People with spasticity often feel embarrassed and frustrated with its limiting effect on daily activities [10, 12]. Severe pain and stiffness, in addition to loss of function, can have a devastating effect on the patient, and problems with sleep due to spasms can lead to fatigue and depression. Spasms in the limbs may also result in problems with positioning and pain that may, in addition, affect sexual relationships. Maintaining hygiene may prove difficult adjacent to areas with increased tone, and patients with spasticity are also at a high risk of developing pressure ulcerations [13]. The patient’s emotional and psychological state can be in constant turmoil, with a strain on their social life, and referral to appropriate specialist agencies may be of benefit [14]. For some patients, spasticity may not only be distressing and painful, but an expensive cause of disability in terms of increased carer burden and reduced rehabilitative progress.

It may be seen, therefore, that secondary complications arising due to spasticity include impaired movement, hygiene, and self-care; poor self esteem, body-image, and sleep patterns; low mood; deformity; weakness; pain; contractures; and pressure ulcers. Patients with spasticity are also more likely to live in institutional care than in their own home, and are significantly more functionally impaired than those without spasticity.

Spasticity assessment includes both identifying which muscles or muscle groups are overactive, and also determining the effect of spasticity on all aspects of patient function, including mobility, employment, and activities of daily living. Furthermore, factors such as cognition and deficits of sensation, attention, and vision (that may exacerbate spasticity) need to be evaluated. A systematic approach to assessment is required by a multidisciplinary team involving medical specialists (often from rehabilitation medicine or neurology disciplines), nurses, and allied healthcare professionals including physiotherapists, occupational therapists, orthotists, and rehabilitation engineers.

Formal assessment of tone may be measured using clinical scales such as the modified Ashworth and Tardieu scales (Table 10.1), or using techniques such as electrogoniometry to measure range of movement across a joint or quantitative neurophysiology [15, 16]. Whilst the latter two techniques are not widely available or practical in routine clinical practice, the clinical scales require no instrumentation, are quick to carry out, and have good inter- and intra-observer reliability [17–19]. The modified Ashworth scale is most widely used but its validity, reliability, and sensitivity are acknowledged to have limitations [20]. A number of scales also exist to assess patients’ self-reported health status including pain, comfort, mobility, continence, and fatigue [21, 22]. Since pain and stiffness are important and troublesome symptoms in relation to spasticity, visual analogue, and verbal rating scales are often usefully employed to record objective change following treatment. In those who have communication deficits or who lack numerical skills, pictoral rating scales may be used. In people with severe cognitive deficits and problems with communication, tools such as the AbilityQ may be used to test an individual’s ability to use different types of scales and thus help present questions in an appropriate format [23].

In patients with selective, underlying, voluntary movement in limbs with increased tone limiting “active” function, functional assessments are helpful tools to guide rehabilitative progress. Examples include the Action Research Arm, Frenchay, and nine-hole peg tests for the upper limbs; the Functional Ambulation Category, 10-m walking time, and 6-min walking distance tests for lower limbs [11]. Passive function can also be assessed using verbal or visual analogue ratings of “ease of care”, timed-care tasks (for example, the time taken for washing and dressing), or formal scales that measure dependency or carer burden (such as the Barthel’s index of activities of daily living).

First introduced in the 1960s, goal setting and its attainment has developed into a crucial element of spasticity assessment [24]. The attainment of goals following interventions varies amongst patients, and a single outcome measure is not always able to capture all domains. The Goal Attainment Scale (that involves simple recording of treatment goals achieved) has proved useful in terms of being suitable for patients with health problems, who need a multidimensional but individualised approach to treatment planning and outcome [25].

The management of muscle tone is an integral part of therapy for patients suffering from spasticity. Muscle tone is a dynamic, complex process that is part of an overall pattern of posture and movement. Appropriate management of tone is one of the fundamental principles of the Bobath method of facilitative physiotherapy, which gives priority to normalisation of tone and improving symmetry even at the cost of postponing standing or walking. However, this pre-occupation with normalisation of tone is not supported by evidence, and there are several other approaches which combine early mobilisation with active muscle tone management during rehabilitation [26].

The management of abnormal tone and spasticity is difficult, as it depends on achieving the right balance between hypo- and hypertonia between different muscle groups. The problem is compounded by the fact that spasticity varies between different groups of muscles and times of the day, and is affected by the emotional state of the patient, activity being undertaken, limb posture, and the timing of medication. Inappropriate exercise can result in inappropriate tone patterns, to the ultimate detriment of the patient. If not managed correctly, spasticity leads to poor gait patterns, contractures, and loss of function.

Spasticity should be considered in relation to other impairments, and in the context of therapy goals, because interventions directed solely at reduction of spasticity are unlikely to result in significant functional gains. The therapeutic management of spasticity is closely related to the aims of rehabilitation; these include avoidance of complications, restoration of movement, re-education of movement and gait, development of self-dependency, and social integration, improving self-esteem and overall body image, as well as promoting new neurophysiological dynamics and neural plasticity. A further aim of treating spasticity is to relieve pain and other distressing symptoms that have a detrimental effect on quality of life.

There should be a multidisciplinary team approach to spasticity management, through which realistic goals and expectations of the patients, families, and caregivers can be established. It is important that treatment be tailored to the individual patient, and factors that may aggravate spasticity, including inter-current medical illness, medications that increase muscle tone, and emotional stressors, should be managed in the first instance [27, 28]. It should also be borne in mind that some patients may be able to use their increased tone to aid with function and maintaining postural control and ambulation, and so global reduction of tone may be destabilising. Appreciation of the differing treatment options for focal versus global spasticity is important, as is the awareness that treatment of spasticity may ameliorate weakness in affected limbs.