Spasticity is typically associated with inhibiting effective walking, restricting activities of daily living, and negatively influencing quality of life (Adams and Hicks 2005).
Conventional treatment approaches to reduce spasticity include both conservative therapeutic (e.g. stretching, positioning, bracing) and medical management (e.g. medications, Botulinum Toxin injections, surgery).
Recently, alternative approaches such as dry needling (DN) and electrical stimulation have been used to manage spasticity.
Clinical Symptoms of Spasticity
Clonus: muscle spasm involving repeated, often rhythmic contractions
Dystonia: unintentional sustained muscle contractions leading to abnormal postures
Contracture: a permanent tightening of the muscles/tendons/skin, and surrounding tissues that causes the joints to shorten and stiffen
Hypertonia: an abnormally high level of muscle tone or tension
Muscle spasms: a sudden, involuntary movement in one or more muscles
Development of spasticity after stroke and spinal cord injury occurs gradually over time scale of months; suggesting an adaptive change of the nervous system.
Spasticity is evident in physiotherapy through assessment of muscles, joints, mobility and balance. Spasticity will be experienced differently depending on modulation of muscle activity by central and peripheral influences.
Physiotherapy assessment can determine suitable treatment approach and apply several modalities mentioned below.
Electrical Stimulation
Electrical stimulation is a physiotherapy method used to reduce spasticity in individuals living with damage to the central nervous system.
Ongoing use of electrical stimulation may induce plasticity in spinal cord circuitries leading to a reduction in spasticity.
A 2019 systematic review of electrical stimulation to the lower limb in the spinal cord injury population reported (15 of 23 studies) 45-60% decrease in symptoms of lower limb spasticity.
The highest rating evidence supports combining electrical stimulation and botulinum toxin injection for reduction in spasticity of the upper limb.
Botulinum Toxin Injection (medical intervention only)
Botulinum Toxin (Botox) injections are a treatment option for spasticity that affects only a few muscles. It is a local injection of Botulinum toxin that blocks the chemical signal between nerves and muscles that makes the muscle contract or tighten.
Botox can reduce muscle pain, spasm and stiffness.
For people living with spasticity, relaxing the muscles means less stiffness in the muscles and improved range of motion.
A doctor may recommend Botox if spasticity is limited to only as few muscle groups like arms and legs.
The effects of Botox usually last three months. In many cases, physiotherapy and occupational therapy is recommended after injections to maximise the benefits i.e. improve walking patterns with greater range of motion and strengthen weak muscles from chronic contraction.
A period of rehabilitation (typically six weeks) and exercise following Botox can improve quality of life.
Dry Needling
Dry needling is a skilled intervention commonly used for the management of neuro-musculo-skeletal pain and movement impairments using a thin monofilament needle, which is manipulated into the target muscle by a trained practitioner to stimulate underlying neural, muscular and connective tissue.
Currently there is low to moderate evidence in support of using dry needling to reduce spasticity in adults with neurological disorders, particularly in those with a history of stroke.
The evidence indicates successful applications of dry needling include shoulder, arm and wrist flexor spasticity to increase range of motion; and into the calf to decrease spasticity and ultimately improve walking.
Secondary to the short-term effectiveness of dry needling on muscle spasticity, physiotherapy includes functional activities and training immediately after dry needling to maximise on the benefits of reduced spasticity.
Stretching
There is a role for stretching in the management of spasticity. Regular stretching can help improve flexibility, reduce muscle stiffness, and enhance overall mobility for individuals dealing with spasticity. Consulting physiotherapy for an individualised stretching routine, focusing on major muscle groups affected by spasticity is key for proper technique and consistency.
In clinical experience, dynamic stretches are more effective than static stretches for muscle tightness/tension from spasticity. Dynamic stretches are meant to get the body moving.
The stretches aren’t held for any length of time. Dynamic stretches include movement, such as walking lunges, trunk twists, or leg swings. Static stretches, on the other hand, are where muscles are extended and held for a period of time.
Rehabilitation
Addressing spasticity in gait/functional walking is complex because it includes interaction between:
Biomechanics and soft tissue changes;
Underlying weakness and postural control issues;
Learned strategies and reduced or altered experiences of movement
Identifying and treating all contributing factors is an important part of spasticity management. Lawes 1995 provides the concept that the central nervous system can rewire after injury; physiotherapy rehabilitation can influence the neuronal and non-neuronal elements of spasticity.
The Physiotherapists at Restore Function endeavour to use the most recent evidence-based treatments to maximise rehabilitation.
We also combine treatment modalities to gain maximum response.
If you have any other questions regarding spasticity management or if it may be beneficial for you, please contact us on (07) 3148 4417 to book an appointment with our Neurological Physiotherapist, Sabina!
References:
Adams, MM. Hicks AL. Spasticity after spinal cord injury. Spinal Cord (2005) 43, 577-586
Houston, D.J. Lee, J.W. Unger, J. Masani, K. Musselman, K.E. Functional Electrical Stimulation Plus Visual Feedback Balance Training for Standing Balance Performance Among Individuals With Incomplete Spinal Cord Injury: A Case Series. Frontiers in Neurology (2020) Vol 11, Article 680