Clinical update: spasticity and botulinum toxin

Stephen Ashford outlines an update to guidelines on managing spasticity in adults, using BoNT.

Spasticity is involuntary muscle over-activity, which commonly follows damage to the central nervous system (brain and spinal cord). It presents in a variety of ways depending on the size, location and age of the lesion, and may have a number of harmful secondary effects such as pain, deformity and impaired function.
Spasticity management is challenging due to the diversity of patient presentation and goals or aims of treatment. It will normally include a combination of physical and pharmacological management, often using a variety of approaches according to the patient’s needs.
Local intramuscular injection of botulinum toxin (BoNT) is an established, well-tolerated treatment in the pharmacological management of focal spasticity. There is a strong body of evidence for its effectiveness in the management of both upper and lower limb spasticity.
The national guidelines (Royal College of Physicians et al 2018) provide an update to the original document published in 2009. In further developing the guidance, the new edition assists in practice progression. 
There is now a substantial body of trial-based evidence for the effectiveness of BoNT in reducing spasticity in the arm and leg. However, there is little direct trial-based evidence to inform the exact process and context of BoNT administration and the surrounding management of spasticity within a rehabilitation programme, which is the main focus of the new guidance document. 
The selection of appropriate patients likely to respond and the definition of clear, achievable, realistic and measurable goals are crucial to the successful use of BoNT in spasticity management. 


Common goal areas for intervention include (Ashford et al 2016)

  • pain relief
  • reduction of involuntary movements (eg, associated reactions, spasms)
  • prevention of contractures and deformity
  • passive function (making it easier to care for the affected limb) 
  • active function (using the affected limb)
  • mobility 
If used according to the guidance, BoNT has the potential to reduce the overall costs of ongoing care in people with severe spasticity through the prevention of contracture and deformity, and improved ease of care and handling.
Because a substantial body of evidence now exists for specific BoNT effectiveness, further research should focus on the totality of what is a complex intervention. This should include physical interventions often applied with pharmacological interventions such as BoNT in the management of spasticity. 
  • Dr Stephen Ashford is clinical lecturer and consultant physiotherapist at the Regional Hyper-acute Rehabilitation Unit, London North West University Healthcare NHS Trust.Department of Palliative Care, Policy and Rehabilitation,  King’s College London. On behalf of the guideline development group: Ashford S (Ed),Turner-Stokes (Co-Ed) L, Allison R, Duke L, Bavikatte G, Kirker S, Moore P, Ward A, Bilton D


  • Ashford S et al (2016) Common goal areas in the treatment of upper limb spasticity: a multicentre analysis. Clinical Rehabilitation. 30, 6, 617-622.
  • Royal College of Physicians et al (2018) Spasticity in Adults: Management Using Botulinum Toxin. National Guidelines 2018. London, Royal College of Physicians.

Clinical implications

  • The purpose of the guidelines is to provide clinicians with the knowledge and tools to use BoNT appropriately within rehabilitation incorporating spasticity management. 
  • The principles are appropriate patient selection establishment of clear goals for treatment clear establishment of the immediate and ongoing treatment programme including rehabilitation and maintenance physical interventions formal evaluation of outcome.

Key points: spasticity and BoNT 

  • The inclusion of BoNT within the wider rehabilitation programme has been developed, with greater emphasis on pre- and post injection physical and postural management interventions. Evidence for combined physical and pharmacological interventions is provided where this is available
  • Changes in UK legislation regarding the administration and prescribing of medication mean that, in addition to medical staff, physiotherapists and nurses (and, in some instances, other health professionals) are trained to inject and/or prescribe BoNT and other pharmacological agents used in the management of spasticity. This was addressed in the last edition, but is expanded and integrated into the practice-based advice
  • All BoNT injections should be accompanied by a formal assessment of outcome. Outcome measures should be relevant to the documented goals for treatment. In the last decade, a substantial body of work has been undertaken to develop a consistent approach to outcome measurement that can be used in this area of practice.  

This includes

  • A structured approach to goal attainment (using goal-attainment scaling) to capture achievement of the intended goals for treatment.
  • A focal spasticity index that applies a limited set of standardised measures alongside GAS; the choice of measures for the individual patient being determined by their priority goal areas for treatment.
  • The rationale for this is to combine a person-centred approach to goal-setting and standardised outcome measurement, which provides comparable information across different populations, practices and programmes of care, and avoids an excessive burden in data collection.

Further reading

Dr Stephen Ashford Clinical lecturer, consultant physiotherapist at the Regional Hyper-acute Rehabilitation Unit, London North West University Healthcare NHS Trust.Department of Palliative Care, Policy and Rehabilitation, King’s College London.

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