Contractures and spasticity

Also called Muscle tightness, Spasms, Tone

Stiffness that becomes a fixed shortening if nothing is done. Almost entirely preventable, and largely permanent once it has happened.

What it is

Two related things that get run together.

**Spasticity** is increased muscle tone from damage to the brain or spinal cord: muscles that resist being moved, and spasms that come on with movement, pain or a full bladder. It follows stroke, brain injury, cerebral palsy, multiple sclerosis, motor neurone disease and spinal cord injury.

**A contracture** is what happens when a joint is not moved through its full range for long enough: the muscle, tendon and other soft tissue shorten and the joint becomes fixed. Unlike spasticity, a contracture does not relax, and beyond a certain point it does not come back with exercise.

That distinction is the whole point of this entry. Spasticity is managed. Contractures are prevented, and once established they usually are not reversible without surgery.

The prevention is unglamorous and reliable: daily passive movement through full range, good positioning, and treating the things that make tone worse. It requires somebody to do it every day, which is why it is skipped, and why fixed hands, flexed elbows, plantarflexed feet and adducted hips are so common in people with severe disability.

A hidden trigger is worth knowing: pain, constipation, a full bladder, a urinary tract infection, an ingrown toenail or a pressure ulcer all increase tone. A sudden worsening of spasticity is a symptom to investigate, not just something to medicate.

Signs you might notice

Stiffness, resistance when a limb is moved, particularly when moved quickly.

Spasms, sometimes painful, sometimes triggered by movement or touch.

A limb held in a position: elbow flexed, hand fisted, foot pointed, knees together.

Reducing range at a joint over weeks: the earliest and most important sign, and the one only noticed by somebody who moves the limb regularly.

Skin breakdown in a closed hand or between pressed-together knees, and difficulty with washing, dressing and positioning.

Investigate rather than medicate when tone suddenly worsens: pain, constipation, urinary infection, pressure damage, an ill-fitting splint, a fracture, or a new illness.

How it can affect day-to-day life

This is a daily practice problem, not a specialist appointment problem. The therapist writes the programme; whether it happens depends on whoever is there every morning.

Programmes are abandoned because they are not explained, not built into an existing routine, or handed over without anybody showing how. Equipment and splints get left in a cupboard for the same reasons.

Splints and standing frames are only useful if worn and used to the schedule, and wearing schedules need checking rather than assuming.

Positioning through the night is as important as anything done in the day, because that is where most of the hours are.

Botulinum toxin injections into specific muscles can reduce focal spasticity and are usually combined with therapy and splinting. They wear off and need repeating, and they are not a substitute for daily movement.

Contractures make personal care painful and dignity hard, and pain in a person who cannot report it shows up as distress or resistance to care.

Supporting someone well

Move every joint through its full range every day. This is the intervention. It takes minutes and it prevents something that cannot be undone.

Ask for physiotherapy and occupational therapy early, before there is a problem, rather than after.

Get the programme written down and demonstrated, and make sure everybody who provides care can do it.

Check splint wearing schedules and check the skin under them every time.

Position deliberately, in bed and in the chair, and vary it.

When tone suddenly worsens, look for the cause: pain, bowels, bladder, skin, infection, footwear.

Treat pain properly. Untreated pain increases tone, and increased tone causes pain.

Ask about a spasticity service or botulinum toxin if tone is limiting function or care despite all of the above.

Where to get help

The neurology, rehabilitation or community therapy team, and a specialist spasticity service where one exists.

A GP practice for medication review and for the triggers above.

Chartered Society of Physiotherapy and Royal College of Occupational Therapists for what these professions should be providing.

MS Society and Stroke Association both publish practical guidance on managing tone.