Chances are good that you regularly see presentations of spasticity in clients as you conduct seating and wheeled mobility evaluations. But its familiarity doesn’t make spasticity easier to work with.

That’s because spasticity can be notoriously difficult to pin down. It can manifest differently in clients with the same diagnosis. It can even manifest differently in the same client at different times of the day, or from moment to moment.

At the same time, spasticity can enormously impact a client’s function, seating tolerance and quality of life. Managing spasticity well can go a long way toward seating and wheeled mobility success.

A Common Challenge

Spasticity impacts a number of mobility-related conditions, said Lee Ann Hoffman, OT, MSc.

“It has been estimated that spasticity affects more than 12 million individuals worldwide,” she noted. “There are approximately 400,000 people in the United States with some degree of cerebral palsy (CP)-related spasticity, and around 320,000 with some degree of multiple sclerosis (MS)-related spasticity (AANS 2017).”

A wide range of diagnoses can result in spasticity, Hoffman added. “In our complex rehabilitation population, several diagnoses present with spasticity, namely spinal cord injury (SCI); anoxic and traumatic brain injury (TBI); cerebrovascular accident (CVA); meningitis; encephalitis; adrenoleukodystrophy; phenylketonuria; amyotrophic lateral sclerosis (ALS); MS and CP. Complications resulting from these diagnoses and the associated spasticity are commonly noted as, but not limited to, reduced joint range of movement and also asymmetric postures. These factors are often accompanied by pain and discomfort, decreased functional ability, often resulting in changes to independence and quality of life.”

The Hows & Whys of Spasticity

Complicating the spasticity challenge is that the condition varies in presentation, said Wade Lucas, PT, DPT, ATP, Clinical Education Manager in the Western U.S. for Quantum Rehab.

“Spasticity can present in numerous ways depending on the individual,” he noted. “Spasticity is dependent on the severity and the location of damage to the nervous system. The individual can exhibit flexor tone, extensor tone or a combination of both in different parts of the body. The spasticity can also fluctuate and vary throughout the day. It often presents asymmetrically and can cause a variety of postural changes or disturbances which can have a detrimental effect on the individual’s function.”

Spasticity can occur, Lucas said, “when there is damage or injury to the upper motor neurons of the central nervous system (brain, spinal cord). The damage in the nervous system causes imbalances or faulty signals from the brain and spinal cord to the skeletal muscles. This results in increased muscle tone, hyperactive reflexes, and pain. This tone, hyperactive reflexes and pain can be triggered by a number of environmental stimuli, with spasticity resulting.

“Any diagnosis that has caused damage to the upper motor neurons can cause spasticity in the individual,” Lucas said.

In practical terms — such as how it could look during that seating evaluation — Hoffman said, “Spasticity is characterized by selected muscles continuously contracting. This contraction results in stiffness or tightness of the muscles, thereby interfering with typical or normal movement, speech and gait. Spasticity negatively affects both the muscles and joints of the extremities (AANS 2017).

“High tone or spasticity occurs when the muscle tension becomes tighter, which leads to the muscle(s) shortening. Reduced muscle length will affect the joint’s range of motion, and thereby the associated functional movement output. The joint will, in most cases, become fixed, and this is known as a contracture.”

The Impact on Daily Life

One reason that spasticity can be so difficult to manage is that the condition can change, sometimes from moment to moment. Something as simple as rolling over a bump or being startled can cause an incident for a wheelchair user prone to spasticity.

“Environmental or extrinsic factors can indeed trigger spasticity,” Lucas said. “Spasticity can be triggered by temperature, time of day, or anything really that causes pain or discomfort. An improperly prescribed wheelchair and seating system can also be a trigger for spasticity. This includes positioning supports, the fit of the chair, material in the positioning equipment and suspension in the chair. The trick is to try to address these factors with the wheelchair and seating system in order to decrease the spasticity the individual experiences.”

“Spasticity can be exacerbated by sudden movements, position changes, extremes in temperature, humidity and infections,” Hoffman said. “When spasms or spasticity become problematic and interfere with the function or care of the individual, then other interventions may need to be considered.”

Unfortunately, spasticity can also be linked to pain — either directly causing it or exacerbating pain that already exists.

“Pain can often trigger an increase in pain, or the spasticity can be very painful itself,” Lucas said. “Thus, we try to set up the wheelchair seating and mobility system to decrease the spasticity itself, but also make sure that the materials or parts of the chair do not cause pain that may trigger the spasticity.

“Power positioning can have great benefits with managing spasticity and should be considered with individuals who can benefit from its use. For example, for someone with flexor spasticity, the ability to recline the system may assist in stretching the muscles to decrease the tone. For an individual with extensor spasticity, power recline should be used with caution, as it could elicit the tone. However, for someone with strong extensor tone, who is pushing into the seating system, the use of power recline may provide an outlet for the body, somewhat like a dynamic seating system, and minimize the amount of time they are actively pushing into extension.”

Managing Spasticity Situations

Lucas noted that spasticity should be strongly considered when the seating and mobility team is choosing equipment.

“In fact, spasticity is a major factor in the decision-making process for the seating and mobility equipment recommendations,” he said. “Spasticity is very much dependent on the position of the body. The seating system is set up to support the individual in a position that inhibits or decreases the spasticity. Some of these recommendations could include angles of backrest/legrests, shape of cushion, amount of support, and suspension in the wheelchair.”

The team could also have to consider how a client’s spasticity will present in the future, Lucas said, because in some cases, spasticity can be expected to worsen.

“This depends on the condition causing the spasticity to occur,” he said. “If the person has a progressive condition, such as multiple sclerosis, then the severity of the spasticity will likely change or progress. If the spasticity is caused by a single event (spinal cord injury, cerebral palsy, etc.), then the severity of the spasticity typically would not progress.”

Spasticity interventions should be considered when “the secondary complications, such as increased muscle tightness, negatively impact and impair function and lead to increased pain, creating a snowball effect which, in turn, results in increased care needs and positioning difficulties,” Hoffman said.

When it comes to overall intervention, she added, the best approach can be a multi-pronged one.

“Whilst there is a myriad of treatment modalities applied to addressing spasticity and the resulting symptoms, not one intervention alone is a suitable solution in the holistic management of the individual,” Hoffman said. “Treatment methods should ideally be inclusive of prevention. The treatment ranges from non-invasive therapeutic interventions, splinting, positioning, oral medications and injectables to more invasive treatment approaches, i.e., surgical interventions.”

Regardless of how the consumer, family members, physicians and the seating and mobility team decide to act, it’s critical to find a way to manage spasticity — and that includes using seating and wheeled mobility technology to intervene, Lucas said.

“Spasticity can significantly affect a person in many ways. Due to the tightening and the effect that it has on voluntary muscle control, the person could have difficulty completing normal everyday activities, such as their activities of daily living, completion of mobility (gait or wheelchair), or speaking. This decreases their independence and increases the reliance on caregivers.

“Spasticity can also cause significant postural asymmetries, placing the individual at risk for complications such as pressure injuries and non-correctible reducible deformities. As mentioned previously, spasticity can be triggered by or cause pain. This causes decreased tolerance for daily activities and may require the increased use of medications. Therefore, it is important for clinicians and ATPs to complete a comprehensive evaluation to assess the postural support needs and positions that limit/inhibit spasticity.”

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