PT Classroom - The Role of the Physical Therapist for Management of Spasticity ׀ by Kostandinos Tsoulfas, MD & Chai Rasavong, MPT, MBA

Spasticity is considered one aspect of abnormal muscle tone that increases muscle tone at rest and may alter the dynamic activation of a muscle. It is characterized by increased resistance to passive stretch, is velocity dependent and is asymmetric about joints (i.e. greater in the flexor muscles at the elbow and the extensor muscles at the knee) (1). Exaggerated deep tendon reflexes and clonus are also additional manifestations (1). It is also considered a component of Upper Motor Neuron Syndrome and its’ etiology can include injury or disease of the brain, spinal cord, and connecting pathways (2).

As a motor disorder, spasticity alters the activity patterns of motor units in response to sensory and central command signals. This leads to co-contractions, mass movements, and abnormal postural control (3). In our practice we will often see patients with upper motor neuron lesions who present with spasticity. Some examples of such cases can include: cerebral vascular accident, multiple sclerosis, Huntington’s Chorea, Parkinson’s Disease, traumatic brain injury, spinal cord injury, Cerebral Palsy and an acquired brain injury.

As healthcare practitioners, we play a pivotal role in assessing spasticity and with the referral process. When assessing spasticity it is important to remember that there are other factors to consider which can impact spasticity and therefore the reliability measurement. These factors can include: body position, speed of passive movement, presence of musculoskeletal changes and activity level of patient prior to testing (4). Referral to rehab early vs. later is also vital and can help decrease impact on soft tissues especially in the pediatric population. The traditional step ladder approach for treatment of spasticity involves: 1) removing noxious stimuli (e.g. bladder distension, constipation, pressure ulcers, UTI, ingrown toenails, etc.) 2) rehabilitation therapy 3) oral medication 4) injection therapies (phenol, botulinum toxins) 5) orthopedic surgery 6) Intrathecal Baclofen Therapy (ITB)/selective dorsal rhizotomy (SDR) (5).

Various questions that should be asked when selecting the best treatment approach are (5):
1) Is moderate to severe spasticity present?
YES: Potentially appropriate for all of the treatement options
NO: Define movement disorder and explore appropriate treatments
YES & NO: Sort out the impact of spasticity from other movement disorders with reversible methods (e.g. oral meds, injections)
2) Is there influence of weakness?
YES: Address in therapy regime
3) Is there influence of selective motor control?
YES: Address in therapy regime
4a) Is there contribution of muscle stiffness or contracture (non-neural components)?
YES: Address with PT/OT modalities, ortho surgery and/or injection therapies with casting
4b) Is there contribution of the spastic catch (neural component)?
YES: Appropriate for all spasticity treatment options
5) Is the spasticty generalized or focarelated to the clinical problem?
Generalized: oral meds, SDR, ITB Therapy, ortho surgery
Focal: injection therapy, ortho surgery
Focal and Generalized: Usually treat generalized spasticity first, rehab, and then address the focal spasticity if still a clinical problem
6) Does spasticity interfere with function, care or comfort?
YES: Determine what the primary problem of the patient and/or family is and address in therapy regime while considering other spasticity treatment options as well.

Although there may be some advantages (e.g. maintaining muscle bulk, helping support circulatory function, assisting with postural control and assisting with activities of daily living) for patients in having spasticity, it is our job as healthcare practitioners to determine the extent of how spasticity affects our patients and to determine what will be best for our patients in the spectrum of care for spasticity management. Only through better clinical decision making will we be able to help our patients achieve their functional outcome potential.