This document provides an overview of spasticity in cerebral palsy from a physiotherapist's perspective. It defines cerebral palsy and spasticity, describes the pathophysiology and clinical evaluation of spasticity, and outlines various management techniques including movement and handling, soft tissue lengthening, electrical stimulation, thermal treatments, advanced techniques like vestibular stimulation and hippotherapy. The goal of management is to reduce spasticity and its consequences through a stepped care approach beginning with more conservative methods.

1. MANAGING SPASTICITY IN
CEREBRAL PALSY
– A Physiotherapist’s perspective
A.S.Jebaraj Fletcher

2. Definition: Cerebral Palsy
Defined as a persistent but not unchanging disorder
of posture and movement, caused by damage to the
developing nervous system, before or during birth or
in the early months of infancy
(World commission for Cerebral Palsy,1988)

3. Definition: Spasticity
 Defined as a velocity dependent increase in
resistance to passive stretch of a muscle,
with exaggerated tendon reflexes
(Lance,1990; Parziale et al., 1993)

4. SPASTICITY IN CP
 Altered muscle tone is one of the earliest signs of
cerebral palsy (Binder H. Eng.GD 1989)
 The nature of the movement disorder in spastic cp
is a combination of hyper tonus, impaired postural
control and equilibrium reactions, persistent
primitive reflexes, upper extremity flexor and lower
extremity extensor synergies and associated
weakness (Winters et al1987)

5. Cont..
 Spasticity may coexist with other movement
disorders such as athetosis, chorea, or
dystonia
 These neurologic abnormalities may lead to
muscle shortening, joint capsule tightness
and osseous deformities (Vinken PJ & Bruyn)

6. Types of Spastic CP

7. PATHOPHYSIOLOGY OF
SPASTICITY

8. 1) EXAGGERATED SEGMENTAL REFLEXES
 Exact mechanism is uncertain
 The pathological basis of spasticity is the
abnormal enhancement of spinal stretch
reflexes
 They could be enhanced by increased
muscle spindle activity or increased
excitability of central synapses involved in
the reflex arc.

9. 2) EXAGGERATED SUPRA SEGMENTAL
REFLEXES
 Lesions at level of brain stem and above,
then supra segmental reflexes through the
spinal cord and brain stem became
hyperactive (e.g., tonic neck and vestibular
reflexes)

10. 3) ABNORMAL VOLUNTARY CONTROL
Imbalance in antagonist – agonist voluntary
Control
4) RELEASE REFLEX PHENOMENON
Hyperactive Excitatory neuronal firing

11. 5) DECORTICATE & DECEREBRATE RIGIDITY
 Decorticate: Upper limb flexed and lower limb
Extended
 Lesions above superior colliculus lead to
decorticate rigidity
 Decerebrate: Full Extension Upper and lower
limbs
 Lesions below superior colliculus may lead to
de cerebrate rigidity

12. Direct and Indirect Consequences of
Spasticity:
 Increased Tone
 Decreased Range of Motion
 Involuntary Movements
 Increased Autonomic Reflexes
 Exaggerated Reflexes
 Muscle Weakness
 Balance Problems

13. Cont…
 Abnormal Bone Stress
 Contracture
 Pain
 Sleep Dysfunction
 Patient Care (hygiene, transportation)
 Bowel and Bladder Dysfunction
 Respiratory Dysfunction

14. Cont…
 Communication, Speech, and Swallowing
Dysfunction
 Impaired Social, Psychological, and
Vocational Development

15. CLINICAL EVALUATION
OF SPASTICITY

16. 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

17. Oswestry Scale
 It is based on clinical observation and is
graded from 0 to 5( No, Mild,
Moderate,Severe, Very Severe and solely
severe)

18. 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

19. Adductor Tone Rating
0 = no increase in muscle tone
1 = increased tone, hips easily abducted 45
degrees by one person
2 = hips abducted 45 degrees by on person
with mild effort
3 = hips abducted 45 degrees by one person
with moderate effort
4 = two people are required to abduct the hips
45 degrees

20. Tardieu scale
 A scale depending upon the responses of
each muscle to both high and low speed After
ranging a joint slowly and then quickly, the
spasticity is assigned one of the following
scores

21. Cont.. Tardieu scale
0 No resistance throughout the course of the passive movement.
1 Slight resistance throughout the course of the passive
movement with no clear catch at a precise angle.
2 Clear catch at a precise angle, interrupting the passive
movement, followed by a release.
3 Fatiguable clonus, less than 10 seconds when maintaining the
pressure, appearing at a precise angle.
4 Unfatiguable clonus, more than 10 seconds when maintaining
the pressure, at a precise angle

22. Gait Analysis
 A test based on timed 10 m walks during
which step are counted has been shown to
be of use ( Collen et al, 1990)
 Parameters are Stride length, step length and
cadence can be measured
 Video recording( Still man, 1991)
 Photography

23. Others..
 ROM tests: Helps to find tonal changes and
severity of tightness
 EMG Studies… Pendular tests
 Tendon reflex
 Babinski Sign

24. MANAGEMENT FOR
SPASTICITY

25. Stepped Care
 Stepped Care for spasticity begins with conservative
methods that carry fewest side effects and progress
to aggressive treatments with the most side effects.
 First any remedial sources of nociception should be
eliminated. UTI, BOWEL IMPACTION, Pressure
sores, fractures, paronychia etc may increase
spasticity and hypertonus

26.  Second Patient education should be
provided. Education allows patients to
minimize adverse effects and to function
despite spasticity

28. MOVEMENT & HANDLING
The use of manual handling techniques is
one of the principle means available to the
neurological physiotherapist in the physical
management of spasticity

29. MAINTANENCE OF SOFT TISSUE
LENGTH
1) ACTIVE & PASSIVE ROM EXERCISES
 Without the full range of motion, peripheral changes cause
muscle imbalance and this compounds any central motor
dysfunction (Ada & Canning, 1990; Carr & Shephard,1995)
 This can be achieved by passive stretching of tight structures or
any active exercises
 Daily ROM & Static muscle stretch prevents contracture &
capsule tightness and can reduce stretch reflex hyperactivity and
improve motor control (Odeen I. Scand. J. Rehabil. Med, 1981)

30. 2) WEIGHT BEARING EXERCISES
 Standing is an excellent way of maintaining length in soft tissues
 Standing is effective in altering tone via. The vestibular system,
which is a major source of excitatory influence to extensor
muscles, whist reciprocally inhibiting flexor muscles (Markhern,
1987; Brown, 1994)
 It is another form of static stretch and it can reverse early
contracture and may reduce stretch reflex excitability (Richards CL
et al., Scand. J. Rehab. Med, 1991)
 Back slabs or Standing frames may be used to assist Standing
(Davies, 1994)

32. 3) POSITIONING
 Various body or head positions can be used minimize facilitation
that is contributing to hyper tonus and to maximize facilitation to
muscles that have reduced voluntary recruitment (Stejskal L, Am.
J. Physic. Med.. 1979)
 In Children with Cerebral Palsy, Lumbar extensor muscle activity
can be altered by adjusting head position and seat and back
angles of seating systems (Nwabhi OM et al., Dev. Med. Child.
Neurology 1983)

35. 4) MODULATION OF MUSCLE TONE
 Movement and alteration of the alignment of
particular parts of the body can influence
muscle tone in other areas
 For Example, the rotational element is
extremely important and is emphasized in the
approaches like PNF (Voss et al, 1985) & Bobath
(1990)

36. HANDLING TECHNIQUES
According to Mary Lynch,
For Spasticity,
 Speed: Slow
 Range: Full
 Repetition: Yes
 Voice: Quiet, Minimal
 Other: Longitudinal traction

37. SPLINTING

38.  Different types of splinting were described
and reviewed by Edwards & Charlton (1996)

39. Prophylactic Splinting:
 It is appropriate for patients who need more
than positioning and assisted movements to
maintain joint range (Conine et al., 1990)
 For example, prophylactic splinting can take the
form of Plaster boots for Achilles tendon or
plaster cylinders for limb to prevent tightness or
contractures

40. Corrective Splinting/ Serial Casting
 Corrective splinting is used to increase ROM in
the presence of contracture
 For example, Serial Casting for elbow
contracture which is helpful in slowly correcting
contracted joints

42. Dynamic Splinting
 Dynamic splinting aims to facilitate recovery
and assist stability for improved function
 For example, In children with CP, AFO’s with
tone reducing features have been used to
inhibit tonic postures of the foot (Hylton N.,
1990)

43. ELECTRICAL
STIMULATION

44. ES.. Cont..
 Vang et al, (1995) found electrical stimulation
resulted in a measurable reduction in
spasticity in upper limb
 O’Daniel & Krapfl, 1989 reported that the
use of ES increases the effectiveness of
stretching spastic muscles by reciprocal
inhibition
 ES at nearly all levels of the nervous system
relieves spasticity ( Stefanovska. A, 1991)

45. ES.. Cont..
 Shindo (1987), has reported a reduction of
spasticity by clinical evaluation, lasting 8 to
72 hours after each session of FES.
 Stefanovska (1988) measured decreased
tone and increased voluntary strength in
ankle plantarflexors after peroneal nerve
stimulation for 1 year

46. THERMAL TREATMENTS
Cryotherapy:
 Ice can be used as an adjunct to other treatment
methods or as a means of controlling tone in a
specific area
 Muscle cooling reduces phasic stretch reflex
activity and clonus (Hartviksen. K, 1962; Giebler KB, 1990)
 Slow Icing reduces spasticity (Roods Approach)
 Ice can be used with static stretch to overcome
hyperactive stretch reflexes (Giebler KB, 1990)

47. Apply warm water soaks to spastic muscles
or have child sit or lie in warm water

48. HYDROTHERAPY
 Pool therapy can be used a adjunct
management for cerebral palsied Children
 It helps in stretching large muscle groups & to
help movements in trunk.

49. BIO FEEDBACK
 The effectiveness of EMG biofeedback machines in
the treatment of increased muscle tone is yet
unproven (Moreland & Thompson, 1994)
 Bio feedback using either EMG or Joint position
sensors and providing auditory or Visual feedback,
has reduced spasticity in patients with preservation
of voluntary motor control (Neilson et al., J. Neurol. Neuro Surg.
Psychiatry, 1982)
 It can provide the patient with useful feedback
between therapy sessions

50. Advance techniques

51. VESTIBULAR STIMULATION
 All static positions and or movement patterns
facilitate the vestibular system which in turn has
effects over muscle tone (Anne G. Fisher et al..)
 Various researches proves vestibular stimulation as
a therapeutic modality in managing abnormalities of
muscle tone. (Weeks ZR, Am. J. Occupational therapy, 1979)
 Vestibular stimulation has more impact on the
development of Cerebral Palsied or Mentally
retarded Children than a normal, at risk or
premature infants (Ottenbacher KJ et al., Clinical Paediatrics, 1983)

52. In Standing
Swinging in Glider

53. Sitting
Using Net Hammock

54. Sitting/ Prone

55. Prone/supine
In a Barrel

56. Supine/Sit
In Scooter Board

57. Bouncing

58. HIPPOTHERAPY
 Hippotherapy is a physical, occupational and
speech therapy treatment strategy that utilizes
equine movement (The American hippo therapy Association)
 Benda W et al 2003, reported improvements in
muscle symmetry in Children with CP after equine
assisted therapy (The Journal of Complimentary
Medicines, 2003)
 Casady R et al reports positive outcome in 10 CP
Children after having hippotherapy

60. Suit therapy
 Suit therapy is often used as part of a
comprehensive program of intensive physiotherapy
of 5–7 hours a day for four weeks (UCP, 1999).
 This therapy is based on a suit originally designed
by the Russians for use by cosmonauts in space to
minimize the effects of weightlessness. The idea is
to move body parts against a resistance, thus
improving muscle strength.

61.  Through placement of the elastic cords, selected
muscle groups can be exercised as the patient
moves limbs; thus, suit therapy is a form of
controlled exercise against a resistance. It is also
claimed that the suit improves coordination.
 The suit consists of a cap, a vest, shorts, knee pads,
and shoes. An attached series of elastic cords
provides compression to the body’s joints and
resistance to muscles when movement occurs.

63. “..much study is a weariness of the
flesh.” Ecclesiastes 12:12
(Bible)
THANK YOU