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http://www.Mdvu.org/library/disease/spastic/spa_mpath.

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Spasticity
Pathophysiology
Although the pathophysiology of spasticity is not clearly understood, several theories have been proposed to
explain this change in muscle tone, which comprises one component of the upper motor neuron syndrome.
In general, spasticity develops when an imbalance occurs in the excitatory and inhibitory input to α motor
neurons, leading to hyperexcitability.
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Possible mechanisms of spasticity
Increased neuronal excitability
Enhanced excitatory synaptic input
Segmental afferents
Regional excitatory interneurons
Descending pathways, i.e., lateral vestibulospinal tract
Reduced inhibitory synaptic input
Renshaw cell recurrent inhibition
Ia inhibitory interneurons
Ib afferent fibers
Change in intrinsic electrical properties of the neuron
Change in passive membrane electrical properties
Change in voltage sensitive membrane conductance
Enhanced stretch-evoked synaptic excitation of neurons
γ efferent hyperactivity
Excitatory interneurons more sensitive to muscle afferent
Lesion of the upper motor neuron
An upper motor neuron lesion, such as occurs with a CP, stroke, TBI, or SCI, disrupts not only the pyramidal
tract, but also the corticospinal tract that is involved in voluntary movement. The same damage to the
higher centers provokes an imbalance in spinal reactivity through a modification of the descending input
received by spinal neurons.
After a variable period of time, spinal circuits undergo plastic rearrangements that lead to abnormal muscle
contractions and abnormal reflex responses, some of which meet the classic definition of spasticity. A
reciprocal potentiation is then likely to occur between spasticity and muscle shortening.
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Pathophysiology of Impairment After a Central Nervous System Lesion
Spinal versus Cerebral Models of Spasticity
The spinal model of spasticity posits that removal of inhibition on segmental polysynaptic
pathways leads to a slow progressive rise of the excitatory state through cumulative excitation.
What follows is afferent activity from one segment leading to muscle response many segments
away and an overexcitation of flexors and extensors. In the cerebral model, enhanced
excitability of monosynaptic pathways causes a rapid build-up of reflex activity, subsequently
leading to a bias toward overactivity in the antigravity muscles and the development of
hemiplegic posture.
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Spasticity may cause pain (which may also affect sleep and, subsequently, affect), joint deformity,
macerated skin, difficulty performing activities of daily living or ambulating, muscle tightness or stiffness
(particularly when the patient attempts to use fine-motor skills), muscle spasms, or fatigue. Spasticity also
manifests in typical patterns, although they may not always be as readily apparent as those shown below.

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Diagnosis and Assessment
A key point in the assessment of spasticity is to standardize the environment, i.e., to perform the patient's
assessment at the same time of day and in the same manner, at each visit. Exacerbating factors, such as
urinary tract and other infections, pressure sores, ingrown toenails, and constipation, should be accounted
for and removed to the extent possible before performing the assessment. Observing the person with
spasticity perform activities such as walking, drinking from an open cup, and moving from one position to
another often yields valuable information. In this manner, the assessment should examine the extent to

ease of caregiving or hygiene. such as the Fugl-Meyer Scale. Note should be made of the point at which the catch occurs and the speed with which the joint is moved when the catch occurs. These nerve fibers usually originate in the cerebral cortex. primarily for research purposes. When stretching a limb affected with spasticity. Formal measures. Performing the range of motion may also elicit the "clasped-knife" phenomenon. the Tardieu Scale also includes the angle and velocity of the movement that elicits the response. 19 Corticospinal/pyramidal tract These are the neural tracts which descend in the spinal cord. each joint is moved through its full range of motion at various speeds. and the Tardieu Scale. have been developed to measure functioning in patients with spasticity. the examiner will feel a "catch. Other scales are used less frequently. Therefore. from no change in or diminished muscle tone (0) to complete inability to move the joint (5). 16 A variety of scales have been developed to standardize the recording of these findings from the clinical examination of spasticity. normalization of gait). or overall quality of life. these tools may not be sensitive to changes in spasticity per se and are infrequently used outside of the research setting. carrying signals for voluntary movement of skeletal muscle. The clinical assessment should also include and evaluations of the change in level of pain. The 6 points of the Modified Ashworth Scale (which includes a 1+ rating) correlate with clinician-determined increasing levels of spasticity during passive range of motion. then gather in the internal capsule before crossing over to the opposite side (decussation) in the medulla oblongata and proceeding down the spinal cord to meet lower motor neurones in the anterior horn 01000900000374f80300000063de010000001610000026060f002220574d4643010 0000000000100ef3e000000002200000000200000e00d0400e02d0400010000006c 000000000000000000000096010000570200000000000000000000233800009d52 000020454d4600000100e02d04000c0000000100000000000000000000000000000 00005000020030000c40100001a010000000000000000000000000000e3e306006e 4e0400460000002c00000020000000454d462b014001001c000000100000000210c 0db01000000600000006000000046000000806f0000746f0000454d462b22400400 0c000000000000001e4009000c00000000000000244001000c00000000000000304 0020010000000040000000000803f214007000c0000000000000008400005cc6e00 00c06e00000210c0db0100000000000000000000000000000000000000010000008 ."—a sudden increase in resistance to the stretch. However. The most often used are the Modified Ashworth Scale. the clinical assessment becomes more important and is likely to focus on patients' ability to complete a task. and the length of time that it takes them to complete the task. In addition to the degree of spasticity.which spasticity is limiting function— • The amount of spasticity in each limb • The impact of changing spasticity on function • The degree of weakness • The impact of weakness on function A standard evaluation of the nervous system forms the first step of the clinical examination. 17. the ability to measure change in function is important.. ease of movement. the quality of their completion of the task (e.18 Because one of the primary reasons to treat spasticity is its effect on function. in the lateral columns.g. with the patient fully relaxed. Clasped knife occurs when the spastic muscle is stretched—the resistance to stretch is initially marked but then suddenly relents. including an assessment of both strength and reflexes. Next.

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