|Ahead of print publication
The impact of spasticity and contractures on dependency and outcomes from rehabilitation
Stephen Ashford1, Barbara Singer2, Hilary Rose3, Lynne Turner-Stokes4
1 The Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare NHS Trust; Centre for Nursing, Midwifery and Allied Health Led Research, University College London Hospitals; Department of Palliative Care, Policy and Rehabilitation, The Cicely Saunders Institute, King's College London, London, UK
2 School of Medical and Health Science, Edith Cowan University, Perth, WA, Australia
3 The Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
4 The Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare NHS Trust; Department of Palliative Care, Policy and Rehabilitation, The Cicely Saunders Institute, King's College London, London, UK
|Date of Submission||08-Jun-2022|
|Date of Decision||10-Aug-2022|
|Date of Acceptance||17-Aug-2022|
|Date of Web Publication||16-Sep-2022|
Regional Hyper-acute Rehabilitation Unit, London North West University Healthcare NHS Trust, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ
Source of Support: None, Conflict of Interest: None
Background: Acquired brain injury (ABI) can result in severe physical impairment causing difficulty with moving which, if not actively managed, can lead to contracture and deformity. Delayed access to rehabilitation may result in more contracture, with potential to increase duration of rehabilitation, cost and therapy time required. Objective: Describe the amount of therapy input for patients undergoing specialist in-patient rehabilitation following ABI, the differences in the type of therapy received by people with and without contracture and/or spasticity, and the impacts on functional outcomes including care needs and cost of care. Materials and Methods: A cohort analysis of prospectively collected data from 426 patients with ABI in a UK tertiary inpatient rehabilitation program. The Neurological impairment Scale (NIS) was used to identify the presence of spasticity or contracture. The Northwick Park Therapy Dependency Assessment (NPTDA) was used to calculate the therapy hours and type of treatment provided to people with and without spasticity and/or contracture. Outcomes (change in function and independence) were compared including the UK Functional Assessment Measure (UK FIM+FAM). Results: The Male/Female ratio was 63:37% with a mean age: 44.0(SD 13) years and a mean length of stay in specialist inpatient rehabilitation: 103 (SD 49) days. Aetiology: Stroke (63%), Trauma (20%); Hypoxia (7%): Other (10%). Patients with contractures were significantly more dependent than those without, both on admission and discharge. They stayed on average 31 days longer (95%CI 21.1, 40.5) (P=0.001) with an additional mean episode cost of £25,588 (95%CI £18.085, 34,043) (P<0.001). Despite this, they made similar overall functional gains resulting in similar long-term savings in the cost of ongoing care. Conclusion: Routine collection of the NPTDA supported quantification of the impact of spasticity and contracture on therapy inputs, length of stay, functional gains, and costs. People with contractures following ABI require more therapy time in rehabilitation to achieve similar functional gains, but nevertheless were cost-efficient to treat.
Keywords: Acquired brain injury, contracture, cost, functional gains, spasticity
|How to cite this URL:|
Ashford S, Singer B, Rose H, Turner-Stokes L. The impact of spasticity and contractures on dependency and outcomes from rehabilitation. J Int Soc Phys Rehabil Med [Epub ahead of print] [cited 2022 Sep 29]. Available from: https://www.jisprm.org/preprintarticle.asp?id=356220
| Introduction|| |
Acquired brain injury (ABI) of any etiology (trauma, hypoxia, stroke, etc.) can result in a range of physical and cognitive impairments that affect an individual's ability to engage in everyday activities and their wider participation in society. After the initial injury, many people with ABI require a period of inpatient rehabilitation to support recovery, manage or adapt to their disability, and to re-develop skills to support their functioning and participation in society.
Immobility presents known risks for further impairment, and this is particularly relevant to those with ABI, where movement may be impaired. Adaptive change occurs in soft tissues when limbs are held in certain positions, e.g., sustained flexion of a limb, resulting in increased stiffness and eventually contracture.,, Over half of people with stroke and 84% of people with a severe traumatic brain injury develop at least one joint contracture.,
Spasticity is also a common complication following ABI. It is defined by the EU-SPASM group as “a disorder of sensory-motor control resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles”. If moderate-to-severe spasticity is present and is left untreated, a vicious cycle can occur, in which unopposed contraction (spastic dystonia) in affected muscle groups leads to a sustained abnormal limb posture, resulting in soft tissue shortening and contracture., A four-fold increase in direct costs of care associated with rehabilitation of those with spasticity compared to without spasticity has been reported in the first year after stroke.
Evidence for the effectiveness of contracture management with interventions to stretch the soft tissues (including positioning) is limited., A preventative approach is likely to be more effective than trying to restore muscle length once a contracture is present. Regular changes in posture and physically positioning muscles in a lengthened position have been shown to improve muscle length in a small number of studies.,,, Interventions to provide more sustained stretch, such as serial casting, may also have a role in preventing or reducing contracture, depending on the clinical presentation.,,,
In the United Kingdom (UK), people with severe disability following ABI often experience delays getting into rehabilitation services and can develop significant contractures that might have been avoided through earlier identification and treatment, including effective spasticity management. There are significant long-term impacts and potential to increase the cost of overall care and rehabilitation, if effective programs to reduce spasticity and prevent/manage contractures are not in place from early in the rehabilitation process, even in acute care settings. In addition to impacting outcomes, the presence of contracture and/or spasticity might be expected to impact the amount of therapy time required by individuals in rehabilitation and also the amount of care and nursing time required in the short and longer term; however, data to support this contention are not generally available.
In England, the UK Rehabilitation Outcomes Collaborative (UKROC) database provides the national clinical registry, and collates data on care needs, costs, and outcomes for all patients admitted for specialist inpatient rehabilitation. The standardized UKROC dataset includes measurement tools that record staff time (hours), and the different professionals providing care, nursing, and therapy, including interventions for spasticity and contracture. This was a proof of principle study to determine the extent to which these routinely collected data can provide information regarding the impact of spasticity and/or contractures on the costs of direct care and treatment.
To describe and quantify the amount of therapy input for patients undergoing specialist inpatient rehabilitation following ABI, the differences in the type of therapy received by people with and without contracture and/or spasticity, and the impacts of these impairments on functional outcomes including care needs and cost of care.
| Methods|| |
Design and setting
This was a retrospective analysis of prospectively collected data from consecutive adults (16 years and over) with ABI admitted to a single tertiary specialist inpatient rehabilitation program in South-East England. This regional center provides multidisciplinary rehabilitation, including integrated spasticity management, for patients with highly complex neurological disability.
Participants and intervention
Over the period 2012-2019, 426 people with ABI received an individualized, goal-directed multidisciplinary rehabilitation program based on clinical need, as decided by the treating teams. Wherever appropriate, management of spasticity and contractures is integrated into these programs and will typically comprise a 24-h positioning program, with splinting/serial casting and antispasmodic medication (including botulinum toxin where relevant) in accordance with the national clinical guidelines.,
The UK Rehabilitation Outcomes Collaborative (UKROC) national clinical registry systematically collects data on rehabilitation needs, the inputs provided to meet those needs, outcomes, and cost efficiency for all patients admitted to inpatient specialist rehabilitation in England. https://www.kcl.ac.uk/cicelysaunders/research/studies/uk-roc/index. This study used prospectively collected data from the UKROC dataset, as follows:
The Neurological Impairment Set (NIS) (score range: 0–50) is a 13-item tool which records: motor activity, spasticity and/or contracture, sensation, perceptual function, speech and language, cognitive function, behavior, mood, seeing and vision, hearing, pain, fatigue, and others. Items (including impact of spasticity and contracture) are scored by clinical teams using a four-point numeric scale: none (no impact), mild (affecting high-level function only), moderate (significant impact, but some useful function), or severe (little or no useful function, effectively limiting rehabilitation). The NIS score on admission was used in this analysis to identify the presence of contractures and/or spasticity within the cohort. Using the NIS, patients were dichotomized into spasticity or not and contracture or not.
The UK Functional Assessment Measure (UK FIM+FAM) (score range: 30–210) comprises the FIM (18 items) together with an additional 12 items to extend the tool's coverage of cognitive and psychosocial function., The UK FIM+FAM scores on admission and discharge were used in this analysis to quantify functional status and gains in independence.
The Rehabilitation Complexity Scale Extended (RCS-E) version 12 (score range: 0-20) provides a simple overall measure of an individual's needs for Care, Nursing, Therapy, Medical, and Equipment. The RCS-E is timely to complete, and provides a valid and reliable indicator of caseload complexity. The RCS-E scores on admission and discharge were used to identify the overall rehabilitation complexity of those individuals with either spasticity or contracture and those with spasticity and contracture combined.
The Northwick Park Nursing Dependency Scale (NPDS) (score range: 0–100) is an ordinal scale of dependency on nursing staff time (number of helpers and time taken to assist with each task) designed to assess needs for care and nursing in clinical rehabilitation settings. It also translates via a computerized algorithm to Northwick Park Care Needs Assessment (NPCNA) which provides a generic assessment of care needs and their associated costs. A primary goal for rehabilitation is to improve independence, thereby reducing the cost of ongoing care in the community and demonstrating value for money. Cost efficiency of rehabilitation is routinely reported by UKROC as the time taken for savings in ongoing care costs in the community to offset the cost of the rehabilitation episode., The NPDS and NPCNA scores on admission and discharge were used to quantify the nursing and care needs associated with the management of spasticity and/or contracture.
The Northwick Park Therapy Dependency Assessment (NPTDA) is a 26-item tool categorizing therapy intervention provided under six domains: (a) physical handling program, (b) basic functions, (c) activities of daily living, (d) cognitive psychosocial and family support, (e) preparing for discharge, and (f) additional activities. The health professional(s) providing treatment is also recorded in the measure.
As with the NPDS, a computerized algorithm calculates the total delivered therapy hours per each profession involved for each domain of therapy treatment delivered and the therapy intensity (mean hours per admission). The NPTDA was used to identify treatment given as part of a spasticity and/or contracture management program within the wider rehabilitation plan. NPTDA scores are routinely recorded every fortnight in this rehabilitation facility. The therapy hours were summed to calculate the total for each patient throughout their inpatient stay. We reasoned that the physical handling domain would be most affected by the presence of spasticity/contractures.
For clinical evaluation and treatment planning, detailed assessment of spasticity and contracture are required by clinical teams considering the individualized impacts of these impairments on activity and participation for people with ABI. However, the focus in this analysis was specifically to look at the presence of spasticity and/or contracture, as recorded in the UK national dataset using the NIS, and the influence on the type of therapy treatment received and the impact of these impairments on functional outcomes including care needs and cost of care. The detailed and varied clinical reasoning and treatment planning undertaken for all patients going through this rehabilitation program (and similar programs in other centers) are not considered in this analysis.
Data extraction and permissions
Data for all patients admitted to the specialized rehabilitation program are systematically recorded in the UKROC electronic database. Data are securely stored on the main NHS server at Northwick Park Hospital and handled in accordance with the standard Data Protection requirements (General Data Protection Requirements) and standards for clinical data. Data used in the analysis were de-identified.
Although research ethics permission is not required in the UK for service evaluation or secondary analysis of de-identified data collected for clinical purposes, the unit holds ethics permission (REC 04/Q0405/47) to use routinely collected clinical data for research.
De-identified data were extracted for all patients discharged consecutively from the specialized rehabilitation program between April 2012 and July 2019. After cleaning in Microsoft Excel, they were transferred to SPSS v 27 (Armonk, NY, USA: IBM Corp.) for analysis. Between-group differences were analyzed using one-way ANOVA tests with post hoc Bonferroni correction. T-tests were used for significance testing with continuous data. Two-tailed significance tests were performed with Levene's test for equality of variances. A significance level for a P value was set at <0.05.
| Results|| |
Study participants consisted of 268 (63%) men and 158 (37%) women, with a mean age of 44.0 (SD13) years. The mean length of stay was 103 (SD49) days. The etiology of injury in study participants was 268 (63%) stroke, 85 (20%) traumatic brain injury, 30 (7%) hypoxic brain injury, and 43 (10%) other neurological impairments (e.g., encephalitis). Of these 426 participants, 413 (97%) had valid data to determine their spasticity/contracture status and were used in the analysis. [Table 1] outlines the cohort demographics, care and therapy needs, and functional dependency on admission. Data are provided for the overall sample and then categorized by the presence or absence of contracture and/or spasticity.
|Table 1: Demographics of participants with mean (95% confidence interval*) scores for functional dependence, nursing/ care costs, and therapy needs on admission|
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One-way ANOVA tests demonstrated significant between-group differences in dependency and care costs on admission, as well as in episode costs. Post hoc significance tests demonstrated that the presence of spasticity alone was not significantly associated with greater care needs or dependency, but the presence of contractures (with or without spasticity) was associated with significantly greater functional dependency (P < 0.001), nursing care hours (P < 0.001), and weekly costs of care (P < 0.001) (data available on request). There was no significant difference in the presence of spasticity or contracture based on the etiology of brain injury. Other individual patient factors that may be contributory to spasticity or contracture development were not explored in this analysis.
[Table 2] shows the comparison between participants with and without contracture. Patients with contractures were significantly more dependent than those without, both on admission and discharge. They stayed on average 31 days longer (95% confidence interval [CI]: 21.1, 40.5) (P = 0.001) in specialist inpatient rehabilitation with an additional mean episode cost of £25,588 (95% CI £18.085, 34,043) (P < 0.001) than those without contracture. The number of nursing care hours/week and care costs were significantly higher in the group with contractures. However, functional independence in both groups improved to a similar degree over the rehabilitation program. If anything, the group with contractures showed slightly greater improvement, and consequent reduction in long-term cost savings, than those without contractures, but the between-group differences did not reach statistical significance.
|Table 2: Comparison of those with contractures to those without for demographics, dependency, and care needs on admission and discharge|
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[Table 3] shows the mean (95% CI) hours of targeted therapy intervention per admission for the physical handling domain as captured by NPTDA.
|Table 3: Mean (95% confidence interval) hours of therapy intervention per admission for the “physical handling” dimension of the Northwick Park Therapy Dependency Assessment|
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Significant differences in the total therapy time were identified between the group with no spasticity or contracture and those with spasticity alone (mean [95% CI] difference: 36.2 (9.6, 62.8) h, P = 0.002), contracture alone (mean difference: 62.2 (28.2, 96.2) h, P < 0.001), and both spasticity and contracture (mean difference: 88.5 (57.6, 119.4) h, P < 0.001).
[Table 3] also shows the breakdown of this intervention time for the five items of the NPTDA Physical Handling domain, which are Medical intervention (of all types); Orthotics for arm; Orthotics for leg; Wheelchair seating or positioning, and Therapeutic physical therapy intervention. Significant differences were seen between the group with no spasticity or contracture and all other groups for the categories “splinting/orthotics” and “physiotherapy.” Time spent on “medical interventions” and “wheelchair/seating” was significantly higher in the presence of contractures, but not for those with spasticity alone.
[Figure 1] illustrates the effect of contractures and/or spasticity across the six domains of the NPTDA, and across the different staff disciplines. To some extent the presence of spasticity and contractures is a marker for overall complexity of rehabilitation needs, but (as we had hypothesized) the impact is greatest within the physical handling domain of the NPTDA and for physiotherapy and occupational therapy time.
|Figure 1: Mean total hours of intervention in a rehabilitation admission (a) per NPTDA domain and (b) per staff discipline. NPTDA: Northwick Park Therapy Dependency Assessment|
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[Figure 2] illustrates the differences in functional gains between those with and without contracture in this cohort. Patients with contracture were more dependent and by discharge remained more impaired than those without (in terms of both physical and cognitive ability). Nevertheless, they made significant functional gains during the program, which were not significantly different from those without contractures [Table 2].
|Figure 2: Median item scores for the FIM+FAM, for patients with and without contractures. FIM: Functional independence measure, FAM: Functional Assessment Measure|
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| Discussion|| |
In this study, patients undergoing specialized rehabilitation following ABI who had contractures were significantly more dependent (as measured by both the NPDS and the UK FIM+FAM) than those without, both on admission and discharge. They stayed on average 31 days longer in specialist inpatient rehabilitation and had a resulting additional mean episode cost of £25,588 (95% CI £18.085, 34.043) (P < 0.001). Despite this, they made similar overall functional gains [Figure 2] and [Table 2] resulting in long-term cost savings and demonstrating the cost-efficiency of treating this group.
As noted earlier, while the presence of contracture and/or spasticity might be expected to impact the amount of therapy time required by individuals in rehabilitation, data to support this assumption have so far been lacking. To our knowledge, the only previous study to address this question is that by Lundström et al. who examined the impact of spasticity on the direct costs of care and treatment in the first year after a stroke. They found a four-fold difference in direct costs in those presenting with spasticity. However, there were only 25 patients in their spasticity group, limiting the conclusions which can be drawn from these data. In this study, the time spent on medical interventions (including botulinum toxin administration) and physical therapies was significantly greater in the presence of spasticity, contracture or both together [Table 3], but the differences were smaller than those shown by Lundström et al. However, the group in this study was a selected group of patients with severe complex disability undergoing specialist inpatient rehabilitation following ABI of any etiology, versus the Lundström et al. study which focused on poststroke spasticity. The samples are therefore different and not directly comparable.
Of course, it is possible that the presence of contractures is simply a marker for more severe impairment and disability, rather than the direct cause of an increased requirement for therapy input. This explanation would be supported to some extent by the FIM+FAM data – in particular the finding that patients with contractures had poorer cognitive function as well as motor function [Figure 2]. On the other hand, management of spasticity alone may also lead to a reduction of care needs in the longer term and is often a goal for targeted intervention.,
In this study, the proportionate increase in therapy hours for patients with contractures was greater (approximately 30%) in those domains of the NPTDA where the main focus of intervention is on physical therapy (i.e., Physical Handing and Basic Function) than in other domains (e.g., Cognitive/Psychosocial) where the differences were proportionately smaller [Figure 1]. Within a fully integrated holistic multidisciplinary rehabilitation program, it is not possible to separate entirely the effects of spasticity/contracture management from other aspects of rehabilitation. Nevertheless, to our knowledge, the data presented here provide the strongest published evidence so far that development of contractures has a direct impact on increased requirements for therapy intervention in rehabilitation settings.
Strengths and limitations
The authors acknowledge a number of strengths and weakness to this study:
Weaknesses include the fact that data collected in the course of routine clinical practice are often incomplete, because there may be a potential for inaccuracy in recording, when this is not the main focus for clinical staff. However, data recording is a key focus for this service and systems are in place to ensure the robust data collection, including weekly data monitoring and validity checks. In addition, although the NPTDA provides a validated estimate of the therapy hours expended on different domains of the rehabilitation, it is based on a computerized algorithm, rather than providing direct capture of specific intervention times. On the other hand, the challenges of collecting the latter accurately in real-life clinical settings are well recognized. The collection of detailed information about specific therapy interventions provided would be valuable in future work to inform rehabilitation planning. In addition, detailed information on impairment presentation, other confounding impairments (e. g., heterotrophic ossification), and the clinical reasoning process leading to treatment planning would inform future models of care.
Strengths include the fact that this study was conducted in the course of routine clinical practice, and the cohort therefore has real-world validity. In addition, it uses standardized tools from the UKROC national clinical dataset, which means that it could easily be replicated in other centers that systematically apply the same tools (this includes the majority of the specialist rehabilitation units in England).
| Conclusion|| |
In summary, this study used routinely collected clinical data to quantify for the first time the impact of spasticity and/or contracture on therapy requirements and patient outcomes in a multidisciplinary inpatient specialist neurorehabilitation program following ABI. People with contractures and/or spasticity required more therapy time in rehabilitation. Patients with contractures had significantly longer lengths of stay in rehabilitation, higher episode costs, and required more therapy input. Despite this, they made similar overall functional gains in rehabilitation resulting in long-term cost savings and demonstrating cost-efficiency of treating this group. This has implications for the cost and length of stay in inpatient settings as well as for staffing provision in relation to caseload.
Future work is required to understand in greater detail the specifics of the interventions applied for spasticity and contracture management in this population, and to explore the association between these inputs, goals set for intervention, and clinical outcomes, in order to add to the evidence for efficacy of management approaches for spasticity, and particularly for the prevention and management of contractures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]