Spasticity in practice: assessment, decision-making and management

Spasticity is a common and often complex symptom of neurological conditions, and can have a significant impact on function and quality of life.

Yet during this Neurology Academy webinar, a panel of allied health professionals (AHPs) and nurses explained that not all cases need treatment – the key is understanding what matters to each individual patient, multidisciplinary input, and continuous review.

Assessment in spasticity

Spasticity is characterised by a velocity-dependent increase in muscle tone, in some cases with a “clasp-knife” response in which resistance gives way during stretch as well as more sustained activity and altered sensory processing. Noxious stimuli, such as pain, bladder issues, or constipation, can be exacerbating factors.

Before planning management, practitioners must determine whether spasticity is truly present, identify the affected muscles, and understand how it affects the individual, said Dr Stephen Ashford, consultant physiotherapist and honorary associate professor (reader) in rehabilitation at King’s College London.

Key assessment considerations include measurement of range of motion, and distinguishing between spasticity and structural muscle changes, such as shortening or contracture. This is important as each requires different interventions, Stephen explained. “When (differentiation) is difficult, we might consider assessment under an anaesthetic or a local nerve block, or we might support it with things like electromyogram (EMG) or needle EMG to specifically test muscles.” Another essential factor is the impact of spasticity function, or “why this is important to the patient”.

Common tools include the Modified Ashworth Scale (MAS), which measures passive resistance to movement, is quick and easy to administer, but has significant limitations. It does not, for example, identify the effect of speed or motion, it has poor correlation with clinical and laboratory markers, and low levels of inter- and intra-rater reproducibility.

The Modified Tardieu Scale, which considers movement speed and quality, offers more information, but is more time-consuming and “only slightly” more reliable than the MAS. “We do have problems with the scales that are available in practice… but they're very useful in enabling us to assess what's going on for the patient,” said Stephen.

While advanced methods using EMG, electrogoniometry, and force can mechanise the Tardieu scale, and improve accuracy, such approaches are not always practical or feasible in routine care.

Stephen introduced the Focal Spasticity Index, a structural tool that assesses the impact of spasticity on body function, activity, and participation using individualised goal setting. It helps evaluate the effectiveness of treatments, tracked to quality of life and cost-effectiveness outcomes.

Setting personalised goals in this way allows the patient, the family and the team to focus on how spasticity impacts on that particular person, and is used alongside standardised measures such at the Arm Activity and Leg Activity measures, explained Stephen. “It helps us think about is spasticity, as it currently presents, a problem for them, and does it need to be managed? Because not all spasticity will need to be managed,” he added.

Practical approaches to assessment and management

Liz Keenan, nurse consultant in neuro-disability at University College London Hospitals NHS Foundation Trust, explained that a structured, multidisciplinary, and goal-oriented approach to assessment optimises patient outcomes in spasticity management.

During a multidisciplinary team (MDT) clinic, HCPs/AHPs start with open questions about the patient’s main issue, whether that be pain, stiffness, mobility, or sleep, and how it impacts on their daily activities.

The MDT will review previous therapies and medications, and identify spasticity triggers, such as bowel and bladder dysfunction, pressure sores, or poor posture, before moving on to the hands-on assessment. Based on this framework, they will then develop a summary and list of recommendations, and share it with the patient, the GP, and community teams.

“We always need to think about the goal, and whether spasticity needs treatment,” she said, adding that spasticity can have positive and negative impacts on function, and that it is different for everyone. It is about “looking at the objective and the subjective scores and outcome measures, and building a bigger picture of what's impacting the patient”.

Liz presented the case study of Pat, a 54-year-old man with secondary progressive multiple sclerosis (MS), to illustrate the process. Pat experienced severe lower limb spasticity that disrupted his sleep and his mobility, which he said were his biggest concerns. Despite taking baclofen and gabapentin, his nighttime spasms persisted. Following review if his medications, triggers and goals, clonazepam at night while gradually reducing his nighttime baclofen. This significantly improved his sleep quality, daytime alertness, and functional mobility, allowing him to reposition in bed and perform exercises more easily.

Pat’s story, Liz said, highlighted the importance of individualised medication planning, that targets symptoms based on patient goals, and the principle of “start low and go slow” when adjusting medications.

MDT approach to management of spasticity and outcome evaluation

Lynsay Duke, associate AHP director of neurological and specialist services and professional lead of neuro occupational therapy at Walkergate Park Centre for Neurorehabilitation and Neuropsychiatry, reiterated the importance of MDT care and a personalised approach to management.

Goal setting and outcome measurement are crucial, she went on. “You need to continue to monitor and review,” she said, adding that managing triggers, especially pain, was really important and that presentations may change with comorbidities, aging, or other factors such as infection or times of stress.

She outlined the case of George, a 56-year-old man, who, after suffering a stroke, experienced focal spasticity in his left arm and hand. This caused functional limitations, altered gait, pain, and cosmetic concerns. He said his main problem his arm pulling up and his tight fingers, and his goals included lowering his elbow during walking and improving hand opening for hygiene and nail care.

Treatment involved botulinum toxin injections into targeted muscles, as well as non-pharmacological strategies, including a custom thermoplastic hand splint, a Lycra arm sleeve, community physiotherapy, and psychological support. The interventions were tailored to balance spasticity reduction with functional stability: while the tightness in his fingers was troubling, it also helped him with grip while in the gym, Lynsay explained.

Using objective measures, including 10-meter walk tests and functional assessments, alongside goal attainment and satisfaction scores, allowed the team to adjust treatment to address triggers like pain or posture. Over time, his elbow and hand function improved, and his perceived burden of spasticity decreased significantly.

The case demonstrated that effective spasticity management is a dynamic, iterative process of continuous assessment that requires patient engagement and MDT input.

“Getting patients involved and… educated is really key”, Lynsay went on, adding that practitioners needed to be aware of their own limitations and to refer on where necessary.

Medication monitoring: Involving AHPs in clinical effectiveness

AHPs have a vital role in monitoring spasticity medications, as it directly impacts rehabilitation outcomes and patient well-being, said Dr Wendy Hendrie, MS specialist physiotherapist at the Norwich MS Centre.

“We often think it's somebody else's job to put these people on medications and monitor them,” said Wendy. “(But) it is very important that you engage with these drugs because getting it right is a balancing act.”

Oral spasticity medications such as baclofen, gabapentin, and tizanidine need to be tailored to the induvial, monitored for effectiveness, and regularly reviewed, she explained.

Muscle changes over time, meaning response to medication may also alter. Many factors, from the weather to background disease activity, can influence symptoms and necessitate dose adjustments to avoid under- or over-medication.

Too high a dose can cause muscle weakness, reduce cognitive function, and increase fatigue and ataxia. Too low a dose can lead to hypertonia, postural abnormalities, spastic gait, secondary complications, and poor sleep.

In addition, spasticity medications are “not terribly selective” meaning “they may hinder rehab” in some instances, and they can come with side effects that may mimic underlying condition progression.

Wendy shared the story of Mary, who is living with MS and had been taking gabapentin for her spasticity for 15 years. When she developed incontinence five years ago, she and her care team thought her condition was deteriorating. After a review with her physiotherapist, however, she spoke to her GP and slowly discontinued the drug. Not only did the incontinence resolve, but she had reduced fatigue, improved posture, and, importantly, a better quality of life.

“My physio has given me my life back,” said Mary, with Wendy explaining that the drug had been preventing her patient from maximising her rehab potential, and may have led to secondary complications if it had not been stopped.

Wendy recommended using spasm diaries to track timing, triggers, and functional impact of medications, and collaborating with patients and prescribers to suggest dose adjustments or timing changes.

Ultimately, she concluded, regularly reviewing medications helps ensure they remain effective, appropriate, and tailored to patient’s individual goals.

Q&A

Where can I find the Goal Attainment Scaling (GAS) measure?

GAS, along with arm (ArmA) and leg (LegA)activity measures, are available from the Cicily Saunders Institute, King’s College London website. While the latest version of ArmA is not yet online, it will be uploaded shortly.

How can practitioners differentiate between contracture, fibrotic changes, and spasticity?

Practitioners should assess muscle reactions during both slow and fast stretches and examine the available range of motion. In complex cases, interventions such as nerve blocks orexamination under anaesthetic, may be required to distinguish underlying issues.

What is the difference between spasms following stroke versus spinal cord injury?

Spasms vary depending on their neurological origin. Stroke-related spasms are centrally driven from the brain, while spinal cord-related spasms may involve full-body extensor rigidity. Practitioners should observe spasms, and discuss symptoms with the patient, asking them what they mean by the word “spasm” and what the triggers are.

Can mobilisation or weight-bearing worsen spasticity, or can it improve over time?

Spasticity is highly individual. Weight-bearing may temporarily reduce tone in some patients, but not all. Positioning, such as maintaining head and trunk flexion, can significantly influence tone during activities. Over time, improvements in motor control, particularly post-stroke, may reduce spasticity, though variability is high.

Should spasticity be treated immediately or only at a later stage?

Treatment can be considered at any stage. Decisions should weigh risks, benefits, alternatives, and the option of watchful waiting. Tailoring intervention to the patient’s individual circumstances is essential.

How should therapy and splinting be managed following botulinum toxin injections?

Effects typically begin 5–10 days post-injection. Patients should continue stretche, exercise, and splint use. A review at six weeks allows clinicians to evaluate effectiveness and adjust therapy. Education for patients is essential to maintain interventions between clinical reviews.

Are AHPs permitted to monitor or provide feedback on medications?

Yes. While prescribing will only be within scope for AHP’s specifically qualified and licenced, monitoring and providing feedback on medication effects is within scope of practice for all and is essential for effective rehabilitation.

What non-neurological factors can exacerbate spasticity?

Spasticity may worsen due to triggers such as inappropriate or uncomfortable positioning, infections, ingrown toenails, constipation, or urinary tract infections. Addressing these can prevent unnecessary medication use and optimise functional outcomes.

How should spasticity management be integrated into rehabilitation programs?

Effective physical management requires individualised assessment and is an integral part of spasticity management. Interventions may include for example: task-training, re-education, splinting, and serial casting.