Patel_US_Neuro 16/02/2010 10:02 Page 47

Brain Trauma Stroke

Early Diagnosis of Post-stroke Spasticity and Treatment Options

Atul T Patel, MD, MHSA

Medical Director, The Rehabilitation Institute of Kansas City, and Physiatrist, Kansas City Bone and Joint Clinic

Abstract
Stroke is a leading cause of long-term disability. As a consequence of stroke and associated upper motor neuron (UMN) syndrome, stroke survivors
are often left with muscle overactivity, including spasticity. Post-stroke spasticity often has a negative impact on functional activities and daily living,
and is frequently accompanied by pain and abnormal limb postures and contractures. Spasticity can be beneficial occasionally but usually is
detrimental to a patient’s function. Several factors need to be considered in the evaluation and management of these patients. This article discusses
the various instruments and methods of assessing patients with post-stroke spasticity, as well as the spectrum of current treatment options,
including the potential side effects.

Keywords
Stroke, post-stroke, spasticity, antispasticity medications, botulinum toxin, baclofen, tizanidine, upper motor neuron

Disclosure: Atul T Patel, MD, MHSA, is a speaker for Allergan and has participated in clinical trials for this company in the past.
Received: January 4, 2010 Accepted: January 29, 2010
Correspondence: Atul T Patel, MD, MHSA, Kansas City Bone and Joint Clinic, 10701 Nall Avenue, Suite 200, Overland Park, KS 66211. E: [email protected]

Stroke is a leading cause of long-term disability. Approximately 610,000 The effects of PSS can interfere with daily activities that include tasks
people suffer a new stroke each year in the US,1 often resulting in such as walking, picking up objects, washing, dressing, and sexual
disability due to motor impairment and consequences of the upper activity. 12 Indeed, a recent patient/care-giver survey reported that PSS
motor neuron (UMN) syndrome. UMN syndrome results in both positive may also be a hindrance to effective post-stroke rehabilitation
and negative motor effects. The positive features include muscle therapy. 13 In addition, the presence of PSS can negatively affect
overactivity including spasticity, clonus, flexor/extensor spasm, and mood, self-image, and motivation, which in turn is a likely contributor
hyper-reflexia. Negative features consist of weakness, loss of dexterity, to a post-stroke patient’s psychosocial burden and depression. 12,14
and decreased co-ordination.2 The combination of these effects often Spasticity can also have an impact on the care-giver burden in
leads to complications of contractures at the involved joints. patients who are dependent on others for their basic activities of daily
living. 15 Figures 1–4 show a few examples of common deformities
Spasticity is characterized by a velocity-dependent increase in resistance due to PSS.
to muscle stretch associated with attempts to flex or extend a limb.3 It is
a leading cause of morbidity and long-term post-stroke disability. Methods of Spasticity Assessment
Observational cohort studies have estimated that post-stroke spasticity Assessment is critical in developing a treatment plan and gauging the
(PSS) may affect 17–43% of the 6.5 million American stroke survivors.4,5–9 progress and outcome of the treatment. On initial evaluation it is
These patients often present with characteristic antigravity postural necessary to confirm that the patient has a UMN syndrome.
patterns with shoulder adduction, elbow and wrist flexion, hip adduction, The degree of spasticity may change according to the position
knee extension, ankle plantar flexion, and foot inversion. Symptoms vary and the activity being performed with the affected limb. 6 The increase
in localization and severity and may include hypertonicity (increased in tone may be related to spasticity or intrinsic changes of the
muscle tone), clonus (a series of rapid muscle contractions), exaggerated muscle. 16,17 There also is no consensus as to the number of patients
deep tendon reflexes, muscle spasms, scissoring (involuntary crossing of developing spasticity post-stroke or the timing post-stroke. One
the legs), and fixed joints. The degree of spasticity may vary from mild study reported that 39% of patients with first-ever stroke are
muscle stiffness to severe, painful, and uncontrollable muscle spasms.10 spastic after 12 months. 18 Another more recent study found that
Spasticity may be associated with disabling pain, and over time may lead spasticity was present in 19% of patients three months post-first
to permanent contractures that may eventually result in posture and joint ever stroke. 6 Physical assessment is the single most important
deformities. Therefore, early intervention for spasticity may be critical for method in evaluating spasticity. 19 This includes observation of patient
the preservation of muscle reactivity.11 movements and gait in addition to a detailed neuromusculoskeletal

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Brain Trauma Stroke

Figure 1: Shoulder Adducted, Elbow and Wrist Flexed, Global measures of pain, patient satisfaction with treatment, and
and Forearm Pronated overall improvement in spasticity as rated by the physician, patient,
or care-giver may also be utilized. 27 Goniometry is often used to
measure joint flexibility (range of motion) and electrophysiological
measurements may be useful for identifying electrical activity in
agonist and antagonist muscles during movement. No single
instrument is ideal to assess all aspects of spasticity, hence the
choice of scales should be based on the change expected and
treatment goals. While the validity and reliability of spasticity
measures are important, in the clinic practical variables such as
clinical relevance, ability to capture patient functioning, and time
needed to complete the assessment are also important. 28 Figure 5
shows a summary of the different assessment methods.

Spasticity Treatment
There are a variety of physical and pharmacological therapeutic
options for treating PSS. Therapy typically focuses on the reduction of
excessive muscle tone, and is designed to provide patients with
improved range of movement and an enhanced ability to perform
Figure 2: Clenched Fist activities of daily living. In general, spasticity treatment regimens are
multidisciplinary and include physical and occupational therapy,
systemic central nervous system neurotransmitter agonists or
antagonists, surgical intervention, and chemodenervation. 24,27,29

Spasticity is not always detrimental and it is important to determine

whether it is useful for an individual, for example where the spasticity
provides support while the patient is standing or walking. 30 Treating
the spasticity in this instance may unmask underlying weakness,
making it difficult to stand or walk.

Once the decision has been made to treat spasticity, there may be
advantages to treating sooner than later. There is some consensus
that early treatment may avoid secondary maladaptation and
functional impairment. 31 Specific and function-oriented treatment
goals need to be established with the patient and care-giver prior to
spasticity treatment. 20 Spasticity is only one of a constellation of
symptoms observed in individuals post-stroke, and a multidisciplinary
examination of the affected limbs. Particular attention is paid to the team approach seems to be most effective. 31,32
presence of long-tract signs, spastic catch, clonus, or clasp-knife
phenomenon. The assessment should also include observing patients Treatment Options
during functional activities (such as putting on a shirt) in order to A number of conditions can exacerbate spasticity, and these need to be
evaluate dynamic muscle tone, which does not necessarily correlate ruled out or managed before initiating other treatments. These include
with static muscle tone. 20 conditions such as a urinary tract infection, stool impaction, skin
breakdown, ingrown toenail, fracture, heterotopic ossification, or any
Several rating instruments are available to evaluate various noxious stimulation.33 The next line of treatment involves physical therapy.
aspects of spasticity. Muscle tone can be measured using the
Ashworth, modified Ashworth, and Tardieu scales. 21,22 These scales Physical Therapies
can be easily applied in the clinic setting to assess resistance to Physical and occupational therapy include stretching and
passive stretch or movement across a particular joint. In the upper strengthening of the appropriate muscles, working on posture and
limb, standardized positioning can make this evaluation more positioning, and facilitation of movement to reduce the effect of
reliable. Instruments such as the Functional Independence Measure spasticity. 34 Patients may require the use of orthotics to maintain
(FIM) 23 and the Disability Assessment Scale 24 can be used to evaluate muscle length and range at the affected joints. Modalities such as
the effects of spasticity on outcomes, such as the ability to dress heat, ice, and electrical stimulation can help in different ways to
oneself or complete personal-hygiene-related tasks. In cases where temporarily reduce tone. 30 Both physical and occupational therapy are
meaningful voluntary activity is retained, it can be measured with involved in maximizing function with a focus on mobility and activities
tests such as the Fugl-Meyer 25 and the Nine Hole Peg Test. 26 of daily living. 35

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Early Diagnosis of Post-stroke Spasticity and Treatment Options

Medical Therapies Figure 3: Flexed Elbow

Medical therapies require the consideration of several factors before
selecting a particular treatment. These are the patient’s pattern of
spasticity, the efficacy of the treatment, potential adverse effects,
the reversibility of the treatment, and accessibility of treatment. 36,37
Spasticity can be classified as either focal or generalized to help
determine which treatment may be more effective. It is also
important to determine whether the treatment will be for a brief
period or a longer period of time. Many post-stroke individuals have
cognitive deficits and any additional impairment with the treatment
for spasticity may be counterproductive; hence, in this situation a
more focal type of treatment may be more appropriate. Several types
of medical therapy are discussed in the following sections.

Oral Medications
Several different oral medications have been used for the treatment
of spasticity. The most commonly used are baclofen, diazepam,
tizanidine, and dantrolene. All but dantrolene act centrally. They have
different mechanisms of action and side effects (see Table 1).

Intrathecal Baclofen
Patients who benefit from the effects of oral baclofen but cannot
tolerate the side effects or are not optimally treated with the highest
oral dose may benefit from intrathecal baclofen. The medication is Figure 4: Clenched Fist and Equinovarus Foot Deformity
delivered into the subarachnoid space of the spinal cord through an
implanted pump and catheter. The drug level is relatively constant
and well tolerated. 36 Complications related to the pump include
infection, catheter dislocation or kinking, impaired wound healing,
and pump malfunction. Adverse reactions can include headaches,
nausea, vomiting, excessive weakness, and transient urinary
retention. Despite this, treatment can be quite effective in patients
with intractable spastic hemiplegia. It is more effective in treating
lower-limb spasticity. 39

Chemodenervation with Alcohol or Phenol

These treatments are administered directly into the muscle near a
motor point or peri-neural region. 33 These neurolytic agents cause
tissue destruction that interferes with nerve conduction. The effect is
usually immediate and can last from a few weeks to years. The
drawback is that it results in tissue destruction and associated
complications, development of chronic dysesthesia, especially with
injury to sensory nerves, and limitation to the treated areas due to the
lack of motor nerve selectivity. Inaccurate medication delivery can
result in unwanted weakness. 40

Chemodenervation with Botulinum Toxin

Botulinum toxin is administered intramuscularly and inhibits muscle
contraction by blocking acetylcholine release at the neuromuscular
junction. It is a focal treatment and reduces the tone in hyperactive
muscles, resulting in a functional response lasting for about three
months. 12 As the effect wears off, repeat treatments may be required.
The drawbacks of this treatment are that injection into the wrong into units of one another since there is no universally applicable
muscles or excessive response can result in loss of temporary safe dose conversion ratio. 48 Proper delivery of the agents in
function, that there is potential for antibody development, and that chemodenervation is crucial to optimize outcomes. Several different
repeated injections may be required. 41–47 The dosing units of the techniques are utilized. Phenol injections are performed with
various botulinum toxins cannot be directly compared or converted electrical stimulation to identify the nerve using small currents of <1

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Brain Trauma Stroke

Figure 5: Summary of Spasticity Assessment Methods muscles that mimic the targeted muscle. A newer technique with some
promise of more accurate muscle identification is musculoskeletal
ultrasound. It can help sort out specific portions of target muscles and
Activity- avoid vital structures such as blood vessels and nerves.49
related or
functional
measures Surgical Treatments
Selective dorsal rhizotomy involves the transection of selected posterior
Range of
Measures rootlets in the lumbosacral region of the spinal cord. This interrupts
motion
of muscle tone
measures the sensory input for stretch reflexes, resulting in reduced spasticity.30
Complications of this procedure include infections, altered sensory
responses, transient bladder incontinence, and adverse muscle atrophy.50

Methods of
spasticity Orthopaedic procedures to help patients with joint deformities and
assessment issues of positioning secondary to increased tone include tendon
Electro-
Measures
of pain
physiological lengthening, tendon transfer, osteotomy, and joint arthrodesis. 51
methods
These types of procedure can also help with pain reduction,
prevention of further joint deformity, and increased range of joint
motion. The potential risks include unintended weakening of the
Global agonist muscle, complications of infection, and improper placement
improvement of tendon attachment.
Quality of
or treatment
life measures
satisfication
measures
Conclusions
Spasticity is a common problem in post-stroke patients and can have a
significant impact on function. Proper assessment of the patient with
Table 1: Oral Medications for the Treatment of Spasticity
spasticity is crucial for treatment guidance and monitoring of the
outcomes. Hence, clinicians should be aware of the common
Medication Mechanism of Action and Side Effects
assessment instruments. Many different medical therapies are available
Baclofen Baclofen is a selective GABA-B agonist providing a net
inhibitory effect and reducing spasticity by decreasing the for spasticity and its sequelae. Oral medications and intrathecal
activity of alpha motor neurons. Significant side effects baclofen are reversible in that the drugs can be discontinued.
include central depression and lower seizure threshold. Additionally, these drugs are most useful for general spasticity given
It can also cause drowsiness and lethargy.36 that they are distributed systemically.
Diazepam Diazepam reduces spasticity by its inhibitory effects on
GABA-B receptors in the central neurons. Its use is limited Chemodenervation agents have reversible actions and are most useful
by central side effects such as sedation, fatigue, and for focal or multifocal spasticity. These agents include alcohol, phenol,
reduced cognitive function.36
and botulinum toxin. Physicians should be aware of localizing techniques
Tizanidine Tizanidine is a central alpha-2 adrenergic agonist and acts
such as electromyography, motor point or nerve stimulation, and
centrally to prevent pre-synaptic excitation of alpha motor
ultrasound to accurately deliver the neurolytic agents.
neurons. Side effects include drowsiness, dizziness, dry
mouth, and sedation.36
Dantrolene Dantrolene sodium acts peripherally by reducing the release Surgeries for spasticity and its orthopaedic sequelae are generally
sodium of calcium from the sarcoplasmic reticulum in skeletal irreversible. Selective dorsal rhizotomy is most often used for generalized
muscles. This results in the reduction of muscle contraction or diffuse spasticity of the lower limbs. Local surgeries such as tendon
force and phasic stretch reflexes.38 It does not have central lengthening are often used to improve orthopaedic deformities.
side effects, but other side effects include generalized
weakness and hepatotoxicity. Like all medical therapies, the treatments described here have the
GABA = gamma-aminobutyric acid. potential for adverse effects. When selecting a medical therapy,
the adverse effects of each treatment must be considered along with
milliamp that produce contractions in the target muscle. treatment efficacy and applicability to the patient’s particular pattern
Electromyographic guidance is used for botulinum toxin injections to of spasticity. The selection of a therapy for spasticity should be
confirm delivery into muscle tissue. Anatomical landmarks and joint guided by the treatment goals. Other factors such as the chronicity,
movement can help better identify the proper muscles; however, severity, and cause of the spasticity may play a role in treatment
synergistic motor patterns may preclude the ability to distinguish selection, in addition to concomitant medical conditions, concurrent
nearby muscles that mimic the targeted muscles. medications, and treatment cost. Tangible benefits are often
achieved by matching the right treatment to the right patient, which
Nerve stimulation can be employed for botulinum injections, similar to offers the potential to dramatically improve the lives of patients and
that used for phenol injections. The drawback is that this is more their care-givers. However, it must be emphasized that the treatment
technically challenging and it may still be difficult to distinguish nearby of spasticity is undertaken as part of a multidisciplinary management

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Early Diagnosis of Post-stroke Spasticity and Treatment Options

program that includes numerous professionals, as well as the patient

and his/her family or care-giver. Atul T Patel, MD, MHSA, is Medical Director of the
Rehabilitation Institute of Kansas City in Missouri and a
Physiatrist at the Kansas City Bone and Joint Clinic in
Just as important as selecting the appropriate medical treatment for the Overland Park. His main area of interest is post-stroke
right patient is the adjunct and combination treatment. In most cases, rehabilitation and the management of patients with
physical and/or occupational therapy is crucial in achieving the full spasticity, movement disorders, musculoskeletal
problems, and neuromuscular disorders. He was
benefit of the medical and/or surgical treatments. In patients with formerly an Associate Professor at the University of
generalized spasticity, the optimal treatment often involves both Kansas Medical Center. He received his MD from Baylor
systemic and focal treatments. Finally, most patients require some type College of Medicine.

of maintenance treatment. n

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