Spasticity post stroke

Learning objectives

Post stroke spasticity Recognise Preventing Management

Definition: It has been defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.

Introduction

• Increased tone or spasticity as it is better known. Tone is usually reduced initially and then can increase and if excessive is termed spasticity.
• Spasticity is seen in 30% of post-stroke patients. There is however no universal definition.
• Spasticity is a dynamic phenomenon which can be seen early or late post stroke and may be transient.
• It can vary with posture, position, activity, pain, infection and mood.
• Spasticity can induce pain, poor positioning, skin pressure issues, tendon retraction and muscle weakness.
• It can reduce the potential success of rehabilitation.
• Scales have been used and the most common is the Modified Ashworth Scale (MAS) which measures the level of resistance to passive movement but does not assess other factors but is easy and quick to use and has been the basis of much-related research.

Modified Ashworth Scale
0	No increase in muscle tone
1	Slight increase in muscle tone, manifested by a catch or by minimal resistance at the end of the range of motion (ROM) when the affected part(s) is (are) moved in flexion or extension
1+	Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2	More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
3	Considerable increase in muscle tone, passive movement difficult
4	Affected part(s) rigid in flexion or extension

Summary of the most common patterns observed in the upper motor neuron syndrome, the muscles involved and the most observed side-effects. Adapted from [6].
Pattern	Muscles involved	Side-effects
Adducted/internally rotated shoulder	Pectoralis major, Teres major, Latissimus dorsi, Anterior deltoid, Subscapularis	Muscle contractures and pain Shoulder stiffness and painful passive range of motion Skin maceration, breakdown and malodour in the axilla Difficulties for dressing Limitation of the reaching-forward behaviour
Flexed elbow	Teres major, Latissimus dorsi, Long head of triceps, Posterior deltoid	Muscle contractures and pain Persistent elbow flexion during sitting, standing and walking Difficulties for transfer (no fulcrum), dressing and reaching objects Skin maceration, breakdown and odour in the antecubital fossa Disfiguring appearance Stretch injury to the ulnar nerve (at the bend of the elbow). The nerve is vulnerable to repeated trauma and can be compressed in the cubital tunnel leading to intrinsic muscle atrophy in the hand and weakness of ulnar wrist and finger flexion
Pronated forearm	Pronator teres, Pronator quadratus	Muscle contractures and pain Difficulties to reach underhand to a target Limitations to turn the patients hand palm side up for fingernail trimming (important for patients with fingers that are flexed into the palm secondary to a clenched fist deformity) Difficulties to feed (e.g., hold a spoon)
Flexed wrist	Flexor carpi radialis, Flexor carpi ulnaris, Palmaris longus, Extensor carpi ulnaris	Muscle contractures and pain Compression of the median nerve at wrist with carpal tunnel syndrome and hand pain Disfiguring appearance Awkward hand placement during reaching and impairs positioning of objects held Weakened grip strength
Clenched fist	Flexor digitorum sublimis and profundus	Patients cannot perform the reach phase to grasp an object Fingernails digging into palmar skin with pain Nail bed infections Pain when somebody attempts to pry fingers open to gain palmar access Disfiguring appearance Skin maceration, breakdown and malodour in the palm Difficulties to wear gloves or hand splints Limitation for grasping, manipulation and release of objects Development of muscle, skin and joint contractures
Thumb-in-palm	Flexor pollicis longus and brevis deformity, Adductor pollicis, First dorsal interosseous	Difficulties to wear gloves or hand splints Limitation of thumb extension and abduction that open the web space before grasp Difficulties to execute grasp patterns (three-jaw chuck, lateral grasp and tip pinch)
Flexed hip	Iliopsoas, Rectus femoris, Pectineus Adductors longus and brevis	Interfered with positioning on a chair, sexuality and gait Walking with a crouched gait pattern and compensatory knee flexion to maintain balance (leading to fatigability)
Adducted thigh	Adductor longus and brevis, Adductor magnus, Gracilis, Iliopsoas, Pectineus	Scissoring thighs interfere with perineal care, sexual intimacy, sitting, transfers, standing and walking Difficulties with limb clearance and advancement during swing phase of gait
Stiff knee	Rectus femoris, Vastus intermedius, medialis and lateralis, Gluteus maximus	Gait deviation with the knee remaining extended through the gait cycle Functional lengthening of the leg during the gait with dragging of the toe and risk to trip and fall Need of leg elevation support when seated Problems for standing, climbing stairs and transfers
Flexed knee	Medial and lateral hamstrings	Compensation of ipsilateral hip flexion during stance phase with flexed knee and contralateral hip and knee flexion (crouch gait pattern) Muscle contraction and pain Difficulties with transfers and wheelchair positioning Limitation of limb advancement due to the lack of knees extension during the terminal swing (short step lengths) When acting to the hip joint, hamstring cause the extension of the trunk leading to the deformity slide forward in the wheelchair
Equinovarus foot	Medial and lateral gastrocnemius, Soleus, Tibialis anterior and posterior, Long toe flexor, Extensor hallucis longus	Compression of the lateral border of the foot against the mattress, bed rail, footrest or floor Skin breakdown on the fifth metatarsal head Pain upon weight bearing over the lateral border of the foot Difficulties to put on and wear shoes Limitation of dorsiflexion during early and mid-stance Short contralateral steps Deviant knee flexion during pre-swing Occurrence of an early swing phase foot drag

References

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