Spasticity Management and ROM Guideline

Raphael Medical Centre

1 | Page

Spasticity
Spasticity is a common symptom of neurological disease and may be experienced by people with
multiple sclerosis, cerebral palsy, stroke, brain and spinal cord injuries.
What is spasticity?
In simple terms spasticity can be described as stiff muscles that resist passive movement. It is
one component of the upper motor neuron syndrome, which occurs as a result of acquired
damage to any part of the central nervous system. As well as this involvement of nerves,
spasticity can be made worse by changes to muscle and other soft tissues caused by immobility
and disuse. The upper motor neuron syndrome has a range of symptoms including spasms,
clonus, increased reflexes, weakness, fatigue and loss of dexterity. Most people present with a
combination of these features. The term spasticity is often used by health care professionals to
describe an individuals presentation of a range of these symptoms
Advantages of spasticity

Substitutes for strength, allowing standing, walking, gripping

May improve circulation and prevent deep venous thrombosis and edema

May reduce the risk of osteoporosis

Morbidity/disadvantages of spasticity

Orthopedic deformity, such as hip dislocation, contractures, or scoliosis

Impairment of activities of daily living (eg, dressing, bathing, toileting)

Impairment of mobility (eg, inability to walk, roll, sit)

Skin breakdown secondary to positioning difficulties and shearing pressure

2 | Page

Pain or abnormal sensory feedback

Sex/age
Spasticity is not affected by sex, race, or age group, nor is it more prevalent in any of those
groups.
Assessment Tools
Spasticity is difficult to quantify, but clinically useful scales include the following:
Modified Ashworth - From 0-4 (normal to rigid tone)
The most frequently used clinical methods for estimation of spasticity are the Ashworth Scale
(AS) and the Modified Ashworth Scale (MAS).The AS is simple, requires no instrumentation
and is easy and quick to carry out.
Modified Ashworth Scale Instructions
Place the patient in a supine position .If testing a muscle that primarily flexes a joint, place the
joint in a maximally flexed position and move to a position of maximal extension over one
second (count "one thousand one)
If testing a muscle that primarily extends a joint, place the joint in a maximally extended position
and move to a position of maximal flexion over one second (count "one thousand one)
Score based on the classification below
Scoring (taken from Bohannon and Smith, 1987):
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at
the end of the range of motion when the affected part(s) is moved in flexion or extension
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance
throughout the remainder (less than half) of the ROM

3 | Page

2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily
moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension

Spasm scale - From 0-4 (no spasms to >10/h)

Penn spasm frequency scale and the Spasm frequency score (An alternative spasm frequency
score

Penn spasm frequency scale

No spasms
Mild spasms at stimulation
Irregular strong spasms less than 1
time/h
Spasms more often than 1 time/h
Spasms more than 10 times/h

Scor

Spasm frequency score

e
0
1

No spasms
One or fewer spasms per day

Between 1 and 5 spasms per day

Five to less than 10 spasms per day

Ten or more spasms per day, or continuous

contraction

Functional scales such as the Functional Independence Measure or Gross Motor Function
Measure also may be valuable, although they do not measure spasticity directly.
Research-oriented tools for measurement include the Tardieu scale, surface electromyography,
isokinetic dynamometry, the H reflex, the tonic vibration reflex, the F-wave response, the flexor
reflex response, and transcranial electrical/magnetic stimulation.[1]
Factors that can exacerbate pre-existing spasticity from spinal injury, brain tumor/injury,
cerebral palsy, or multiple sclerosis may include the following:
4 | Page

Infection (eg, otitis, urinary tract, pneumonia)

Pressure sore

Noxious stimulus (eg, ingrown toenail, ill-fitting orthotics, occult fracture)

Deep venous thrombosis

Bladder distention

Bowel impaction

Cold weather

Fatigue

Seizure activity

Stress

Malpositioning

Goals of spasticity management

To improve function related to the activities of daily living, mobility, the ease of care by
caregivers, sleep and overall functional independence

To prevent orthopedic deformity, the development of pressure areas and the need for
corrective surgery

To reduce pain

To allow the stretching of shortened muscles, the strengthening of antagonistic muscles,

and the appropriate orthotic fit
5 | Page

Considerations that impact treatment

Duration of spasticity and the likely duration of therapy

Severity of spasticity

Location of spasticity

Success of prior interventions

Current functional status and future goals

Underlying diagnosis and comorbidities

Ability to comply with treatment and therapy

Availability of support/caregivers and follow-up therapy

Treatment interventions
Interventions vary from conservative (therapy and splinting) to more aggressive (surgery); most
often, a variety of treatments are used at the same time or are employed interchangeably.
Treatment options do not need to, and should not simply be used in a stepladder approach.
Current spasticity management options include the following:
Preventative measures
Prevention consists of the alleviation or treatment of precipitating factors, such as the following:
Pressure areas
Infections - Such as bladder, toenail, ear, or skin infections
Deep venous thrombosis
Constipation
6 | Page

Bladder distention
Fatigue
Cold

Therapeutic interventions and physical modalities

Physical and occupational therapists often are involved in providing the following

Sustained stretching

Massage

Vibration

Heat modalities

Cryotherapy

Functional electrical stimulation/biofeedback

7 | Page

Strengthening of antagonistic muscle groups

Hydrotherapy

Orthotics/positioning -Including taping, dynamic and static splints, wheelchairs, and

standers
Serial or inhibitive casting of the ankles, knees, fingers, wrists, and elbows
Splinting/orthotics - Upper and lower extremities, soft or hard, custom or prefabricated;
an orthosis may help to hold a limb in a functional position, reduce pain, and prevent
deformity.
Positioning to reduce synergy patterns - For example, wheelchair seating and bed
positioning Posture in standing, lying and sitting is crucial in managing a persons
spasticity, and for preventing pain, soft tissue shortening and skin breakdown.
Correct positioning cannot be underestimated in reducing an individuals spasticity and
pain.Further, it can improve comfort and prevent secondary tissue changes such as skin
breakdown. Over time an individuals posture and positioning needs are likely to change,
especially if their spasticity persists, and a physiotherapist or occupational therapist may
be helpful in reviewing posture both in lying and sitting positions.
Oral Medication

Baclofen
Acts on the central nervous system and is the most commonly used antispasticity drug. To
avoid side effects it needs to be started at low doses, slowly increased and maintained at a
dose that does not cause undue side effects. The effect of an oral baclofen dose can last
8 | Page

between 4-6 hours so doses need to be taken regularly to ensure adequate control of
symptoms. Side effects can include weakness, drowsiness and dizziness.

Tizanidine

Also works on the central nervous system and needs to be introduced slowly to avoid side
effects. It is claimed that tizanidine does not increase muscle weakness as much as baclofen
but this varies from individual to individual.Regular blood tests need to be completed to
ensure there is no adverse effect on liver function. Other side effects can include dizziness
(postural hypotension), drowsiness and dry mouth.

Diazepam / Clonazepam

These can be used on their own or in combination with other drugs. If spasms are particularly
troublesome at night they can be useful prior to sleep. Side effects can include drowsiness
and dizziness.

Dantrolene

Is the only anti-spasticity drug that works directly on the muscles. It can be used in
combination with other drugs. Often it is not well tolerated and can cause nausea, vomiting,
diarrhea and weakness. Regular blood tests need to be completed to check for any adverse
effect on liver functional medications

Gabapentin

An anti epileptic drug has also been found to be useful in reducing spasticity and associated
pain. Side effects can include drowsiness, dizziness and fatigue.

Cannabinoids

Several studies have shown a small benefit or trend in reducing spasticity with a combination
of the cannabis extracts delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD).
Generally the treatment was well tolerated however all of the studies reported some side
9 | Page

effects, mostly the psychotropic effects of cannabiswhich seemed to be dose related12. Delta9-tetrahydrocannabinol (THC) and cannabidiol (CBD) (Sativex) is an oromucosal spray
containing a 50:50 combination of cannabis extracts THC and CBD. It has been used as addon therapy in MS patients, previously identified as Sativex responders, who have not had
adequate symptom relief with their existing anti-spasticity therapy. As of May 2010, a licence
decision is awaited in the UK.

Injectable medication
Botulinum toxin
This is a toxin which when injected into muscles causes them to become weak. It can take 14
days for the full effect to occur and must be used in conjunction with therapy. Often the
injections can allow the individual and therapists to work with the muscle more effectively to
minimize the effects of the spasticity, but this does not always lead to functional change.

Intrathecal
Baclofen
Baclofen delivered directly into the spinal fluid acts by binding to gamma aminobutyric acid
(GABA) receptors, thus reducing spasticity, spasms, clonus and pain. A concentration of GABA
receptors is situated in the intrathecal space of the spinal cord. Delivering baclofen intrathecally
accentuates its anti-spasticity effect while minimizing the troublesome systemic side effects
associated with oral intake. An implanted pump can deliver baclofen directly to this area and can
10 | P a g e

be used to treat generalized lower limb spasticity. It requires commitment from the individual
during a trial implant phase and for ongoing maintenance of regular reservoir refills and pump
replacements.
Phenol
Phenol can be injected into the intrathecal space where it destroys nerves and thus reduces lower
limb spasticity. Repeat injections can be required. Negative effects on lower limb sensation,
sexual function, bladder and bowel management can occur and may be permanent. Selection
criteria include that effective management strategies for bladder and bowel management are in
place, such as urinary catheter or regular use of suppositories.
Surgical options
Myelotomy (severing of tracts in the spinal cord), which is rarely used, or microDREZotomy
(incisions within the dorsal root entry zone) may be considered in intractable cases, though this is
more commonly used in children with cerebral palsy 18,19. Occasionally orthopaedic procedures
such as tenotomies can be used to treat fixed contractures; it is essential that care is taken to
establish clear functional goals of treatment.
Alternative therapies
Some individuals with spasticity report that alternative therapies such as acupuncture can help
relieve symptoms.

Ongoing Management/Follow-up Care

Because tolerance can occur with medications, drug dosages should regularly be reviewed and
implantable devices (pumps, stimulators) should be checked. Ongoing documentation of
compliance with therapeutic interventions and evaluation of orthotic or positioning devices is
important.

11 | P a g e

If spasticity worsens, caregivers may have difficulty transferring patients safely or providing
adequate hygiene and general care. Recognizing caregiver difficulties and intervening to educate
and help caregivers ensure that patients receive proper care.
Monitoring skin integrity is essential because pressure ulcers can lead to sepsis and death.
Overly aggressive surgical lengthening of severe contractures should be avoided because
compression or overstretch injuries to the nerves and arteries of the limb may occur.
The ability of muscles to function after spasticity reduction varies. Treating spasticity does not
always facilitate the acquisition of previously undeveloped skills.
The importance of physical and occupational therapy intervention for achieving functional goals
cannot be overemphasized.
Measuring ROM in clinical settings

Who should take ROM measurements:

The ROM is a usual procedure undertaken by physiotherapist, occupational therapist or
doctor. However, in hospital settings this procedure can be carried out by the therapy
assistance as well. There are no direct evidence suggesting of who should do what. It is
appropriate and recommended that each therapist/doctor who does full physical
examination to perform ROM measurements of all limbs, trunk, head and neck for their
reference. However, using one common ROM measurement chart the findings of
everyone could be entered together after agreement between each assessor.

Frequency of ROM measurements:

The frequency of measuring the ROM will vary always depending upon patients
condition, treatment and prognosis. This includes the type of injury that patient suffers
from; the medications that the patients is on; secondary conditions/infections that may
exacerbate the muscle to and therefore reflect on the range; frequency of exercises and 24
hour postural management. For example: if the patient is on Tizanedine, the exercises
should be delivered 2 hour after administrating of the drug and the measurements must be
12 | P a g e

taken at the end of the session. This will give a good overview on whether the drug is
effective in reducing the muscle tone and improve the ROM. Thus each condition,
medication or treatment will have a different impact on the frequency of measuring the
ROM. The senior members of staff should be aware of this when undertaking this
procedure and also should be able to guide the new members of the staff whenever
necessary.

13 | P a g e