SPASTICITY

Spasticity is a condition in which there is an abnormal increase in muscle tone or

stiffness of muscle, which might interfere with movement, speech, or is associated with
discomfort or pain. Spasticity is usually caused by damage to nerve pathways within the
brain or spinal cord that control muscle movement. It may occur in association with:

• Spinal cord injury

• Multiple sclerosis
• Cerebral palsy
• Stroke
• Brain or head trauma
• Amyotrophic lateral sclerosis
• Hereditary spastic paraplegias
• Metabolic diseases such as adrenoleukodystrophy, phenylketonuria, and krabbe
Clinical Features
-Increasing tightness
-Worsening spasm
-Physical activities like walking,transferring are affected
-Functional activities like picking,grasping are affected

Symptoms may include:

• Hypertonicity (increased muscle tone)
• Clonus (a series of rapid muscle contractions)
• Exaggerated deep tendon reflexes
• Muscle spasms
• Scissoring (involuntary crossing of the legs)
• Fixed joints (contractures)
Pathophysiology

• Spasticity is defined as velocity dependant increase in muscle tone with

exxagerated tendon jerks, resulting from hyperexcitability of the stretch reflex
i.e:the faster the passive movements of the limb through it’s range, the greater
the increase in muscle tone
• Spasticity is seen to be a positive feature of upper motor neuron syndrome.
This is because it is due to a loss of inhibition of the lower motor neuron
pathways, rather than a loss of connection to the lower motor neuron (or other
pathways).
• This results from disordered sensorimotor control of movement due to a lesion
of the upper motor neuron which regulate muscle control. Therefore, there is an
imbalance of the signals between the central nervous system (CNS) and
muscles, presenting as intermittent or sustained involuntary activation of
muscles.
Tracts involved in spasticity:

In human spastic paretic syndrome , the three important pathways involved are -
-Corticospinal tract
-Reticulospinal tract and
-Vestibulospinal tract

• In spasticity, cutaneous reflexes (flexor or withdrawal) are enhanced . Dorsal horn neurons
give rise to both long axons which form ascending tracts and short propriospinal axons to
innervate motor neurons.
• Rostral lesions in CNS disrupting descending reticulospinal tract or Spinothalamic tract alter
normal mechanisms in dorsal horn so that pain is experienced to rather innocuous stimuli.
• Spasticity is due to loss or reduction of the inhibitory influences conducted by the dorsal
reticulospinal tract.
CLASSSIFICATION ACCORDING TO SEVERITY

• Mild spasticity:

-Clonus or mild increase in tone

-No or minimal loss of range
-Mild spasms: Generally not problematic or affecting physical functions but is causing
some inconveniences.
• Moderate Spasticity
-Loss of range of movement and possible contracture.
-Walking is often effortful and may require aid or wheelchair
-Difficulty releasing grip or in hand hygiene.
-Minor adaptations required for position in lying: t-roll, wedge, pillows and lumbar roll

• Severe Spasticity
-Marked increase in tone.
-Loss of range of motion and probable contractures.
-Often hoisted for transfers.
-Difficulty positioning despite complex seating systems.
-Often reliant on a catheter and regular enemas (injections of fluid used to cleanse or
stimulate bowel movement)
Epidemiology

Spasticity affects approximately:

• 35% of those with stroke.

• More than 90% with Cerebral Palsy.
• About 50% of Traumatic Brain Injury patients.
• 40% of Spinal Cord Injury patients.
• Between 37% and 78% of Multiple Sclerosis patients.
• Physical Examination

Positive signs Negative signs

Hyperreflexia Fatigue

Babinski responses Reduced motor control

Clonus Loss of coordination

Muscle weakness
ASSESSMENT
Most commonly used scale for the assessment of spasticity are -
1.Modified ashworth scale:
GRADE Description

0 No increase in muscle tone.

1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the
end of the range of motion when the affected part(s) is moved in flexion or extension.

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout
the remainder (less than half) of the ROM.

2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.

3 Considerable increase in muscle tone, passive movement difficult.

4 Affected part(s) rigid in flexion or extension

2.Tardieu scale
-Velocity to stretch
V1 As slow as possible
V2 Speed of the limb segment falling (with gravitational pull)
V3 At a fast rate (>gravitational pull)

-Quality of Muscle Reaction

0 No resistance throughout passive movement

1 Slight resistance throughout,with no clear catch at a precise angle.

2 Clear catch at a precise angle followed by release

3 Fatiguable Clonus (< 10 secs) occurring at a precise angleFatiguable

Clonus (< 10 secs) occurring at a precise angle
4 Unfatiguable Clonus (> 10 secs) occurring at a precise angle

5 Joint immobile
-Spasticity Angle
R1 Angle of catch seen at Velocity V2 or V3
R2 Full range of motion achieved when muscle is at rest and tested at V1 velocity

Another test for spasticity include:

-Pendulum test:
The pendulum test assesses quadriceps spasticity by dropping the lower leg of a relaxed patient
from the horizontal position and observing limb movement.
Physiotherapy Management for spasticity

There are a number of stimuli which can exacerbate spasticity, some may need
multidisciplinary input alongside implementing physiotherapy management. These include:
• Skin: pressure ulcers, ingrown toe nails
• Bladder or bowel: constipation, full bladder
• Pain / discomfort: restrictive clothing, wheelchair straps, catheter straps
• Seating / positioning
• Fatigue
• Infections: UTI, pneumonia, skin infection etc
• Stress
• Disease progression
• Menstruation
• Other medical conditions (e.g. kidney stones)
Planned interventions should consider a balance between movement and positioning . This
includes:

• Standing:
-Standing frame
-Treadmill training (body-weight supported if needed)
-Tilt table
• Active exercises
• Passive movements.
• Functional electrical stimulation
• 24 hour positioning management
• Stretches
While considering management for spasticity the following aspect must be considered:

1.Patient care:
-Preventing or treating contractures.
-Monitoring skin to prevent pressure areas.
-Positioning of trunk, head and limbs in supine and in chair/ wheel chair.
• If possible, standing promotes anti-gravity muscle activity in the trunk and lower limbs. It
also maintains or improves soft tissue and joint flexibility..
• Introduction to Orthotics to maintain / improve available range.
2.Movement improvement:
-Accelerating the spontaneous recovery process
-Modifying the immature motor pattern.
-Using new recovery techniques to promote guided neuroplasticity, e.g. robotic rehabilitation
-New functional pattern in moving and walking.

3.ADL's and transfers

-Getting around
-Putting on clothes
-Personal hygiene
-Driving, etc.
4.Quality of life

-Independent living.
-Social and professional reintegration.
-Task specific activities can have a positive psychological effect.

• Patients should be educated on maintaining a daily stretching and range of motion program.
• In addition to the patient, the family and caregivers should be educated about proper
positioning, daily skin inspection, an adequate and regular bowel/bladder regimen, avoiding
noxious stimuli and identifying signs of infection and pain.