Spasticity
Management
Clinical Problem Solving II
McCaul Benson
1
Outline of Presentation

Patient information
◦
◦
◦
◦

Subjective
Objective
ICF model
Progress summary
Intervention
◦ Question and evaluation of evidence

Conclusion and clinical application
2
Patient History
HPI: 27 yo female, status post left ACA/MCA embolic CVA, R side
hemiplegia
PMH: none, delivered healthy baby 3 months prior
Prior level of function: Independent
Social
•
•
•
•
history:
Single marital status
Supportive boyfriend
8 month old daughter
Social work in DC
3
Patient Goals

Current functional limitations: speech,
moving arm, walking, taking care of my little girl,
cooking, cleaning, climbing stairs

“I want to be able to walk, have enough balance
and hold my daughter and walk around while I
am holding her.”

Seeking “normal” movement patterns
4
Objective

Seated posture: WNL
R LE
Strength
Assessment
Grade

Standing posture: left lean
Hip flex/ext
2-/5
Knee flexion
1/5

Sensation: grossly intact
Knee
extension
2+/5

Strength: Pt has emerging
active movement in right
lower extremity
DF
0/5
PF
3/5
Hip abd/add
2/5
5
Objective
Tone/Spasticity: Modified Ashworth Scale for
Grading Spasticity (MAS)
 Limitations associated with scale
R Wrist flexors, supinators,
shoulder adductors,
shoulder flexors: 1+
R Hip flexors, knee
extensors, ankle plantar
flexors: 3
6
Objective

Bed mobility: modified independent

Transfers: modified independent

Locomotion/gait: Pt was modified independent
for 200 feet
◦ Small based quad cane
◦ Pt compensates with hip hike and circumduction to
advance R LE
◦ Absent heel strike
◦ Increased left trunk lean
◦ Retracted pelvis
◦ Gait speed significantly reduced
7
Progress Summary

Functional mobility

Strength

Berg balance


◦ Progressed to single point cane
◦ 55/56
10 meter walk test
◦ 0.62 m/s
Tone/Spasticity
◦ No change
LLE
Strength
Initial
Progress
Hip
flex/ex
t
2-/5
3/5,2/
5
Knee
flex
1/5
2-/5
Knee
ext.
2+/5
4+/5
DF
0/5
0/5
PF
3/5
3/5
Hip
abd/ad
d
2/5
3-/5
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Summary of Findings
Body
Structure +
Function
Activity
Limitations
Participation
Restrictions
Contextual
Factors
•Strength,
AROM
•Hypertonicity
•Spasticity
•Selective
motor control
•Coordination
•Balance
•Cadence
•Bed mobility
•Transfers
•Gait
•Self-care/ADLs
•Stairs
•Driving
•Communication
•Work
•Romantic
relationship
•Social activities
•Hobbies, leisure
activities
•Role as new
mother
•Single mother
•Personal
relationship
•Family
relationship and
location
•Complexity of
occupation
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Physical Therapy Goals







Strength
Balance
Normalized gait speed
Floor transfers
Upright bike transfers
Reciprocal stair climbing
Carrying and handling objects
10
Intervention
Patient was seen 3x/week for 1 hour in addition to speech, OT, group
therapy, and FES UE bike
 Neuromuscular re-education: hip abduction, hamstrings, emphasis on selective
motor control
 NMES/FES-neuro re-ed and functional activity training
 Balance activities, coordination training
 Squats, mini squats, lunges
 Functional transfer training
 Berg balance activities
 Stair training
 Gait training
 Upright bike
 Manual stretching and passive ROM
 Rhythmical rocking, reciprocal movements
 WB to quadriceps with emphasis of exercises done in tall kneel, half kneel,
quadruped
 PNF techniques

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Spasticity and Tone

Occurs as part of damage to descending motor tracts

Tone: resistance of muscle to passive elongation or stretch when
an individual attempts to maintain muscle relaxation

Spasticity: a hypertonic motor disorder characterized by
velocity-dependent resistance to passive stretch
◦ Imbalance between inhibitory vs. excitatory components
◦ Loss of inhibitory control on lower motor neurons, increased
alpha motor neuron excitability, disordered spinal reflexes
12
Complications Related to
Spasticity

Decreased functional outcome

Decreased quality of life

Abnormal movement patterns

Contracture, deformity, pain

Impaired ADL’s
13
Intervention Question
Spasticity complications negatively affect outcome
 Limited improvements with alternative approaches
 Readily available electrical stimulation components

For a 27 year old female s/p left
CVA, is electrical stimulation an effective
intervention to decrease spasticity in the
lower extremity?
14
Electrical Stimulation (ES) for
Spasticity Management

Neuroplasticity

Increase inhibitory interneuron

Promotes reciprocal inhibition

Fatigue spastic muscles
15
Effects of Electrical Stimulation in Spastic
Muscles After Stroke: Systematic Review
and Meta-Analysis of Randomized
Controlled Trials
Cinara Stein, MSc; Carolina Gassen Fritsch, Ft; Caroline Robinson, MSc; Graciele Sbruzzi, DSc;
Rodrigo Mea Plentz, DSc
16
Effects of Electrical Stimulation in Spastic
Muscles After Stroke

Introduction: “The aim of our study was to systematically
review the effect of treatment with NMES on spastic muscles
after stroke compared with placebo or another intervention.”

Methods:
◦ Two reviewers searched for RCTs with use of NMES alone or
with additional intervention approach vs. control group
◦ Modified Ashworth and ROM
◦ Upper and lower extremity included
◦ No specificity of NMES dosage
◦ Control group-less exposure than intervention
◦ 29 RCTs, 940 subjects
◦ 95% CI
◦
Stein et al.
17
Spasticity Results-MAS

Mean difference with 95% CI
P<0.05
Design
Outcome
12 Studies: NMES +
Other vs. Control
Significant
[-0.35 (-0.63, -0.07)]
2 Studies: NMES vs.
Control
Not Significant
[0.13 (-1.53, 1.78)]
5 Studies: NMES on LE
Significant
[-0.78 (-1.02, -0.54)]
6 Studies: NMES on
Wrist
Not Significant
[0.12 (-0.41, 0.64)]
4 Studies: NMES on
Hand
Not significant
[-0.39 (-0.89, 0.11)]
Stein et al.
18
Discussion

Demonstrates NMES + other intervention approach
decreased spasticity and increased ROM
◦ Eleven studies showed significant increase in ROM

Recommend application of NMES to reduce spasticity to
improve functional activity

Limitations:





Variability of patient factors
Lack of methodology related to specific studies
Lack of standardized dosage
Variable conventional treatment approach
Limited scope of outcome measures
Stein et al.
19
Conclusion:

“NMES combined with other intervention
modalities is a treatment option that
provides improvements in spasticity and
range of motion in stroke patients.”
Stein et al.
20
Effects of Surface Electrical Stimulation on
the Muscle-Tendon Junction of Spastic
Gastrocnemius in Stroke Patients
S.C. Chen, C.J. Chen, C.H. Lai, W.H. Chiang, and W. L. Chen
21
Introduction

The purpose of this study was to explore
the effect of spasticity suppression by
surface ES on the muscle-tendon
junctions of spastic muscles.
◦ Theorized mechanism: Ib inhibitory pathway
facilitation
Chen et al.
22
Methods

24 selected stroke patients
◦ Mean age 57
◦ 12-35 months s/p CVA

Ankle spasticity graded 2 or 3 on Modified Ashworth Scale

Outcome measures:
◦ Modified ashworth scale
◦ Fmax/Mmax ratio
◦ H-reflex latency
◦ 10m walk test
Chen et al.
23
Intervention

20 minutes of ES, 6x/week for one month
◦ Gastrocnemius muscle and achilles tendon
junction

Parameters: Frequency of 20 Hz, 0.2ms
pulse duration, max intensity without
muscle contraction

Control group: zero intensity
Chen et al.
24
ES
Cases
Initial
One
month
Control Initial
One
Month
1
2
1+
1
2
2
2
2
1+
2
2
2
3
2
1+
3
3
3
4
3
2
4
2
2
5
2
2
5
3
3
6
3
2
6
2
2
7
2
1+
7
2
2
8
2
2
8
3
3
9
2
1+
9
2
1+
10
2
1
10
2
2
11
2
2
11
2
2
12
2
2
12
2
2
MAS Results
Chen et al.
25
Results
ES Group
Initial
One Month
Fmax/Mmax (%)
8.10+/- 4.84
4.00 +/- 1.36**
H-reflex latency (ms)
28.87 +/- 2.45
29.40 +/- 2.57**
10m walk (s)
89.75 +/- 20.69
80.75 +/- 19.23**
Control
Initial
One Month
Fmax/Mmax (%)
8.16+/- 4.11
8.23 +/- 4.01
H-reflex latency (ms)
28.91 +/- 2.53
28.85 +/- 2.47
10m walk (s)
87.91 +/- 23.05
88.05 +/- 22.88
**P<0.01
Chen et al.
26
Discussion




Spasticity was significantly reduced after one month of ES
Ib inhibitory pathway
◦ Results varied secondary to different methods used
Utilized both subjective and objective outcome measures
Included 10m walk time
Limitations:
◦
◦
◦
◦
◦
Mean age, Time since stroke, Anti-spastic medications
Time constraints of intervention
Small sample size
Modified Ashworth Scale limitations
10m walk results
Chen et al.
27
Conclusion

“Surface ES on the muscle-tendon
junctions of spastic gastrocnemius
muscles is an effective way to suppress
spasticity at the metameric site and to
improve 10m walking time in stroke
patients.”
Chen et al.
28
Conclusion and Application

Lack of standardization of intervention
◦ No specific dosage or parameters


Variability in spasticity pathophysiology and
theory of intervention approach
Variability between study subject’s and patient
presented
◦ Age, time since onset of stroke, anti-spastic medications

Limited functional outcomes assessed
◦ Problems associated with MAS
29
Conclusion and Application

QUESTIONABLE, Electrical stimulation can effectively
reduce spasticity in some cases
◦ More effective in combination with other treatment approaches
◦ Limitations related to the patient presented

Electrical stimulation is an intervention approach to
consider for spasticity management
◦ Recommend use of electrical stimulation either on spastic muscles or the
muscle-tendon junction with the patient presented in addition to the
alternative intervention approaches
◦ No known adverse effects
◦ Readily available

Future Research:
◦ Standardized dosage and parameters
◦ Functional outcome tools
◦ Long term follow up
30
Questions
31
References
Chen, S., Chen, Y., Chen, C., Lai, C., Chiang, W., Chen, W. “Effects of surface electrical stimulation
on the muscle-tendon junction of spastic gastrocnemius in stroke patients.” Disability &
Rehabilitation. 27.3 (2005):105-110.
Stein, Cinara, MSc, Carolina Gassen Fritsch, Ft, Caroline Robinson, MSc, Graciele Sbruzzi, DSc, and
Rodrigo Mea Plentz, DSc. "Effects of Electrical Stimulation in Spastic Muscles After Stroke:
Systematic Review and Meta-Analysis of Randomized Controlled Trials." Stroke Journal 46.8
(2015): 2197-2205.
Sullivan, S. (2007). Physical rehabilitation (5th ed.). Philadelphia: F.A. Davis.
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