Neurological rehabilitation
Spasticity
Spasticity is an increase in muscle tone that follows damage to the pathways running from the brain down the spinal cord. Those pathways normally hold the spinal reflexes in check; when they are interrupted, the reflexes become overactive and the muscle resists being stretched. It is not a disease in itself but a consequence of an injury elsewhere — most often a stroke, a traumatic brain injury, a spinal cord injury or multiple sclerosis — and it usually appears in the weeks after that injury rather than immediately.
How it presents
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Stiffness that depends on speed
The defining feature. Move the limb slowly and it gives; move it quickly and the muscle catches and resists. This is what distinguishes spasticity from the constant stiffness of a joint or of established contracture.
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Spasms and clonus
Sudden involuntary contractions, sometimes triggered by movement or by touch, and rhythmic beating at the ankle when the foot is pushed up quickly. Spasms are often worse at night.
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A characteristic posture
The stronger muscle groups win. In the arm that commonly means a bent elbow and wrist with a clenched hand; in the leg, a straight knee with the foot pointed down and turned in.
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Pain and disturbed sleep
Sustained contraction is painful in itself, and spasms that break sleep affect fatigue, mood and how much rehabilitation is possible during the day.
What causes it
Any injury to the motor pathways above the level of the reflex arc can produce it. What differs is the pattern and the distribution.
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Stroke
Affects one side of the body. Tone typically begins to rise some weeks after the stroke, following an initial period in which the limb is flaccid.
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Traumatic brain injury
The distribution depends on what was injured and can affect one limb, one side, or all four limbs.
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Spinal cord injury
Affects the body below the level of the injury, and spasms tend to be more prominent than in spasticity of brain origin.
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Multiple sclerosis and cerebral palsy
Two of the common non-traumatic causes. In multiple sclerosis it can fluctuate with the course of the disease; in cerebral palsy it is present from early childhood and interacts with growth.
Why it is treated
The problems it leads to
Spasticity is treated for what it does rather than for its own sake. A stiff muscle that is not causing any of the following may reasonably be left alone — and sometimes should be, because tone in a weak leg can be what a person stands on.
- Contracture — permanent shortening of muscle and surrounding tissue
- Pain, both from sustained contraction and from spasms
- Difficulty with washing, dressing and hand hygiene in a clenched palm
- Skin breakdown where a limb is held hard against the body or a chair
- Loss of function: walking, transfers, and use of the hand
How it is assessed
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Moving the limb at different speeds
The examination compares resistance to slow and fast passive movement. Resistance that is the same at both speeds points to contracture rather than to spasticity, and the two are treated very differently.
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Grading tone
Simple scales are used to record resistance to passive movement so that change over time can be compared. They are a record rather than a decision.
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What the stiffness is preventing
The useful question is not how high the tone is but what it is stopping — a palm that cannot be cleaned, a foot that catches when walking, a shoulder that cannot be dressed. The goal is what treatment is judged against.
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Looking for aggravating factors
Pain, infection, a full bladder, constipation and poorly fitting equipment all raise tone. These are checked before the treatment itself is escalated.
Treatment options
Treatment is layered: the first measures apply to everyone and continue regardless of what is added on top of them.
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Stretching, positioning and splinting
The foundation, and the part that prevents contracture. A regular stretching programme and correct positioning in bed and in a chair are what preserve range; nothing that follows works without them.
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Oral medication
Baclofen, tizanidine and dantrolene reduce tone throughout the body. They are useful where spasticity is widespread, and their limit is sedation and additional weakness — a person can be made drowsier and weaker in exchange for a limb that is less stiff.
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Focal injection
Botulinum toxin injected into specific overactive muscles reduces tone where it is causing the problem and leaves the rest of the body alone. It suits spasticity concentrated in a few muscles and has to be repeated.
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Intrathecal baclofen
A pump delivering medication directly into the fluid around the spinal cord, at a small fraction of the oral dose and with far less sedation. Considered for severe, widespread spasticity, particularly of spinal origin.
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Surgery
Lengthening a shortened tendon addresses contracture that no longer responds to anything else. Selective dorsal rhizotomy, which divides some of the sensory nerve roots feeding the reflex, is used in carefully chosen cases, most often in cerebral palsy.
Common questions
Is spasticity the same as a muscle spasm?
No, although they occur together. Spasticity is a sustained increase in resistance to stretch; a spasm is a sudden involuntary contraction. Both come from the same overactive reflexes.
Does it get worse over time?
Tone usually rises over the first months after an injury and then settles. What does get worse without treatment is its consequences — contracture in particular, which is much harder to reverse than to prevent.
Should all of it be treated?
No. Spasticity that supports a weak limb can be doing useful work, and reducing it indiscriminately can cost more function than it returns. Treatment is aimed at the stiffness that is causing a specific problem.
Can it be cured?
The underlying injury to the nerve pathways does not reverse, so the tendency remains. It is managed rather than cured, and management can be very effective at keeping range, comfort and function.
General reference information, and not advice about your own case. It may not reflect the most recent guidance or what is offered on a given day — call (201) 408-5151 to check.
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