As noted above, there are a wide variety of approaches in treating spasticity. It is generally accepted practice to employ more conservative approaches initially and gradually administer more invasive treatments with the understanding that no one approach is likely to be universally successful for all individuals (Kirshblum 1999). However, some have contended that this stepwise approach is not necessarily the ideal. For example, Gormley Jr. et al. (1997) have asserted that in the hands of an experienced clinical team, it may be decided that aggressive measures are needed early on, based on the individual presentation and the many factors that may influence spasticity. More recently, D’Amico et al. (2014) have suggested that “increasing the excitation of the spinal cord with spared descending and/or peripheral inputs by facilitating movement, instead of suppressing it pharmacologically, may provide the best avenue to improve residual motor function and manage spasticity after SCI.” Regardless, in general most clinicains feel that active exercise and physical therapy modalities should be the first line of treatment before adding pharmacological (e.g., oral medications, BTX, or intrathecal agents), orthopaedic, or neurosurgical options (Kirshblum 1999; Rekand et al. 2012). It is important that the clinical team have a thorough understanding of these factors as these may impact assessment and treatment decisions. For example, it is generally accepted that posture has a major impact on the clinical presentation of spasticity (Kakebeeke et al. 2002) and there are suggestions from clinical experience that consideration of the wheelchair and seating equipment being prescribed plays an important part in the management of spasticity. Regardless, effective clinical management requires an individualized and often a combinational approach, thereby necessitating a broad knowledge of the various options available. In the present section, non-pharmacological interventions are outlined-from the more conservative options such as passive and active movement-based interventions, to those based on forms of electrical and other types of stimulation and finally to more invasive neurosurgical interventions.
For the purpose of this review we have classified the various non-pharmacological approaches into six general categories. These include interventions based on i) passive movement, ii) active movement, iii) direct muscle electrical stimulation, iv) various forms of afferent stimulation, v) direct spinal cord stimulation and vi) repetitive transcranial magnetic stimulation. It should be noted that although we have tried to be as specific as possible within these distinctions, there may be some overlap across the categories for specific modalities. For example, passive movements produce afferent outflow and may have also been classified as a form of afferent stimulation. Hydrotherapy, classified as an active movement-based intervention given the buoyancy and viscous properties of water in aiding active movement exercise (Kesiktas et al. 2004), often involve passive movements as well as the contributions of afferent stimulation associated with heated water. We have tried to categorize the approaches based on the primary intent of the authors in describing the various interventions. In addition, when considering final conclusions, we have tried to be as specific as possible within each category, despite the obvious need to bring together evidence from different sources.