Espasticidade/Spasticity: Characterization and treatment

Autor Jasper Hansen

In the following slides, we will discuss the characterization and treatment considerations of spasticity.

 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.