Assessment and

Treatment of
Spasticity

Cori Ponter, PT, MPT, NCS

Barrow Neurological Institute
3/23/19
Learner Objectives

The learner will:

• Participants will be able to identify and differentiate various

assessment tools used in assessing spasticity
• Participants will be able to discuss various treatment options for
patients with spasticity

2
Where do we start?

Choice of
Assessment Goal-Setting
Treatment
How can we make our
assessments meaningful?
 Ashworth/Modified Ashworth

• One of the most commonly used assessment for spasticity in

the clinic
• Frequently used as the “gold-standard” to validate other
spasticity measures against.
• Measure of RESISTANCE TO PASSIVE MOVEMENT 1
• Is NOT a measure of spasticity, but scores may by influenced
by spasticity 2
• Is performed at one speed only (one-second1), so does not
capture the “velocity-dependent” component of spasticity
• Good screening tool to indicate when further assessment
needed

1. Bohannon R,, et al. Physical Therapy 1987. 67:1068-1071 2.

Pandyan AD, et al. Clin Rehab 1999;13(5):373 – 383
 Psychometrics – Mixed Reviews
Author Subjects Results/Findings
Sloan et al 34 hemiplegic “MAS has acceptable interrater reliability for testing of upper limb spasticity, but not
so for testing of the lower limb spasticity.”

Nuyens,et al 30 MS “AS more reliable for muscles of the ankle than for muscles of the knee, and least
reliable for muscles of the hip.”

Haas, et al 30 SCI Interrater reliability varied between AS and MAS, between muscle groups (hip
adductors > hip extensors/flexors > ankles plantarflexors), and between limbs.
Recommended for both to be used with caution when assessing LE spasticity with
SCI patients

Allison et al 30 TBI Low interrater reliability for ankle plantarflexors, and argued that there was no
support for continued use of MAS to assess PFs in pts with TBI.

Gregson, et al 32 acute CVA Intra/inter-rater reliability found to be “good to very good for the elbow, wrist and
knee, but less satisfactory over the ankle.”

Blackburn et al 36 CVA Acceptable intra-rater reliability, but poor inter-rater reliability for MAS. Most
agreement was with scores of “0,” so conclusion was that reliable measurements
could be obtained to determine whether normal or low muscle tone is present or not.

Pandyan AD, et al. Clin Rehab 1999;13(5):373 – 383

Malhotra S, et al. Clin Rehabil. 1998: 1005-1115
 Ashworth/Modified Ashworth

0 No increase in tone
1 Slightly increased tone, with a catch & release or
minimal resistance at terminal ROM
1+ Slight increase, catch followed by minimal
resistance throughout the remainder of the range
(<1/2 of the ROM) (only in MAS)
2 Marked increase through most of the ROM, but
affect part is easily moved
3 Considerable increase, passive ROM difficult
4 Affected part is rigid

Passive movements of muscle groups should be

performed over a one-second time frame

Bohannon R,, et al. Physical Therapy 1987. 67:1068-1071

 “The results...are clear and tell us the Ashworth
Scale has insufficient validity and reliability to be
used as a measure of spasticity. However, we are
left with the problem of how to measure spasticity
in a valid and reliable way. The quest for this holy
grail is ongoing.”

- Katharina S Sunnerhagen

Sunnerhagen, K. Stop Using the Ashworth scale for the assessment of

spastisity [letter]. J Neurol Neurosurg Psychiatry 2010. 81:2
Slow down!

• MAS performed as a 1-second movement

– which is not as fast as many of us
learned in school
• The score is based on the resistance felt
during that one second of passive
movement
• Should be done 1-3 times at most
MAS
Case Example
 36 y/o male with R CVA, resulting in spastic left hemiparesis. Below are the
MAS scores for his L UE and LE.

UE Muscle Group MAS LE Muscle Group MAS

Shoulder Flexors 0 Hip Flexors 0
Shoulder Extensors 2 Hip Extensors 3
Shoulder Adductors 3 Hip Adductors 3
Elbow Flexors 2 Hip Int Rotators 0
Elbow Extensors 0 Hip Ext Rotators 2
Wrist Flexors 3 Knee Extensors 0
Wrist Extensors 0 Knee Flexors 2
Finger Flexors 3 Ankle Plantarflexors 3
Thumb Adductors 0 Ankle Inverters 0
Ankle Everters 0
So how do we assess further??
 The Tardieu Scale

The Tardieu Scale

Measures two aspects of spasticity

1) Quantity -- Spasticity Angle
2) Quality - Spasticity Grade

May be more useful in terms of predicting the

functional implications of the spasticity, as well as
assessing the effects of treatment

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

 Spasticity Angle

Range of motion measured at two different velocities

V1 – Slow as possible (R2)
V3 – Fast as possible (R1)

Spasticity
R2 R1 Angle

Large spasticity angles indicate a large dynamic

component (spasticity), whereas small differences
indicate predominantly muscle contracture

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

 Spasticity Grade

0 No resistance throughout passive movement

1 Slight resistance throughout passive movement
2 Clear catch at precise angle, interrupting passive
movement, followed by release

3 Fatigable clonus (<10 s when maintaining pressure)

occurring at a precise angle, followed by release
4 Unfatigable clonus (>10s when maintaining
pressure) occuring at a precise angle

Notes:
If spasticity angle = 0, grade must be a 0 or 1 by definition
If spasticity angle > 0, grade must be at least a 2, even if no
definite “release” felt

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

 What does the literature say?
 More likely to identify presence of spasticity [but not severity]
and the presence of contractures than MAS/AS1
 Very good intra-rater reliablity across 2 sessions in elbow
flexors and ankle plantarflexors 2
 Good reliability in assessing elbow flexor and ankle
plantarflexor spasticity 3
 Reliability significantly increases with training3
 “In patients with severe brain injury and impaired
consciousness the Modified Tardieu Scale provides higher
test retest and inter-rater reliability compared with the Modified
Ashworth Scale and may therefore be a more valid spasticity
scale in adults.” 4

See additional references

How to perform the Tardieu Scale

• Measure R2 – Achieved with a SLOW and powerful

passive movement (V1). This should give us the full
range of motion of the muscle group.
• Should be slow enough to prevent eliciting any
stretch reflexes
• Should be powerful enough to overcome any
resting dystonia
• R2 is documented as the point where no further
passive movement is achievable.

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

How to perform the Tardieu Scale

• Measure R1 – Achieved with a passive movement that is

as fast as possible (V2)
• R1 is documented as the angle at which the first
resistance is felt

• Calculate Spasticity angle – the difference between the

two angles of R2 and R1

• Assign Spasticity Grade to the resistance felt during R1

measurement
Case Example, cont
UE Muscle Group MAS R2 R1 Spasticity > Prob Implication
Shoulder Extensors 2 180 40 140  Spasticity

Shoulder Adductors 3 120 120 0 M Tightness

Elbow Flexors 2 150 120 30 M Tightness
 Spasticity
Wrist Flexors 3 100 80 20 M Tightness
 Spasticity
Finger Flexors 3 150 150 0 M Tightness
Hip Extensors 3 100 100 0 Tightness (M, C?)
Hip Adductors 3 120 110 10 M Tightness
Hip Ext Rotators 2 110 110 0 Capsular
Knee Flexors 2 180 60 120  Spasticity
Ankle Plantarflexors 3 70 70 0 M Tightness
Assessing the spasticity
angle
 Active Range of Motion

• NOT a measure of strength, but a measure

of how much the spastic muscle can be
overcome!
• Documented as the number of degrees of
active movement.
• Are we seeing co-contraction of the
antagonist?

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

 Rapid Alternating Contractions

• Looking at the time it takes to perform

a set number of active movements
(into their full AROM)
• Co-contraction usually increases with
effort and fatigue
• May be more indicative of what we see
in functional mobility (ie, gait, feeding).

Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.

Modified Frenchay Scale
Modified Frenchay Scale

0 = not able to perform any of

task/no mvmt
5 = barely accomplished task
10 = normal performance

 High intra- and inter-rater

reliability (Baude et al. ESNR,
2015)

Gracies,Handbook of botulinum toxin 2002; 2009; 2015

FUNCTION!!!

Severity Significance
 Functional Assessment

 ASK QUESTIONS!
 How is this impacting their lives? Severity ≠ Significance!
 What are THEIR goals of treatment?

 OBSERVE!
 Watch them walk, transfer, maneuver w/c, eat, dress, etc
 How are they positioned?
 VIDEO, VIDEO, VIDEO!

 BE OBJECTIVE
 Use measures such as 10-meter walk, 6-minute walk test,
Gaitrite, Goal Attainment Scale

1. Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8

2. Doan, et al. PMR 2012 Jan; 4(1):4-10 (abstract)
Pre-trial gait
Post-trial gait
Handwriting
Setting goals

Choice of
Assessment Goal-Setting
Treatment
 Clinician
Goals

Patient
Goals
Who are we focused on when setting
goals?
Goal check

Meaningful Realistic/Achievable

Patient-
centered

Functional Objective
Treatment options

Choice of
Assessment Goal-Setting
Treatment
Interdisciplinary Treatment
Patient &
Family

Nursing Pharmacist

Social
Physical
Work/Case
Therapy
Management

Occupational
Physician
Therapy
ITB patient education

What we are
The pre and post looking for during
Implant process
trial process the post-trial
assessment

Possibility of initial
What a pump may functional decline
Pump precautions or may not help • Necessity for further
with therapy

Signs of
Potential for Importance of withdrawal!!!
weight gain refills • Itcy, witchy, twitchy

Graham, L. Oxford Journals, 2013 (42)435-441

Therapy management
 Therapy-driven neuroplasticity?

• 23 patients at least 6 months post-CVA

– Documented spasticity and at least trace activation in
selected UE muscle groups
• Outcome measures – MAS, FM, sensory tests, fMRI
• Intervention – 12 week motor learning therapy program,
including treatment for spasticity
• Results
– Greater spasticity correlated with poorer function
according to FM scores, and with greater severe sensory
deficits
– Significant gains in motor function measured with FM total
score
– Improvements in spasticity correlated with increased task-
related brain activation in the CONTRAlesional M1, LPM,
S1 and AS regions

Pundik, et al. Stroke Research and Treatment (2014); 306325

 BWSTT vs Tilt Table in SCI

When body weight supported treadmill

training and tilt table programs were
compared in patients with SCI -
– BWSTT had greater decreases in flexor
spasms, clonus, and self-reported mobility
after 4 weeks of treatment
– Tilt table standing had greater reduction in
extensor spasms after 4 weeks of treatment.
– Participants in BWSTT appeared to have
higher scores on QoL measures

Adams, M and Hicks A. The Journal of Spinal Cord Medicine; 2011 (31)
488-494
 Casting

• A conservative and effective modality to reduce

muscle tightness, decrease chance of deformity,
and achieve optimum alignment of a joint.
• Casts offer a temporary, specific, and
noninvasive intervention as an alternative or
complement to other interventions.
• Casting may help eliminate, delay, or minimize
the need for surgical interventions.
• Best outcomes combined with
medical management
Verplancke D, et al. Clinical Rehabilitation. 2005. 19(2): 117-125
Park E, et al. Yonsei Medical Journal. 2010; 51(4): 579-584
Alternatives
Positioning
Positioning
Modalities

• Heat and Cold

– Temporarily decreases tone and increases pain
thresholds
– May be beneficial in conjunction with
strengthening antagonistic muscles or prior to
casting
• Vibration
– Shown to have short term decreases in tone as
well as improvement in function
– Should be used in conjuction with other
therapies
Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38
 Modalities
Estim leading to muscle contraction:

 Pure sensory stimulation thought to inhibit overactivity through

influencing the excitability of the alpha motor neurons and
triggering sensorimotor reorganization
 Stimulation of the overactive muscles may lead to fatigue, thus
decreasing activation

 Minimal results published regarding long-term effects, but

has been shown to have good short term effects
 Increases in function are thought to be a result of increased
motor control gained during brief inhibitory period following
e-stim
50
Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38
 Strengthening
Does strengthening a
spastic muscle Historical thought
increase the over-
was…YES
activity?
Research says…..NO
• Research shows us that spastic muscles are weak muscles
• Strengthening (post-CVA) has been shown to
• Increase function
• Decreased perceived limitations & increase perceived QOL
• Increase gait speed
• Has not been shown to increase spasticity (as measured by
Pendulum test or MAS)

Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38 51

The dreaded PLATEAU

Who is plateauing?
The patient?
The therapist?
The physician?
Can we change the recovery trajectory for
the patient?
Is one year all we get?
Self-Guided Contract

• Retrospective study by Pradines, et al in 2015

• 30 subjects (all > 1 yr post lesion) all followed
self-guided contract
– Antagonist-based
– Diary-based
• Alternating stretching and rapid maximal
amplitude alternating movements (eccentric
stretches), documented in daily diary, performed
for at least 1 year
Responder rate
Gait speed
Optimizing Outcomes

Medical Therapy Better

management interventions outcomes!
Pre and post Botox
Pre and post Botox
Outcome
Team approach to spasticity
management

• 37-yo male who suffered

a severe traumatic brain
injury from an assault two
years earlier
• Completed one month of
inpatient rehabilitation
• Was sent home just as
he was emerging from a
coma

66
Outcome
Team approach to spasticity
management

• Home therapy cannot do

much because of posture
• Drugs and injections to
treat muscle tightness did
not work
• Surgery?

67
Outcome
Team approach to spasticity
management

Before Any Therapy Can be Done:

• INFECTIOUS DISEASES CONSULTATION
• Antibiotics for groin abscess
• ORTHOPEDICS
• Hip contracture release
• Groin abscess I&D
• NEUROSURGERY
• Intrathecal Baclofen therapy

68
Outcome
Team approach to spasticity
management

Before After Surgeries

69
Outcome
Team approach to spasticity
management

• Inpatient
rehabilitation
• PHYSICAL AND
OCCUPATIONAL
THERAPY
• Botulinum toxin
injections to neck
• SPEECH THERAPY
• Improved speech and
swallowing

70
Outcome
Team approach to spasticity
management

• ORTHOPEDIC
SURGEON
• Knee flexion
contracture
• Repeat botulinum
toxin injections to
wrists and neck
• More therapies

71
 Botox™ 200 units :

Finger flexors (FDS, FDP)

Long thumb flexor (FPL)

67/male, 3 years post TBI, Anoxia, Stroke

Botox™ 200-250 units : Occupational therapy:

Finger flexors (FDS, FDP) Stretch/weight-bearing

MCP flexor (lumbricals) Serial casting
FPL “Forced-use”
Questions???
Additional References
1. Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the
Ashworth Scale is confounded by it. Clinical Rehabilitation. 2006;20(2):173–181.
2. Singh P, Joshua A, Ganeshan S, Suresh S. Intra-rater reliability of the modified Tardieu scale to
quantify spasticity in elbow flexors and ankle plantarflexors in adult stroke subjects. Annals of
Indian Academy of Neurology 2011. 14(1): 23-36
3. Gracies JM, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D et al. Reliability of the Tardieu
Scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil
2010;91:421-8.
4. Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R, Pohl M. Reliability of the
Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury:
a comparison study. Clin Rehabil. 2005. 19(7): 751-759
TIRR Memorial Hermann and the
Memorial Hermann Rehabilitation Network

TIRR Memorial Hermann Entities

Memorial Hermann Rehabilitation

Network Entities

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