Upper Limb Spasticity Management Protocol

I. Clinical Presentation of Upper Limb Spasticity

Upper limb spasticity, a velocity-dependent increase in tonic stretch reflexes, commonly presents after an upper motor neuron lesion (e.g., stroke, traumatic brain injury, cerebral palsy, multiple sclerosis). It results from an imbalance of excitatory and inhibitory signals within the central nervous system, leading to increased muscle tone and resistance to passive movement. The clinical presentation can vary significantly based on the severity and distribution of the spasticity.

Common Clinical Features:

• Increased Muscle Tone: Hypertonicity, especially with rapid passive movement. Assessed using the Modified Ashworth Scale (MAS).
• Clonus: Rhythmic, involuntary muscle contractions elicited by a quick stretch, often seen in the wrist or ankle.
• Abnormal Posture: Typical patterns include shoulder adduction, internal rotation, elbow flexion, forearm pronation, wrist flexion, and finger flexion ("spastic posture").
• Pain and Discomfort: Resulting from prolonged muscle contraction and abnormal joint loading.
• Limited Range of Motion (ROM): Due to muscle tightness and contractures.
• Difficulty with Functional Tasks: Impaired ability to perform activities of daily living (ADLs) such as dressing, eating, and hygiene.
• Skin Breakdown: Increased risk due to prolonged pressure on bony prominences in contracted positions.
• Fatigue: Increased energy expenditure due to constant muscle activity.

II. Rehabilitation Phases

Phase 1: Acute/Early Management (Focus on Prevention)

• Goals: Prevent contractures, maintain ROM, manage pain, and educate the patient/caregiver.
• Interventions:
  • Positioning: Regularly reposition the affected limb to prevent prolonged postures that exacerbate spasticity. Use pillows or splints to maintain optimal alignment.
  • Gentle Stretching: Slow, sustained stretches to maintain muscle length. Hold each stretch for at least 30 seconds.
  • Splinting/Orthotics: Serial casting or custom-made splints to gradually improve ROM and prevent contractures. Dynamic splints can provide low-load, prolonged stretch.
  • Pain Management: Modalities such as ice, heat, or transcutaneous electrical nerve stimulation (TENS) to manage pain and muscle spasms.
  • Patient/Caregiver Education: Instruction on proper positioning, stretching techniques, and skin care.

Phase 2: Subacute/Intermediate Management (Focus on Tone Reduction & Motor Control)

• Goals: Reduce spasticity, improve active ROM, and begin to re-establish motor control.
• Interventions:
  • Pharmacological Interventions: Work closely with the physician to optimize medication management (e.g., oral baclofen, tizanidine). Botulinum toxin injections can be beneficial for focal spasticity.
  • Neuromuscular Electrical Stimulation (NMES): Used to facilitate muscle activation and reduce spasticity in antagonist muscles.
  • Prolonged Static Stretching with Weight-Bearing: Use techniques like weight bearing through the affected arm to reduce tone and improve alignment.
  • Task-Specific Training: Practicing functional tasks that are challenging but achievable. This helps to improve motor control and reduce compensatory strategies.
  • Constraint-Induced Movement Therapy (CIMT): Restricting the less-affected limb to encourage use of the affected limb.

Phase 3: Chronic/Late Management (Focus on Functional Independence & Maintenance)

• Goals: Maximize functional independence, maintain gains, and prevent recurrence of contractures.
• Interventions:
  • Strengthening Exercises: Focus on strengthening agonist and antagonist muscles to improve functional performance.
  • Advanced Task-Specific Training: Complex tasks that mimic real-life activities.
  • Adaptive Equipment: Provision of adaptive equipment to compensate for residual deficits and enhance independence.
  • Home Exercise Program: A tailored exercise program to maintain ROM, strength, and functional skills.
  • Community Reintegration: Support and resources to facilitate participation in community activities.

III. Exercise Examples

These are just examples and must be modified based on individual needs and abilities:

1. Shoulder Protraction/Retraction: Seated or standing, focus on controlled movement of the shoulder blades.
2. Shoulder External Rotation with Wand: Lying supine, use a wand to assist in external rotation, aiming to increase ROM.
3. Elbow Extension/Flexion: Seated, actively extend and flex the elbow, focusing on full ROM. Use gravity as resistance if appropriate.
4. Forearm Pronation/Supination: Seated, actively rotate the forearm, focusing on controlled movement.
5. Wrist Extension/Flexion: Actively move the wrist up and down, focusing on full ROM and controlled movement.
6. Finger Extension/Flexion: Actively move the fingers through full ROM. Use putty or therapy balls to improve grip strength.
7. Weight-Bearing on Extended Wrist: Place the hand flat on a table and gently lean forward, stretching the wrist extensors.
8. Bilateral Reaching: Reaching for objects in different directions, focusing on symmetrical movement.
9. Modified Plantigrade: Position yourself on your hands and knees with affected limb facing the floor and weight bear through the affected arm. Encourage trunk rotation.
10. Scapular clock reaches: While laying on your back, instruct patient to extend arm and reach towards "clock positions" to work through scapular motion.
11. Self-Cath with reaching in multiple planes of motion.
12. Active Trunk Rotation with Arm Extension.

IV. Evidence-Based Return to Function Criteria

Return to function is individualized and depends on the patient's goals and premorbid function. The following criteria are general guidelines:

• Improved Muscle Tone: Reduction in spasticity as measured by the Modified Ashworth Scale (e.g., a decrease of at least one grade).
• Increased Active ROM: Demonstrable improvement in active ROM at the shoulder, elbow, wrist, and fingers.
• Improved Motor Control: Improved coordination and control of movements, as assessed through functional tasks and standardized assessments (e.g., Action Research Arm Test (ARAT)).
• Increased Strength: Improved muscle strength, as measured by manual muscle testing (MMT) or dynamometry.
• Functional Independence: Improved ability to perform ADLs such as dressing, eating, and hygiene with minimal assistance.
• Pain Management: Adequate pain control that does not significantly interfere with participation in rehabilitation activities.
• Patient Satisfaction: Patient report of improved quality of life and satisfaction with functional performance.
• Sustained Gains: Maintenance of gains over time, as demonstrated through follow-up assessments.