1. Spasticity: Characterization and Treatment Considerations
Insert Presenter’s Name
In the following slides, we will discuss the characterization and treatment considerations of spasticity.

2. Definition of Spasticity
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
This slide shows the most frequently cited definition of spasticity, from an article by Lance, 1980.
1Lance JW. Symposium synopsis. In Feldman RG, Young RR, Koella WP (eds) Spasticity: Disordered Motor Control. Year Book Medical Pubs, Chicago, 1980: pp
1 Lance JW. Symposium synopsis. In Feldman RG, Young RR, Koella WP (eds) Spasticity: Disordered Motor Control. Year Book Medical Pubs, Chicago, 1980: pp

3. 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 movement2,3
Positive Symptoms4
Negative Symptoms4
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
As noted in the preceding definition, spasticity typically occurs as part of the upper motor neuron syndrome. The upper motor neuron syndrome is a group of symptoms that may be caused by damage or injury to the motor neuron pathways or brain regions that control movement.2,3
Upper motor neuron symptoms have been classified as positive or negative depending on whether they represent muscle overactivity or underactivity.4 Here you see that spasticity is classified as a positive symptom, along with clonus, spasms, and dystonia. In contrast, decreased dexterity, weakness, and paralysis are examples of negative symptoms.4
2Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil 1989; 70:144-55
3O'Brien CF, Seeberger LC, Smith DB. Spasticity after stroke. Epidemiology and optimal treatment. Drugs Aging 1996; 9:332-40
4Young RR, Wiegner AW. Spasticity. Clin Orthop Relat Res 1987; 50-62
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
4 Young RR ,Wiegner AW. Spasticity.ClinOrthop Relat Res 1987; 50-62

4. Classification of Spasticity
Classification of Spasticity According to Distribution of Affected Body Regions5,6
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
Spasticity is often classified according to the distribution of body regions affected, which may be focal, multifocal, regional, or generalized.5
Focal spasticity affects an isolated body area such as the arm or foot, whereas multifocal spasticity affects multiple isolated or non-contiguous body areas.
Regional and general spasticity denote more diffuse involvement, with regional spasticity affecting a large contiguous region and generalized spasticity affecting multiple, large areas of the body.
The distribution of spasticity is important to identify because it has definite treatment implications.5,6
Post-stroke patients commonly experience focal spasticity, although focal stroke may lead to regional or generalized spasticity if the lesion is large or located in key motor control regions of the brain.5 Spinal cord injury and multiple sclerosis are often but not exclusively associated with more diffuse patterns of spasticity that may be regional or generalized.6
5Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment considerations. Clin Geriatr 2004; 12:27-35
6Gracies 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
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

5. Signs and Symptoms of Spasticity
Patients with spasticity may experience a range of sensations in the affected limbs7
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 life8
Abnormal posture, pain, or inability to sleep
34.5%
Stiffness/ limited range of motion
42.0%
Limitations in activities of daily living
23.5%
Patients with spasticity may experience a range of sensations in the affected limbs, from mild muscle stiffness to painful muscle contractures and spasms.7
In a recent survey,8 810 individuals with spasticity were asked to rate which of the following 5 symptoms had the most substantial negative impact on their quality of life:
• Stiffness or limited range of motion in affected muscles
• Abnormal posture
• Pain
• Inability to sleep
• Limitations in activities of daily living such as bathing, getting dressed, etc.
More than 40% of respondents indicated that stiffness or limited range of motion in their affected limb(s) had the most substantial negative impact on their quality of life, followed by limitations in activities of daily living (23.5%).
7O'Brien CF. Treatment of spasticity with botulinum toxin. Clin J Pain 2002; 18:S182-90
8WE MOVE. Profile of Patients with Spasticity, Available at: 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.8
7 O'Brien CF. Treatment of spasticity with botulinum toxin. Clin J Pain 2002; 18:S182-90
8 WE MOVE. Profile of Patients with Spasticity, Available at: Accessed March 26, 2009

6. Common Limb Deformities in Upper Limb Spasticity
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.
The flexed elbow is bent
into flexion and this posture
may dramatically worsen
with ambulation, causing
more-severe angle flexion.
The common clinical patterns seen in the upper limbs are depicted on the followingpage. These deformities and abnormal postures are caused by marked muscle overactivity of the flexor muscles.
This slides shows the adducted/internally rotated shoulder, the flexed wrist posture, and the flexed elbow.

7. Common Limb Deformities in Upper Limb Spasticity
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.
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.
This slides shows pronation of the forearm, thumb-in-palm deformity, and clenched fist postures – all of which are common clinical patterns seen in individuals with upper limb spasticity.

8. Major Causes of Spasticity in Adults
Stroke
Multiple sclerosis
Spinal cord injury
Traumatic brain injury
Adult cerebral palsy
Affects 795,000 Americans annually9
% with spasticity10
10%
Upper and lower limb 7%
Upper limb only 1%
Lower limb only
The major causes of spasticity in adults are stroke, multiple sclerosis, spinal cord injury, traumatic brain injury, and adult cerebral palsy.
Of these conditions, stroke is the most prevalent, affecting an estimated 795,000 Americans each year.9
Ten percent of stroke survivors have spasticity of both upper and lower limbs, whereas spasticity is limited to the upper limbs in 7% and to the lower limbs in 1%.10
9Centers for Disease Control and Prevention. Stroke facts and statistics. Available at: Accessed April 7, 2009.
10Lundstrom E, Terent A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke. Eur J Neurol 2008; 15:533-9
9 Centers for Disease Control and Prevention. Stroke facts and statistics. Available at: Accessed April 7, 2009
10 Lundstrom E, Terent A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke. Eur J Neurol 2008; 15:533-9

9. Methods of Spasticity Assessment11
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.
Regardless of the cause of spasticity, it is important to assess the condition and its contribution to the individual’s functioning. Such evaluation and measurement is critical in determining whether spasticity should be treated, setting treatment goals, monitoring progress, and assessing outcomes.
Outcome goals and assessments used to monitor spasticity patients can be classified into five categories.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.
Many clinicians select more than one assessment method, which may vary from patient to patient depending on the pattern of spasticity and treatment goals.
11Elovic 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
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

10. Methods of Spasticity Assessment: Examples
Ashworth Scale12
Disability Assessment Scale14
Domain
Description
Grade
Description
No increase in muscle tone
Extent of palm maceration, ulceration, and/or infection; palm cleanliness; ease of cleaning and nail trimming; effect of hygiene related disability in patient’s life
Hygiene
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
Ability to put on clothing; effect of
dressing-related disability due to
upper-limb spasticity on patient’s life
Dressing
Considerable increase in tone, passive movement difficult 3
Psychological and/or social
interference that the limb’s posture
has in the patient’s life
Limb Posture
Affected parts rigid in flexion or
extension 4
Intensity of pain; discomfort and
interference of upper limb pain in
patient’s life
Pain
This slide shows two scales that have been used for the assessment of spasticity.
This slide shows the Ashworth scale, a commonly used measure of muscle tone.12 The Ashworth scale ranges from 0=no increase in muscle tone to 4=affected parts rigid in flexion or extension. The modified Ashworth scale incorporates a 1+ to differentiate a catch that is felt in some patients when limbs are passively moved.13
The Disability Assessment Scale assesses the degree of functional impairment in 4 areas: hygiene, dressing, limb posture and pain.14 Scores on each of these domains are rated from 0=no functional disability to 3=severe disability.
12Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192:540-2
13Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67:206-7
14Brashear A, Zafonte R, Corcoran M, Galvez-Jimenez N, Gracies JM, Gordon MF, 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:
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.13
Scores:
0 = no functional disability
1 = mild
2 = moderate
3 = severe
12 Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192:540-2
13 Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67:206-7
14 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:

11. Problems That May Be Associated With Spasticity15-18
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
Although spasticity is not always detrimental, it can lead to problems. These may include pain, contracture, fatigue, functional limitations (for instance, in hygiene, dressing, and transfers), diminished self image due to abnormal limb posture, increased risk of falls, pressure sores, skin maceration, and poor orthotic fit.15-18
15Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction. Muscle Nerve Suppl 1997; 6:S21-35
16Adams MM, Ginis KA, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil 2007; 88:
17Wissel J, Ward AB, Erztgaard P, Bensmail D, Hecht MJ, Lejeune TM, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med 2009; 41:13-25
18Bhakta BB. Management of spasticity in stroke. Br Med Bull 2000; 56:476-85
15 Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction.Muscle Nerve Suppl 1997; 6:S21-35
16 Adams MM, Ginis KA, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil 2007; 88:
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
18 Bhakta BB. Management of spasticity in stroke. Br Med Bull 2000; 56:476-85

12. Decision to Treat Spasticity
Factors to Consider in Spasticity Treatment19
Chronicity of spasticity
Severity of spasticity
Distribution of spasticity
Locus of central injury or damage
Patient co-morbidities
Availability of care and support
A number of factors must be considered when determining whether, when, and how spasticity should be treated.19 These factors include the duration or chronicity of spasticity, the severity and distribution of spasticity, the locus of central nervous system injury, co-morbidities, and the availability of care and support.19
19Gormley 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
19 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

13. Treatment Goals
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
Increase range of motion
Reduce tone
Reduce spasm
Technical Objectives
Improve activities of daily living (e.g., dressing, hygiene)
Reduce pain
Enhance ease of care
Improve limb position (cosmesis)
Improve gait
Functional Objectives
Identification of treatment goals is the first step in devising a treatment program for spasticity. Goals should be specific and function-oriented, and should be developed in consultation with the patient and caregiver.19
The inclusion of patients and caregivers in the discussion is critical because patient goals do not always coincide with physician goals. For instance, the physician’s goal for an individual with a flexed wrist may be to regain as much range of motion in the joint as possible; however, the individual may be most concerned with how abnormal the positioning of his or her wrist appears during social events.
Alternatively, the physician’s goal may be to open the patient’s hand to enable hygiene, whereas the patient’s goal may be to play the piano again.
Functional goals of treatment may include the improvement of hygiene, pain, activities of daily living, ease of care, cosmesis, limb position, and gait; to decrease the frequency of spasm; and to improve or enable orthotic fit.19 Technical goals, which subserve the functional goals, may include increased range of motion, reduced muscle tone, and improved joint position.19
Prevention of secondary complications such as contractures, skin maceration, and decubitus (pressure) ulcers may also be important goals of treatment.20
19Gormley 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
20Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001; 47:295-9
Prevent contracture
Prevent skin maceration
Prevent skin ulcers
Preventive Objectives
19 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
20 Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001; 47:295-9

14. Spasticity Management Team21
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)
As we discussed earlier, spasticity is only one of a constellation of symptoms usually observed in individuals with upper motor neuron syndrome. Comprehensive rehabilitation programs are typically needed to address the multiplicity of problems observed in these patients.
As a result, spasticity management should involve a multidisciplinary team consisting of a physical medicine and rehabilitation specialist or neurologist specializing in rehabilitation, physical therapist, occupational therapist, speech therapist, nurse, patient, and relatives/caregivers.21
21Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord 2005; 43:577-86
21 Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord 2005; 43:577-86

15. 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
As our discussion has shown, spasticity is a distressing, debilitating consequence of upper motor neuron lesions.
Spasticity may result from stroke, trauma to the brain or spinal cord, multiple sclerosis, cerebral palsy, or other conditions; and it may be focal, regional, or general in its distribution.
As we saw in the photos, 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.
Left untreated, spasticity may result in permanent contracture of muscle and soft tissue, leading to increasing disability, pain, and deformity

16. Summary
Thorough assessment of the patient’s 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
Prior to undertaking any treatment for spasticity, thorough assessment of the patient’s condition is essential in determining whether or not to treat spasticity, in order to develop a treatment plan, and to be able to gauge 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 as we saw with the numerous different individuals who are typically part of the spasticity team.

17. Questions?
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