European Journal of Neurology 2002, 9 (Suppl.

1): 17–22

Physical therapy in spasticity

D. Richardson
National Hospital for Neurology & Neurosurgery, Department of Physiotherapy, Queen Square, London, UK

Keywords:
intervention cycle,
physiotherapy, Bobath,
motor relearning,
cognitive approach,
spasticity
Physiotherapists are part of the rehabilitation team involved in the management of
adult spasticity. Physical therapy is one part of the armoury in the fight against this
disabling symptom of the upper motor neurone syndrome. Identifying the physiolo-
gical changes brought about by physical therapy or physiotherapy, is difficult. As with
many interventions in rehabilitation, this area is poorly studied and, until recently,
there was little or no evidence for its effectiveness. The aim of this presentation is to
identify key components of a physiotherapy approach and outline specific techniques.
The key components considered are: education of the patient and their carers; the
‘intervention cycle’ – involving accurate assessment, careful measurement, interven-
tion and evaluation; accurate goal setting and a staged stepwise approach over
prolonged periods. The specific techniques used include treatments targeted at: muscle
length changes, muscle strengthening and functional performance. Broadly these
techniques can be divided into biomechanical, cognitive and neurophysiological, each
being interdependent on the others. Physiotherapy combined with the other available
treatments should meet the challenge arising from adult spasticity.

In the past, the approach to managing spasticity tended
to be largely trial and error with poor evaluation and
follow up.
Today, we have moved to a multidisciplinary team
approach with a focus on evaluation of the various
interventions. Input and communication between the
different disciplines is necessary to provide targeted
therapy, using a parallel model, in order that all
strategies to help the patient are available at any
particular time. Large randomized double blind placebo
controlled trials are very difficult to implement in the
rehabilitation field particularly when looking at such a
dependent variable as spasticity.
We continue to use a variety of methods, but in a
more skilled and targeted manner. Physiotherapy, as a
discipline, has moved from professional artistry to an
evidence-based, scientific approach, over the last 15–
20 years. This process has been facilitated by a clearer
understanding of the pathophysiology of spasticity
(Sheean, 2002, this proceedings).
Further training includes biomechanics, kinematics and
motor learning programmes. The study of normal
movement guides our treatment approaches.
Spasticity
Spasticity is one part of the upper motor neurone
syndrome, it has an impact on all the other components,
that is: weakness, lack of dexterity and fatigue. Physical
therapy is part of the treatment plan and one aspect of
spasticity management. In this review, we will consider
the component parts of physical therapy and some of the
different approaches available, focusing on some specific
techniques and the published evidence in these areas.
The physical manifestations of spasticity are pain,
involuntary movements, abnormal postures, and resist-
ance to movement. This can lead to secondary problems
involving changes in muscle length, leading to the
development of contractures, deformity, and pain
(Yarkony and Sahgal, 1987).

What is physiotherapy? Aims of physical management of spasticity

Physiotherapists are movement scientists and teachers,
trained in the neurophysiology of control of movement.
Detailed knowledge of the musculoskeletal system and
functional anatomy are components of the training.
Correspondence: Ms D. Richardson, National Hospital for Neurology
& Neurosurgery, Department of Physiotherapy, Queen Square,
London WC1N 3BG, UK
(tel.: + 44 207 8373611; e-mail: D.Richardson@ion.ucl.ac.uk).
Physical management is aimed at promoting optimal
movement patterns, to enable an individual patient to
function as effectively as possible, to minimize contrac-
ture and the development of deformity, and reduce pain
in order to reduce the burden of care and improve the
quality of life.
Presentations are often complex. The challenge is to
identify which problem can be effectively treated and
how.

ª 2002 EFNS 17
18 D. Richardson
Components of physical therapy
in spasticity management
The first component is accurate assessment of the
physical presentation and clear identification of the
presenting problem.
The second component is identification of the goals
of intervention; accurate goal setting is essential
(Richardson, 1998). This goal setting allows for
focussed treatment.
The third component is accurate and appropriate
measurement of the identified problem (Johnson, 2002,
this proceedings).
The fourth component is implementation of the
chosen intervention.
The fifth component is reassessment and follow up of
the intervention provided.
Approaches to physical management
In order to attain the identified goals there are many
and various physical treatment approaches. Historic-
ally, there have been fashionable trends in therapy, but
currently a combination of different approaches is used,
although some centres tend to emphasize one more than
another.
There are three broad categories of techniques: bio-
mechanical, neurophysiological and cognitive, al-
though they tend to go by the name of their
proponents. Bobath (1990) for the neurophysiological
approach and Carr and Shepherd (1987) for motor
relearning or biomechanical approach. Currently, the
cognitive approach is not clearly defined, since it has
developed from the explosion of scientific evidence on
motor control and the use of motivation, planning,
cognitive reinforcement of motor output by imagery,
and thinking about it (Muir and Stevens, 1997). It has
no ‘trade’ name yet, so I have termed it ‘cognitive’.
The neurophysiological approach was first used by
Bobath (1978) in which they described a hierarchical
model of the motor control in the nervous system.
Using this technique, therapists employed reflex
inhibitory positioning to normalize muscle tone.
However, there are limitations to using this approach
alone. The patients all have damaged nervous sys-
tems, so their muscle tone may never become entirely
normal. It is also important to address all the other
factors of the upper motor neurone syndrome, with
the loss of strength and power in planning the best
intervention and movements.
The biomechanical approach was proposed by Carr
and Shepherd (1987) who described a motor relearning
programme, but drew on biomechanics and kinematics
from the engineering field. They considered the strength
required to perform different tasks. This technique has
moved away from normalizing tone, to improving
muscle strength and practising a task, which has some
important benefits. Recently, Langhammer’s group in
Holland (Langhammer and Stanghelle, 2000), pub-
lished the results of a study in which they compared the
motor relearning programme with the Bobath tech-
nique. They concluded that the motor relearning
programme allowed people to leave hospital earlier,
since they were able to function at a higher level. In
focusing on the statistical significance, it is sometimes
easy to overlook the clinical significance in the evidence
of benefit from physical management. There is currently
a big debate about clinical significance and statistical
significance, which we need to be aware of when reading
the literature on the physical approaches to the
management of spasticity.
Fetters, in the United States, has done a lot of work
using the cognitive approach (Fetters, 1991; Fetters and
Kluzik, 1996). This involves the dynamic systems
approach with respect to combining sensory input with
cognition and imagery (Schmidt, 1991). Motivation and
arousal can be very important in these patients, because
many of them are poorly motivated and depressed, with
low mood and they often do not comply with the
recommended course of treatment. It is probable that
this whole area will expand, but as yet there is very
limited evidence in the literature on the benefit of this
approach.
Modalities in physical management
Although there are various approaches, with different
therapy techniques in each, a multimodal technique will
probably produce the best results. Target areas for
therapy include:
Muscle length
Returning to the nature of spasticity, it is not only
velocity dependent, but also length dependent. For this
reason, in all our approaches, we consider muscle
length (Goldspink and Williams, 1990; de Lateur,
1994).
There are many techniques for stretching the
muscle. These include splinting, casting, positioning
(which can be used in lying, sitting or standing), and
seating. The French clinicians Tardieu et al. (1998)
did some work in cerebral palsy patients to investi-
gate the time required to stretch a muscle in order
that a change would occur. He came up with a value
of 6 h. With the best will in the world, and all the
resources at our disposal, it is impractical to stretch
muscles manually for 6 h, so we resort to splinting
and casting.
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 17–22

Ada and Canning (1990) looked at the effect of
casting the ankle in order to improve the length of the
gastrocnemius and soleus muscles. They concluded that
casting was useful in the management of muscle length
change.
Positioning patients is also important in trying to
improve their muscle length. This is a combination of
countering the effects of both spasticity and weakness.
Pope (1992) has published some work in which she
describes the different techniques which can be used.
She has also published a chapter on the importance of
seating (Pope, 1996).
When it comes to splinting, there is such an array of
different types of material, that the therapists must be
skilled in the principles of splinting and in its use. It is
essential that the muscle is not overstretched. Ten years
ago splinting was taboo in the world of neurology and
particularly in the treatment of spasticity. Clinically
there was a firmly held belief that splinting enhanced the
afferent input and increased the motor output, making
the spasticity worse. There was no evidence for this, it
was only based on clinical experience. However, with the
publication of Carr & Shepherd’s work in 1987, report-
ing muscle length change and strengthening, there was a
return to splinting which has had considerable clinical
benefit.
All manner of materials can be used for splinting, if a
little imagination is used. There is very little informa-
tion in the literature concerning these techniques and it
is only now that the importance of providing an
evidence base is becoming clear. We need to let
everybody else know the benefits arising from what
we are doing (ACPIN, 1999).
There is one report in the literature (Teixera-Salmela
et al., 1999) on the use of dynamic lycra splinting. This
group in Australia use what they call a second skin,
but which are in fact lycra splints, that can be
pulled over an arm or a leg. These splints provide a
consistent sensory input, with some support, and are
reported to reduce tone. However, this finding is largely
anecdotal.
Another important approach is patient positioning in
order to avoid muscle shortening. There are a number
of different methods for achieving this including the
adduction roll, which can easily be used in the home.
It helps prevent adductor spasms and the improved
posture also benefits perineal hygiene.
It is also worth considering the dynamic nature of
contracture. Is it in the joint or is it in the muscle?
There are a lot of problems with contracture develop-
ment especially in patients with little or no mobility. It
is important to evaluate the problem, see what tools are
available and apply the most appropriate to each
individual situation.
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 17–22
Physical therapy in spasticity 19
Muscle strength
In addition to changes in muscle length we also need to
consider muscle strength and the musculoskeletal
physiology associated with this. Once again, the
evidence is fairly slim, but there are a few single case
studies.
Facilitatory techniques are widely used, including
cooling (icing), brushing, etc. The aim is to restore
movement, addressing the issue of antagonist and
agonist interaction, and to facilitate the prime mover
enabling it to work against the spasticity.
Positioning in this context has a different aim than in
preventing muscle length changes, in that the therapist
will analyse how a patient moves and position them
such that they can recruit some activity. For example,
someone may find it too difficult to control their
shoulder, elbow and hand, when reaching for an object
at a height where they require proximal stability. The
effort required in performing this task at a height,
precludes performance in the hand, due to increased
tone. They may however, be able to lean forward and
reach for something on the floor, because this requires
less effort proximally. It is therefore possible to build on
the movement they have and encourage them to use the
hand. With practice, the muscle can be strengthened,
and this also helps in the management of movement
disorders and spasticity.
It is also useful to draw on the expertise of different
disciplines. In sports medicine they use a lot of
isokinetics, where machines can match the resistance
a patient exerts. This has been underused in neuro-
logical conditions and the management of spasticity,
due to the previously held belief that any effort or
work in a muscle will increase the spasticity. However,
as Dr Sheean has stated in these proceedings (Sheean,
2002), our understanding has changed and this
approach is now used to help normalize tone. When
there is less effort, there will be less increase in tone, so
it becomes a cycle and it is important to gauge
carefully what the patient may or may not do in order
to achieve strengthening without exacerbating the
spasticity.
Training and free weights can also be used in the
same way, as long as this is monitored and evaluated, as
part of the intervention cycle.
Motor learning
Evidence is now emerging on the benefits of motor
relearning programmes in improving function.
Underlying this is task breakdown and set up, integrated
into function. Papers by Carr and Shepherd (1987),
following on from Ada and Canning (1990) describe
20 D. Richardson
practice and training in these techniques. There is also a
recent report from Taub et al. (1998) on constraint
therapy, looking at the effect of practice on the ability to
perform a specific task. This approach is also supported
by evidence from Liepert et al. (1998), investigating
motor cortex plasticity and some of the authors com-
ment that muscle tone is also reduced.
The impact of enhanced training on the motor
cortex mapping provides evidence that encouraging
the patients to practice a task has a lasting effect,
which in turn leads to an improvement of their
condition, allowing them to move more easily.
Another of these techniques is treadmill training
(Gardner et al., 1998), which is also discussed by
Professor Mauritz (2002, this proceedings).
Practice is the mainstay of constraint therapy.
Essentially this means that the normal limb has to be
constrained to allow the affected limb to be used in
practising a task. By our nature, we all tend to take
the easiest option. If we have one functioning and one
nonfunctioning limb, we will always use the one with
the function. This re-enforces the nonuse of the
impaired limb. The role of the therapist is to encour-
age use in the nonfunctioning limb, which often
requires a lot of effort in order to persuade the
patients to perform a task. However, the reports that
this approach can achieve its aims are very encour-
aging. These findings essentially substantiate what we
have seen in practice.
This also ties in with the work of Fetters and Kluzik
(1996) looking at motivation and arousal, mentioned
above. In using constraint therapy, it is important to
plan the task, and ensure that the patients are in a
position where they can achieve it. However, due to the
severity of the CNS damage, many patients cannot
move normally. Physiotherapists together with occupa-
tional therapists, psychologists, speech and language
therapists, and carers, may resort to compensatory
techniques in order to allow the patient to function
optimally for their condition. This is an important
element of physical therapy.
Electrical modalities
There are a number of electrical modalities used in the
treatment of spasticity, including the functional electri-
cal stimulator (FES). In the UK, Salisbury, in the
south-west, have developed the Odstock foot drop
stimulator. Jane Burridge and colleagues have investi-
gated the effect of the stimulating the common perineal
nerve on dorsiflexion (Burridge et al., 1997; Burridge
and McLellan, 2000). They recently published a paper
looking at the effects of using the foot drop stimulator
on spasticity. This paper makes an important
contribution to this area of work as it combines a
number of the different issues: the use of EMG in
quantifying muscle problems, the relative contribution
of stiffness, and neural components. They concluded
that the patients who benefited most from the func-
tional electrical stimulation were those in whom the
neural element played a larger role in the problems with
the calf musculature. The treatment itself affected the
reciprocal inhibition, by activating the dorsiflexors
electrically.
There was another publication on the use of trans-
cutaneous electrical nerve stimulation. Sonde et al.
(1998) reported that stimulating the skin early after a
stroke, made no difference to the patients’ spasticity.
Dimitrijevic et al. (1996) reported use of a glove with
electrodes throughout it, to stimulate the sensory
aspects of the hand. They stated that this resulted in a
slight improvement in function, but concluded that
further research is required.
Education and advice
In stating that physiotherapists have a role in educating
and advising carers and teachers, it is helpful to
consider exactly what that means. What are we telling
them?
We spend a lot of time in spasticity clinics explain-
ing the aggravating and easing factors of spasticity,
and the basic muscle length changes. Most people do
not understand that muscle is malleable and plastic
and that the demands made on it affect the way it
functions. Nor do they understand its ability to
shorten and lengthen. Explaining this, even in simplis-
tic terms, helps the patients understand the underlying
reasons for their treatment and enables them to help
themselves.
They also need to know the basic anatomy of the
muscles, because a lot of these patients do not under-
stand which muscles they are stretching and which
exercise stretches which muscles. A good understanding
can help compliance with an agreed programme, but a
poor understanding often works against the desired
goals. They also need to realize that it must be self or
carer initiated, and controlled, such that it becomes a
way of life. These are the issues we try and address in
our education.
Meeting the challenge
Part of the title of this symposium is ‘meeting the
challenge’ so what is the challenge? For physiothera-
pists it is to provide the most effective treatment for
each individual at any given time in the continuum of
living with spasticity. This is one reason why modern
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 17–22

management has improved. We have better facilities,
a better understanding of the condition and better
follow-up for these patients.
We need to match the treatment to the symptoms. It
is sometimes difficult to tease out the contribution of
spasticity from the other features of the upper motor
neurone syndrome. We have to decide whether it is the
spasticity which is creating the problem or whether it
arises from one of the other aspects. We need to achieve
a change and maximize the functional potential of each
individual.
The best way to meet this challenge is by accurate and
skilled assessment over time. If the problem is incorrectly
assessed at the outset, the treatment will be poorly
targeted and the results poor. Skilled goal setting is
essential and this can only be learnt by experience.
For the future, we should be moving away from a
hierarchical model and closer to a parallel model in
which all treatment modalities are available at all times.
The pattern of the patient receiving one type of treatment
(e.g. physiotherapy), followed by another (e.g. medical
treatment) when benefit is not observed, followed by yet
another (e.g. orthopaedic- or neuro-surgery), should
disappear. Each patient should be assessed and appro-
priate treatment provided where necessary. We also need
to educate the patients to explore the techniques which
are most effective for them.
A case study
Case MA had a diagnosis of systemic lupus with
cerebral involvement. She had a left intracerebral
haemorrhage, leaving her with a residual right hemi-
paresis and she was right hand dominant. The problems
identified 3 years after the haemorrhage were; difficul-
ties using the right hand for any functional tasks,
shortening of the intrinsic thumb and finger muscles, an
underlying tremor and increased tone in the wrist,
thumb and finger flexors. MA was also frustrated and
anxious over the aesthetics of her hand.
Goals of intervention
At the first level, level 1, the goal was to reduce the tone
in the affected muscles. At level 2, we wanted to
improve the range of movement, by increasing the
length of the affected muscles. At the subsequent levels,
we wanted to explore how the improved length would
help with strengthening and functional activities and we
wanted to improve the aesthetics of the hand.
Measurements used included: Ashworth scale of
spasticity – to quantify changes in tone; a standard
hand held goniometer – to measure the range of
movement; a nine-hole peg test – to look at dynamic
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 17–22
Physical therapy in spasticity 21
function; and the Rivermead Motor Assessment
score – a 15 item dichotomous functional score in
which a task can either be performed or not (including
things like using a knife and fork, bouncing a ball or
moving a limb to a specified position). We also
identified a subjective goal of how she felt about the
look of the hand and used video and still photography
to quantify this.
Treatment involved injection with botulinum toxin
into the wrist, finger and thumb flexor muscles, with
physiotherapy incorporating all aspects mentioned
above and splinting (Richardson et al., 1997; Richard-
son et al., 2000). From the Ashworth scale, the thumb
adductor was problematic at the start, with a score of
three. This was reduced to one by six weeks after the
toxin injection, which is when it is most effective.
Towards the end of a 3-month period it was beginning
to increase again. Finger and wrist flexion remained
lower than before injection, physiotherapy and splinting.
Before treatment the peg test took 4 min, but this
improved to 2 min at week 12. MA was given a further
injection and more stretching exercises and this reduced
further to 1.5 min. The Jamar grip strength and the
visual analogue scale improved, as did the Rivermead
test, in which she improved by six points which is
encouraging and probably also clinically significant.
The Jebsen hand function test improved in all its
assessment areas.
There was also an appreciable improvement in hand
posture and appearance, with better extension of the
fingers and better function.
She was very pleased with the results and was able to
use the right hand. At a 3-year follow-up, she was still
able to use her hand functionally and was no longer
frustrated about how it looked. In addition she has
avoided surgical intervention.
Summary
This is intended as a brief overview of the author’s
thoughts on the current management of spasticity.
Although from our clinical experience we believe that
the treatment we provide is of real benefit to the
patients, the evidence base is limited. Further research
is clearly required.
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