Spasticity and Contracture

  • Hyun-Yoon Ko


Spasticity, which indicates an abnormal stretch reflex behavior, is a disabling component of upper motor neuron lesion including spinal cord injury. The upper motor neuron system consists of all the pathways above the anterior horn cell, including the brain, brainstem, and spinal cord. Spasticity includes a wide range of abnormal motor behavior due to upper motor neuron lesion. This causes increased muscle tone, increased muscle reactivity, reduced precision of voluntary muscle control, and the emergence of involuntary motor output. All of these effects can show time-dependent differences in static versus dynamic conditions, flexor versus extensor movements, and many other permutations. Clinically, spasticity can be easily recognized, but can be difficult to quantify and treat. The pathophysiology of spasticity is complex and controversial. There are many subtle considerations in the management of spasticity, and sometimes the clinician has to negotiate with the patient when adjusting the spasticity.


  1. Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord. 2005;43:577–86.CrossRefGoogle Scholar
  2. Adams MM, Ginis KAM, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil. 2007;88:1185–92.CrossRefGoogle Scholar
  3. Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner. 1964;192:540–2.PubMedGoogle Scholar
  4. Benz EN, Hornby TG, Bode RK, et al. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil. 2005;86:52–9.CrossRefGoogle Scholar
  5. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67:206–7.CrossRefGoogle Scholar
  6. Cleland CL, Rymer WJ. Neural mechanisms underlying the clasp-knife reflex in the cat. I. Characteristics of the reflex. J Neurophysiol. 1990;64:1303–18.CrossRefGoogle Scholar
  7. Davidoff RA. Antispasticity drugs: mechanisms of action. Ann Neurol. 1985;17(2):107–16.CrossRefGoogle Scholar
  8. Dietz V, Sinkjaer T. Spasticity. Handb Clin Neurol. 2012;109:197–211.CrossRefGoogle Scholar
  9. Dietz V, Young R. The syndromes of spastic paresis. In: Brandt T, Caplan L, Dichgans L, et al., editors. Neurological disorders. Course and treatment. Amsterdam: Academic Press; 2003. p. 1247–57.CrossRefGoogle Scholar
  10. Ditunno JF, Little IW, Tessler A, et al. Spinal shock revisited: a four-phase model. Spinal Cord. 2004;42:383–95.CrossRefGoogle Scholar
  11. Fleuren JF, Voerman GE, Snoek GJ, et al. Perception of lower limb spasticity in patients with spinal cord injury. Spinal Cord. 2009;47:396–400.CrossRefGoogle Scholar
  12. Francisco GE. The role of intrathecal baclofen therapy in the upper motor neuron syndrome. Eur Med Phys. 2004;40:131–43.Google Scholar
  13. Haas BM, Bergstrom E, Jamous A, et al. The inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in patients with spinal cord injury. Spinal Cord. 1996;34:560–4.CrossRefGoogle Scholar
  14. Hiersemenzel LP, Curt A, Dietz V. From spinal shock to spasticity: neuronal adaptations to a spinal cord injury. Neurology. 2000;54:1574–82.CrossRefGoogle Scholar
  15. Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil. 1989;70(2):144–55.PubMedGoogle Scholar
  16. Kheder A, Nair KP. Spasticity: pathophysiology, evaluation and management. Pract Neurol. 2012;12:289–98.CrossRefGoogle Scholar
  17. Kita M, Goodkin DE. Drugs used to treat spasticity. Drugs. 2000;59(3):487–95.CrossRefGoogle Scholar
  18. Ko HY, Ditunno JF, Graziani V, et al. The pattern of reflex recovery during spinal shock. Spinal Cord. 1999;37:402–9.CrossRefGoogle Scholar
  19. Little JW, Ditunno JF Jr, Stiens SA, et al. Incomplete spinal cord: neuronal mechanisms of motor recovery and hyperreflexia. Arch Phys Med Rehabil. 1999;80:587–99.CrossRefGoogle Scholar
  20. Lui J, Sarai M, Mills PB. Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review. Spinal Cord. 2015;53:252–64.CrossRefGoogle Scholar
  21. Penn RD, Savoy SM, Corcos D, et al. Intrathecal baclofen for severe spinal spasticity. N Engl J Med. 1989;320:1517–21.CrossRefGoogle Scholar
  22. Priebe MM, Sherwood AM, Thornby JI, et al. Clinical assessment of spasticity in spinal cord injury: a multidimensional problem. Arch Phys Med Rehabil. 1996;77(7):713–6.CrossRefGoogle Scholar
  23. Rekand T. Clinical assessment and management of spasticity: a review. Acta Neurol Scand Suppl. 2010;190:62–6.CrossRefGoogle Scholar
  24. Rymer WZ, Houk JC, Crago PE. Mechanisms of the clasp-knife reflex studied in an animal model. Exp Brain Res. 1979;37(1):93–113.CrossRefGoogle Scholar
  25. Strommen JA. Management of spasticity from spinal cord dysfunction. Neurol Clin. 2013;31:269–86.CrossRefGoogle Scholar
  26. Tardieu G, Shentoub S, Delarue R. Research on a technic for measurement of spasticity. Rev Neurol (Paris). 1954;91:143–4.Google Scholar
  27. Wartenberg R. Pendulousness of the legs as a diagnostic test. Neurology. 1951;1:18–24.CrossRefGoogle Scholar
  28. Westerkam D, Saunders LL, Krause JS. Association of spasticity and life satisfaction after spinal cord injury. Spinal Cord. 2011;49:990–4.CrossRefGoogle Scholar
  29. Woolacott AJ, Burne JA. The tonic stretch reflex and spastic hypertonia after spinal cord injury. Exp Brain Res. 2006;174(2):386–96.CrossRefGoogle Scholar

Suggested Reading

  1. Afifi AK, Bergman RA. Functional neuroanatomy: text and atlas. 2nd ed. New York: Lange Medical Books/McGraw-Hill; 2005.Google Scholar
  2. Campbell WW. DeJong’s the neurologic examination. 7th ed. New York: Wolters Kluwer Lippincott Williams & Wilkins; 1992.Google Scholar
  3. Cardenas DD, Dalal K, editors. Spinal cord injury rehabilitation, Physical medicine and rehabilitation clinics of North America. Philadelphia, PA: Elsevier; 2014.Google Scholar
  4. Cardenas DD, Hooton TM, editors. Medical complications in physical medicine and rehabilitation. New York: Demos Medical Publishing, LLC; 2015.Google Scholar
  5. Chhabra HS, editor. ISCoS textbook on comprehensive management of spinal cord injuries. New Delhi: Wolters Kluwer; 2015.Google Scholar
  6. Kirshblum S, Campagnolo DI, editors. Spinal cord medicine. 2nd ed. Philadelphia, PA: Wolters Kluwer, Lippincott, Williams & Wilkins; 2011.Google Scholar
  7. Mtuid E, Gruener G, Dockery P. Fitzgerald’s clinical neuroanatomy and neuroscience. 7th ed. Philadelphia, PA: Elsevier; 2016.Google Scholar
  8. Pandyan AD, Hermens HJ, Conway BA. Neurological rehabilitation: spasticity and contractures in clinical practice and research. In: Scherer MJ, Muller D, editors. Rehabilitation science in practice series. Boca Raton, FL: CPC Press; 2018.Google Scholar
  9. Passias PG, editor. Cervical myelopathy. Philadelphia, PA: Jaypee Brothers Medical Publishers (P) Ltd.; 2016.Google Scholar
  10. Patestas MA, Gartner LP. A text book of neuroanatomy. Oxford: Blackwell Publishing; 2006.Google Scholar
  11. Vanderah T, Gould DJ. Nolte’s the human brain. Philadelphia, PA: Elsevier; 2016.Google Scholar
  12. Verhaagen J, McDonald JW III. Spinal cord injury. In: Aminoff MJ, Boller F, Swaab DF, editors. Handbook of clinical neurology, 3rd series, vol. 109. London: Elsevier; 2012.Google Scholar
  13. Vinken PJ, Bruyn GW, editors. Injuries of the spine and spinal cord. Part I. Handbook of clinical neurology, vol. 25. Oxford: North-Holland Publishing Company; 1976.Google Scholar
  14. Vinken PJ, Bruyn GW, editors. Injuries of the spine and spinal cord. Part II. Handbook of clinical neurology, vol. 25. Oxford: North-Holland Publishing Company; 1976.Google Scholar
  15. Vogel LC, Zebracki K, Betz RR, Mulcahey MJ, editors. Spinal cord injury in the child and young adult. London: Mac Keith Press; 2014.Google Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Hyun-Yoon Ko
    • 1
  1. 1.Department of Rehabilitation MedicineRehabilitation Hospital, Pusan National University Yangsan Hospital, Pusan National University School of MedicineYangsanSouth Korea

Personalised recommendations