Spasticity and Hypertonicity: From Definition to Multidisciplinary Treatment

Spasticità e ipertono: dalla definizione al trattamento multidisciplinare

Spasticity is a complex disorder of muscle tone that occurs following an upper motor neuron (UMN) lesion. This phenomenon is characterized by a velocity-dependent increase in the stretch reflex, which leads to excessive and inappropriate muscle activation, contributing to muscle hypertonia. Understanding this disorder is essential to developing effective treatment strategies.

The Role of Muscle Tone in Posture and Movement

Muscle tone plays a crucial role in maintaining posture and facilitating movement. The neuromuscular system constantly adjusts tone in response to muscle elongation by modulating the stretch reflex. This modulation is essential for controlling movement and maintaining balance.

Characteristics of spasticity

Spasticity depends not only on the speed of stretching, but also on the length of the muscle. For example, in the quadriceps, spasticity is more pronounced when the muscle is in a shortened position. This phenomenon contributes to the so-called "switchblade effect", a distinctive clinical feature of spasticity.

Definition and evolution of the concept of spasticity

The definition of spasticity has undergone several revisions over the years, reflecting the evolving understanding of this disorder:
  • 1980: Lance defines spasticity as "a motor disorder characterized by a velocity-dependent increase in the tonic stretch reflex."
  • 2003: An American panel of experts proposes a redefinition, describing spasticity as "a velocity-dependent increase in hypertonicity with a step when a certain threshold is exceeded".
  • 2005: A European consortium suggests a more clinical definition: "a disordered sensorimotor control, resulting from an upper motor neuron lesion, presenting as an intermittent or sustained involuntary activation of muscles".
These definitions reflect the complexity of the phenomenon and the difficulty in distinguishing between spasticity and hypertonicity, often used as synonyms in clinical practice.

Pathophysiology of spasticity and hypertonicity

Understanding the pathophysiological mechanisms underlying spasticity is essential to develop targeted treatment strategies:
  • Altered stretch reflexes: In patients with spasticity, a positive linear correlation is observed between the electromyographic activity of the stretched muscle and the velocity of stretch.
  • Stretch Reflex Control Systems: Studies have identified two major balancing systems: inhibitory control of the dorsal reticulospinal tract and facilitatory control of the medial reticulospinal and vestibulospinal tracts.
  • Synaptic control mechanisms: Pre- and postsynaptic inhibition and post-activation depression are often reduced in patients with spasticity.
  • Non-neural alterations: Muscle properties such as intrinsic stiffness and viscosity contribute to hypertonicity.

Implications for treatment

Understanding the pathophysiology of spasticity has important implications for treatment:
Limb Mobilization: Fundamental to Prevent and Treat Muscle Hypertonicity.
Prevention of shortening postures: Essential to avoid muscle contractures.
Targeted physiotherapy: Individualized stretching programs, correct limb positioning and application of orthoses.
Functional rehabilitation approach: Necessary to achieve optimal recovery.

Multidisciplinary rehabilitation and use of botulinum toxin

The management of spasticity requires a multidisciplinary approach (MD) that integrates pharmacological and physical interventions:
Botulinum toxin: Facilitates muscle stretching and lengthening, preventing the progression of contractures.
Physical therapies: These include physiotherapy, occupational therapy, and other related disciplines.
Integrated approach: Recent guidelines emphasize the importance of an MD approach to optimize treatment outcomes.

Scientific evidence and research limitations

A Cochrane Library review analyzed the effectiveness of MD rehabilitation treatments in combination with botulinum toxin. However, the authors found several limitations in the existing studies:
  • Low methodological quality of studies
  • Lack of clear parameters for the intensity, duration and frequency of therapies
  • Lack of selection criteria for the ideal patient
  • Inconsistent use of terminology and definition of "spasticity"

Conclusions and future perspectives

Effective management of spasticity requires the development of integrated multidisciplinary rehabilitation teams. To improve patient outcomes and ensure long-term continuity of care, it is necessary to:
  • Conduct further evidence-based studies
  • Establish a consistent and shared definition of "spasticity"
  • Develop standardized yet flexible treatment protocols
  • Implement personalized approaches based on individual patient characteristics
Only through these efforts will it be possible to optimize the management of spasticity and significantly improve the quality of life of patients affected by this complex condition.

Spasticity and Hypertonicity: From Definition to Multidisciplinary Treatment