Spasticity Management in Spinal Cord Injury

Spasticity refers to velocity-dependent increased muscle tone and exaggerated reflex activity that can develop after injury to the brain or spinal cord. In spinal cord injury, it may appear as stiffness, resistance to movement, involuntary jerking, extensor spasms, or muscles that “fight back” during transfers and care. ^[1][2][3]

Not all spasticity is purely harmful. In some people, a certain degree of increased tone may assist standing transfers or help maintain muscle bulk. The problem arises when spasticity interferes with comfort, hygiene, sleep, wheelchair positioning, skin protection, catheterization, or daily function. Management therefore targets troublesome spasticity, not simply any increase in tone. ^[1][2][4]

Why does spasticity occur, and is it the same in everyone?

After spinal cord injury, descending inhibitory control is disrupted, and spinal reflex circuits may become overactive. The pattern and severity vary by injury level, completeness, time since injury, medical complications, and triggers such as infection or skin problems. ^[1][2][3]

For that reason, two people with similar injuries may have very different experiences. One may notice mild stiffness only in the morning, while another may have severe spasms that impair transfers, sleep, or safety. ^[2][4][5]

How is spasticity evaluated?

Assessment includes the patient’s goals, range of motion, trigger identification, functional impact, pain, skin integrity, bowel and bladder status, seating, sleep, and any sudden change from baseline. Clinicians often use physical examination and standardized scales, but the most clinically meaningful question is whether the spasticity is helping, neutral, or harmful in daily life. ^[1][2][5]

A sudden increase in spasticity should never be dismissed automatically. It may signal a urinary tract infection, constipation, pressure injury, fracture, ingrown toenail, catheter issue, or another noxious stimulus below the injury level. ^[1][2][4]

What treatment options are available?

Treatment may include stretching, positioning, range-of-motion work, splinting, trigger management, oral medications such as baclofen or tizanidine, focal injections in selected muscles, intrathecal baclofen in severe cases, and management of contributing pain or skin issues. ^[1][2][3]

The best plan is individualized. Some patients mainly need trigger control and therapy, whereas others need a medication review or advanced interventions. Because overtreatment can cause weakness, fatigue, or loss of useful tone, treatment must balance symptom relief with function. ^[2][4][5]

When is urgent or rapid assessment needed?

Rapid assessment is appropriate if spasticity worsens abruptly, becomes painful, interferes with catheterization or breathing, causes repeated falls or unsafe transfers, or is accompanied by fever, skin injury, urinary symptoms, or signs of autonomic dysreflexia. ^[1][2][4]

Triggers that can worsen spasticity in daily life

Common triggers include urinary infection, bladder distention, constipation, skin irritation, pressure injuries, tight clothing, poor wheelchair positioning, fractures, heterotopic ossification, and untreated pain. Finding and treating the trigger may improve spasticity more effectively than simply increasing medication. ^[1][2][4]

How are long-term goals set?

Long-term goals usually focus on comfort, easier care, safer mobility, preservation of range of motion, prevention of contracture, improved sleep, and greater participation in daily activities. The goal is rarely “zero tone at any cost.” Instead, the aim is functional control with the lowest effective treatment burden. ^[1][2][5]