Muscle Spasticity

Muscle spasticity is a condition where muscles become stiff, tight, and resist being stretched, making movement difficult and sometimes painful. It affects people with various neurological conditions and can range from mild muscle tightness to severe, uncontrollable spasms that significantly impact daily life.

Table of contents

• What is Muscle Spasticity?
• What Causes Muscle Spasticity?
• Signs and Symptoms
• Possible Complications
• How Common is Spasticity?
• Testing and Diagnosis
• Treatment Options
• Self-Care and Daily Management
• When to Seek Medical Care

What is Muscle Spasticity?

Muscle spasticity is a disruption in muscle movement patterns that causes certain muscles to contract all at once when you try to move or even at rest^[1]. The muscles remain contracted and resist being stretched, which interferes with movement and can also affect your speech and the way you walk^[1].

Muscle tone refers to how tight or loose your muscles are. In spasticity, muscle tone increases abnormally, a condition called hypertonia^[3]. This happens because muscle movements are normally controlled by a complex system that allows some muscles to contract while others relax. When nerves in your central nervous system (your brain and spinal cord) are damaged, this pattern is disrupted^[1]. As a result, many muscles may contract all at once, making it difficult to perform voluntary movements^[1].

Spasticity is considered a positive sign of upper motor neuron syndrome, which refers to motor behaviors resulting from damage to nerve pathways in the spinal cord or brain^[3]. The damage leads to loss of inhibition downstream and increased sensitivity of the reflex arc within the spinal cord^[3].

The severity of spasticity varies greatly from person to person. It may be as mild as a feeling of tightness in your muscles or so severe that it causes painful, uncontrollable stiffness and spasms of your arms and legs^[1]. In some people, spasticity is hardly noticeable, while in others it is severely limiting^[10].

What Causes Muscle Spasticity?

Spasticity is usually caused by damage to nerve pathways within your brain or spinal cord that control movement and stretch reflexes^[1]. This damage is generally caused by disruption to the area of the brain and spinal cord responsible for controlling muscle and stretch reflexes^[2]. These disruptions can be due to an imbalance in the signals sent to the muscles, causing them to lock in place^[2].

Many clinical conditions can lead to spasticity, including:

• Stroke — interrupts blood supply to part of the brain, causing brain cells to die^[4]
• Spinal cord injury — disrupts spinal cord function, potentially causing muscle overactivity^[5]
• Multiple sclerosis (MS) — damages the protective covering of nerve fibers in the brain and spinal cord^[1]
• Cerebral palsy — a group of disorders affecting movement and coordination, originating from damage to the developing brain^[4]
• Traumatic brain injury (TBI) — severe injuries to the brain can disrupt its ability to send proper signals to muscles^[5]
• Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease — a progressive neurological disease that causes death of neurons controlling voluntary muscles^[1]
• Hereditary spastic paraplegias — inherited conditions involving progressive stiffness and weakness, particularly in the legs^[5]

Other less common causes include infections of the brain or spinal cord, metabolic diseases, brain damage from lack of oxygen, and certain rare genetic conditions such as phenylketonuria and Krabbe disease^[4].

Signs and Symptoms

Spasticity can involve a range of symptoms that vary in severity^[1]:

• Increased muscle tone (hypertonia) — muscles feel stiff, heavy, and difficult to move and bend^[2]
• Muscle spasms — quick or sustained involuntary muscle contractions that can be painful^[1]
• Clonus — a series of fast involuntary muscle contractions that may feel like a tremor, most often experienced in the ankles^[1]
• Involuntary crossing of the legs^[1]
• Pain or discomfort^[1]
• Abnormal posture^[1]
• Difficulty stretching muscles^[2]
• Muscle fatigue^[2]
• Limited, slow movements^[4]
• Exaggerated deep tendon reflexes, like an overly strong knee-jerk reflex^[4]

Spasticity commonly affects specific areas of the body. In the arms, it usually happens in the muscles that pull the arm toward the body and bend the elbow, wrist, and fingers^[10]. In the legs, it usually affects the muscles that turn the hip inward, extend the knee, and pull the foot down and inward^[10]. Spasticity can also affect speech and swallowing in some people^[2].

The condition can make it difficult to perform daily activities and make it harder for others to help with tasks such as dressing and bathing^[1]. Sleep may be disrupted due to painful spasms or muscle tightness^[1].

Possible Complications

If left untreated, spasticity can lead to several serious complications^[1]:

• Contractures — permanent contraction of muscles and tendons, causing joints to become frozen or immobilized in one position^[1]
• Muscle, joint, or bone deformities^[1]
• Bone fractures^[1]
• Partial or full dislocation of joints^[1]
• Pressure injuries (bedsores), which can lead to infection and sepsis (a life-threatening response to infection)^[1]
• Urinary tract infections^[1]
• Chronic constipation^[1]

In a severe state, spasticity can interfere with daily function and cause extreme pain. It can also make it more difficult to perform basic hygiene tasks and personal care^[1].

However, spasticity is not always harmful. For some patients, it can prove beneficial, allowing them to walk or simply stand and bear weight, which in turn decreases their risk of developing osteoporosis, aids in improved circulation, and improves overall mental health^[3].

How Common is Spasticity?

Spasticity is a common complication of several neurological conditions. The frequency varies depending on the underlying disease^[3]:

• About 25% to 43% of stroke survivors will have spasticity in the first year after their stroke^[7]. Approximately 35% of those with stroke are affected^[3]
• More than 90% of people with cerebral palsy experience spasticity^[3]
• About 50% of traumatic brain injury patients develop spasticity^[3]
• Approximately 40% of spinal cord injury patients are affected^[3]
• Between 37% and 78% of multiple sclerosis patients experience spasticity^[3]

Spasticity is more common in younger stroke survivors^[7].

Testing and Diagnosis

Due to the varying degrees of spasticity, diagnosis may not always be straightforward^[2]. A physical examination with neurological testing will be done to test for spasticity and its severity^[2].

During the examination, your healthcare provider will check for increased muscle tone and resistance when trying to move your joints. They will also test your reflexes and observe your movement patterns^[2].

Imaging tests such as magnetic resonance imaging (MRI) can provide more information on the source of spasticity and the extent of the damage that has caused it^[2].

Your provider will ask about your medical history, including when the spasticity was first noticed, how long it has lasted, whether it is always present, which muscles are affected, and what makes it better or worse^[4].

Treatment Options

A variety of treatment strategies are available for managing spasticity, and patients usually undergo more than one treatment at a time^[2]. The following treatments have been shown to effectively alleviate symptoms and improve quality of daily life^[2].

Physical and Occupational Therapy

Physical therapy involves stretching and strengthening exercises focusing on large muscle groups to improve range of motion and mobility^[2]. Occupational therapy uses exercises that focus on small muscle groups to improve strength and coordination, allowing for improved performance of daily tasks^[2]. Speech therapy can also help patients whose spasticity has affected their speech^[2].

Your physical therapist can teach you and your caregiver stretching exercises you can do at home. These stretches will help keep your muscles from getting shorter or tighter^[15]. Being active also helps keep your muscles loose. Aerobic exercise, such as swimming, and strength-building exercises are helpful, as are playing sports and doing daily tasks^[15].

Assistive Devices and Positioning

Casting or bracing prevents involuntary spasms and reduces tightening of the muscles^[2]. Your provider or physical/occupational therapist may place splints or casts on some of your joints to keep them from becoming so tight that you cannot move them easily^[15].

Assistive devices such as braces, foot drop supports, orthotics, wrist supports, walkers or canes, grab bars, shower benches, and raised toilet seats may help you move around more easily and maintain your independence^[16].

Oral Medications

Oral medications are used in combination with other therapies and are typically prescribed if symptoms interfere with daily functioning or sleep^[2]. Common medications include:

• Baclofen (brand name Lioresal) — the most commonly used medication to help relax muscles or reduce tone^[14]
• Tizanidine (brand name Zanaflex) — a short-acting drug useful for treating nighttime spasms^[14]
• Benzodiazepines such as diazepam (Valium) and clonazepam (Klonopin) — sedatives that slow the central nervous system^[14]
• Dantrolene sodium (brand name Dantrium) — works to reduce muscle contraction but may cause liver damage^[14]
• Gabapentin (brand name Neurontin)^[2]

These medicines have side effects including tiredness during the day, confusion, feeling “hung over” in the morning, nausea, and problems passing urine^[15]. Contact your provider if you experience any troublesome side effects. Do not just stop taking these medicines suddenly, as it can be dangerous^[15].

Botulinum Toxin Injections

Botulinum toxin (Botox) injections can be used to paralyze the spastic muscle, preventing it from contracting^[2]. In small amounts, Botox is injected directly into the muscle at carefully selected sites determined based on the pattern of spasticity^[2]. Botox injections can last up to 12 to 16 weeks^[2].

Intrathecal Baclofen Pump

If high oral doses of medication result in too much sedation, an intrathecal baclofen pump can be considered^[14]. The pump is surgically implanted in the abdomen and delivers small, continuous doses of medication directly to the spinal canal^[14]. This can result in better performance with minimal side effects. The pump can be programmed to release a specific amount of medicine at select times and needs to be refilled every one to three months^[14].

Phenol Injections

Phenol or alcohol injections can be used to block nerve signals that cause spasticity^[9]. These are focal injections administered at specific sites.

Surgical Options

Surgical treatments may be considered in severe cases and include selective dorsal rhizotomy (cutting specific nerve roots) and neurectomy (cutting the nerve-muscle pathway)^[15]. Surgery to release tendons or correct deformities may also be performed^[2].

Self-Care and Daily Management

Several factors can make spasticity worse, and learning to recognize and manage these triggers is important^[15]:

• Being too hot or too cold^[15]
• The time of day^[15]
• Stress^[15]
• Tight clothing^[15]
• Bladder infections and spasms^[15]
• Being very tired or not getting enough sleep^[15]
• New skin wounds or ulcers^[15]
• Constipation^[21]
• Infections^[21]
• Fatigue and poor sleep^[21]

It is important to be as active as possible. The less you move, the worse muscle spasticity may get^[19]. Keep doing your exercises as recommended by your physiotherapist or occupational therapist. Join an exercise group or get into activities you enjoy with friends and family^[19].

Stretch every day. Though stretching usually won’t improve your symptoms, it helps prevent your muscles from permanently shortening or shrinking^[16]. When you stretch, make sure it doesn’t hurt or isn’t too uncomfortable, as that might indicate the stretching is too much for you^[16].

Practice stress management and, if needed, speak to a therapist to reduce stress and avoid spasticity flare-ups^[21]. Get adequate sleep and maintain a healthy diet^[16].

Be careful about getting pressure sores from exercise or being in the same position in a bed or wheelchair for too long^[15]. Muscle spasticity can increase your chances of falling and hurting yourself, so be sure to take precautions^[15].

When to Seek Medical Care

It is important to seek medical care when^[2]:

• Spasticity is experienced for the first time with no known cause
• The spasticity is worsening and becoming more frequent
• Pain is experienced due to stiff joints and muscles
• The condition is preventing performance of everyday tasks

Always contact your provider if you have^[15]:

• Problems with the medicines you are taking for muscle spasms
• Can’t move your joints as much (joint contracture)
• Harder time moving around or getting out of your bed or chair
• Skin sores or skin redness
• Your pain is getting worse

Prolonged and untreated spasticity can lead to frozen joints or pressure sores on the skin, which are very painful^[2]. Pay attention to changes in your muscle spasticity, as changes may mean that your other medical problems are getting worse^[15].

Talk with your doctor, physiotherapist, and occupational therapist about any changes to your muscles^[19].