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Upper limb spasticity

Upper limb spasticity is muscle overactivity in the shoulder, elbow, forearm, wrist or hand after stroke, brain injury, spinal cord injury, multiple sclerosis or similar conditions. It causes a bent, tight arm and closed hand that are painful, hard to wash and dress, and difficult to use. Targeted injections into the specific overactive muscles, with stretching and splinting, can open the hand, ease the arm and reduce pain.

The muscles that bend and close the arm are stronger than those that open it, so when control is lost after brain or spinal cord injury the arm is drawn into flexion: shoulder against the body, elbow bent, forearm palm-down, wrist and fingers curled. Upper limb spasticity is the most visible consequence of stroke and brain injury, and one of the most treatable.

The patterns. Spasticity in the arm is assessed as a set of recognisable patterns, each produced by particular muscles. An adducted, internally rotated shoulder makes dressing painful and the armpit hard to wash. A flexed elbow catches on sleeves and doorways. A pronated forearm turns the palm away. A flexed wrist and clenched fist trap moisture in the palm, breaking down skin and nails, and block whatever grip might otherwise be possible. A thumb-in-palm posture makes the hand impossible to open. Most people have several of these at once, and treating them in the right combination is what produces a useful result.

What treatment aims for. Goals depend on how much voluntary movement remains. Where the hand has no active movement, the goals are comfort, hygiene, skin care, dressing and positioning — a hand that can be opened and cleaned, an arm that rests without pain. Where some movement remains, reducing the tone that fights it can improve reach, grasp and release, and treatment is paired with task-specific therapy to build on that. The goal is agreed before treatment so that success can be judged against it.

Treatment. Spasticity injections are placed into the specific muscles producing each pattern. In the forearm, where many small muscles lie close together, ultrasound or electrical stimulation guidance ensures the intended muscle is reached. Effect develops over one to two weeks and lasts a number of months, then treatment is repeated. Between cycles, stretching, splinting and occupational therapy maintain the range gained. Where the fingers or elbow have already shortened permanently, serial casting or surgical opinion is arranged.

The shoulder. Shoulder pain is common after stroke and brain injury and has more than one cause: spasticity pulling the joint, a subluxed joint from weakness, and an immobile joint stiffening. These are distinguished on examination, because they are treated differently. Dr Martin's training in both pain medicine and rehabilitation medicine means the painful spastic shoulder can be assessed and treated as one problem.

Who is seen. Adults with upper limb spasticity after stroke, traumatic brain injury, spinal cord injury (including tetraplegia), multiple sclerosis, cerebral palsy and other neurological conditions. Telehealth assessment and review are available for rural and remote patients, with injection visits in Perth.