**4. Physical management of spasticity(physiotherapy or occupational therapy)**

The key to a satisfying treatment for spasticity is to educate the patient properly and ensure that the patient follows the instructions correctly. Also, as spasticity changes during the treatment, treatment regimens should change with the patient's condition and be flexible. Proper patient management requires physiotherapy initiation immediately after the disease diagnosis and at regular intervals throughout the disease course, depending on the patient's condition and the diagnosis made by the treatment team. On the other hand, assessment and differentiation between the neuronal and non-neuronal (connective tissue, joint component, muscle, and tendon) causes of hypertonia are critical because the treatment of non-neuronal [14] (passive) causes involves physical therapies such as stretching and splinting; these problems do not respond to medical treatments.

### **4.1 Physical management strategies**

The goal of physical management is to maintain and even improve the performance level and prevent the problems secondary to spasticity. In fact, spasticity reduction is not always a treatment goal, as in some cases maintaining the patient's function requires a little spasticity and increased tone. Therefore, physical management focuses on the performance, discomfort and pain relief, and prevention of secondary complications including contractures and pressure ulcers. The key goals of a physical management plan include the following [2]:

• Maintaining the viscoelastic characteristics of tissues including tendons, muscles, and joints to prevent contractures. This goal is achieved through active and passive movements as well as standing and stretching with splints. the patient's daily life activities and include all the involved muscles [23, 24]. Although no specific protocol has been suggested for this kind of patients, most studies recommend the protocol adapted from the sport sources. These traditional training rates are a load of 60–80% of one repetition maximum (the maximum load that can be lifted once), three sets of 10 repetitions carried out three or four

Alongside these exercises, cardiovascular fitness exercises have been recommended in various papers [25, 26]. Because these exercises are being

be used in an intensive program over a short period (e.g., 4–8 weeks) [27].

ondary non-neuronal complications, and improving positioning [2]. It is

recommended to perform the passive movements daily, and it can be carried out before the patient repositioning. These movements should be safe and comfortable for both the patient and caregiver. Spasmolytic medication taking in 20–30 minutes before the movements can be helpful [2]. Sometimes sudden stretching can exacerbate the spasm, so the movements should be performed at slow speed. Skin irritations can cause symptom exacerbation as well; thus, the best way is to desensitize the skin on a gradual basis or handling the limb on top of clothes. Grabbing and holding the ball of the foot should be avoided because it is usually a sensitive point for these triggers and better not to be touched [2]. Moreover, the movements should be carried out with the best alignments of the muscles and joints, overstretching should not occur, and stereotypical spasticity patterning (e.g., flexing the hip in the midline rather than in adduction and internal rotation) should

The critical point is that after the movements are over, the patient should be positioned properly. The position should not be the same as the previous position caused by spasms to keep the benefits of the movements [2]. Usually, these movements are not performed by the physician or therapist because it is time-consuming and is not cost-effective. So in addition to providing written material on the right techniques for the patient and caregivers, assistance appliances such as continuous

passive movement machines (CPMs) or lifters (hoist) can also be used [2].

following protocol can be considered for the daily schedule [30, 31].

Typically, with a 2-day immobilization, muscle changes initiate, including muscle shortening and atrophy, muscle compliance reduction, and increasing the ratio of collagen to muscle fibers [21]. Following these changes, there will be an increase in the sensitivity of muscle spindles to stretching, which can exacerbate the neuronal component of spasticity and subsequently the non-neural component [28]. On the other hand, stretching induces actin and myosin synthesis; as a result, the number of sarcomeres as well as the muscle length increases [21, 29]. So far, there is no agreement on the duration and frequency of stretching exercises but the

The task-focused active-use therapy techniques such as the constraint-induced movement therapy can sometimes be used for upper limbs. The techniques should

When the patient cannot move his/her limb, passive movements can be carried out by another person. In passive movement, generally, all the body joints should be moved in their ranges of motion daily. According to the studies, it seems that using passive movements can be effective in changing spasticity pattern, alleviating sec-

neglected in these patients due to their inactivity especially.

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

times a week.

be avoided.

**4.5 Stretches**

**93**

**4.4 Passive movement**


## **4.2 Standing**

Standing is considered as a therapeutic option since it activates the anti-gravity muscles, improves flexibility, reduces contractures, modulates the neuronal component of spasticity, reduces sensory inputs and lower limb spasms, and has positive psychological effects [15–18]. Regarding the duration and frequency of this physical therapy, studies have suggested a duration of between 30 minutes and 1.5 hours while most patients have performed this exercise for 40 minutes and with a frequency of three to four times a week [18–20]. Remember that the duration and frequency depend on the patient's condition; so, the decision should be made based on this factor. However, at least 30 minutes of standing seems to be reasonable. The best standing position is in an extended posture with neutral alignment of the trunk, pelvis, and lower limb joints, carried out actively by the patient himself/herself or by using standing aids including Oswestry standing frames, motorized or hydraulically assisted standing systems, standing wheelchairs, or at least a tilt table (according to the patient symptom severity respectively) [2]. In all these cases, hypotension is the most notable complication, which can be prevented by arrangements such as avoiding sudden position change or by using compression stockings.

### **4.3 Active exercise and promotion of optimal movement patterns**

In most of the cases, patients with spasticity are advised for spasticity reduction and less attention is paid to muscle weakness, and sometimes strengthening exercises are not prescribed because of the concern for spasticity exacerbation [21]. It is recommended, to the extent possible, to perform active exercises in order to increase the strength, re-educate movement patterns, and improve cardiovascular fitness. The outcomes achieved by these exercises are not usually observed in passive exercises. Nowadays, it has been found that not only is antagonist muscle weakness effective in spasticity, but also an imbalance between agonist and antagonist muscles exacerbates the symptoms and causes atrophy [21]. The movement patterns should also change; in fact, proper movement patterns should be instructed. At the same time with limb exercises, the alignments of the trunk and pelvic girdle should be maintained. These exercises alter muscle functions and structures [22]. The strengthening recommendations should be realistic and close to

### *Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

the patient's daily life activities and include all the involved muscles [23, 24]. Although no specific protocol has been suggested for this kind of patients, most studies recommend the protocol adapted from the sport sources. These traditional training rates are a load of 60–80% of one repetition maximum (the maximum load that can be lifted once), three sets of 10 repetitions carried out three or four times a week.

Alongside these exercises, cardiovascular fitness exercises have been recommended in various papers [25, 26]. Because these exercises are being neglected in these patients due to their inactivity especially.

The task-focused active-use therapy techniques such as the constraint-induced movement therapy can sometimes be used for upper limbs. The techniques should be used in an intensive program over a short period (e.g., 4–8 weeks) [27].

### **4.4 Passive movement**

• Maintaining the viscoelastic characteristics of tissues including tendons, muscles, and joints to prevent contractures. This goal is achieved through active and passive movements as well as standing and stretching with splints.

• Maintaining the individual's level of performance. It can be achieved by

• Evaluation of spasticity as a positive factor in the patient's function. But a balance should be maintained between the benefits and spasticity-induced

• Generally, there is no single physical modality and the treatments are parallel and concomitant, depending on the patient's conditions. In the following, the

Standing is considered as a therapeutic option since it activates the anti-gravity muscles, improves flexibility, reduces contractures, modulates the neuronal component of spasticity, reduces sensory inputs and lower limb spasms, and has positive psychological effects [15–18]. Regarding the duration and frequency of this physical therapy, studies have suggested a duration of between 30 minutes and 1.5 hours while most patients have performed this exercise for 40 minutes and with a frequency of three to four times a week [18–20]. Remember that the duration and frequency depend on the patient's condition; so, the decision should be made based on this factor. However, at least 30 minutes of standing seems to be reasonable. The best standing position is in an extended posture with neutral alignment of the trunk, pelvis, and lower limb joints, carried out actively by the patient himself/herself or by using standing aids including Oswestry standing frames, motorized or hydrauli-

cally assisted standing systems, standing wheelchairs, or at least a tilt table (according to the patient symptom severity respectively) [2]. In all these cases, hypotension is the most notable complication, which can be prevented by arrangements such as avoiding sudden position change or by using compression stockings.

**4.3 Active exercise and promotion of optimal movement patterns**

patterns should also change; in fact, proper movement patterns should be

instructed. At the same time with limb exercises, the alignments of the trunk and pelvic girdle should be maintained. These exercises alter muscle functions and structures [22]. The strengthening recommendations should be realistic and close to

In most of the cases, patients with spasticity are advised for spasticity reduction and less attention is paid to muscle weakness, and sometimes strengthening exercises are not prescribed because of the concern for spasticity exacerbation [21]. It is recommended, to the extent possible, to perform active exercises in order to increase the strength, re-educate movement patterns, and improve cardiovascular fitness. The outcomes achieved by these exercises are not usually observed in passive exercises. Nowadays, it has been found that not only is antagonist muscle weakness effective in spasticity, but also an imbalance between agonist and antagonist muscles exacerbates the symptoms and causes atrophy [21]. The movement

strengthening activities and keeping cardiovascular fitness.

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

treatment options will be discussed in detail.

exacerbating the symptoms.

complications.

**4.2 Standing**

**92**

• Controlling the spasticity and spasm so that they will not be self-perpetuating; for example, using techniques and methods in the situations and positions

> When the patient cannot move his/her limb, passive movements can be carried out by another person. In passive movement, generally, all the body joints should be moved in their ranges of motion daily. According to the studies, it seems that using passive movements can be effective in changing spasticity pattern, alleviating secondary non-neuronal complications, and improving positioning [2]. It is recommended to perform the passive movements daily, and it can be carried out before the patient repositioning. These movements should be safe and comfortable for both the patient and caregiver. Spasmolytic medication taking in 20–30 minutes before the movements can be helpful [2]. Sometimes sudden stretching can exacerbate the spasm, so the movements should be performed at slow speed. Skin irritations can cause symptom exacerbation as well; thus, the best way is to desensitize the skin on a gradual basis or handling the limb on top of clothes. Grabbing and holding the ball of the foot should be avoided because it is usually a sensitive point for these triggers and better not to be touched [2]. Moreover, the movements should be carried out with the best alignments of the muscles and joints, overstretching should not occur, and stereotypical spasticity patterning (e.g., flexing the hip in the midline rather than in adduction and internal rotation) should be avoided.

> The critical point is that after the movements are over, the patient should be positioned properly. The position should not be the same as the previous position caused by spasms to keep the benefits of the movements [2]. Usually, these movements are not performed by the physician or therapist because it is time-consuming and is not cost-effective. So in addition to providing written material on the right techniques for the patient and caregivers, assistance appliances such as continuous passive movement machines (CPMs) or lifters (hoist) can also be used [2].

### **4.5 Stretches**

Typically, with a 2-day immobilization, muscle changes initiate, including muscle shortening and atrophy, muscle compliance reduction, and increasing the ratio of collagen to muscle fibers [21]. Following these changes, there will be an increase in the sensitivity of muscle spindles to stretching, which can exacerbate the neuronal component of spasticity and subsequently the non-neural component [28]. On the other hand, stretching induces actin and myosin synthesis; as a result, the number of sarcomeres as well as the muscle length increases [21, 29]. So far, there is no agreement on the duration and frequency of stretching exercises but the following protocol can be considered for the daily schedule [30, 31].

It is suggested to administer the stretching according to the patient's daily schedule and his/her posture [2]. The stretching can be carried out actively or passively (by someone else or with FES). We can use the positioning, for example standing, sitting, or lying down with using splints and orthosis, to achieve a prolonged stretching. Another important point is that while stretching a muscle, the antagonist muscle shortens, so there should be a balance in the stretching schedules for all the muscles [2, 32]. Regarding the duration of stretching, studies have suggested 20, 30, or even 60 minutes. So, there is no single protocol [30], but it seems that the efficacy increases with longer durations. Also, it seems that stretching before the exercises has a more favorable effect.

providing support for the patient's back (by the backward movement of the backrest). Also, these seats improve kyphosis and breathing of the patients and reduce

As the patient's spasticity status changes throughout the treatment, it is neces-

Orthoses or splints are tools for improving limb performance and preventing

• Providing control over the joint's range of motion and thus improving its

• Modifying deformities established (e.g., using heel raise in leg length

• Maintaining prolonged stretches on the muscle's tendon to alter or modify the

• Changing the neuronal component of spasticity through prolonged stretches

In administering orthoses, in addition to discussing the treatment goals with patients, the method of use, duration, and times of use should be discussed as well. In each visit, the patient should be asked about pain, discomfort, and sleep disorder, while muscle wasting and the places under pressure by orthosis should be examined. Incorrect orthosis usage and feeling discomfort with orthosis use can exacerbate the symptoms and cause new deformities. There is no contraindication for administering orthoses; however, some problems addressed in **Table 4** can limit the use of splints, so these points should be noticed during the follow-up visits and

The most common splints based on the usage area are discussed here according

according to **Tables 5** and **6** [40]. However, some of the splints are not mentioned here, we did not intend to deny their effects but only the splints with the best

to the evidence from different sources and guidelines. Evidence grading is

deformity. These appliances are usually custom-made [39]. Non-removable splinting devices made of plaster or casting tape are referred to as "casts." Casts are also a type of splint. Orthoses are used for the following treatment

fatigue and pressure ulcers.

**5. Orthosis**

goals [27, 39]:

performance.

discrepancy).

changes occurred in tissues.

and sensory input alteration.

• Increasing the patient's comfort.

• Improving walking efficiency.

proper solutions should be considered [2].

evidence are discussed.

**95**

• Correction of upper extremity performance.

• In children, preventing hip migration or slowing its progress.

• Correction of the posture.

sary to re-evaluate the patient's sitting position.

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

The patient should be given written instruction on stretching. Stretches should include the back muscles, quadriceps, hip flexors, hip adductors, hamstrings, calf muscles (gastrocnemius and soleus), wrists, and fingers, and should be performed actively or passively. The therapist should modify the stretching based on each patient's condition.

### **4.6 Positioning**

As well as improving the effective stretching and subsequent maintaining of range of motion, correct positioning also helps in altering the spasticity pattern, modifying asymmetry, and decreasing the risk of pressure-induced skin injuries [33]. The golden key to good positioning is to change the position during the day. An ideal position is important in both lying and sitting; moreover, the presence of exacerbating factors and triggers (e.g., pressure sore, pain) is critical in position selection. Performing passive exercises before positioning is helpful; for example, when the patient tries to use a T roll for the leg flexion position, performing several knee and hip flexions and bending the hips and knees up toward the chest and abdomen facilitate this position [34].

In correct positioning, muscles should be stretched and longer than usual. For example, these are the suggestions to improve the positioning in a patient with continuous spasticity-induced hip adduction: The patient should monitor his/her sitting position and try to keep his/her knees apart while sitting so that he/she does not get accustomed to the wrong position. The impact of trunk and pelvis positions on the legs should be evaluated. In a flexed posture with a posteriorly tilted pelvis, the legs tend to be in internal rotation and adduction; so, having a firmer seat base, a contoured cushion, or extra trunk support may facilitate a more anteriorly tilted pelvis position, trunk extension, and better lower limbs alignment. In patients unable to reduce adduction, using aids including a pummel, rolled-up towel, cushion or T roll can help in reducing the adduction.

### **4.7 Wheelchair and seating**

In patients suffering from spasticity, the sitting position should be modified to improve the performance, accommodate to contractures and deformities established, maintain comfort, and reduce fatigue [35, 36]. The main requirements for a good sitting position are a firm seat base and backrest with subtle changes by altering the seat base to promote an anterior tilt of the pelvis to help in achieving hip flexion, abduction, and external rotation as well as trunk extension.

Patients with weakness in the trunk and neck extensors can use the tilt-in-space systems [37, 38], where the patient seat has a reclining at the back and flexion at the hip. In this system, hip flexion decreases the extension tone and spasticity as well as *Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

providing support for the patient's back (by the backward movement of the backrest). Also, these seats improve kyphosis and breathing of the patients and reduce fatigue and pressure ulcers.

As the patient's spasticity status changes throughout the treatment, it is necessary to re-evaluate the patient's sitting position.
