When to image, when to refer, and how to structure conservative care.

Spasticity is a velocity-dependent increase in muscle tone that follows an upper motor neuron lesion. In adult physiatry practice, spasticity most often presents after stroke, traumatic brain injury, spinal cord injury, or multiple sclerosis, and its impact on function, hygiene, pain, and caregiver burden varies widely across patients.

A structured assessment begins with a goal-oriented history: what is spasticity preventing the patient from doing, and what would a meaningful improvement look like? Physical examination should document tone using the Modified Ashworth Scale, active and passive range of motion, selective motor control, and the presence of contracture. Video capture of gait or transfers is invaluable when tracking response to therapy.

Management is layered. Stretching, positioning, orthoses, and task-specific therapy form the foundation. Oral agents can address generalized spasticity but often at the cost of sedation. Focal chemodenervation with botulinum toxin remains the workhorse for problematic muscle groups, ideally guided by ultrasound or electrical stimulation and coordinated with a therapy plan. Intrathecal baclofen and surgical options are reserved for severe or refractory cases and should be considered within a multidisciplinary team.