Overview
Definition
Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone) to passive muscle stretch.
Pathophysiology
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Motor dysfunction secondary to lesions proximal to the alpha motor neuron
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Loss of descending inhibitory influences on the 1A interneuron
Benefits of spasticity
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Helps maintain muscle bulk
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Facilitates ambulation, standing, and transfers
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Helps promote venous return and decreases edema
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Helps prevent deep venous thrombosis (DVT)
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Helps prevent osteoporosis
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Decreases the risk of orthostatic hypotension
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Helps awareness of potentially noxious stimuli
Disadvantages of spasticity
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Pain
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Risk of contractures
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Risk of heterotopic ossification
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Risk of joint subluxation and dislocation
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Interference in activities of daily living (ADLs) and nursing care
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Skin breakdown
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Masks volitional movement
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Negatively affects ambulation, bed positioning, sitting, standing, and transfers
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Bowel/bladder dysfunction
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Sleep disturbances
Clinical presentation
Tables 25.1 and 25.2 include the most common upper and lower extremity presentations after traumatic brain injury (TBI).
| Upper Extremity Pattern | Involved Muscles |
|---|---|
| Shoulder adduction and internal rotation | Latissimus dorsi, teres major, pectoralis major, subscapularis. |
| Elbow flexion | Brachioradialis, biceps brachii, brachialis. |
| Wrist flexion | Flexor carpi radialis, flexor carpi ulnaris, FDS, FDP |
| Forearm pronation | Pronator teres, pronator quadratus |
| Clenched fist | FDP, FDS |
| Thumb in palm deformity | Adductor pollicis, FPL, FPB |
| Lower Extremity Pattern | Involved Muscles |
|---|---|
| Hip flexion and adduction | Iliopsoas, rectus femoris, adductors |
| Knee flexion | Biceps femoris, semitendinous, semimembranous |
| Equinovarus | Gastroc-soleus complex, tibialis anterior/posterior |
| Toe curling | FDL, FDP, FHL, FHB |
Physical examination
Inspection
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Resting body position and use of orthotics
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Muscle spasms associated with movement
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Gait assessment
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Skin integrity
Physical maneuvers
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Perform a passive motion maneuver across the joint of the affected limb to elicit an involuntary velocity-dependent tonic stretch reflex.
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Exaggerated phasic stretch reflexes—tendon jerks and clonus—can also often be elicited because of hyperexcitability of the stretch reflex.
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Depending on the degree of spasticity, the muscles will exhibit varying degrees of resistance.
Grading scales
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Help qualify the spasticity and aid in determining response to treatment
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Two main grading scales qualify the degree of spasticity: Modified Ashworth Scale (MAS) and Tardieu Scale ( Table 25.3 )
TABLE 25.3
Modified Ashworth Scale
0
No increase in muscle tone with ROM
1
Slight increase in tone with a catch and release at end ROM
1+
Slight increase in tone followed by catch and slight resistance throughout remainder of ROM
2
More marked increase in muscle tone through most of ROM, but affected part easily moved
3
Considerable increase in tone, passive movement is difficult
4
Affected part held in rigid flexion or extension
ROM, Range of motion.
Workup
Increases in spasticity should prompt further evaluation:
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Initial workup should begin with a thorough history and physical examination to assess for exacerbating factors along with basic laboratory studies to rule out underlying infection.
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Common precipitants are urinary tract infections, kidney stones, bladder distension, stool impaction, wounds, DVT, pain, restrictive clothing, psychological or emotional stressors, and changes in temperature.
Treatment
Treatment goals
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Balance out the benefits and disadvantages of spasticity
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Increase patient comfort
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Facilitate caretaker management
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Optimize function
Prevention of spasticity
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Avoid noxious stimuli
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Maintain proper positioning
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Maintain a daily stretching and range of motion program
Nonpharmacological management: Physiotherapy and modalities *
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Physiotherapy: stretching, splinting, serial casting
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Cryotherapy
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Local heat
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Ultrasound
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Transcutaneous electrical nerve stimulation
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Electromyographic biofeedback
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Vibration
Pharmacological management
Oral route of administration
See Table 25.4 includes information on commonly used oral medications for spasticity. ,
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