Spasticity Management

Definition and Evaluation

Definition

• Spasticity is defined as a motor disorder characterized by a velocity-dependent increase in muscle tone or tonic stretch reflexes resulting from hyperexcitability of the stretch reflex pathway.¹
• It represents a positive feature of upper motor neuron syndrome and commonly manifests as muscle stiffness, involuntary contractions, impaired voluntary movement, and functional limitation.¹
• A wide range of neurologic disorders can produce spasticity, including stroke, cerebral palsy, traumatic brain injury, anoxic brain injury, spinal cord injury, multiple sclerosis, and other neurodegenerative diseases.¹
• Regardless of cause, the common pathway involves heightened excitability of segmental reflex circuits due to impaired supraspinal modulation.

Evaluation

• Evaluation begins with identifying the neurologic diagnosis and determining whether new symptoms reflect progression or secondary aggravators such as infection, pain, medication changes, or metabolic disturbances.
• New-onset spasticity should raise concern for an acute central nervous system process, whereas worsening chronic spasticity often signals potentially reversible causes.
• Physical examination focuses on tone, range of motion, impact on mobility or self-care, and the presence of spasms or contractures. Reversible factors such as infection, metabolic derangements, and improper positioning should be treated before escalating therapy.
• To quantify severity and monitor therapeutic response, several standardized tools are used. The most widely used clinical tool is the Modified Ashworth Scale, which measures resistance to passive movement (Table 1).^1-3 The Tardieu Scale provides additional information by assessing how muscle response varies with stretch velocity and by measuring the spasticity angle (Table 2).^1,2 The Penn Spasm Frequency Scale evaluates the frequency of spontaneous or elicited spasms and is especially useful in patients with spinal cord injury (Table 3).^1,3

Management and Treatment Options

• Managing spasticity requires a structured approach that pairs correction of reversible contributors with individualized treatment aligned with the patient’s functional goals. Treatment follows a stepwise approach, progressing from conservative measures to pharmacologic therapy and, when necessary, interventional or surgical modalities.

Initial Management and Conservative Measures

• Nonpharmacologic therapies form the foundation of care. Treatment begins by addressing modifiable factors that may exacerbate spasticity, including infection, metabolic abnormalities, pain, positioning problems, poor sleep, and noxious stimuli. Stretching routines, physical and occupational therapy, orthotic devices, and strengthening programs help maintain joint mobility and prevent contractures.

First-Line Pharmacologic Therapy

• Medication is added when nonpharmacologic measures are insufficient.
• First-line oral agents include oral baclofen, benzodiazepines (such as diazepam or clonazepam), gabapentin, and tizanidine.^1,4 These medications reduce muscle hyperactivity through different mechanisms, and selection is individualized based on patient comorbidities, side-effect profiles, and overall functional goals.
• Baclofen is commonly used for its GABA B receptor agonist effects and its favorable efficacy in both spinal and supraspinal spasticity.
• Tizanidine is a centrally acting alpha-2 adrenergic agonist that may be used. Sedation is a common limiting side effect.
• Diazepam is the most commonly used benzodiazepine for spasticity, often in conjunction with baclofen or tizanidine.⁴ Sedation, confusion, and gastrointestinal symptoms can be dose-limiting. It is a Schedule IV controlled substance in the United States with potential for abuse, requiring caution in prescribing, especially for the long-term use.⁵

Second-Line and Adjunctive Therapies

• Patients with focal spasticity or who do not achieve sufficient relief with first-line agents may benefit from second-line therapies.
• For focal or segmental spasticity, botulinum toxin A can be used to weaken overactive muscles.
• Patients with diffuse, function-limiting spasticity who do not respond to or cannot tolerate high-dose oral agents may benefit from intrathecal baclofen.^1,4
• Please see the OA summary on baclofen. Link
• Additional medications that may alleviate spasticity-related pain include carbamazepine, oxcarbazepine, and cannabinoids in appropriately selected patients.²

Monitoring and Adjustment of Treatment

• Treatment is tailored to functional goals, and clinicians regularly reassess tone, spasm frequency, and functional outcomes, modifying therapy in response to progress or side effects.
• Patients with intrathecal pumps require ongoing evaluation of pump function, catheter integrity, and reservoir volume to prevent withdrawal or overdose events.
• Collaboration among rehabilitation specialists, neurologists, anesthesiologists, and therapists enhances long-term outcomes.