Rajiv Reebye ^1* Luis J. Jacinto ² Alexander Balbert ³ Bo Biering-Soerensen ⁴ Stefano Carda ⁵ Nathalie Draulans ⁶ Franco Molteni ⁷ Mike O'Dell ⁸ Alessandro Picelli ⁹ Andrea Santamato ¹⁰ Monica Verduzco-Gutierrez ¹¹ Heather Walker ¹² Joerg Wissel ¹³ Gerard Francisco ¹⁴

• ¹ University of British Columbia, Vancouver, Canada
• ² Centro de Medicina de Reabilitacao do Alcoitão, Alcabideche, Portugal
• ³ Sverdlovsk Regional Hospital for War Veterans, Yekaterinburg, Russia
• ⁴ Rigshospitalet, University of Copenhagen, Copenhagen, Capital Region of Denmark, Denmark
• ⁵ Lausanne University Hospital, Lausanne, Geneva, Switzerland
• ⁶ Libra Rehabilitation & Audiology, Eindhoven, Netherlands
• ⁷ Villa Beretta Rehabilitation Center, Valduce Hospital, Costa Masnaga (LC), Lombardy, Italy
• ⁸ Weill Cornell Medicine, Cornell University, New York, United States
• ⁹ Neuromotor and Cognitive Rehabilitation Study and Research Centre, Department of Neuroscience, Biomedicine, and Movement Sciences, University of Verona, Verona, Veneto, Italy
• ¹⁰ Unit of Spasticity and Movement Disorders, Division of Physical Medicine and Rehabilitation, University Hospital of Foggia, Foggia, Italy, Foggia, Italy
• ¹¹ University of Texas Health Science Center at San Antonio, Department of Rehabilitation Medicine, San Antonio, Texas, USA, San Antonio, United States
• ¹² Department of Physical Medicine and Rehabilitation, Ralph H. Johnson VA Medical Center, United States Department of Veterans Affairs, Charleston, United States
• ¹³ University of Potsdam, Potsdam, Germany
• ¹⁴ University of Texas Health Science Center at Houston, Houston, United States

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 spasticity-associated impairments (e.g., neural and nonneural 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.