Spasticity Management: Physiotherapy

What is Spasticity?

Assessment Tools

Physiotherapy Interventions

1. Stretching

• Sustained/prolonged passive stretching is the cornerstone of PT for spasticity
• Reduces muscle stiffness, maintains range of motion (ROM), and may modulate reflex excitability
• Should be performed daily — brief stretches (30 seconds) have limited benefit; prolonged holds (20–30 minutes) show better outcomes
• Both manual stretching and self-stretching programmes are used

2. Positioning and Postural Management

• Correct positioning reduces abnormal reflex patterns (e.g., inhibitory positioning in stroke)
• 24-hour postural management programmes (supine, sitting, standing) are recommended, especially in severe spasticity
• Tilt-table standing has evidence for reducing lower limb spasticity in SCI and stroke

3. Splinting and Orthotics

• Static splints (resting hand splints, ankle-foot orthoses [AFOs]): maintain joint position and prevent contracture
• Dynamic/serial splinting: progressively increases ROM over time
• AFOs are particularly important in managing equinovarus foot deformity post-stroke
• Serial casting: used in fixed or developing contractures — evidence supports short-term ROM gains

4. Exercise and Active Movement

• Active movement and task-specific training may reduce spasticity via reciprocal inhibition and normalization of supraspinal drive
• Strengthening the antagonist muscle can help modulate spastic agonist tone
• Aquatic/hydrotherapy: warm water reduces muscle tone and allows easier active movement
• Constraint-Induced Movement Therapy (CIMT): forces use of the affected limb in upper limb spasticity post-stroke

5. Neurophysiological Approaches

• Bobath/Neurodevelopmental Treatment (NDT): uses handling techniques to inhibit spastic patterns and facilitate normal movement; widely used though evidence base is debated
• Proprioceptive Neuromuscular Facilitation (PNF): techniques such as contract-relax and hold-relax used to reduce tone and improve ROM

6. Electrical Stimulation

• Transcutaneous Electrical Nerve Stimulation (TENS): applied to spastic muscles or antagonists; evidence for short-term tone reduction
• Functional Electrical Stimulation (FES): stimulates antagonist muscles to reduce agonist spasticity through reciprocal inhibition; also improves motor function
• Neuromuscular Electrical Stimulation (NMES): evidence supports reduction in spasticity in upper limb post-stroke

7. Extracorporeal Shock Wave Therapy (ESWT)

• Evidence shows statistically significant improvement in MAS scores at short-term (1–2 weeks), mid-term (3–4 weeks), and long-term (up to 12 weeks) follow-up compared with sham or conventional physiotherapy
• However, the mean differences in MAS scores were not considered clinically significant (MD: −0.43 to −0.81), per evidence reviewed in stroke rehabilitation guidelines (Management of Stroke Rehabilitation, p. 73)
• May be used as an adjunct, particularly for focal upper and lower limb spasticity

8. Vibration Therapy

• Focal muscle vibration (FMV) and whole-body vibration (WBV): applied to spastic muscles, may reduce tonic vibration reflex and transiently decrease tone
• Short-term effects are documented; long-term benefit requires further study

9. Trigger Avoidance and Environmental Modification

• Identifying and removing spasticity triggers is critical:
  • Urinary tract infections
  • Pressure sores / skin breakdown
  • Constipation/fecal impaction
  • Pain, tight clothing, bladder distension
  • Posture and temperature changes
• Addressing triggers often results in immediate reduction in spasticity (Harrison's, p. 12626)

Integration with Pharmacological Management

Goal-Setting in Physiotherapy

• Improving ease of caregiving (passive ROM for hygiene, dressing)
• Reducing pain from spasms
• Improving gait pattern and walking speed
• Facilitating active use of limb
• Preventing contracture and skin complications

Summary: PT Intervention Pyramid

         ┌──────────────────────┐
         │  FES / ESWT / Vibra- │  Adjunct modalities
         │  tion / ESWT         │
         ├──────────────────────┤
         │  Splinting / Casting │  Prevent contracture
         ├──────────────────────┤
         │  Exercise / Active   │  Motor relearning
         │  Movement / CIMT     │
         ├──────────────────────┤
         │  Positioning /       │  24-hr management
         │  Postural mgmt       │
         ├──────────────────────┤
         │  Stretching          │  Daily cornerstone
         └──────────────────────┘