Synopsis
Manage spasticity by function and triggers, preserve useful tone and recognise autonomic dysreflexia after high spinal injury as a hypertensive emergency requiring immediate trigger removal.
- Spasticity is a velocity-dependent increase in stretch reflex tone after upper-motor-neurone injury; spasms, clonus, stiffness, dystonia, rigidity and fixed contracture are related but not interchangeable findings.
- Tone can help standing, transfers, venous return or continence, so treatment targets pain, sleep, hygiene, skin, gait or care goals rather than a normal tone score.
- A sudden increase usually signals a trigger below the neurological level: urinary infection or retention, catheter blockage, constipation, pressure injury, fracture, ingrown nail, tight equipment or pain.
- Positioning, stretching, splinting, standing, task practice and equipment review are the foundation, delivered by rehabilitation teams after triggers and biomechanics are assessed.
- For generalised spasticity in MS, NICE recommends oral baclofen first line when goals are improved mobility, pain or spasms; titrate slowly to benefit because weakness can worsen function.
- Botulinum toxin treats selected focal overactivity, while intrathecal baclofen is considered for severe generalised disease after a successful specialist test and support plan.
- Abrupt baclofen withdrawal can cause rebound spasticity, fever, confusion, autonomic instability, rhabdomyolysis and seizures, particularly after pump failure.
- Autonomic dysreflexia is uncontrolled sympathetic discharge below a usually T6-or-higher lesion after spinal shock, most often triggered by bladder distension or a blocked catheter.
- The person's baseline blood pressure may be low, so a dangerous rise can still appear normal to an unfamiliar observer; compare with their usual value and symptoms.
- After sitting upright, examine the catheter and bladder first, then bowel, skin and other triggers; use short-acting antihypertensive treatment under the emergency plan if pressure remains dangerously elevated.
Key red flags
Previously stable tone suddenly increases with urinary symptoms, blocked catheter, constipation, pressure damage, fracture, tight splint, menstruation or another painful stimulus.
A high cord-injured person develops sudden hypertension above baseline, pounding headache, facial flushing, sweating or nasal blockage, sometimes with bradycardia and cool piloerect skin below.
A kinked, blocked or overfull catheter bag, retention, instrumentation or urinary infection precedes the episode; bladder distension is the commonest cause and is checked first.
Abrupt oral cessation or pump interruption causes rapidly escalating generalised tone, pruritus, fever, agitation, hallucination, autonomic instability or seizures and can mimic sepsis.
Investigation priorities
Separate neural spasticity from contracture and determine which activity, comfort or care outcome treatment should change.
Management branches
Tone, spasms or clonus becomes painful, functionally limiting or suddenly worse.
- Define one or more measurable goals and establish whether current tone helps posture or transfer, while distinguishing dynamic spasticity from fixed shortening or dystonia.
- Search systematically for bladder, bowel, skin, infection, fracture, pain and equipment triggers and correct these before escalating long-term antispastic treatment.
- Optimise positioning, stretching, orthoses, standing and task practice, then introduce low-dose baclofen or a focal intervention through rehabilitation or neurology review.
- Reassess goal and adverse weakness after each change and refer complex generalised disease for toxin, intrathecal or multidisciplinary options.