**2.2 Physical therapy**

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

3.Considerable increase in tone, passive movement difficult.

The modified Ashworth scale (Bohannon & Smith, 1987) is similar to the original one, except for a 1+ scoring category to indicate resistance through less than

It's demonstrated that burden of care is higher in neurological patients who developed spasticity than that of those without it, in particular regarding treatment costs, quality of life, caregiver burden, and the effects of comorbidities [21]. The treatment of muscle overactivity may be considered when the condition is disabling. Muscle overactivity usually impairs motor command, so this itself justifies the treatment. Moreover, independently from the aetiological context, it contributes to impair patient's function [22]. Nevertheless, not all patients with muscle overactivity need a specific treatment. Treatment in spasticity should be carried out only after rigorous clinical analysis, in order to determine the severity of functional impairment. A multidisciplinary approach is necessary in order to obtain this specific assessment, being different according to patient's clinical condition; it may include variably physician, physical therapist, occupational therapist, nurse, and/or caregiver [22]. In order to obtain an individual, task-oriented therapeutic strategy, it is necessary to analyse a list of personal measurable objectives, which may be different for each patient. The clinical follow-up is required in order to show the benefits as well as adverse events. Muscle spasticity, which usually is responsive to drug treatment, is not the only motor impairment in spastic paresis. It is necessary also that physiotherapy is associated to drug treatment, in order to obtain maximum gain in paresis. For example, stretch programmes can be used to treat soft tissue shortening. Therefore, before treatment, the following three questions

• Is muscle overactivity handicap an activity of daily living? Only after a detailed analysis of the functional impairment induced by spasticity, it is possible to carry out an appropriate treatment, which could be really effective to improve

• Is disability caused by muscle spasticity, or is it only a comorbidity? In the latter case, which components are involved? It is important to specify the quality of motor control and weakness. If motor impairment is induced or worsened by muscle overactivity, its treatment is to be considered mandatory, in order to

• Does muscle overactivity involve one specific muscle group, or does it spread to

Pharmacological interventions for spasticity can be divided into two groups: those that act systemically and those that act locally [24] with the locally acting treatments tending to be more invasive, systemically acting drugs used as a first step [24]. If a systematic approach, which includes baclofen, tizanidine,

other? The correct therapeutic approach depends on the answer.

4.Limb rigid, sometimes fixed in flexion or extension.

half of the movement [20].

**2.1 Indications for treatment**

must be answered:

patient's quality of life.

be helpful to the patient [23].

**2. Treatment options of spasticity**

**118**

Physiotherapy is the basic treatment for all patients with spasticity [28, 29]. It may help limit muscle contractures and reduce overactivity for a short period. Physiotherapy together with drug treatment is fundamental to obtain the best functional gain, in order to help patients adapt to changes. In all cases, physiotherapy must be considered as complementary to drugs and surgery. In fact, stretching is considered an import goal in a physiotherapy session, as largely demonstrated [30]. Functional electrical stimulation allows spasticity reduction in antagonists of the stimulated muscles. An interesting use of electrical stimulation is the stimulation of hand and finger extensors during prehension training and mixing of overactive flexor inhibition with extensor activation [31]. Finally, it is important to educate patient in self-rehabilitation sessions comprehensive of stretching postures and active exercises, eventually assisted by caregivers and/or orthoses.
