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Spasticity

Condition: Spasticity

Brief Overview: According to Yale Medicine, “Spasticity is a condition in which muscles become stiff or tight, making movement difficult or less fluid. It is marked by an involuntary, velocity-dependent increase in muscle tone, which means that the affected muscles become more resistant to movement the faster that they are moved.”

Prevalence: According to Open Evidence, “The prevalence of spasticity depends on the underlying neurological condition, since spasticity is a manifestation of upper motor neuron syndrome rather than a standalone disease. Across major CNS disorders, reported prevalence is approximately: stroke ~25–43% (up to 80% by some estimates), spinal cord injury ~65–78%, multiple sclerosis ~60–90%, and ALS ~84%. There is no single general-population figure; spasticity is best quantified within each diagnostic group.”

Etiology: According to Open Evidence, “Spasticity results from an upper motor neuron (UMN) lesion in the brain or spinal cord that disrupts the normal balance between descending excitatory and inhibitory control over the spinal stretch reflex, producing hyperexcitability of the muscle stretch reflex. It is not a disease itself but one of the positive features of the UMN syndrome, and its cause is best understood as the loss of descending inhibition combined with maladaptive plastic reorganization at both supraspinal and spinal levels.”

Risk Factors: Per Yale Medicine, “Risk factors for spasticity include:

  • Stroke
  • Cerebral palsy
  • Multiple sclerosis
  • Spinal cord injury
  • TBI
  • Neurodegenerative diseases, conditions in which nerve cells in the brain or spinal cord are progressively damaged over time, such as amyotrophic lateral sclerosis (ALS), hereditary spastic paraparesis (also called hereditary spastic paraplegia, HSP), and adrenoleukodystrophy (ALD)
  • Brain damage from lack of oxygen
  • Infections of the brain or spinal cord
  • Tumors in the brain or spinal cord
  • PKU
  • Vitamin or mineral deficiencies (such as vitamin B12, vitamin E, or copper).”

Commonly Associated Conditions:

  • Stroke.
  • Multiple sclerosis.
  • Spinal cord injury.
  • Traumatic brain injury.
  • Anoxic brain injury.
  • Cerebral palsy.
  • Brain injury from other causes.
  • Spinal cord disease.
  • Certain neurodegenerative disorders.

Common Medications:

  • Baclofen
  • Tizanidine
  • Diazepam
  • Dantrolene sodium
  • Less commonly used: clonidine, gabapentin, cannabinoids, cyproheptadine

Common Labs, Imaging, and Tests:

  • EMG
  • Nerve conduction studies
  • MRI, CT
  • Labs: urinalysis/urine culture, CBC, CMP, renal function, creatine kinase

Common Treatments:

  • Medication (see above)
  • Surgery: Per UpToDate: “Surgical destructive procedures, rhizotomy, myelotomy, cordotomy, and cordectomy are reserved for refractory cases [23]. Surgical muscle or tendon releases can be used to treat established contractures.”
  • Neuromodulation: electrical stimulation
  • Botox
  • Physical, occupational, and speech therapy
  • Splinting, casting, bracing
  • Nerve blocks

Common Symptoms: According to Yale Medicine, “Symptoms of spasticity may include:

  • Muscle stiffness or tightness
  • Increased muscle tone
  • Muscle spasms, which may be painful or uncontrollable
  • Exaggerated reflexes
  • Abnormal posture
  • Involuntary crossing of the legs
  • Difficulty with walking or movement
  • Decreased mobility or impaired limb function
  • Muscle fatigue
  • Pain in affected muscles or joints
  • Repetitive, jerky motions
  • Difficulty with daily activities such as dressing, bathing, or eating
  • Speech difficulties (if muscles involved in speech are affected)
  • Problems with hygiene or comfort
  • Sleep disturbance.”

Physical Findings:

  • Increased muscle tone.
  • Increased resistance to rapid passive movement.
  • Hyperreflexia.
  • Clonus.
  • Muscle spasms.
  • Abnormal limb posture.
  • Reduced range of motion.
  • Contractures.
  • Weakness.
  • Abnormal gait.
  • Difficulty with transfers.
  • Toe walking or equinovarus positioning.
  • Flexed elbow, wrist, or fingers.

Potential Complications and Contraindications: According to Yale Medicine, “People with spasticity may be at increased risk for certain complications, including:

  • Contractures: Permanent tightening of muscles, tendons, or joints that limit movement and flexibility.
  • Joint deformities: Abnormal positioning or shape of joints due to prolonged muscle stiffness.
  • Pressure sores: Skin breakdown caused by difficulty moving and maintaining proper positioning.
  • Pain: Discomfort or aching in affected muscles or joints.
  • Difficulty with hygiene: Challenges in cleaning and caring for the body due to limited movement.
  • Impaired mobility: Trouble walking, moving, or performing daily activities.
  • Sleep disturbances: Difficulty sleeping due to muscle spasms or discomfort.
  • Bone fractures: Increased risk of broken bones due to falls or abnormal muscle forces.
  • Urinary tract infections: Increased risk due to difficulty with bladder function or hygiene.
  • Chronic constipation: Ongoing difficulty with bowel movements.
  • Frozen joints: Joints that become immobile due to long-term stiffness.
  • Increased risk of subluxation or dislocation: Partial dislocation (subluxation) or complete displacement of a joint.
  • Extra bone in soft tissues: Abnormal bone growth in muscles or soft tissues.
  • Skin breakdown: Damage to the skin from pressure or friction.
  • Depression or mood changes: Emotional effects due to loss of independence or chronic discomfort.”

General Health and Lifestyle Guidance:

  • Take medications exactly as prescribed.
  • Do not abruptly stop baclofen.
  • Attend scheduled neurology, rehabilitation, or spasticity-clinic appointments.
  • Attend intrathecal pump-refill appointments on schedule.
  • Perform stretching or range-of-motion exercises according to the physical or occupational therapist's recommendations.
  • Use prescribed splints, braces, walkers, canes, or other equipment as directed.
  • Change position regularly when mobility is limited.
  • Monitor skin for redness or pressure injuries.
  • Maintain bowel regularity according to the healthcare provider's plan.
  • Report urinary symptoms promptly.
  • Maintain adequate hydration according to individualized medical recommendations.
  • Use appropriate fall-prevention strategies.
  • Avoid excessive sedation from combinations of medications when possible; medication concerns should be reviewed by the healthcare provider.
  • Track changes in spasms, stiffness, pain, mobility, and function.

Suggested Questions to Ask Patients:

Spasticity Symptoms

  • Has your muscle stiffness or spasticity changed since our last call?
  • Is it improving, worsening, or staying about the same?
  • Which part of your body is affected?
  • Are you having muscle spasms?
  • Are the spasms painful?
  • How frequently are they happening?
  • Are they waking you at night?
  • Are your muscles becoming harder to move or stretch?
  • Are you noticing a new position of your arm, hand, leg, foot, or toes?

Functional Impact

  • Is spasticity affecting your ability to walk?
  • Are you having more difficulty transferring from bed to chair or standing up?
  • Is it interfering with dressing?
  • Is it making bathing or personal hygiene difficult?
  • Is it affecting your ability to use your hand?
  • Is it interfering with sleep?
  • Is it making caregiving more difficult?

Mobility and Falls

  • Have you fallen or almost fallen since our last call?
  • Has your walking changed?
  • Are you using your prescribed cane, walker, brace, or other device?
  • Do you feel safe transferring and walking?

Screening for Triggers

If spasticity has suddenly worsened, ask:

  • Do you have burning, pain, frequency, or urgency with urination?
  • Have you had difficulty urinating?
  • Any fever or chills?
  • Any cough or other signs of illness?
  • When was your last bowel movement?
  • Are you constipated?
  • Any new pain?
  • Any skin redness, sores, or pressure injuries?
  • Any new injury?
  • Is a brace, shoe, or piece of clothing rubbing or fitting too tightly?
  • Have you changed your positioning or activity recently?
  • Have any medications recently changed?

Medication Questions

  • What medication are you taking for spasticity?
  • Are you taking it exactly as prescribed?
  • Have you missed any doses?
  • Have you noticed dizziness, unusual sleepiness, weakness, confusion, or falls?
  • Have you recently started an antibiotic?
  • If taking tizanidine: have you recently been prescribed ciprofloxacin?
  • Do you feel your current medication is helping?

Intrathecal Baclofen Pump Questions

For patients with an implanted pump:

  • When was your last pump refill?
  • When is your next refill scheduled?
  • Have you missed or rescheduled a refill appointment?
  • Have you heard any pump alarms?
  • Has your spasticity suddenly become much worse?
  • Do you have new itching without a rash?
  • Any fever?
  • Any new confusion?
  • Any unusual sleepiness?
  • Any significant decrease in muscle tone?
  • Any difficulty breathing?

⚠️ Standard Neurology Symptom-Change Guidance

For any new neurologic symptom or change/worsening of an existing neurologic symptom, advise the patient or caregiver to contact the patient's neurologist to report the change.

Examples include new or worsening:

  • Spasticity.
  • Muscle spasms.
  • Weakness.
  • Numbness or tingling.
  • Balance or walking difficulty.
  • Falls.
  • Abnormal movements.
  • Pain associated with neurological symptoms.
  • Changes in bowel or bladder function associated with neurological symptoms.
  • Other neurological changes.

Care coordinators should not independently determine that a new or worsening neurological symptom is simply expected progression of the patient's chronic neurological condition.

If symptoms meet criteria for urgent or emergency evaluation, do not delay appropriate care while waiting for the neurologist to respond. Follow organizational escalation policies and direct the patient to the appropriate level of urgent or emergency evaluation.

⚠️ Telephone Escalation Guidance

Emergency — Follow 911/Emergency Protocol

Follow organizational emergency protocol for:

  • Sudden facial droop.
  • Sudden one-sided weakness or numbness.
  • Sudden speech difficulty.
  • Sudden severe balance or coordination difficulty.
  • New inability to walk.
  • New severe confusion or loss of consciousness.
  • Seizure.
  • Severe breathing difficulty.
  • Serious fall with head injury, loss of consciousness, significant bleeding, or inability to get up.
  • Rapid neurological deterioration.
  • New severe weakness or sensory loss accompanied by acute bowel/bladder dysfunction when spinal cord compression or another acute neurological process is possible.

Suspected Intrathecal Baclofen Withdrawal — Emergency

Emergency evaluation is warranted for a patient with an intrathecal baclofen pump who develops concerning symptoms such as:

  • Sudden severe rebound spasticity.
  • Increasing muscle rigidity.
  • Fever.
  • New altered mental status.
  • Severe itching without rash or abnormal sensations followed by rapidly worsening symptoms.
  • Signs suggesting pump or catheter failure.

Severe withdrawal can progress to rhabdomyolysis, organ failure, and death.

Suspected Intrathecal Baclofen Overdose — Emergency

Emergency evaluation is warranted for:

  • Marked or rapidly increasing drowsiness.
  • Severe decrease in muscle tone.
  • Respiratory depression.
  • Seizure.
  • Loss of consciousness.
  • Coma.

These are recognized manifestations of intrathecal baclofen overdose.

Prompt Provider/Neurology Follow-Up

Advise the patient to contact the neurologist for:

  • New or worsening spasticity.
  • Increasing frequency or severity of spasms.
  • New pain related to spasticity.
  • New difficulty walking or transferring.
  • Increased falls or near-falls.
  • New difficulty dressing, bathing, or completing ADLs.
  • New abnormal limb positioning.
  • Suspected contracture.
  • New skin problems related to positioning.
  • Treatment no longer providing adequate symptom control.
  • Significant medication adverse effects.
  • Sudden increase in spasticity associated with possible infection, constipation, urinary problems, pain, or another trigger.

If symptoms meet organizational criteria for urgent or emergency care, follow the escalation pathway rather than waiting for routine neurology follow-up.

Suggested Talking Points:

Explaining spasticity

"Spasticity happens when an injury or neurological condition affects the signals that normally control muscle tone. This can make muscles feel unusually tight or cause involuntary spasms."

Explaining symptom changes

"If your spasticity suddenly becomes worse, we want to know about it. Things like an infection, constipation, bladder problems, pain, or skin irritation can sometimes trigger an increase."

Discussing neurology follow-up

"Any new or noticeable change in your neurological symptoms should be reported to your neurologist so they can decide whether your treatment or evaluation needs to change."

Discussing treatment goals

"The goal isn't always to remove every bit of muscle tone. For some people, a certain amount of tone actually helps with standing or transfers. Treatment should focus on what improves your comfort and function."

Discussing baclofen

"Baclofen should be taken exactly as prescribed and shouldn't be stopped suddenly. If you're having side effects or want to change it, contact your healthcare provider first."

Discussing an intrathecal baclofen pump

"If you have a baclofen pump, keeping every refill appointment is very important. A sudden interruption in the medication can become a medical emergency."

Discussing therapy

"Stretching, positioning, braces, and therapy can be just as important as medication for managing spasticity."

Suggested SMART Goal Examples

1. Stretching
"Following my therapist's recommendations, I will complete my prescribed stretching routine at least ___ days per week for the next 4 weeks."

2. Medication Adherence
"I will take my spasticity medication exactly as prescribed each day for the next 30 days and report side effects or concerns to my healthcare provider."

3. Neurology Follow-Up
"I will schedule and attend my recommended neurology or spasticity-clinic appointment within the next ___ days."

4. Pump Refill Adherence
"For my intrathecal baclofen pump, I will attend my next scheduled refill appointment on ___ and contact the pump clinic immediately if I cannot attend."

5. Symptom Tracking
"I will record when my muscle spasms occur and what I was doing at the time at least 3 days per week for the next 4 weeks."

6. Trigger Tracking
"I will track my bowel movements, urinary symptoms, pain, and spasticity for the next 2 weeks to help identify possible triggers."

7. Skin Protection
"I or my caregiver will check the skin over areas affected by abnormal positioning every day for the next 30 days and report redness or sores."

8. Fall Prevention
"I will remove loose rugs and clutter from my main walking areas within the next 7 days."

9. Assistive Device Use
"I will use my prescribed cane/walker/brace as directed for the next 30 days."

10. Positioning
"Following my therapist's recommendations, I will reposition my affected arm or leg at least ___ times each day for the next 4 weeks."

11. Bowel Management
"I will follow my prescribed bowel-management plan for the next 30 days and report persistent constipation to my healthcare team."

12. Therapy Follow-Up
"I will complete my scheduled physical or occupational therapy visits over the next 4 weeks and practice my recommended home exercises."

Sources:

⚠️ Medical Disclaimer

This resource is provided for educational and informational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. The information presented is general in nature and may not apply to every individual or health situation.

Individuals should consult their physician or other qualified healthcare professional for personalized medical advice, diagnosis, or treatment recommendations related to their specific health conditions and should not begin any new exercise program or change their diet or medications without consulting their healthcare professional.

Call 911 if you are experiencing a medical emergency.