Spasticity: A Care Staff Guide to Stiffness, Spasms and Contractures

Spasticity is one of the most common and most under-managed problems in people living with the effects of stroke, spinal cord injury or multiple sclerosis. For the person, it can mean stiff or painful limbs, difficulty with washing and dressing, poor posture and skin that is hard to keep clean. For care staff, it is often the reason a task suddenly becomes difficult. This guide explains what spasticity is, what makes it worse, and the practical steps care teams can take. It is relevant to anyone supporting people after a stroke or with a neurological condition.

What spasticity is

A general practice review in the British Journal of Medical Practitioners defines spasticity as disordered sensori-motor control resulting from an upper motor neuron lesion, which presents as intermittent or sustained involuntary activation of muscles. In plain terms, the nerve signals that should relax a muscle are disrupted, so the muscle stays tight or goes into spasm. It ranges from mild stiffness to severe, uncontrollable spasms.

The same review lists common causes as brain injuries (including stroke, trauma, hypoxia, infection and cerebral palsy), spinal cord injury and multiple sclerosis. Our guides to multiple sclerosis care and spinal cord injury care cover those conditions in more depth.

Why it matters in care homes

A cross-sectional study of 60 care home residents with upper motor neuron syndrome across 22 care homes in Derbyshire and Nottinghamshire (Ellis and colleagues, Clinical Rehabilitation, 2019) found that 46 residents (77%) had spasticity-related needs and 35 (58%) had needs that were not being met. Thirty-five residents had at least one established joint contracture and six had a pressure sore. The most frequent unmet needs were contracture risk and skin hygiene or skin integrity in the upper limb. Among the 31 residents followed up, telling the GP about unmet needs led to no change in management in 23 cases (74%). The lesson for care teams is that spasticity needs to be recognised, recorded and followed up persistently, rather than accepted as a fixed part of the condition.

Problems spasticity can cause

The general practice review lists these associated problems:

• pain and muscle discomfort;
• difficulty with activities of daily living such as washing, dressing and using the toilet;
• posture and mobility problems;
• deformities and contractures;
• pressure ulcers;
• sleep disturbance and social isolation.

Hands that are clenched shut are a classic example: the palm is hard to clean, skin can break down, and nails can press into the skin. Daily checks and a clear skin care plan are essential, and our guide to pressure ulcer prevention sets out the wider approach.

How spasticity is assessed

The Modified Ashworth Scale is the most widely used tool for grading muscle tone. It runs from 0, meaning no increase in tone, to 4, meaning a rigid limb. Scores are used by physiotherapists and doctors to track change. Care staff do not usually score tone themselves, but good observations feed into the assessment: which limbs are affected, when it is worse, what position helps, and whether it interferes with care, comfort or sleep.

What can make it worse

The review is clear that some triggers should be managed early, because they make spasticity worse: pressure sores, infections such as urinary tract infections, constipation and chronic pain. A sudden increase in stiffness or spasms is therefore a prompt to look for a cause. Check for a new skin problem, signs of infection, bowel habits and pain, and report the change rather than assuming the condition has progressed.

Management options

Management is led by the clinical team and usually combines several approaches.

• Physical measures: stretching and positioning, heat and cooling techniques, orthotics and equipment, and physiotherapy.
• Oral medicines: baclofen is the most common, with tizanidine, benzodiazepines and dantrolene also used.
• Focal treatment: botulinum toxin injections for specific muscle groups.
• Intrathecal baclofen: a pump delivering the medicine near the spinal cord, for severe cases.

Medicines for spasticity can cause drowsiness or weakness, which may affect falls risk and swallowing, so report any change after a new prescription or dose change. Never stop or reduce these medicines without prescriber advice.

What care staff can do day to day

Follow the stretching and positioning plan written by the physiotherapist or occupational therapist, and carry it out consistently. Move limbs slowly and support them rather than pulling, because a sudden stretch can trigger a spasm. Use the equipment the person has been prescribed, such as splints or specialist seating, and check skin under and around them. Record spasms, pain and sleep so the clinical team has real information to work with. If you are not seeing a response, say so and ask for a review, and consider asking the GP for a referral to a specialist spasticity service.

Frequently asked questions

Is spasticity the same as muscle weakness? No. A person can have both weakness and spasticity, but spasticity is stiffness and involuntary muscle activity caused by damage to the central nervous system.

Can spasticity be cured? The sources we reviewed describe management rather than cure, with the aim of comfort, function and preventing complications.

Where can teams train? Learnsignal's CPD courses for health and care staff include neurological conditions and moving and handling.