Spasticity Summary

Passive standing (v no intervention) on spasticity in people with SCI

consensus: Weak For Recommendation

Passive standing may be provided to treat spasticity in people with SCI.

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	Passive standing (v no intervention) on spasticity in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Passive standing may be provided to treat spasticity in people with SCI.
I	Passive standing
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Spasticity
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Spasticity on the Spinal Cord Injury Spasticity Evaluation Tool 0.1 (-0.3 to 0.1) Favours no intervention
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision No serious	Indirectness Serious	Publication bias Serious

PASSIVE STANDING ON SPASTICITY: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

PASSIVE STANDING ON SPASTICITY: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
KWOK 2005	Passive standing (and usual care) V Usual care	Tilt-table standing 5 x per week for 6 weeks (30 mins)	C5-T7 wheelchair dependent people with SCI	17/17	Spinal Cord Injury Spasticity Evaluation tool	Low Risk of Bias PEDro = 8/10

FES cycling (v no intervention) on spasticity in people with SCI

consensus: Weak For Recommendation

FES cycling may be provided to treat spasticity in people with SCI.

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	Electrically stimulated cycling (v no intervention) on spasticity in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR FES cycling may be provided to treat spasticity in people with SCI.
I	Electrically stimulated cycling
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Spasticity
	SUMMARY	1 RCT (see reference)	¬Mean difference (95% CI): Spasticity on the Ashworth Scale -2 (-4 to 1) Favours FES cycling
	GRADE Very low certainty ⨁◯◯◯	Risk of bias No serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

ELECTRICALLY STIMULATED CYCLING ON SPASTICITY: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

ELECTRICALLY STIMULATED CYCLING ON SPASTICITY: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
RALSTON 2013	ES cycling V No intervention	Four x a week for two weeks (30-45 minutes)	C4 to T10 SCI	14/14	Spasticity - Ashworth	Low Risk of Bias PEDro = 8

Passive range of motion exercises (v no intervention) on spasticity in people with SCI

consensus: Weak Against Recommendation

Passive range of motion exercises should not be administered to treat spasticity in people with SCI.

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	Passive range of motion exercises (v no intervention) on spasticity in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement AGAINST Passive range of motion exercises should not be provided to treat spasticity in people with SCI.
I	Passive range of motion exercises
C	No intervention	Consensus-based opinion statement Weak against (100%)
O	Spasticity
	SUMMARY	2 RCTs	Consider studies independently. Unable to pool I2 = 90%
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Very serious	Imprecision Very serious	Indirectness Very serious	Publication bias Serious

PASSIVE RANGE OF MOTION EXERCISES ON SPASTICITY: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

PASSIVE RANGE OF MOTION EXERCISES ON SPASTICITY: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
CHANG 2013	Continuous Passive Motion (CPM) V No intervention	CPM of the ankle joint for 1 hour per day, 5 x per week for 4 weeks	C5-T12 SCI	7/7	Modified Ashworth	Some Concerns of Risk of Bias PEDro = 5/10
HARVEY 2009	Passive Movements V No intervention	10 minutes of ankle passive movements, 10 x per week for 6 months	C3 -C7 tetraplegia	20/20	Modified Ashworth	Some Concerns of Risk of Bias PEDro = 8/10

Vibration (v no intervention) on spasticity in people with SCI

consensus: No Recommendation

No evidence recommendation or consensus-based opinion statement could be made about vibration to treat spasticity in people with SCI.

Feedback

	Vibration (v no intervention) on spasticity in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No RCTs	No evidence recommendation or consensus-based opinion statement No recommendation can be made on vibration to improve spasticity in people with SCI.
I	Vibration
C	No intervention	Consensus-based opinion statement No consensus statements Reason: No consensus could be reached
O	Spasticity

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The Australian and New Zealand Physiotherapy Guidelines for people with SCI was funded by icare NSW, National Injury Insurance Scheme Queensland, Transport Accident Commission Victoria, and Lifetime Support Authority South Australia.

Acknowledgement of Country – The Australian and New Zealand Clinical Practice Guidelines team acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Honouring Te Tiriti – Ethical approval, including Māori consultation through University of Otago, Christchurch, Te Komiti Whakarite (Canterbury District Health Board), and through Māori consultation (Counties Manukau District Health Board) was obtained for Phase 1 of the study. In developing these guidelines, we were committed to meeting our obligations under Te Tiriti and reflect the principles of tino rangatiratanga, equity, active protection, options, and partnership.