Physiotherapy Management of Spasticity

Physiotherapy Management of Spasticity

Spasticity is a motor disorder characterized by a velocity dependent increase in muscle tone with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex. It is one of the most common symptoms in individuals with upper motor neuron (UMN) lesions, such as those caused by stroke, spinal cord injury, cervical spine nerve compression, multiple sclerosis, cerebral palsy, and traumatic brain injury. While spasticity can sometimes contribute to functional activities (e.g., maintaining posture), in most cases, it interferes with voluntary movement, leading to pain, joint contractures, and decreased mobility and quality of life.

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Only Physiotherapeutic System of Medicine is Gold Standard Treatment of Muscle Spasticity. The assessment and management of spasticity, offering individualized and goal-oriented treatment to reduce muscle overactivity, improve mobility, prevent secondary complications, and enhance function.

Pathophysiology of Spasticity

Spasticity is primarily caused by damage to descending motor pathways that normally inhibit spinal reflexes. Without this inhibition, there is increased excitability of the spinal reflexes, resulting in hypertonia and exaggerated deep tendon reflexes.

This leads to:

• Increased muscle stiffness
• Joint stiffness
• Clonus
• Abnormal posturing
• Synergistic movement patterns

Assessment of Spasticity

Accurate assessment is crucial for planning effective physiotherapy interventions. The assessment should be multidimensional and clinical reasoning, incorporating both objective subjective and investigation.

 1. Clinical Scales

• Modified Ashworth Scale (MAS): Measures resistance during passive stretching. It is widely used but subjective.
• Tardieu Scale: Assesses the response of muscles to stretch at different velocities, offering more insight into the dynamic component of spasticity.
• Penn Spasm Frequency Scale: Measures frequency and severity of muscle spasms.
• Functional Independence Measure (FIM): Evaluates the impact of spasticity on daily living activities.

2. Functional Assessment

• Observation of gait, posture, and motor control during daily tasks.
• Range of motion (ROM) measurements to detect contractures or limitations.

3. On Palpation

• Palpate the individual muscles and joints is there is any hypertonicity, muscle contracted, muscle short of length, joint stiffness.

4. Instrumental Assessment (optional in clinical settings)

• Electromyography (EMG) or H-reflex to measure muscle response.
• Gait analysis labs for advanced functional evaluation.

Goals of Physiotherapy in Spasticity Management

• Reducing muscle tone and abnormal reflexes
• Preventing contractures and deformities
• Improving voluntary movement
• Enhancing independence in activities of daily living (ADLs)
• Managing pain and improving quality of life
• Educating caregivers and family members

Physiotherapy Interventions

Physiotherapy offers a variety of interventions that can be tailored to the patient's needs, severity of spasticity, and functional goals.

1. Stretching Exercises

Purpose: To maintain or increase muscle length, reduce stiffness, and prevent joint contractures.

• Passive stretching of spastic muscles (e.g., hamstrings, adductors, calf muscles) should be done slowly and sustained for at least 30 seconds.
• Active-assisted stretching where the patient contributes partially.
• Prolonged positioning in elongated positions using splints or wedges.

Note: Stretching should be done regularly, ideally multiple times a day.

2. Positioning

Purpose: To manage abnormal postures and reduce muscle tone.

• Proper seating alignment using cushions, wedges, or custom chairs.
• Lying positions such as side-lying with pillows to reduce flexor tone.
• Avoid prolonged same positioning which may increase muscle tone.

Note: Caregivers should be trained on proper positioning techniques.

3. Strengthening Exercises

Purpose: To improve voluntary control and muscle balance.

• Strengthening antagonist muscles (e.g., dorsiflexors in presence of calf spasticity).
• Functional strengthening through task-specific training.
• Use of resistance bands, bodyweight, or gym equipment as tolerated.

Note: Important to avoid provoking spasticity during high-intensity exercises. Aim to strengthen weak muscles, not spastic muscle.

4. Neurodevelopmental Techniques (NDT)

These are hands on techniques aimed at facilitating normal movement patterns and inhibiting abnormal tone.

• Bobath concept: Focuses on key points of control to normalize tone and movement patterns.
• Facilitation of trunk and proximal control to improve distal function.

Note: NDT is particularly useful in stroke and cerebral palsy rehabilitation.

5. Proprioceptive Neuromuscular Facilitation (PNF)

PNF uses stretching and strengthening patterns to enhance motor control.

• Rhythmic initiation
• Repeated contractions
• Slow reversal techniques

Note: These techniques improve coordination and reduce spasticity through reciprocal inhibition.

6. Electrical Stimulation

Functional Electrical Stimulation (FES) can activate muscles with poor voluntary control.

• Stimulates antagonist muscles to reduce tone (e.g., dorsiflexors for foot drop).
• Enhances muscle strength and motor learning.
• Can be used during functional tasks like walking or grasping.

7. Dry Needling

• Interrupts abnormal muscle firing by affecting motor endplates.
• May cause a local twitch response that leads to muscle relaxation.
• Potential to modulate central sensitization and reduce overactive spinal reflexes.

8. Thermotherapy and Cryotherapy

• Heat helps in reducing muscle stiffness and increasing elasticity.
• Cold therapy (ice packs) can reduce muscle spindle activity and tone.

Note: Should be applied with care, especially in individuals with sensory deficits.

9. Vibration Therapy

• Localized or whole body vibration can temporarily reduce tone and increase flexibility.
• May enhance motor control when used before therapy sessions.
• Massage Gun and Matrix Rhythm Therapy is very effective modalities to reduce muscle Spasticity combined with stretching exercises for best result.

10. Constraint-Induced Movement Therapy (CIMT)

• Forces the use of the affected limb by restraining the unaffected one.
• Enhances motor control and reduces learned non-use.
• Particularly beneficial for upper limb spasticity post-stroke.

11. Cupping Therapy

• Reduction in muscle stiffness and pain, potentially decreasing abnormal muscle tone.
• Neuromodulation through stimulation of mechanoreceptors could help downregulate hyperactive reflex arcs.

12. Aquatic Therapy (Hydrotherapy)

• Warm water relaxes spastic muscles and provides buoyancy.
• Facilitates movement and balance training with reduced gravity.
• Excellent for patients with joint pain or significant stiffness.

13. Instrument-Assisted Soft Tissue Mobilization (IASTM)

IASTM involves using specially designed tools (e.g., Graston tools) to apply controlled mechanical pressure and friction to soft tissues.

• Neurophysiological effects: Stimulation of cutaneous and muscle mechanoreceptors may lead to modulation of spinal reflexes, potentially reducing tone.
• Myofascial release: Helps break up adhesions or restrictions that form due to immobility/spastic postures.
• Improved circulation: May reduce localized ischemia and improve muscle elasticity.
• Reduction in pain: Which can indirectly reduce tone since pain can heighten spastic responses.
• Stimulates proprioception: Which may enhance motor control and body awareness, helping reduce abnormal muscle activation.

Role of Assistive Devices

• Splints and orthoses: Prevent contractures and provide stability.
• Mobility aids: Canes, walkers, or wheelchairs depending on mobility level.
• Positioning devices: Cushions, wedges, and adjustable beds.

Note: Physiotherapists help in assessing, prescribing, and training the use of these devices.

Multidisciplinary Approach

Physiotherapy is most effective when integrated into a multidisciplinary team approach including:

• Medical Management: Botulinum toxin injections, oral antispasticity drugs (baclofen, tizanidine), intrathecal baclofen pumps.
• Occupational Therapy: Enhancing hand function, ADLs, and assistive technologies.
• Speech Therapy: In cases of orofacial spasticity affecting speech or swallowing.
• Orthopedic and Neurological Interventions: For deformity correction or surgical management.

Note: Baclofen is common use pharmacology therapy to reduce spasticity. Dosage use minimum 15 mg/day or maximum 80 mg/day.

The baclofen adult dosage can be administered following:

• 5 mg three times a day
• 10 mg three times a day
• 20 mg three times a day

Patient and Caregiver Education

Educating the patient and family is critical for long term success. Education includes:

• Importance of regular stretching and positioning
• Safe transfer techniques
• Use and care of orthoses
• Recognizing triggers that may worsen spasticity
• Encouraging active participation in therapy

Monitoring and Re-evaluation

Spasticity can change over time, regular reassessment is necessary to:

• Monitor treatment efficacy
• Adjust goals and therapy intensity
• Identify secondary complications early (e.g., contractures, pressure sores)

Note: Progress should be documented using standardized tools and functional outcomes.

FAQs

1) How many times a day is physiotherapy needed for spasticity treatment?

✅ Answer:

For most patients, 1 to 3 sessions per day is typical in an intensive rehab setting, especially during early recovery phases (e.g., post-stroke or spinal cord injury).

3 sessions per day is recommended. However, in outpatient or home settings, once a day or even 5-15 times a week may be sufficient depending on the severity of spasticity and individual goals.

2) Can physiotherapy cure spasticity?

✅ Answer:

Yes, Physiotherapy can "cure" spasticity, physiotherapy play vital role to reduce it and help manage its impact on function, pain, and mobility.

💡 Combined approaches (e.g., medications, Botox, orthotics, neuro rehab) often produce the best outcomes alongside physiotherapy.

3. How many days does it take to cure or improve spasticity with physiotherapy?

✅ Answer:

There is no fixed number of days, as it depends on:

The underlying condition (stroke, CP, MS, etc.)

• Severity and chronicity of spasticity
• Age and general health
• Patient adherence and rehab intensity

⏳ Short-term improvements (like reduced tone or better ROM) can often be seen within 2–4 weeks of consistent therapy.

⚙️ Long-term gains in function, posture, and muscle balance may take months of regular therapy.

More: Physiotherapy Management for CCU / ICU Patients