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Spasticity management should be provided within the context of a comprehensive person-centered rehabilitation program. Furthermore, active goal setting for specific spasticity interventions is also important, with a well-established "more is better" approach. It is critical to consider adjunctive therapy and multimodal approaches if patients are not attaining their treatment goals. Often used interchangeably, there may be confusion between the terms adjunctive and multimodal therapy. Yet it is imperative to understand the differences between these approaches to achieve treatment goals in spasticity management. Addition of a secondary pharmacologic or non-pharmacologic treatment to optimize the efficacy of the initial modality, such as adding electrical stimulation or casting to BoNT-A, is considered an adjunctive therapy. Adjunctive therapy is time-specific and requires the added therapy be initiated within a specific period to enhance the primary treatment; usually within 2 weeks. Multimodal therapy is an integrated, patient-centric program of pharmacologic and nonpharmacologic strategies utilized in a concurrent/integrated or sequential manner to enhance the overall treatment effect across a variety of spasticityassociated impairments (e.g., neural and non-neural components). Moreover, within a multimodal approach, adjunctive therapy can be used to help enhance the treatment effect of one specific modality. The objectives of this paper are to clarify the differences between adjunctive and multimodal therapies, provide a brief evidence-based review of such approaches, and highlight clinical insights on selecting multimodal and adjunctive therapies in spasticity management. [ABSTRACT FROM AUTHOR]

Spasticity management should be provided within the context of a comprehensive person-centered rehabilitation program. Furthermore, active goal setting for specific spasticity interventions is also important, with a well-established “more is better” approach. It is critical to consider adjunctive therapy and multimodal approaches if patients are not attaining their treatment goals. Often used interchangeably, there may be confusion between the terms adjunctive and multimodal therapy. Yet it is imperative to understand the differences between these approaches to achieve treatment goals in spasticity management. Addition of a secondary pharmacologic or non-pharmacologic treatment to optimize the efficacy of the initial modality, such as adding electrical stimulation or casting to BoNT-A, is considered an adjunctive therapy. Adjunctive therapy is time-specific and requires the added therapy be initiated within a specific period to enhance the primary treatment; usually within 2 weeks. Multimodal therapy is an integrated, patient-centric program of pharmacologic and non-pharmacologic strategies utilized in a concurrent/integrated or sequential manner to enhance the overall treatment effect across a variety of spasticity-associated impairments (e.g., neural and non-neural components). Moreover, within a multimodal approach, adjunctive therapy can be used to help enhance the treatment effect of one specific modality. The objectives of this paper are to clarify the differences between adjunctive and multimodal therapies, provide a brief evidence-based review of such approaches, and highlight clinical insights on selecting multimodal and adjunctive therapies in spasticity management.

INTRODUCTION: It is known that mechanical ventilation and many of its features may affect the evolution of inspiratory muscle strength during ventilation. However, this evolution has not been described, nor have its predictors been studied. In addition, a probable parallel between inspiratory and limb muscle strength evolution has not been investigated. OBJECTIVE: To describe the variation over time of maximal inspiratory pressure during mechanical ventilation and its predictors. We also studied the possible relationship between the evolution of maximal inspiratory pressure and limb muscle strength. METHODS: A prospective observational study was performed in consecutive patients submitted to mechanical ventilation for > 72 hours. The maximal inspiratory pressure trend was evaluated by the linear regression of the daily maximal inspiratory pressure and a logistic regression analysis was used to look for independent maximal inspiratory pressure trend predictors. Limb muscle strength was evaluated using the Medical Research Council score. RESULTS: One hundred and sixteen patients were studied, forty-four of whom (37.9%) presented a decrease in maximal inspiratory pressure over time. The members of the group in which maximal inspiratory pressure decreased underwent deeper sedation, spent less time in pressure support ventilation and were extubated less frequently. The only independent predictor of the maximal inspiratory pressure trend was the level of sedation (OR=1.55, 95% CI 1.003 - 2.408; p = 0.049). There was no relationship between the maximal inspiratory pressure trend and limb muscle strength. CONCLUSIONS: Around forty percent of the mechanically ventilated patients had a decreased maximal inspiratory pressure during mechanical ventilation, which was independently associated with deeper levels of sedation. There was no relationship between the evolution of maximal inspiratory pressure and the muscular strength of the limb.