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
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
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, 2008. Available at:
http://www.wemove.org/reports/spasticity_2008.pdf. Accessed March 26, 2009
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.
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.
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:
http://www.cdc.gov/stroke/stroke_facts.htm. 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
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.
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; 83:1349-54
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;
88:1185-92
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.
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
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.
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
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.
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.
