects must be considered (Figure 1). Figure 1. Outpatient management of spasticity treatment. • in consideration of current government indications (25), it remains a rule of good clinical practice to limit access to only patients for whom the treatment cannot be postponed (e.g., repetition of treatment with BoNT-A for significant reduction of autonomy consequent to the recovery of spasticity; ITB refill or follow up) (26) • the use of telephone screening tools that allow remote pre-assessment is recommended to coordinate patient access to facilities: this...