This document discusses spasticity after stroke. It defines spasticity as an abnormal muscle tone with increased resistance to passive stretch. There are different types of spasticity including lead pipe, cogwheel, and clasp knife. The pathophysiology involves loss of inhibitory control in the spinal cord. Treatment options include rehabilitation therapy, oral medications, neurolysis, orthopedic procedures, and neurosurgery. Measurement tools include the Ashworth scale and pain scales. The goals of treatment are to improve function and mobility while decreasing pain.

1. Spasticity
After Stroke
Adeagbo, Caleb A
B.Physiotherapy (Lagos)
Department of Physiotherapy,
National Hospital,
Abuja
8/20/2012 1

2. Outline
 Introduction
 Definitions  Measurement
 Types of Tools
spasticity  Treatment
 Pathophysiology  Conclusion
 Other Types of  References
Hypertonicity
 Advantages of
Spasticity
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3. Introduction
 Stroke is the leading cause of
morbidity and mortality
(Lundstrom et al, 2008; Urban et
al, 2012).
 Spasticity is a common
complication of stroke that lead
to impaired gait characteristics in
the upper and lower extremities
(Karadag-Saygi et al, 2010).
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4. Introduction cont
 Optimum management of
spasticity is dependent on an
understanding of its underlying
physiology, an awareness of its
natural history, an appreciation of
the impact on the patient and a
comprehensive approach to
minimizing that impact which is
both multidisciplinary and
consistent over time (Thompson
et al, 2012).
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5. Definitions
 Stroke is an acute/sudden
focal/global disturbance of the
cerebral function with symptoms
lasting for more than 24hours or
sometimes leading to death with
no other cause than vascular
origin.
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6. Definitions cont
 Spasticity (meaning to draw or tug)
 Spasticity is abnormal muscle tone
recognized clinically as resistance
to passive muscle stretch which
increases with velocity of stretch. It
is defined as 'a motor disorder
characterized by velocity dependent
increase in tonic stretch reflexes
with exaggerated tendon jerks,
resulting from hyperexcitability of
the stretch reflex
8/20/2012 6

7. Types of spasticity
 LEAD PIPE: presents as a uniform
resistance to movement throughout
the range of movement.
 COGWHEEL: presents as an
intermittent on/off resistance
throughout the range of movement,
making the movements jerky.
 CLASP KNIFE: presents as increase in
extensors of a joint when its passively
flexed given way suddenly on exertion
of further pressure.
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8. Pathophysiology
 The pathophysiologic basis of
spasticity is incompletely
understood.
 Spasticity is loss of inhibitory
control over the gamma motor
neuron
 This inhibitory influence is in turn
controlled by descending and
peripheral inputs.
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9. Pathophysiology contd
 Lack of descending control over
spinal cord interneuronal circuits
results in a decrease in the
effectiveness of spinal inhibitory
circuits such as those mediating
reciprocal, presynaptic, and
recurrent inhibition.
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10. Pathophysiology contd
 The changes in muscle tone
probably result from
 alterations in the balance of
inputs from reticulospinal and
other descending pathways to the
motor and interneuronal circuits
of the spinal cord
 the absence of an intact
corticospinal system.
8/20/2012 10

11. Pathophysiology contd
 Loss of descending tonic or
phasic excitatory and inhibitory
inputs to the spinal motor
apparatus,
 alterations in the segmental
balance of excitatory and
inhibitory control
 denervation supersensitivity
 neuronal sprouting
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12. Other Types of Hypertonicity
 RIGIDITY - Involuntary, bidirectional,
non–velocity-dependent resistance
to movement
 CLONUS - Self-sustaining, oscillating
movements secondary to
hypertonicity
 DYSTONIA - Involuntary, sustained
contractions resulting in twisting,
abnormal postures
 ATHETOID - Involuntary, irregular,
confluent writhing movements
8/20/2012 12

13. Other Types of
Hypertonicity contd
 CHOREA - Involuntary, abrupt,
rapid, irregular, and unsustained
movements
 BALLISMS - Involuntary flinging
movements of the limbs or body
 TREMOR - Involuntary, rhythmic,
repetitive oscillations that are not
self-sustaining
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14. Advantages of Spasticity
 Maintenance of Muscle tone or
Muscle Bulk
 Tone Effect on Mobility
 Tone effect on ADL's
 Improved Circulation
 Prevention of DVT
 May assist with postural control
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15. Measurement Tools
 Ashworth scale
 Modified Ashworth scale:
 Spasm frequency
 Reflex scale
 Pain scale
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16. Ashworth scale
 0 – no increase in tone
 1 – slight increase in tone given a
catch
 2 – more marked increase in tone
 3 – considerable increase in tone
PM difficult
 4 – limb rigid in flexion and
extension (Ashworth scale, 1964)
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17. Modified Ashworth Scale
0 = no increase in muscle tone
1 = slight increase in muscle tone
(catch or min resistance at end
range)
1 + = slight increase in muscle
resistance throughout the range.
2 = moderate increase in muscle tone
throughout ROM, PROM is easy
3 = marked increase in muscle tone
throughout ROM, PROM is difficult
4 = marked increase in muscle tone,
affected part is rigid (Bohannon &
Smith 1987)
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18. Spasm Frequency
Spasm Frequency Scale: How many
spasms in the last 24 hours in the
affected extremity?
0 = no spasms
1 = 1 / day
2 = 1-5/ day
3 = 5-9 / day
4 = >10/day (Penn et al, 1989)
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19. Pain scale
 Numerical rating pain intensity
scale: a verbal analogue scale.
Scale 0 – 10 (Kremer et al, 1981).
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20. Treatment Goals
 Improve functional ability,
Quality of Life and Mobility
 Decrease pain associated with
spasticity
 Prevent or decrease incidence
of contractures
 Ease of care are possible
 Decrease Cost of Care
 Facilitate hygiene
 Ease rehabilitation procedures
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21. 8/20/2012 21

22. Remove noxious stimuli
 Identify the “triggering” stimulus
 Eliminate the factors that
increase sensory input to the
central nervous system
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23. Rehabilitation therapy
 Positioning  EMG biofeedback
 Joint mobilization  Electrical
 Stretching stimulation
 Strengthening  Orthotics
Exercises  Splinting-
 Modalities: static/dynamic
Cryotherapy,  Casting:
Hydrotherapy, including serial
Thermotherapy casting
 Soft tissue
manipulation
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24. Oral medications
 Lioresal: Baclofen
 Benzodiazepams: Diazepam
(Valium)
 Dantrolene Sodium
 Tizanidine
 Gabapentin (Neurontin)
8/20/2012 24

25. Neurolysis
Botulinum toxin Injections
Phenol Injections
8/20/2012 25

26. Orthopedic approach
 Tenotomy
 Tendon lengthening
 Myotomy
 Tendon transfers
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27. Neurosurgical approach
 Neurectomy
 Myelotomy/Cordectomy/
Chordotomy
 Rhizotomy
 Selective Dorsal Rhizotomy
 Implantable dural electric
stimulator
 Intrathecal Baclofen Pump
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28. Conclusions
 While spasticity management can
be difficult, it may also improve
patient’s quality of life
 Spasticity is not necessarily the
enemy, but is part of a pattern of
abnormal motor control
 The choice of treatment depends
on pattern of involvement
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29. References
 Akosile CO, Fabunmi AA (2011).
Pathophysiology, Functional Implications and
Management of Spasticity in Stroke – A Review.
AJPARS 3(1):6-12
 Ashworth B (1964). Preliminary trial of
crisoprodol in multiple sclerosis. The
practitioners 192:540-2
 Bohannon RW, Smith MB (1987). Interrater
reliability of a modified Ashworth scale of muscle
spasticity. PhysTher 67: 206-7.
8/20/2012 29

30. References cont
 Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan
N, Ofluoglu D (2010). The role of Kinesiotaping
combined with Botulinum Toxin to reduce
plantar flexors spasticity after stroke. Top Stroke
Rehabil; 17(4):318–322
 Lundstromac E, Terentb A, Borgc J (2008).
Prevalence of disabling spasticity 1 year after
first-ever stroke. European Journal of Neurology
15: 533–539
8/20/2012 30

31. References cont
 Urban PP, Wolf T, Uebele M, Marx JJ,
Vogt T, Stoeter P, Bauermann T, Weibrich
C, Vucurevic GD, Schneider A, Wissel J
(2010). Occurence and Clinical Predictors
of Spasticity after Ischemic Stroke. Stroke
41:2016-2020
 Thompson AJ, Jarrett L, Lockley L,
Marsden J, Stevenson VL (2012). Clinical
management of spasticity. Available @
www.jnnp.bmj.com Retrieved on August
06 2012, Published by group.bmj.com
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32. Thank you
Questions
&
contributions
8/20/2012 32