Table 1 Physical techniques in the management of spasticity

From: Spasticity after spinal cord injury

Physical therapy technique description and comment on effectiveness Purpose/suggested mechanisms
Positioning 15, 43  
 •In bed and during sitting •Reports of clinical effectiveness; impact remains to be proven scientifically14  •Important to the maintenance of muscle length15, 43
Range of motion/stretching  
 •Includes passive stretch and passive lengthening14, 43 •Benefits may carry over for several hours15, 16 •Effects remain to be quantified and the efficacy remains to be determined despite the clinical evidence for the benefits14  •Prevents contractures42, 43 •Causes temporary reduction in intensity of muscle contraction in reaction to muscle stretch43 •May cause plastic changes within the central nervous system and/or mechanical changes at the muscle, tendon, and soft-tissue level14
Weight-bearing  
 •Using a tilt table or standing frame •Benefits are greater than stretching alone and may persist into next day8 •Effectiveness has been questioned14  •Prolonged stretch of ankle plantar flexor muscles8, 14, 15 •Mechanism remains uncertain; suggested to include a modulating influence from cutaneous and joint receptor input to the spinal motor neurons, resulting in decreased excitability8
Muscle strengthening  
 •Progressive addition of resistance to muscles with voluntary control16, 43  •Emphasis of balance of agonist and antagonist groups of muscles with voluntary control16, 43
Electrical stimulation  
 •Various methods: stimulation to the antagonist muscle, application of tetanic contraction to the spastic muscle, functional electrical stimulation (FES), and transcutaneous electrical nerve stimulation(TENS)14, 15, 16, 43 •Reports of beneficial effects between only 10 min and 3 h14, 15, 43  •Stimulation of the antagonist muscle: augmentation of reciprocal inhibition of the spastic muscle14 •Repetitive tetanic stimulation of spastic muscle: fatigue of the muscle due to repetitive tetanic stimulation14 •FES: change the mechanical properties of a spastic joint by strengthening the antagonists of the spastic muscle or might decrease the hyperactivity of spastic muscles through reciprocal inhibition54 •TENS: may involve the stimulation of large diameter afferent fibers that travel from mechanoreceptors to the spinal cord14
Epidural spinal cord stimulation  
 •For mild spasticity and incomplete lesions: stimulation below the level of the lesion found effective (spasms)44 •For severe spasticity: stimulation of dorsal roots of the upper lumbar cord segment found effective (hypertonus and spasms)45 •Shown to lack long-term effectiveness46  •May involve the activation of inhibitory networks within the spinal cord56 •More strongly affected patients require stronger stimuli and/or higher frequencies56
Cold/heat application  
 •Application of a cold pack or a vapocoolant spray, or superficial heat •Following cold application: tendon reflex excitability and clonus may be reduced for a short period of time (eg, <1 h), allowing for intermittent improved motor function15, 16 •Following heat application: subsequent passive stretch is facilitated16  •Cold: may cause slowing of nerve conduction, decrease in sensitivity of cutaneous receptors, and alteration of CNS excitability14, 15, 16 •Heat: facilitation of uptake of released neurotransmitters and return of calcium to the sarcoplasmic reticulum16
Splinting/orthoses  
 •Helpful in the continuous application of muscle stretch •Use of splints is questioned14  •Enables long-term stretch42, 43 •Joint can be maintained in a position that does not elicit a spasm15