Editing Spasticity (section)

== Treatment ==
Treatment should be based on assessment by relevant health professionals.  For spastic muscles with mild-to-moderate impairment, [[strength training|exercise]] should be the mainstay of management, and is likely needed to be prescribed by a physiatrist (a doctor specialized in rehabilitation medicine), occupational therapist, physical therapist, accredited exercise physiologist (AEP) or other health professional skilled in neurological rehabilitation.{{citation needed|date=December 2020}}

Muscles with severe spasticity are likely to be more limited in their ability to exercise, and may require help to do this. In spastic [[cerebral palsy]] children the main treatment modality of spasticity is conservative in the form of [[botulinum toxin]] A injection and various physical therapy modalities such as serial casting, sustained stretching and medical pharmacologic treatment.<ref name=farag2020>{{cite journal | vauthors = Farag SM, Mohammed MO, El-Sobky TA, ElKadery NA, ElZohiery AK | title = Botulinum Toxin A Injection in Treatment of Upper Limb Spasticity in Children with Cerebral Palsy: A Systematic Review of Randomized Controlled Trials | journal = JBJS Reviews | volume = 8 | issue = 3 | pages = e0119 | date = March 2020 | pmid = 32224633 | pmc = 7161716 | doi = 10.2106/JBJS.RVW.19.00119 }}</ref><ref name=Blumetti2019>{{cite journal | vauthors = Blumetti FC, Belloti JC, Tamaoki MJ, Pinto JA | title = Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 10 | pages = CD001408 | date = October 2019 | pmid = 31591703 | pmc = 6779591 | doi = 10.1002/14651858.CD001408.pub2 }}</ref> Spasticity in [[cerebral palsy]] children is usually generalized although with varying degrees of severity across the affected extremities and trunk musculature.<ref name=farag2020/><ref name=Blumetti2019/> Neglected or inappropriately treated spasticity can eventually lead to joint contractures. Both spasticity and contractures can cause joint subluxations or dislocations and severe gait difficulties.<ref name=elsobky2018>{{cite journal | vauthors = El-Sobky TA, Fayyad TA, Kotb AM, Kaldas B | title = Bony reconstruction of hip in cerebral palsy children Gross Motor Function Classification System levels III to V: a systematic review | journal = Journal of Pediatric Orthopedics. Part B | volume = 27 | issue = 3 | pages = 221–230 | date = May 2018 | pmid = 28953164 | doi = 10.1097/BPB.0000000000000503 | s2cid = 4204446 }}</ref><ref name=Galey2017/> In the event of contracture there is no role for conservative treatment. Hip dislocation and ankle equinus deformity are known to arise from muscle spasticity primarily. Orthopedic surgical reconstruction of the hip is commonly practiced to improve sitting balance, nursing care and relieve hip pain.<ref name=elsobky2018/><ref name=Galey2017/>
Treatment should be done with firm and constant manual contact positioned over nonspastic areas to avoid stimulating the spastic muscle(s). Alternatively, [[rehabilitation robotics]] can be used to provide high volumes of passive or assisted movement, depending on the individual's requirements;<ref>{{cite book | vauthors = Hillman M | date = 2004 | chapter = Rehabilitation robotics from past to present: A historical perspective. | veditors = Bien ZZ, Stefanov D | title = Advances in ''Rehabilitation Robotics'' | pages = 25–44 | location = Berlin | publisher = Springer-Verlag }}</ref> this form of therapy can be useful if therapists are at a premium, and has been found effective at reducing spasticity in patients with [[stroke]]s.<ref>{{cite journal | vauthors = Krebs HI, Palazzolo JJ, Dipietro L, Ferraro M, Krol J, Rannekleiv K, Volpe BT, Hogan N | year = 2003 | title = Rehabilitation robotics: Performance-based progressive robot-assisted therapy | journal = Automatic Robots | volume = 15 | pages = 7–20 |display-authors = 6 | doi = 10.1023/A:1024494031121 | s2cid = 39313352 }}</ref>  For muscles that lack any volitional control, such as after complete [[spinal cord injury]], exercise may be assisted, and may require equipment, such as using a standing frame to sustain a standing position.{{citation needed|date=December 2020}}

A general treatment guideline can be followed that involves:<ref>{{cite book| vauthors = O'Sullivan S |title=Physical Rehabilitation|year=2007|publisher=F.A Davis Company|location=Philadelphia, PA|pages=496–497}}</ref>
* The initial focus on first activating contraction of antagonist muscles to provide reciprocal inhibition and lengthen spastic muscles
* Reciprocal actions are attempted. Agonist contractions are performed first in small ranges progressing to larger arcs of movement
* Highly stressful activities be minimized early in training
* Functional skills are targeted for training
* Patients and family/caregivers should be educated about the importance of maintaining range of motion and doing daily exercise

Medical interventions may include oral medications such as [[baclofen]], [[clonazepam]], [[clonidine]], [[diazepam]], or [[dantrolene]]. If refractive to oral agents, spasticity may be treated with [[intrathecal]] baclofen therapy (IBT) when spasticity. IBT may also be used in patients with limited tolerance to other modalities.<ref name=Saulino2014>{{cite book | vauthors = Saulino M, Goldman L | date = 2014 | chapter = Spasticity | veditors = Maitin IB, Cruz E | title = CURRENT Diagnosis & Treatment: Physical Medicine & Rehabilitation. | publisher = McGraw Hill | chapter-url = https://accessmedicine.mhmedical.com/content.aspx?bookid=1180&sectionid=70376430 | isbn = 978-0-07-179329-2 }}</ref> [[Phenol]] injections can be used, or [[botulinum toxin]]<ref name=Saulino2014/><ref name=farag2020/><ref name=Blumetti2019/><ref>{{cite web|url=http://www.dddmag.com/news/2014/02/uk-approves-new-botox-use?et_cid=3751256&et_rid=657808477&type=cta|archive-url=https://archive.today/20140206045026/http://www.dddmag.com/news/2014/02/uk-approves-new-botox-use?et_cid=3751256&et_rid=657808477&type=cta|url-status=dead|archive-date=February 6, 2014|title=UK Approves New Botox Use|date=5 February 2014}} </ref> injections into the muscle belly, to attempt to dampen the signals between nerve and muscle. The effectiveness of medications vary between individuals, and vary based on location of the upper motor neuron lesion (in the brain or the spinal cord). Medications are commonly used for spastic movement disorders, but research has not shown functional benefit for some drugs.<ref name="Taricco M 2000">{{cite journal | vauthors = Taricco M, Adone R, Pagliacci C, Telaro E | title = Pharmacological interventions for spasticity following spinal cord injury | journal = The Cochrane Database of Systematic Reviews | volume = 2000 | issue = 2 | pages = CD001131 | year = 2000 | pmid = 10796750 | pmc = 8406943 | doi = 10.1002/14651858.CD001131 }}</ref><ref>{{cite journal | vauthors = Shakespeare DT, Boggild M, Young C | title = Anti-spasticity agents for multiple sclerosis | journal = The Cochrane Database of Systematic Reviews | volume = 4 | issue = 4 | pages = CD001332 | year = 2003 | pmid = 14583932 | pmc = 7028001 | doi = 10.1002/14651858.CD001332 }}</ref> Some studies have shown that medications have been effective in decreasing spasticity, but that this has not been accompanied by functional benefits.<ref name="Taricco M 2000"/> [[Surgery]] could be required for a tendon release in the case of a severe muscle imbalance leading to contracture. In spastic CP, selective dorsal [[rhizotomy]] has also been used to decrease muscle overactivity.<ref>{{Cite journal |last1=Grunt |first1=Sebastian |last2=Fieggen |first2=A Graham |last3=Vermeulen |first3=R Jeroen |last4=Becher |first4=Jules G |last5=Langerak |first5=Nelleke G |year=2014 |title=Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature |journal=Developmental Medicine & Child Neurology |language=en |volume=56 |issue=4 |pages=302–312 |doi=10.1111/dmcn.12277|pmid=24106928 |doi-access=free }}</ref>

Incorporating [[hydrotherapy]] in the treatment program may help decrease spasm severity, promote functional independence, improve motor recovery and decrease medication required for spasticity, which may help reduce the side effects that are possible with oral drug treatments.<ref name="Kesiktas">{{cite journal | vauthors = Kesiktas N, Paker N, Erdogan N, Gülsen G, Biçki D, Yilmaz H | title = The use of hydrotherapy for the management of spasticity | journal = Neurorehabilitation and Neural Repair | volume = 18 | issue = 4 | pages = 268–273 | date = December 2004 | pmid = 15537997 | doi = 10.1177/1545968304270002 | s2cid = 40066099 | doi-access = free }}</ref><ref name="Beresneva">{{cite journal | vauthors = Beresneva J, Stirane D, Kiukucane E, Vetra A | year = 2009 | title = The use of aquatic therapy in stroke patients for the management of spasticity...Proceedings of the 10th Congress of the European Federation for Research in Rehabilitation, Riga, Latvia | journal = International Journal of Rehabilitation Research | volume = 32 | page = S110 | doi=10.1097/00004356-200908001-00145| s2cid = 147336547 }}</ref>   A 2004 study compared the effects of hydrotherapy on spasticity, oral [[baclofen]] dosage and [[Functional Independence Measure]] (FIM) scores of patients with a [[spinal cord injury]] (SCI). It was found that subjects who received hydrotherapy treatment obtained increased FIM scores and a decreased intake of oral baclofen medication.<ref name ="Kesiktas" />  A 2009 study looked at the effect of hydrotherapy to decrease spasticity on post-[[stroke]], [[hemiparetic]] patients with limited mobility and concluded that there was a significantly larger increase in FIM scores compared to the control group that did not receive hydrotherapy.<ref name ="Beresneva" />