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Spasticity after brain injury

Spasticity is common after traumatic brain injury and other acquired brain injuries, often affecting more than one limb and developing within weeks of the injury. It causes pain, difficulty with care and positioning, and — if untreated — fixed contracture. Early assessment, targeted injections into the muscles responsible, and rehabilitation planned around goals set with the person and their family can prevent that progression.

When the brain is injured — by trauma, bleeding, lack of oxygen, infection or tumour — the control it exerts over muscle tone is disrupted. Spasticity after brain injury is common, often affects several limbs rather than one side, and can appear early: within weeks of the injury, while the person is still in hospital or has just come home. Because it can progress to contracture quickly, early assessment matters more here than in almost any other setting.

How it shows up. In the arms, elbows, wrists and fingers held flexed, shoulders pulled inward, forearms turned palm-down. In the legs, feet pointing down and turning in, knees held stiff or drawn up, thighs pulled together. Where injury is severe, whole-body patterns of extension or flexion can make seating and positioning difficult. The consequences are pain, skin problems in closed hands and behind bent knees, difficulty with washing and dressing, seating that no longer fits, and loss of whatever movement might otherwise have recovered.

Why early treatment matters. Muscles held short begin to shorten permanently within months. Once contracture is established, injections can no longer restore the range and surgery becomes the only option. Treating tone early — and lengthening muscles that have begun to shorten with serial casting — preserves the range that recovery may later make use of. Even where the outlook for movement is uncertain, preventing contracture keeps options open.

Setting goals after brain injury. Brain injury often affects thinking, memory, communication and behaviour as well as movement, and goals are set with the person and their family or carers together. They are frequently practical: a hand that can be opened for washing, an arm that fits through a sleeve, a posture that allows comfortable seating, a leg that can be positioned in bed, less pain. Where movement is recovering, goals extend to function. Progress is reviewed against them at each treatment cycle.

Treatment. Targeted injections into the muscles producing each pattern reduce tone for a period of months and are repeated as needed. Serial casting lengthens muscles that have begun to shorten. Splinting maintains the range gained. Physiotherapy and occupational therapy within the treatment window turn the change into a lasting one. Where tone is widespread, oral medication may be considered — with particular care after brain injury, because sedative effects can worsen alertness and thinking.

Pain after brain injury. Headache, shoulder pain, pain from spasticity and heterotopic ossification, and pain generated by the injured brain itself can all be present, and are easily missed in someone who cannot describe them clearly. Assessment here covers pain and tone together. See also pain after brain injury.

Working with your team. Treatment is coordinated with brain injury rehabilitation services, residential care, GPs, community therapists and families. Referrals are accepted from any of these. Telehealth assessment and review are available for rural and remote patients, with injection visits in Perth.

Sources: Synapse — Australia's Brain Injury Organisation; Healthdirect Australia.