Spasticity Clinical Presentation

Updated: Mar 01, 2018
  • Author: Krupa Pandey, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Presentation

History

Assessment of spasticity includes identifying which muscles or muscle groups are overactive and determining the effect of spasticity on all aspects of patient function, including mobility, employment, and activities of daily living (ADLs). Physical and occupational therapists are vital members of the team called in to assess and treat the patient with spasticity.

Identification of spastic muscles can be a complex task, since many muscles may cross the joint involved, and not all muscles with the potential to cause deformity will be spastic. Electromyography and diagnostic blocks with local anesthetics can be used to test hypotheses regarding the deformity and provide information for long-term denervation treatments.

Studies have been made of assessment tools, such as the Lateral Step Up test for adolescents with cerebral palsy and the Modified Ashworth Scale for the assessment of upper-limb muscles. [14, 15]

In an infant, spasticity is generally manifested by increased muscle tone. Abnormalities of muscle tone are most readily documented by assessing tone of supination and pronation of the upper extremities and dorsiflexion and plantar flexion of the lower extremities. In newborns or small infants, spasticity of the lower extremities becomes evident when the examiner suspends the infant by the feet, upside down, and each lower extremity is released in turn. In spasticity, the released lower extremity remains “hung up.”

Spasticity can wax and wane, appearing at variable times relative to the date of injury or disease onset. Involved muscles may demonstrate spontaneous or elicited clonus, as well as increased deep tendon reflexes.

Spasticity can occur in any muscle, but common patterns exist, especially when associated with an upper motor neuron injury. Understanding these patterns helps to predict a patient’s future functional status, as well as cosmetic or orthopedic deformities that may occur, aiding in treatment decisions.

Cerebral palsy

Children with cerebral palsy tend to exhibit one of the following spasticity patterns:

  • Diplegic pattern: Scissoring, crouching, and toe walking

  • Quadriplegic pattern: Diplegic patterning in addition to flexion of the elbow, flexion of the wrist and fingers, adduction of the thumb, and internal rotation, pronation, or adduction of the arms

  • Hemiplegic pattern: Plantar flexion of the ankle, flexion of the knee, adduction of the hip, flexion of the wrist and finger, adduction of the thumb, and flexion, internal rotation, pronation, or adduction of the arms

Equinovarus positioning of the foot is a common posture in the lower extremity, and it can be a major limitation to functional transfers or gait as a child grows older.

While some muscles may maintain underlying volitional strength, others may not. Muscles crossing 2 joints most commonly are involved in contracture development. Spasticity often is worse when the patient awakens or at the end of a tiring day.

Spinal cord injury/multiple sclerosis

Spasticity in patients with incomplete or complete spinal cord injury (SCI) or multiple sclerosis (MS) can vary greatly in location and degree. Spasticity often is worse at night or with fatigue. Chronic compression of nerves secondary to spasticity may lead to problems such as carpal tunnel syndrome.

Spasticity of the upper extremities

The following patterns often are seen in patients with cerebral palsy, stroke, or traumatic brain injury (TBI):

  • Adduction and internal rotation of the shoulder

  • Flexion of the elbow and wrist

  • Pronation of the forearm

  • Flexion of the fingers and adduction of the thumb

Muscles that often contribute to spastic adduction/internal rotation dysfunction of the shoulder include the latissimus dorsi, the teres major, the clavicular and sternal heads of the pectoralis major, and the subscapularis. In the flexed elbow, the brachioradialis is spastic more often than the biceps and brachialis. In the spastic flexed wrist, carpal tunnel symptoms may develop. Flexion with radial deviation implicates flexor carpi radialis.

In the clenched fist, if the proximal interphalangeal (PIP) joints flex while the distal interphalangeal (DIP) joints remain extended, spasticity of the flexor digitorum superficialis (FDS), rather than the flexor digitorum profundus (FDP), may be suspected. A combined metacarpophalangeal flexion and PIP extension also may occur. A patient may be spastic in only 1 or 2 muscle slips of either FDP or FDS. Neurolysis with botulinum toxin is beneficial for spasticity of the intrinsic hand muscles because of their size and accessibility.

Spasticity of the lower extremities

Spastic deformities of the lower limbs affect ambulation, bed positioning, sitting, chair level activities, transfers, and standing up. Equinovarus, the most common pathologic posture seen in the lower extremity, is a key deformity that can prevent even limited functional ambulation or unassisted transfers.

The following flexor patterns often are seen in patients with cerebral palsy, MS, or TBI or who have suffered a stroke:

  • Hip adduction and flexion

  • Knee flexion

  • Ankle plantar flexion or equinovarus positioning

The following muscles typically are involved in the flexor patterns and are targeted for treatment:

  • Adductor magnus

  • Iliopsoas

  • Hamstrings (medial more often than lateral)

  • Tibialis posterior

  • Soleus

  • Gastrocnemius

The following extensor patterns often are seen in patients following TBI:

  • Knee extension or flexion

  • Equinus and/or valgus ankle

  • Great toe dorsiflexion or excessive toe flexion

The following muscles typically are involved in the extensor patterns and are targeted for treatment:

  • Quadriceps femoris

  • Medial hamstrings

  • Gastrocnemius

  • Tibialis posterior

  • Extensor hallucis longus

  • Toe flexors

  • Peroneus longus

Next:

Physical Examination

In patients with new-onset spasticity, a thorough history and physical examination, as well as examination using electromyography, a determination of nerve conduction velocities, or imaging studies of the head, neck, and spine may be useful in eliminating treatable causes of increased tone. [2]

In patients with a previous neurologic insult, a thorough history and physical examination is necessary to rule out any factors that can exacerbate spasticity (eg, medication changes, noxious stimuli, increased intracranial pressure).

Physical and occupational therapy evaluation

Physical and occupational therapists play important roles in the management of patients with spasticity. Patients who are candidates for treatment with botulinum toxin injections need baseline evaluations that include areas beyond the muscles being injected, since reduction of local spasticity may lead to more widespread functional changes. Assessments should include evaluation of tone, mobility, strength, balance, endurance, and the need, if any, for assistive devices. A videotape of the baseline examination is of considerable help.

Standardized assessments for motor control that can be tested for validity and reliability have yet to be devised for use in the patient with neurologic deficits. Because the assessment measures themselves may influence tone, running the testing series in the same order each time is important. Muscle tone should be assessed before any functional assessments. The upper extremity is evaluated in the sitting position, and the shoulder rotators, pronators, supinators, wrist flexors/extensors, and finger flexors are assessed with the elbow in 90° of flexion. Other muscle groups are assessed with the elbow extended.

The patient is placed in the supine position for assessment of all muscle groups of the lower extremity except the knee flexors. The patient is then moved to the prone position for assessment of the right, and then left, knee flexors. The Modified Ashworth Scale assessment should be followed by the Bilateral Adductor Tone measure, if required. Goniometric measurements for active and passive ranges of movement follow muscle tone assessment.

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