Spasticity:

Characterization and
Treatment Considerations
Insert Presenters Name
1
Definition of Spasticity
1
Lance JW. Symposium synopsis. In Feldman RG, Young RR, Koella WP (eds) Spasticity:
Disordered Motor Control. Year Book Medical Pubs, Chicago, 1980: pp. 485-94
Velocity-dependent increase in tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks, resulting
from hyperexcitability of the stretch reflex, as one
component of the upper motor neuron syndrome.
1
Upper Motor Neuron Syndrome
A group of symptoms that may be caused by damage or injury
to motor neuron pathways or brain regions that control movement
2,3
2
Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil 1989; 70:144-55
3
O'Brien CF, Seeberger LC, Smith DB. Spasticity after stroke. Epidemiology and optimal treatment. Drugs Aging 1996; 9:332-40
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Young RR ,Wiegner AW. Spasticity.ClinOrthop Relat Res 1987; 50-62
Positive Symptoms
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Negative Symptoms
4
Characterization Muscle overactivity Muscle underactivity
Examples Spasticity, clonus,
flexor/extensor spasm,
hyper-reflexia,
dystonia, and rigidity
Decreased dexterity,
weakness, paralysis,
fatigability, and
slowness of movement
Classification of Spasticity
5
Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment
considerations. Clin Geriatr 2004; 12:27-35
6
Gracies JM, Nance P, Elovic E, McGuire J, Simpson DM. Traditional pharmacological treatments for spasticity.
Part II: General and regional treatments.Muscle Nerve Suppl 1997; 6:S92-120
Classification of Spasticity According
to Distribution of Affected Body Regions
5,6
Distribution Definition
Isolated, local motor disturbance affecting
a single body part
Focal
Motor disturbance involving a large region
of the body
Regional
Motor disturbance involving widespread
bodily regions
Generalized
Signs and Symptoms of Spasticity
Patients with spasticity may
experience a range of
sensations in the affected limbs
7

Mild muscle stiffness
Painful muscle contractures
and spasms
In a recent survey, most patients
rated stiffness and limited range
of motion as having the most
substantial negative impact on
their quality of life
8
7
O'Brien CF. Treatment of spasticity with botulinum toxin. Clin J Pain 2002; 18:S182-90
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WE MOVE. Profile of Patients with Spasticity, 2008. Available at:
http://www.wemove.org/reports/spasticity_2008.pdf. Accessed March 26, 2009
Percentage of 810 patients with
spasticity who identified each aspect
of their condition as having the most
significant impact on quality of life.
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Abnormal
posture, pain,
or inability
to sleep
34.5%
Stiffness/
limited range
of motion
42.0%
Limitations
in activities
of daily living
23.5%
Common Limb Deformities in Upper Limb Spasticity
The flexed elbow is bent
into flexion and this posture
may dramatically worsen
with ambulation, causing
more-severe angle flexion.
In the adducted/internally
rotated shoulder, the arm
is held closely against the
side, elbow bent, with the
forearm applied across the
front of the chest.
Flexion of the wrist is
caused by hypertonicity
of the wrist flexor
muscles that seem to
easily overpower their
antagonists of wrist
extension, so that this is
the most common
attitude.
Common Limb Deformities in Upper Limb Spasticity
In those with clenched
fist, the fingers are tightly
flexed into the palm. This
can lead to poor palmar
hygiene and pain with
finger manipulation.
Pronation of the forearm
seems to be more
commonly encountered
than supination after
central nervous system
injury.
In those with thumb-
in-palm deformity, the
thumb is held fixed
within the palm with its
distal aspect flexed.
The thumb is limited in
its use as a result of
the abnormal posture.
Major Causes of Spasticity in Adults
Stroke
Multiple sclerosis
Spinal cord injury
Traumatic brain injury
Adult cerebral palsy
Affects 795,000 Americans annually
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Upper and lower limb

Upper limb only

Lower limb only

% with spasticity
10
9
Centers for Disease Control and Prevention. Stroke facts and statistics. Available at:
http://www.cdc.gov/stroke/stroke_facts.htm. Accessed April 7, 2009
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Lundstrom E, Terent A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke.
Eur J Neurol 2008; 15:533-9
10%

7%

1%

Methods of Spasticity Assessment
11
Physiologic measures such as overall excitability of a motor
neuron pool or the shortening of muscle cells that are under
spastic control.
Passive activity measures such as Ashworth scale and
passive range of motion.
Voluntary activity measure such as the Fugl-Meyer test and
the Nine Hole Peg Test.
Functional measures such as the Functional Independence
Measure and the Disability Assessment Scale (DAS) and
measures of pain.
Quality of life measures that assess patient satisfaction and
perceived importance of spasticity treatment.
11
Elovic EP, Simone LK, Zafonte R. Outcome assessment for spasticity management in the
patient with traumatic brain injury: the state of the art. J Head Trauma Rehabil 2004; 19:155-77
Methods of Spasticity Assessment: Examples
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Ashworth Scale
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Grade Description
No increase in muscle tone 0
Slight increase in tone a catch and
release at the end of the range of motion
1
More marked increase in tone through
most of range
2
Considerable increase in tone, passive
movement difficult
3
Affected parts rigid in flexion or
extension
4
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Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192:540-2
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Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67:206-7
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Brashear A, Zafonte R,Corcoran M, et al. Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment
Scale in patients with upper-limb poststroke spasticity. Arch Phys Med Rehabil 2002; 83:1349-54
The modified Ashworth scale incorporates a 1+ (Slight
increase in tone catch, followed by minimal resistance in
remainder of range) to differentiate the catch that is felt in
some patients when limbs are passively moved.
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Disability Assessment Scale
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Domain Description
Extent of palm maceration, ulceration,
and/or infection; palm cleanliness; ease
of cleaning and nail trimming; effect of
hygiene related disability in patients life
Hygiene
Ability to put on clothing; effect of
dressing-related disability due to
upper-limb spasticity on patients life
Dressing
Psychological and/or social
interference that the limbs posture
has in the patients life
Limb
Posture
Intensity of pain; discomfort and
interference of upper limb pain in
patients life
Pain
Scores:
0 = no functional disability
1 = mild
2 = moderate
3 = severe
Problems That May Be Associated With Spasticity
15-18
Pain
Contracture
Fatigue
Functional limitations
(hygiene, dressing,
transfers)
Increased risk of falls
Pressure sores
Skin maceration
Poor orthotic fit
Diminished self image due
to abnormal limb posture
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Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction.Muscle Nerve Suppl 1997; 6:S21-35
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Adams MM, Ginis KA, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil 2007; 88:1185-92
17
Wissel J, Ward AB, Erztgaard P, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med 2009; 41:13-25
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Bhakta BB. Management of spasticity in stroke. Br Med Bull 2000; 56:476-85
Factors to Consider in Spasticity Treatment
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Chronicity of spasticity
Severity of spasticity
Distribution of spasticity
Locus of central injury or damage
Patient co-morbidities
Availability of care and support
Decision to Treat Spasticity
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Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity.
Muscle Nerve Suppl 1997; 6:S14-20
Treatment Goals
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Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity.
Muscle Nerve Suppl 1997; 6:S14-20
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Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001; 47:295-9
The inclusion of patients and caregivers in the discussion of goals
is critical because patient and physician goals do not always coincide.
Major Classes of Treatment Goals with Examples of Each
19, 20
Improve activities of daily living (e.g., dressing, hygiene)
Reduce pain
Enhance ease of care
Improve limb position (cosmesis)
Improve gait
Functional Objectives
Increase range of motion
Reduce tone
Reduce spasm
Technical Objectives
Prevent contracture
Prevent skin maceration
Prevent skin ulcers
Preventive Objectives
Spasticity Management Team
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Physicians
Rehabilitation nurses
Allied healthcare professionals (physical therapists,
occupational therapists, speech therapists)
Family and other caregivers
Coordinator/administrator
Other (wheelchair clinic, gait lab, orthotics clinic,
counseling, social worker)
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Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord 2005; 43:577-86
Summary
Spasticity is a distressing, debilitating consequence of
upper motor neuron lesions
May result from stroke, trauma to the brain or spinal cord,
multiple sclerosis, cerebral palsy, or other conditions
May be focal, regional, or general in distribution
Common clinical patterns of spasticity are identifiable
across etiologies, and are generally caused by marked
overactivity of the flexor muscles
Left untreated, spasticity may result in permanent
contracture of muscle and soft tissue, leading to
increasing disability, pain, and deformity
Summary
Thorough assessment of the patients condition is
essential in determining whether to treat spasticity, for
developing a treatment plan, and for gauging treatment
progress
Prior to treatment of spasticity, goals should be identified in
consultation with the patient and caregiver or family
When spasticity is treated, it is best approached as a
multidisciplinary endeavor
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2010 Allergan, Inc. Irvine, CA 92612
APC90SB10 April 2010